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DOI: 10.1177/0886260511431440
2012 27: 2039 originally published online 10 February 2012 J Interpers Violence
Ban Hong (Phylice) Lim, Lauren A. Adams and Michelle M. Lilly
Stress in Interpersonal Trauma
Self-Worth as a Mediator Between Attachment and Posttraumatic

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1
Northern Illinois University, DeKalb, IL, USA
Corresponding Author:
Ban Hong (Phylice) Lim, Department of Psychology, Northern Illinois University, Psychology-
Computer Science Building, DeKalb, IL 60115, USA
Email: blim1@niu.edu
Self-Worth as a Mediator
Between Attachment and
Posttraumatic Stress in
Interpersonal Trauma
Ban Hong (Phylice) Lim, BA,
1

Lauren A. Adams, BA,
1
and
Michelle M. Lilly, PhD
1

Abstract
It is well documented that most trauma survivors recover from adversity
and only a number of them go on to develop posttraumatic stress disorder
(PTSD). In addition, survivors of interpersonal trauma (IPT) appear to be at
heightened risk for developing PTSD in comparison to survivors of nonin-
terpersonal trauma (NIPT). Despite a robust association between IPT expo-
sure and attachment disruptions, there is a dearth of research examining the
role of attachment-related processes implicated in predicting PTSD. Using a
sample of college undergraduates exposed to IPT and NIPT, this study ex-
plores the mediating effect of self-worth in the relationship between attach-
ment and PTSD. It is hypothesized that insecure attachment will be related
to posttraumatic symptomatology via a reduced sense of self-worth in IPT
survivors but not in NIPT survivors. Mediation analyses provide support for
this hypothesis, suggesting the importance of considering negative cogni-
tions about the self in therapeutic interventions, particularly those offered
to IPT survivors.
Keywords
interpersonal trauma, attachment, self-worth, posttraumatic stress disorder
Article
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2040 Journal of Interpersonal Violence 27(10)
An overwhelming majority of individuals (40% to 90%) have experienced at
least one traumatic event in their lifetime (Breslau, Davis, Andreski, & Peterson,
1991; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Norris, 1992; Resnick,
Kilpatrick, Dansky, Saunders, & Best, 1993). However, the lifetime prevalence
for posttraumatic stress disorder (PTSD) has been estimated to be as low as
7.8% but in some cases up to 20% (Breslau et al., 1991; Kessler et al., 1995;
Perkonigg, Kessler, Storz, & Wittchen, 2000). Furthermore, although noninter-
personal traumatic events (NIPT; 33.3%), such as natural disasters and motor
vehicle accidents, have been shown to be much more prevalent than interper-
sonal traumatic events (IPT), such as physical assault and sexual assault
(10.28% and 14.32% respectively; Resnick et al., 1993), IPT survivors appear
to be more at risk than NIPT survivors for developing posttrauma psychopa-
thology, including PTSD (Breslau et al., 1991). Specifically, Resnick et al.
found the lifetime prevalence of PTSD to be significantly higher in the after-
math of IPT (38.5%) than that of NIPT (9.4%). A meta-analysis revealed that
IPT, when broken down into different types, was more related to PTSD if it
was found in a noncombat scenario, such as domestic violence and sexual
assault, rather than situations associated with combative trauma exposure
(Ozer, Best, Lipsey, & Weiss, 2003). Collectively, these findings suggest
that although differences in trauma exposure account for some variability in
posttrauma functioning, there are likely individual differences that have an
impact on the development of posttrauma psychopathology.
One vulnerability factor that has often been explored in relation to trauma
exposure and PTSD is attachment. Bowlbys attachment theory underscores
the importance of healthy infantcaregiver bonds in an individuals develop-
ment in the areas of emotion regulation, cognition, behavior, and personality,
which in turn has a strong influence on ones long-term psychological well-
being (Fraley & Shaver, 2000). Attachment theorists (e.g., Ainsworth, Blehar,
Waters, & Wall, 1978; Bowlby, 1969/1982; Hazan & Shaver, 1987) have dis-
tinguished between secure and insecure styles of attachment. Secure individu-
als tend to display a positive regard for oneself and others and are comfortable
with both intimacy and autonomy; individuals with an insecure style marked
by anxious attachment tend to view themselves and others negatively, fear
abandonment, and seek heightened intimacy in close relationships; individu-
als with avoidant attachment tend to be uncomfortable with closeness and
dependency on others and prefer to be self-reliant (Ainsworth et al., 1978).
