**1. Introduction**

Childhood traumatic experiences are known to have strong and lasting consequences on the physical, mental and reproductive health of victims as well as confining them to low mental health in adulthood [1]. A body of researches largely documented the severe and long-lasting effects of the adverse childhood experiences (ACEs) on the biological and psychological development of victims [1, 2], highlighting severe impairments in stress regulation and socioemotional development. Indeed, early interpersonal traumas expose victims to attachment disorganization and progressive deterioration in the self-worth from the first and most vulnerable stages of a child's development [3].

Moreover, studies reported a significant odd-ratio for psychiatric disorders in adulthood, including major depression, panic disorder and bulimia nervosa in sexually abused victims [4]. Adults' at-risk behaviors, such as substance abuse and dependence, are twice as common among victims, compared to the general population [5], and a major risk for sexual behaviors as well as for re-victimization is also largely documented [6–8].

Complex trauma, referring to children's experiences of multiple traumatic events that occur within the caregiving system [9], has significant long-lasting effects on brain maturation. Structural and functional abnormalities are reported in abused children, namely reduction in the volume of the orbitofrontal cortex and over reactivity of the amygdala [10]. Both areas are of fundamental importance in emotional and stress responses, which display atypical functioning in abused children from the earliest stages of life [11].

Child maltreatment and adverse childhood experiences are a common occurrence. In 2013, 9.1 per 1000 children in the USA known to child protective services (CPS) had been victims of abuse and neglect experiences [12]. In Europe, more than 18 million children are estimated to suffer from maltreatment, as reported by the World Health Organization [13]. In particular, a prevalence of 9.6% for sexual abuse, 22.9% for physical abuse and 29.1% for mental or emotional abuse is reported. In Italy, around 9.5% per 1000 children and adolescents are subject to some form of violence in childhood [14]; the data support the international portrait.

One of the most studied effects of traumatic experiences in childhood is post-traumatic stress disorder (PTSD). Post-traumatic stress disorder is classified as a "trauma and stress-related disorder" in the new Diagnostic and Statistical Manual of Mental Disorders 5 (American Psychological Association, 2013). PTSD represents the most frequent consequence of interpersonal trauma histories [15], with 48–85% of childhood abuse survivors developing PTSD symptoms across life [16, 17].

Despite the fact that studies have mainly analyzed only the stress-related consequences of physical and sexual traumatic experiences, emotional abuse and neglect have also been shown to be associated with the development of PTSD symptoms [18].

The exposure to traumatic experiences is a necessary but not sufficient condition for the development of PTSD. According to Van der Kolk, to consider a linear relationship between early traumatic experiences and adult psychiatric disorders represents an oversimplification [19]; underlying mechanisms and victims' characteristics involved in the association between traumatic experiences and adult psychopathology is still a matter of on-going study.

**1. Introduction**

vulnerable stages of a child's development [3].

symptoms across life [16, 17].

as well as for re-victimization is also largely documented [6–8].

110 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

tioning in abused children from the earliest stages of life [11].

to be associated with the development of PTSD symptoms [18].

Childhood traumatic experiences are known to have strong and lasting consequences on the physical, mental and reproductive health of victims as well as confining them to low mental health in adulthood [1]. A body of researches largely documented the severe and long-lasting effects of the adverse childhood experiences (ACEs) on the biological and psychological development of victims [1, 2], highlighting severe impairments in stress regulation and socioemotional development. Indeed, early interpersonal traumas expose victims to attachment disorganization and progressive deterioration in the self-worth from the first and most

Moreover, studies reported a significant odd-ratio for psychiatric disorders in adulthood, including major depression, panic disorder and bulimia nervosa in sexually abused victims [4]. Adults' at-risk behaviors, such as substance abuse and dependence, are twice as common among victims, compared to the general population [5], and a major risk for sexual behaviors

Complex trauma, referring to children's experiences of multiple traumatic events that occur within the caregiving system [9], has significant long-lasting effects on brain maturation. Structural and functional abnormalities are reported in abused children, namely reduction in the volume of the orbitofrontal cortex and over reactivity of the amygdala [10]. Both areas are of fundamental importance in emotional and stress responses, which display atypical func-

Child maltreatment and adverse childhood experiences are a common occurrence. In 2013, 9.1 per 1000 children in the USA known to child protective services (CPS) had been victims of abuse and neglect experiences [12]. In Europe, more than 18 million children are estimated to suffer from maltreatment, as reported by the World Health Organization [13]. In particular, a prevalence of 9.6% for sexual abuse, 22.9% for physical abuse and 29.1% for mental or emotional abuse is reported. In Italy, around 9.5% per 1000 children and adolescents are subject to some form of violence in childhood [14]; the data support the international portrait.

One of the most studied effects of traumatic experiences in childhood is post-traumatic stress disorder (PTSD). Post-traumatic stress disorder is classified as a "trauma and stress-related disorder" in the new Diagnostic and Statistical Manual of Mental Disorders 5 (American Psychological Association, 2013). PTSD represents the most frequent consequence of interpersonal trauma histories [15], with 48–85% of childhood abuse survivors developing PTSD

Despite the fact that studies have mainly analyzed only the stress-related consequences of physical and sexual traumatic experiences, emotional abuse and neglect have also been shown

The exposure to traumatic experiences is a necessary but not sufficient condition for the development of PTSD. According to Van der Kolk, to consider a linear relationship between early traumatic experiences and adult psychiatric disorders represents an oversimplification Different studies report that psychopathological outcomes of childhood abuse are related to the quality of early attachment relationship. Around 80% of physical and emotional abuses during childhood are perpetrated by parents or close relatives [20], whom are supposed to be the primary and the first external source of emotion and stress regulation. Indeed, the parentchild relationship represents a key feature for the long-term ability of auto-regulation and social support [19, 21].

