Clinical Neuropsychiatry最新文献

Farina and Schimmenti's proposal, which directs attention in the field of complex trauma treatment toward the central role of attachment trauma (AT), is both timely and highly valuable. Their contribution immediately invites deeper reflection and gives rise to two distinct sets of questions. The first concerns issues of diagnostic assessment: how can clinicians reliably identify and differentiate the specific features of attachment trauma within the broader spectrum of complex trauma presentations? The second pertains to the future development of clinical practice and research, calling for renewed efforts aimed at integrating this promising AT-oriented perspective into the broader domains of case formulation and conceptualization. Such integration could refine our diagnostic tools and expand the theoretical and practical frameworks through which complex trauma is understood and treated.

This article provides a critical review of the concept of attachment trauma, proposing an expanded definition that reflects its psychopathogenic dynamics and clinical outcomes. The first aim of the review is to define attachment trauma and differentiate it from related constructs. Attachment trauma is conceptualized as a condition emerging within primary attachment relationships, characterized by prolonged failures in caregiving and/or ongoing abuse. These relationships create recurrent, inescapable threats, leading to significant disruptions in the child's physiological, socio-emotional, and cognitive development. The second aim of the review is to explore attachment trauma as a permeating psychopathological dimension that may underpin a broad spectrum of mental disorders manifesting in adulthood, including complex posttraumatic stress disorder, dissociative disorders, and borderline personality disorder. Recognizing attachment trauma in adults poses clinical challenges due to its complex and pervasive nature, often presenting with a constellation of symptoms across multiple domains, such as dysregulation of arousal, disintegration of higher-order cognitive processes, emotional and impulse dyscontrol, detachment and dissociative reactions, dysfunctional self and relational representations, impairments in mentalization, maladaptive compensatory strategies, and epistemic mistrust. The third objective of the review is to integrate the recognition of attachment trauma into clinical practice, emphasizing the identification of its impacts based on clinical presentation. The review highlights key therapeutic interventions, including the establishment of a safe therapeutic relationship, regulation of emotions and arousal, modification of pathogenic beliefs, addressing detachment symptoms and dissociated self-states, promotion of mentalization and epistemic trust, and the processing of both implicit and explicit traumatic memories. These interventions aim to repair the psychological damage caused by attachment trauma, fostering integration and healthier relational patterns.

The contribution by Farina & Schimmenti (2025) highlights the impact of childhood maltreatment on adult health. Deep Brain Reorienting (DBR), a neurophenomenological approach, proposes that attachment traumas derive from two primary experiences: shock and pain. Shock, often pre-affective, precedes emotions such as fear or anger and can take different forms (implosive, impact). When it dissipates, a deep pain emerges, linked to loneliness, rejection, and existential emptiness. DBR aims to slow down the shock-pain-affect sequence, separating its components to reduce emotional overload and promote regulation. This allows pathological beliefs of unworthiness to be reworked and contradictory attachment patterns to be addressed. The therapy also addresses dissociative symptoms, differentiated into supracortical, intracortical, neurochemical, and structural forms, reducing fragmentation of the self. In conclusion, DBR hypothesizes that attachment traumas result from alterations in midbrain mechanisms of orientation and affective regulation, compromising attachment development, mentalization, and self-esteem.

The concept of attachment trauma is provocative and stimulates an effort to seek additional definitions of trauma that are more congenial toward understanding the mental injury occurring to a particular individual rather than to a broad population where the focus is on "the size of the bang." What really constitutes an experience of trauma? When does the normative adaptation to adversity that is part of the infant attachment paradigm cross over the line and become attachment trauma? Are there biological considerations in this kind of event or are there only psychodynamic considerations, relational activities? In this brief communication these questions are explored in relation to a multiple self-state psychology of mind that is consistent with Bowlby's exploration of segregated subsystems, detachment, and deactivation.

Farina and Schimmenti bring together a wealth of research data and clinical experience to link the attachment trauma literature with specific symptoms and dynamics in adult patients. Of their many observations and insights, they suggest that attachment trauma should be inferred by clinicians in cases where patients present these specific phenomenological markers, even if the patients' themselves are not aware of such historical experiences. This theorizing provokes a research agenda that challenges scientists to carefully investigate its veracity, to guide accurate clinical reasoning. From the perspective of a therapist with their patient, the framing of attachment trauma as the etiological foundation of a specific collection of complex symptoms and dynamics offers a relational buffer in what is often a very complicated therapeutic journey. The gift of such theorizing is particularly evident in managing ruptures and countertransferential reactions to facilitate relational repair and re-instigate of empathic attunement. This commentary explores the challenge to researchers and the gift to therapists' and their patients' that Farina and Schimmenti's causal inference provides.