Attachment is likely to be most germane to posttrauma functioning in cases of
IPT because exposure to IPT tends to implicate attachment processes and
affect an individuals internal working models of perceptions about self and
others (Cicchetti & Toth, 1995; Cole & Putnam, 1992). For example, betrayal
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Lim et al. 2041
trauma, which is defined as trauma that is inflicted by caregivers or intimate
partners, entails a violation of trust by someone the survivor relies on for sur-
vival (Freyd, 1994) and is highly associated with insecure attachment (e.g.,
Cook et al., 2005).
Research has established a robust relationship between IPT (in both child-
hood and adulthood) and attachment disruptions (Alexander, 1993; Muller,
Sicoli, & Lemieux, 2000; Roche, Runtz, & Hunter, 1999; Sullivan-Hanson,
1990). Studies on childhood maltreatment showed that between 70% and
100% of survivors are insecure, which is in stark contrast to findings by other
studies, that there are only approximately 30% insecure individuals in nona-
bused samples (Carlson, Cicchetti, Barnett, & Braunwald, 1989; Cicchetti,
Cummings, Greenberg, & Marvin, 1990). Crittenden (1997) proposed that
growing up in an inconsistent or abusive environment may lead insecure
individuals to concentrate on pleasing others, thus leaving little time and
energy for self-enhancement. As a result, abuse survivors have frequently
been observed to suffer from an impaired sense of self and concurrent inabil-
ity to relate to others, which are related to attachment processes (Briere &
Elliott, 1994; Gold, Sinclair, & Bulge, 1999). Likewise, emerging research
on adulthood IPT revealed that battered women are not only at increased risks
for developing an impaired attachment compared to nonexposed women but
are also more likely to form insecure attachment to their infants during preg-
nancy (Huth-Bocks, Levendosky, Theran, & Bogat, 2004).
Despite an increasing focus on attachment in IPT survivors, the role of
attachment and related underlying processes implicated in predicting PTSD
has been underinvestigated. Research has established that attachment disrup-
tions contribute to the onset and maintenance of PTSD (MacDonald et al.,
2008; Stovall-McClough & Cloitre, 2006); thus, factors that explain the link
between attachment disruptions and PTSD deserve empirical exploration.
Self-worth may well account for this link given that it is highly associated
with both insecure attachment (e.g., OConnor & Elklit, 2008) and the onset
of PTSD (e.g., Bradley, Schwartz, & Kaslow, 2005). Broadly speaking,
self-worth refers to the satisfaction and acceptance of oneself in regards to
achievements and personal characteristics. Given the substantial impact of
early infantcaregiver interactions on the formation of mental representations
of self, attachment is critical in the development of self-worth (Collins &
Read, 1990; Feeney & Noller, 1990; Griffin & Bartholomew, 1994).
Specifically, secure individuals tend to exhibit higher self-worth that is inter-
nalized and not sought through others acceptance and approval; in contrast,
insecure individuals, particularly those with a fearful or preoccupied
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2042 Journal of Interpersonal Violence 27(10)
attachment style, tend to exhibit lower self-worth that is based on ongoing
external validation (Bartholomew, 1990).
There is ample evidence documenting the implication of self-worth in the
etiology of a broad range of psychopathology, including depression and vari-
ous types of anxiety disorders (e.g., Roberts, Gotlib, & Kassel, 1996; van
Oppen & Arntz, 1994). Furthermore, greater self-worth has also been found
to be vital for adaptive posttrauma functioning. For example, research has
consistently revealed that anxious, fearful, and preoccupied attachment
styles, all of which reflect a negative self-regard, were most related to
posttraumatic stress symptomatology (Browne & Winkelman, 2007;
Muller et al., 2000). Conversely, secure and dismissing attachments, which
reflect a positive view of self, were not connected to posttraumatic stress
symptoms (Mikulincer, Florian, & Weller, 1993). IPT survivors with low
self-worth may be predisposed to experience trauma-specific guilt and
shame, which have been found to hamper trauma-related coping and place
individuals at risk for the development of PTSD (Ehlers & Clark, 2000; Foa,
Steketee, & Rothbaum, 1989; Owens & Chard, 2001). Possessing low self-
worth may also hinder ones ability to cope effectively and regulate affective
responses, which is a key marker of PTSD (Bradley et al., 2005; Sandberg,
Suess, & Heaton, 2010). Being unable to process trauma-related information
adaptively would lead trauma survivors to falsely perceive internal and exter-
nal stimuli as ongoing threats (Ehlers & Clark, 2000). In addition, positive
regard for self, as typically displayed by secure individuals, may also allow
for more tolerance of adversity and a greater sense of efficacy to mobilize and
benefit from the use of internal and external supports posttrauma (Benight &
Bandura, 2004; OConnor & Elklit, 2008).