According to the attachment theory, the quality of early interactions between the caregiver and his/her child determines the child's immediate emotional response to stress and plays a decisive and lasting role in the latter's emotion-regulation ability [22–26]. Through the daily over-repetition of the interactive exchanges, a set of internal working models (IWMs) develops and becomes internalized as a patrimony of personal schema of self and of the other. The internal working models enable people to regulate emotions in interactions and to cope with stressful interpersonal situations across the life. These personal schemas are entirely developed during the first years of a child's life and become relatively stable across the life span. As a consequence, they represent a personal guide influencing interactions and relationships in adulthood [27].

Childhood experiences of abuse and maltreatment constitute a fearful and dangerous developmental environment, in which the intimacy and proximity with the caregiver produce a sense of fear instead of a feeling of "felt security," thus provoking a disorganization of the attachment system. Indeed, child abuse victims show significantly higher rates of attachment insecurity (70–100%) compared to the general population (30%) [28]. In addition, fearful and angry-dismissive patterns are the most associated with interpersonal traumatic experiences [29].

Furthermore, neglectful caregiving, even in the absence of physical and sexual abuse, denies the child the needed coherent external support. Through the inconsistent and neglectful responses of the caregiver, children develop interpersonal strategies characterized by anxious and/or avoidant behaviors [30].

As a consequence, the adverse childhood experiences shape the interpersonal strategies characterizing adult relationships. In particular, high levels of dependency or avoidance in social relationship as well as insecurity, suspiciousness, isolation, emotional distress and low intimacy in close relationships are reported as a consequence of traumatic experiences [19, 31, 32]. Indeed, the core concept of the attachment theory is that childhood attachment quality constitutes the paradigm for forming the adult romantic relationship [33]. Romantic attachment represents a personal system of beliefs and expectations on the availability and the responsiveness of the partner. It is based on the childhood experiences of being loved and felt security in the relationship with the caregiver [33], and it guides the interactive exchanges between partners. People differently experience and manage intimacy with the partner according to their own early experiences of caregiver's proximity and responsiveness. In particular, insecure adults are worried of being abandoned or being too close to and dependent on the partner [33]. According to Hazan and Shaver [33], a lack of self-worth and a negative model of self tend to produce anxiety for not being loved and being abandoned; in contrast, a negative view of the other leads to mistrust feelings, expressed by avoidant behaviors and fear of intimacy.

Adult and adolescent victims of abuse have higher attachment insecurity and display more anxiety and/or avoidance in close relationships [15, 34]. In particular, 70% of female victims of sexual abuse have insecure romantic attachments [35]. Lower satisfaction and couple adjustment are also reported in female victims compared to the women who were not abused [34, 36, 37]. In addition, high levels of insecurity in adult attachments and romantic attachments are reported to be associated with increased distress and psychopathology, in particular depression, anxiety, substance abuse and post-traumatic stress disorder [35, 38, 39].

The attachment patterns characterized by insecure or negative IWMs seem to increase the risk of a post-traumatic stress disorder and promote post-traumatic symptoms [38, 40]. In contrast, secure attachment is reported to be a protective factor in adult trauma survivors, moderating the relationship between a traumatic event and the development of PTSD.

Different studies confirm that insecure schema of self and the other generate interpretation biases in interpersonal stressful situations. This mechanism leads to dysfunctional responses characterized by hyper-activation or deactivation of emotion regulation [30, 41]. In particular, the attachment patterns characterized by high levels of anxiety are likely to display hyperactivation of emotional and behavioral response to stress, causing an exaggerated seeking of proximity. In contrast, people with avoidant attachment deactivate the interpersonal strategies of stress response and suppress the search for support [42]. As a consequence, attachment serves as a regulatory system for the stress response; a mental representation of the other's unresponsiveness during stressful situations can be the mechanism responsible for the increased vulnerability to post-traumatic symptoms [42].

In both PTSD and insecure attachments, there is a lack of security in social and interpersonal contexts. Indeed, people suffering from PTSD report feelings of distrust and a state of anxious apprehension which impedes them from having satisfying interpersonal relationships [43].

As a consequence, both the difficulties in emotion regulation and the lack of interpersonal security represent key variables in association with insecure romantic attachment and posttraumatic stress disorder in victims of childhood traumatic experiences.

Up until now, there are only a few studies investigating the relationship between romantic attachment and the PTSD symptoms in childhood trauma victims. Hence, further studies are needed in order to examine the role played by anxiety and avoidance on the development and the severity of the post-traumatic stress disorder in adult victims of interpersonal traumatic experiences.

Available studies in this field suggest mediating or moderating role for social support, emotion regulation and coping strategies [30]. Few studies showed that romantic attachment styles characterized by high levels of anxiety and avoidance influence the relationship between early traumatic experiences and the development of psychopathology, including post-traumatic stress disorder [44–46]. Another study [47] observed that insecure attachment mediated the relationship between childhood trauma and somatization in adulthood. Other studies [48, 49] reported that adult attachment moderates the association between childhood experiences of abuse and depressive symptoms as well as PTSD in adulthood.

Yet, in other studies [20, 50] it was established that an association between insecure attachment and greater number of PTSD in adult women victims of child sexual abuse exists. Moreover, the ability to maintain closeness in intimate relationships is found to mediate the association between child sexual trauma and global psychological functioning [38].

Finally, all these studies have investigated romantic attachment in clinical samples, while no research has studied the contribution of attachment style to the association between posttraumatic stress disorder and childhood traumatic experiences in a general population [51]. This shortcoming of the available literature represents the starting point for our study.