This commentary offers a critical and appreciative examination of Farina and Schimmenti's contribution to the understanding of attachment trauma as a pervasive, developmentally formative phenomenon. It discusses the authors proposal of an "attachment trauma frame" articulated through three core objectives, extending the conceptualization of trauma and attachment trauma beyond event-based models through an exploration of compelling facets, contributions, and important cautions. Further child specific considerations pertaining to importance of the psychological and neurobiological consequences of attachment trauma within clinical practice with children and families are offered. This work calls for developmentally and relationally attuned systems of care that address the broader intersubjective and systemic ecosystems in which children develop. It concludes with a call for future research to deepen intersectional and culturally responsive understandings of attachment trauma across diverse populations.

Farina and Schimmenti detail and define the potential consequences for their health when children meet and cannot escape from primary caretakers who neglect, maltreat, and abuse them. They define attachment trauma in this frame and thereby overcome some of the limitations of previous formulations. Inspired by their important work, I try to make a few points. Being ecosystems, we must long and strive to get the useful, to avoid and get rid of the harmful, and to leave alone what is useless. Part of the complexity of our being and becoming is that we include multiple longings and strivings, and that these can be contradictory. Per our very nature, and particularly as children, we long and strive to attach to our primary caretakers, defend against threat, and gain power to act. What to feel, think, and do when caretakers we depend on and must learn from are in fact harmful or useless to us, and the rest of our environment does not care or intervene? What is useful, harmful, and meaningless? Attachment trauma, then, is an ecological injury that evolves when harmful powers of caretakers and others far exceed our own power to act. Being ecosystems, the form the injury takes depends on this reciprocal causing. While it is an injury, it also is a creative effort to live and make sense of a mostd difficult life.

Farina and Schimmenti (2025) offer an intriguing reconceptualization of attachment trauma as a developmental process arising from relational failures, even in the absence of identifiable traumatic events. We support their emphasis on clinical symptom constellations-such as dissociation, emotional dysregulation, and interpersonal detachment-as markers of attachment-related dysfunction. However, we suggest a change in emphasis. We argue that any diagnostic change might target dysfunction in the attachment system itself, rather than infer the presence of trauma. This distinction aligns with diagnostic frameworks that prioritize functional patterns over historical assumptions. We also encourage the development of trauma-informed principles specific to attachment disruptions. These refinements, we believe, would increase diagnostic clarity and better support treatment planning. We believe that the enhanced focus on attachment-related psychopathologies, as proposed by Farina and Schimmenti, is of value but would benefit from further attention to the issue of reliable measurement.

Building on recent contributions by Farina and Schimmenti (2025a), this paper advances a more nuanced framework for their concept of attachment trauma focusing on the underlying mechanisms. The injury of attachment trauma, often concealed within ostensibly ordinary family systems, may leave no explicit memory trace yet manifest as enduring patterns of dysregulation. Instead, it becomes apparent through its clinical consequences such as Complex PTSD, borderline phenomena, dissociative disorders and their various complications. Central to the framework presented in this paper are the concept of relational encryption, in which interpersonal signals are coded to establish a balanced interpersonal dependency, and internal moderation, defined as the capacity for flexible regulation between affective and relational extremes, which is needed to overcome trauma-related paradoxes. Encryption vulnerability due to deficient or excessive relational coding, on the other hand, leads to "traumatic attachment" which is one of the consequences of attachment trauma. In accordance with these concepts, Implicit Psychotherapy, as a technique of communication, provides a clinical framework for safely engaging with these pre-reflective, unspoken wounds through pacing, symbolic containment, and embodied relational experience. Dialectical Dynamic Therapy (DDT), as a conceptual framework, facilitates the re-establishment of internal moderation. The paper points toward transformative therapeutic pathways grounded in embodied relational repair, epistemic trust, and dynamic therapeutic engagement. Ultimately, the paper advocates for a post-linear model of trauma, one that embraces complexity, dialectical thinking, and the reparative potential of therapeutic relationships, while insisting on the need to "unpack" the overloaded construct of attachment trauma.

Attachment trauma, as cogently formulated by Farina and Schimmenti (2025), involves traumatic experiences that fundamentally disrupt attachment bonding with primary caregivers and result in impairments in core self and relational capacities that include but extend beyond the symptoms of formal psychiatric nosology. An overview is provided of a clinical framework that similarly is grounded in clinical and scientific evidence of the adverse effects of a combination of traumatic victimization and attachment disruption, Developmental Trauma Disorder (DTD). Six domains of self-dysregulation are identified by DTD, including affective, somatic, attention/ memory, behavioral, interpersonal, and self-identity coherence, and evidence linking the features of DTD with attachment trauma is summarized. This commentary concludes that attachment trauma, as formulated by Farina and Schimmenti, offers an important framework to enable providers, theorists, and researchers to develop clinical formulations and approaches to treatment that explicitly recognize and directly address the all too often overlooked alterations in core self-regulatory capacities that result from coping with the traumatic disruption or loss of attachment security.