Taken together, insecure attachment may likely contribute to posttrau-
matic stress via lowered self-worth (Sandberg et al., 2010). The current
study extends previous research by investigating the role of self-worth in the
relationship between attachment and PTSD, particularly in regard to differ-
ent types of trauma exposure (i.e., IPT and NIPT). The main hypotheses are
as follows:
Hypothesis 1: Consistent with previous studies, greater attachment
anxiety and avoidance will be related to both lowered self-worth
and heightened PTSD symptoms. Self-worth will also be inversely
correlated with PTSD symptoms.
Hypothesis 2: There will be significant differences between individuals who
experienced IPT and those who did not, in terms of attachment, self-
worth, and PTSD symptom severity. More specifically, the IPT group
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Lim et al. 2043
will report greater overall attachment difficulties, lower self-worth, and
greater PTSD symptom severity, compared to the NIPT group.
Hypothesis 3: Self-worth will mediate the relationship between attach-
ment and PTSD for the IPT group. However, self-worth will not
mediate the relationship between attachment and PTSD for the
NIPT group.
As such, we propose a moderated mediation relationship may exist. It is
important to note that, depending on the theory being tested, a variable can be
introduced as a mediator or a moderator. In this case, self-worth is proposed as
a mediator because research has consistently shown a strong relationship
between insecure attachment and PTSD; therefore, a mediator can serve to
clarify the mechanisms behind this relationship (Frazier, Tix, & Barron, 2004).
Method
Participants
The present study is part of a larger data set collected at a Midwestern university,
comprising a sample of 616 undergraduate students. Participants included in the
present study endorsed at least one incident of trauma in their life and had com-
plete data for the Traumatic Life Events Questionnaire (TLEQ; Kubany, 2004).
In addition, participants were chosen if they could identify and report on a trau-
matic event that was the worst or stuck with them on the Posttraumatic
Stress Diagnostic Scale (PDS; Foa, 1995). All other participants were excluded.
The final sample of 228 undergraduate students had a mean age of 19.64 (SD =
3.09), and 66.7% of participants identified as female (n = 152). Most participants
were European American (68.9%, n = 157), 11.0% were African American (n =
25), 5.7% were Hispanic (n = 13), 3.5% were Asian (n = 8), and the remaining
11% identified as biracial or Other (n = 23); in some cases, the participants did
not identify their ethnicity (n = 2). The sample was comprised of mostly fresh-
men (58.3%, n = 133) and sophomores (23.7%, n = 54).
Procedure
Participants were recruited from the introductory psychology subject pool
and received class credit for their participation. Once participants signed up
for the study, they were emailed a unique login name and password as well
as a link to the questionnaires. Participants completed an informed consent
form and a battery of questionnaires online, which took about 60 min to
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2044 Journal of Interpersonal Violence 27(10)
complete. A debriefing form along with resources and referrals were pro-
vided at the end of the study.
At the conclusion of the study, two trauma exposure groups were created
based on participants responses to the Traumatic Life Events Questionnaire
(TLEQ; Kubany, 2004). An interpersonal trauma score was created that
summed participants exposure to the interpersonal trauma items on the TLEQ.
Participants who had a score of zero were placed in the noninterpersonal
trauma (NIPT) group, and participants with nonzero scores were placed in the
interpersonal trauma group (IPT). The groups did not differ in regards to age,
t(226) = 1.86, p = .07; gender,
2
= .46, p = .50; ethnicity,
2
= 7.86, p = .35;
or year in school,
2
= 7.70, p = .26.
Measures
Demographic Questionnaire. Participants were asked a number of questions
focusing on demographics, including age, gender, ethnicity, education level,
sexual orientation, current relationship status, and household/family and per-
sonal income.
Experiences in Close Relationships-Revised Inventory (ECR-R). The ECR-R
(Fraley, Waller, & Brennan, 2000) is a self-report questionnaire that measures
attachment difficulties, specifically attachment avoidance and attachment
anxiety. Each of the 36 items was scored on a 7-point scale ranging from 1
(not at all) to 7 (extremely). For instance, the item, I worry that others wont
care about me as much as I care about them, reflects attachment anxiety,
whereas the item, I try to avoid getting too close to others, reflects attach-
ment avoidance. Respondents rate each item on the extent to which they
agree with each statement about their feelings toward close relationships. The
subscales are created by averaging the responses to the 13 items on each
subscale. A higher total score on each subscale indicates higher attachment
insecurity. Missing scores on several items of the subscales were present for
three participants and were in no particular pattern. These values were
replaced by the series mean. Research using the ECR-R has shown strong
psychometric properties, including strong internal consistency ( = .93 for
avoidance, and = .92 for anxiety), acceptable testretest reliability, and
strong validity across various populations (Fairchild & Finney, 2006; Sibley,
Fischer, & Liu, 2005). Internal consistency in the present study was = .93
for anxiety scale, and = .94 for the avoidance scale.
The World Assumption Scale (WAS). The WAS (Janoff-Bulman, 1989)
assesses cognitive schemas about self and others. There are a total of 32 items
that can be divided into subscales that assess benevolence of the world,
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Lim et al. 2045
benevolence of people, justice, controllability, randomness, self-worth, self-
controllability, and luck. For the purposes of the present study, only the Self-
Worth subscale was used by reverse scoring specified items and summing the
responses to represent participants assumptions regarding self-worth. Items
on the Self-Worth subscale include, I am very satisfied with the kind of person
I am, and I often think I am no good at all (reverse coded). Responses are
based on how much the respondent agrees with each statement on a scale of
1 (strongly disagree) to 6 (strongly agree), with a higher score indicating
more positive assumptions. Two participants had missing values on several
items of the Self-Worth subscale, which were replaced by the series mean.
Discriminant analyses conducted in the development of the measure revealed
that three of the assumptions, including self-worth (Wilkss = .98), were
able to discriminate between survivors and nonsurvivors of trauma (Janoff-
Bulman, 1992). Internal consistency for the Self-Worth subscale was accept-
able ( = .73) in the present study.
Posttraumatic Stress Diagnostic Scale. The PDS (Foa, 1995) measures
the severity of posttraumatic stress symptoms in the previous month.
Respondents are asked to identify a traumatic event that was the worst
or stuck with them and answer a series of questions pertaining to that
event that measure PTSD diagnostic criteria. It also assesses the extent
to which symptoms have interfered with various areas of the respon-
dents life. For the present study, a total symptom severity score, rang-
ing from 0 to 51, was generated by summing the items on the symptom
clusters (i.e., hyperarousal, reexperiencing, and avoidance). Symptom
severity was rated as follows: 0 = no rating, 1 to 10 = mild, 11 to 20 =
moderate, 21 to 35 = moderate to severe, and 36 and above = severe. The
scale has demonstrated good reliability for the symptom severity scale
( = .92) and good testretest reliability (r = .83; Foa, 1995). For the
present study, internal consistency for the PTSD symptom severity scale
was high ( = .92).
Traumatic Life Events Questionnaire. The TLEQ (Kubany, 2004) assesses
exposure to potentially traumatic events and how many times each of these
events has happened. The types of trauma assessed include natural disaster,
sexual assault, physical abuse, war or combat exposure, and motor vehicle
accidents. Each of the 23 items was rated based on the following responses:
never, once, twice, 3 times, 4 times, and more than 5 times. The TLEQ yields a
total trauma history score by tallying the items, with higher scores indicating
greater traumatic event exposure. Scores for both IPT and NIPT were gener-
ated. The IPT score was created by summing the items associated with sex-
ual assault, nonsexual assault (e.g., physical assault, being robbed), or
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2046 Journal of Interpersonal Violence 27(10)
stalking; the NIPT score summed responses to items associated with acci-
dents, natural disasters, war or combat exposure, death or illness of a loved
one, miscarriage or abortion. Given that civilian or everyday traumas are of
interest in this study and that the intent and dynamics of military-related
trauma are very different from civilian trauma and may be differentially
related to attachment and self-worth, we decided to categorize military-
related trauma as an NIPT. Likewise, Ozer et al. (2003) confirmed that
noncombat IPT items, such as domestic violence and sexual assault, were
more related to PTSD compared to that of combative trauma exposure. The
TLEQ has demonstrated high testretest reliability as well as high conver-
gent validity with other measures of posttraumatic stress disorder such as
structured interviews (Kubany et al., 2000).
Results
Participants in the present study reported exposure to an average of 7.55 (SD =
8.09) total traumatic events, which indicates the total number of times each
trauma occurred; thus, this number could include multiple exposures to the
same type of event. In total, participants endorsed exposure to an average of
5.05 (SD = 2.90) of the 23 different types of events assessed on the TLEQ,
which ranged between exposure to only one type of trauma and exposure to
all of the 23 different types of trauma. Table 1 shows the percentage of par-
ticipants who reported at least one exposure to each type of traumatic event
assessed on the TLEQ. Chi-square analyses indicated no gender differences
in exposure to the traumatic events, with the exception of being robbed,
military combat, and exposure to anothers death. Men were overrepre-
sented in the robbed,
2
(1) = 8.14, p = .004, and military combat exposure
group,
2
(1) = 5.01, p = .03, whereas women were overrepresented in the
exposure to anothers death group,
2
(1) = 6.13, p = .01. In regards to IPT,
participants reported exposure to an average of 3.73 total events (SD =
6.24) and an average of 2.69 (SD = 2.11) different types of interpersonal
traumatic events. The mean severity score in regards to PTSD symptoms was
9.43 (SD = 10.45) and ranged between 0 and 48. Using a cutoff score of 28
to suggest diagnostic levels of PTSD symptoms (Coffey, Dansky, Falsetti,
Saladin, & Brady, 1998), 8.8% of the sample (n = 20) achieved a symptom
severity level that may qualify for a PTSD diagnosis. This number is slightly
higher than levels of PTSD reported in the general populations (7.8%;
Kessler et al., 1995). Of the 20 individuals who qualify for a PTSD diagno-
sis, 16 were female. However, a chi-square statistic revealed that this did not
constitute statistically significant overrepresentation by women,
2
(1) = 1.75,
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Lim et al. 2047
p = .19. In regard to attachment, the mean attachment scores for Anxiety and
Avoidance subscales were as follows: attachment avoidance (M = 2.94, SD =
1.18), attachment anxiety (M = 3.39, SD = 1.27). Participant scores on the
WAS Self-Worth subscale had a mean of 17.95 (SD = 4.12). The attachment
and self-worth scores were comparable to those reported for other college
undergraduates who had been previously exposed to traumatic events (Lilly,
2011; Sandberg et al., 2010).
A correlation matrix of the variables of interest is presented in Table 2.
Consistent with the first hypothesis, attachment difficulties were significantly
inversely related to self-worth and positively related to PTSD symptom
severity. As hypothesized, self-worth was significantly inversely related to
PTSD symptom severity. Hypotheses related to interpersonal trauma expo-
sure were partially confirmed. Although interpersonal trauma exposure was
significantly positively related to both PTSD symptom severity and attachment
avoidance, it was not significantly related to attachment anxiety or self-worth.
In addition, although noninterpersonal trauma exposure was significantly pos-
itively related to PTSD symptom severity, it was not related to attachment
difficulties or self-worth. This provides preliminary support for our main
Table 1. Prevalence of Traumatic Events With Chi-Square to Gender Differences
Interpersonal Trauma %
2
Noninterpersonal Trauma %
2
Adolescent CSA 12.3 3.44 Abortion 6.1 0.04
CSA by peer 9.2 .94 Accident, fire, explosion 16.2 1.03
CSA by older person 12.3 2.04 Life-threatening illness 8.3 0.03
CPA 15.4 2.70 Others death 66.2 6.13*
Experienced IPV 16.7 1.01 Others illnesses/trauma 53.5 0.22
Harassment 5.7 0.06 Other traumatic event 18.0 1.49
Robbed 7.5 8.14** Military combat 2.2 5.01*
Physical assault by
stranger
8.3 1.84 Miscarriage 4.4 0.84
Sexual assault 9.2 3.78 Motor vehicle accident 18.0 3.81
Stalked 18.0 0.95 Natural disaster 43.0 0.01
Threatened 26.8 2.20 Witnessed stranger
physical assault
9.2 0.94
Witnessed family
violence
26.3 0.10
Note: N = 228.
*p < .05. **p < .01
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2048 Journal of Interpersonal Violence 27(10)
hypothesis that self-worth will mediate the relationship between attachment
and PTSD for the IPT group; however, self-worth will not mediate the rela-
tionship between attachment and PTSD for the NIPT group.
The second set of hypotheses proposed that there would be significant dif-
ferences between the IPT and NIPT group, with the IPT group reporting
greater overall attachment difficulties, lower self-worth, and greater PTSD
symptom severity. Independent samples t test were conducted and are sum-
marized in Table 3. As hypothesized, significant differences were observed
between the IPT and the NIPT groups on attachment difficulties, self-worth,
and PTSD symptom severity. Individuals in the IPT group reported overall
greater attachment avoidance and anxiety, as well as greater PTSD symptom
severity, whereas individuals in the NIPT group reported significantly greater
self-worth, with small to moderate size effects.
Next, we aimed to examine whether self-worth mediated the relationship
between attachment difficulties and PTSD symptom severity. We proposed
that self-worth would mediate the relationship between attachment difficul-
ties and PTSD symptom severity for those in the IPT group but would not
mediate the relationship for those in the NIPT group. As such, we proposed
that a moderated mediation relationship may exist.
According to Frazier et al., four statistical conditions need to be fulfilled
to establish a mediation effect: (a) The predictor variable is significantly
related to the criterion variable, (b) the predictor variable is related to the
mediator variable, (c) the mediator variable is related to the criterion variable
when controlling for the effects of the predictor variable on the criterion vari-
able, and (d) inclusion of the mediator variable in the model must significantly
reduce the magnitude of the relationship between the predictor variable and the
criterion variable. A complete mediation is observed when this relationship is
Table 2. Correlation Matrix Between Primary Variables of Interest
1 2 3 4 5 6
1. Self-worth
2. Attachment anxiety .56***
3. Attachment avoidance .40*** .61***
4. Posttraumatic stress symptom severity .30*** .29*** .20**
5. Interpersonal trauma exposure .11 .06 .18** .18**
6. Noninterpersonal trauma exposure .00 .00 .06 .13* .38**
Note: N = 228.
*p < .05. **p < .01. ***p < .001.
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Lim et al. 2049
reduced to zero; otherwise, the relationship between the predictor variable
and criterion variable is partially mediated, which is more prevalent (for fur-
ther discussion on mediation and the distinction between mediation and mod-
eration, see Frazier et al., 2004).
Prior to running the regression analyses, the interrelationships between
demographic variables (i.e., age, gender, income, race, and relationship sta-
tus) and outcome variables in each step of the regression analyses were
examined. Given that none of the demographic variables was significantly
related to self-worth or posttraumatic stress symptomatology, no covariate
variables were included in subsequent regression analyses. Using the proce-
dures outlined in Frazier et al. (2004), we conducted a series of regression
analyses, the results of which are shown in Table 5 (attachment avoidance as
predictor) and Table 5 (attachment anxiety as predictor). First, we aimed to
determine whether self-worth mediated the relationship between attachment
avoidance and PTSD symptom severity for individuals in the IPT group but not
the NIPT group. In the first step, PTSD symptom severity was significantly
related to attachment avoidance only in the IPT group ( = 1.63, p = .02) and
not in the NIPT group ( = 1.73, p = .10). Given the lack of a significant
relationship between the predictor variable and criterion variable for the
NIPT group, it was determined that self-worth could not mediate the relation-
ship between attachment avoidance and PTSD symptom severity. As such,
the remaining analyses were only completed for the IPT group. Proceeding
with the mediation, self-worth and attachment avoidance were significantly
positively related ( = 1.34, p < .001) to the IPT group. In the final step,
PTSD symptom severity was regressed on both self-worth and attachment
avoidance. Consistent with the presence of a partial mediation relationship, it
Table 3. Comparisons Between Survivors of Interpersonal Trauma (IPT) and
Survivors of Noninterpersonal Trauma (NIPT) on Primary Variables of Interest
IPT Group NIPT Group
M (SD) M (SD) t p Cohens d
Attachment anxiety 3.53 (1.32) 3.16 (1.15) 2.10 .04* .29
Attachment avoidance 3.05 (1.25) 2.73 (1.02) 1.99 .05* .28
Self-worth 17.50 (4.33) 18.73 (3.62) 2.30 .02* .31
Posttraumatic stress
severity
10.63 (10.69) 7.34 (9.73) 2.31 .02* .32
*p < .05. **p < .01.
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2050 Journal of Interpersonal Violence 27(10)
was found that the mediator of self-worth was significantly related to PTSD
symptom severity ( = .65, p = .003) and that attachment avoidance no lon-
ger predicted PTSD symptom severity ( = .76, p = .31) (see fig. 1). A Sobel
test was conducted to examine the significance of the partial mediation,
which revealed a z score of 2.63 (p = .009).
The same procedures were adopted to determine whether self-worth medi-
ated the relationship between attachment anxiety and PTSD symptom sever-
ity for the IPT group but not the NIPT group. Unlike for attachment avoidance,
attachment anxiety was significantly related to PTSD symptom severity for
both the IPT ( = 2.16, p = .001) and the NIPT ( = 2.40, p = .009) groups.
Similar results were observed in the second step, as attachment anxiety was
significantly related to self-worth for both the IPT ( = 1.95, p <.001) and
NIPT ( = 1.40, p < .001) groups. However, the regression models diverged
in the third step. For the IPT group, a partial mediation model was suggested,
as attachment anxiety no longer predicted PTSD symptom severity ( = 1.13,
p = .16) whereas self-worth was significantly related to PTSD symptom
Table 4. Linear Regression Analyses Testing Self-Worth as a Mediator of the
Relationship Between Attachment Avoidance and Posttraumatic Stress
Interpersonal Trauma
(IPT) or Noninterpersonal
Trauma (NIPT)
Adj. R
2
B (SE B) Sig.
IPT NIPT IPT NIPT IPT NIPT
Regression 1
Outcome: Posttraumatic
stress
.03 .02
Predictor: Attachment
avoidance
1.63 (.71) 1.73 (1.05) .02* .101
Regression 2
Outcome: Self-worth .14
Predictor: Attachment
avoidance
1.34 (.27) .000***
Regression 3
Outcome: Posttraumatic
stress
.08
Mediator: Self-worth .65 (.21) .003**
Predictor: Attachment
avoidance
.76 (.74) .31
Note: N = 228.
*p < .05. **p < .01. ***p < .001.
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Lim et al. 2051
severity ( = .53, p = .03). A Sobel test of significance revealed a z score of
2.14 (p = .03), suggesting that self-worth significantly, partially mediated the
relationship between attachment anxiety and PTSD symptom severity for the
IPT group (see fig. 2). Consistent with the study hypotheses, a mediation
Table 5. Linear Regression Analyses Testing Self-Worth as a Mediator of the
Relationship Between Attachment Anxiety and Posttraumatic Stress
Interpersonal
Trauma (IPT) or
Noninterpersonal
Trauma (NIPT)
Adj. R
2
B (SE B) Sig.
IPT NIPT IPT NIPT IPT NIPT
Regression 1
Outcome:
Posttraumatic stress
.06 .07
Predictor: Attachment
anxiety
2.16 (.65) 2.40 (0.899) .001** .009***
Regression 2
Outcome: Self-worth .35 .19
Predictor: Attachment
anxiety
1.95 (.22) 1.40 (0.31) .000*** .000***
Regression 3
Outcome:
Posttraumatic stress
.09 .08
Mediator: Self-worth 0.53 (.24) .42 (0.32) .03* .19
Predictor: Attachment
anxiety
1.13 (.80) 1.81 (1.00) .16 .07
Note: N = 228.
*p < .05. **p < .01. ***p < .001.
Figure 1. Self-worth as a mediator of the relationship between attachment
avoidance and posttraumatic stress for individuals exposed to interpersonal trauma
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2052 Journal of Interpersonal Violence 27(10)
model was not observed for the NIPT group, as neither attachment anxiety (
= 1.81, p = .07) nor self-worth ( = .42, p = .19) were significantly related
to PTSD symptom severity in the final regression.
Discussion
Early experiences with caregivers have repeatedly been shown to bear pro-
found influences on mental health well-being. Indeed, many studies have
demonstrated the implication of attachment in a myriad of psychological
disorders, including depression, anxiety disorder, and PTSD (e.g., Bifulco,
Moran, Ball, & Lillie, 2002; OConnor & Eklit, 2008; van Buren & Cooley,
2002). Nevertheless, the mechanisms through which attachment difficulties
lead to heightened risk of developing PTSD have remained relatively
unknown. More effort is needed to elucidate the underlying mechanisms of the
attachmentPTSD relationship to improve related therapeutic interventions,
as suggested by Sandberg et al. (2010). Correspondingly, the present study
sought to investigate the role of self-worth in the relationship between
attachment and PTSD, particularly in regard to different types of trauma
exposure (i.e., IPT and NIPT).
Consistent with previous research, findings in the current study revealed
that insecure attachment was inversely related to self-worth (e.g., OConnor
& Elklit, 2008) and positively related to PTSD symptom severity (e.g.,
Bradley et al., 2005). Self-worth was also significantly inversely related to
PTSD symptom severity. These findings provide preliminary support for the
proposed mediationthat self-worth will mediate the relationship between
attachment and PTSD. However, although IPT exposure was significantly
positively related to both PTSD symptom severity and attachment avoidance,
it was not significantly related to attachment anxiety or self-worth. This
Figure 2. Self-worth as a mediator of the relationship between attachment anxiety
and posttraumatic stress for individuals exposed to interpersonal trauma
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Lim et al. 2053
finding is contrary to previous research that had shown attachment anxiety to
be more associated with IPT and that attachment avoidance was more strongly
related to NIPT. In particular, Elwood and Williams (2007) observed that IPT
survivors tend to display greater attachment anxietybut not more avoid-
ancecompared to individuals who did not endorse IPT. Renaud (2008) also
suggested that attachment avoidance, relative to attachment anxiety, may be
more related to PTSD following NIPT such as combat exposure, likely
because attachment avoidance is more pertinent to perceptions of external
threat rather than perceptions of self (e.g., self-worth). One explanation for
our finding is related to the composition of the IPT group in the current study;
individuals in the IPT group may also have been exposed to NIPT, as the
analyses indicate a positive, significant correlation between IPT and NIPT
(see Table 2). Alternatively, attachment avoidance, which involves distancing
oneself from aversive emotions, may also serve as a self-protective adapta-
tion in the face of trauma (Sandberg et al., 2010). Nevertheless, these contra-
dictory findings merit further investigation to clarify whether attachment
anxiety and attachment avoidance indeed lead to differential outcomes in
response to varying types of trauma exposure.
Consistent with both betrayal trauma theory (Freyd, 2009) and world
assumptive theory (Janoff-Bulman, 1992), the IPT and NIPT groups were
found to differ significantly on their attachment, self-worth, and PTSD symp-
tom severity. In contrast to the NIPT group individuals, who reported greater
self-worth, individuals in the IPT group reported greater attachment avoid-
ance, attachment anxiety, and PTSD symptom severity, and thus, appeared to
be less adaptive . These findings are consistent with past research suggesting
that IPT exposure typically leads to heightened psychological distress (Freyd,
2009; Janoff-Bulman, 1992). More specifically, because IPT is frequently
inflicted by someone the survivor trusts or relies on for survival (e.g., care-
giver or intimate partners), individuals exposed to IPT are likely to be less
adaptive in the face of trauma (Freyd, 2009). Likewise, Janoff-Bulman pro-
posed that IPT may be more detrimental to our core conceptual system and
may subsequently lead to poor posttrauma functioning. Indeed, being harmed
by another person can result in humiliation, questions of personal autonomy
and strength of will, as well as shattering of self-worth. Furthermore, because
NIPT such as exposure to natural disasters is usually considered an unfortu-
nate event and not a result of ones own doing, NIPT survivors typically
receive greater support and validation from others (Janoff-Bulman, 1992).
Findings in the current study provide support for the hypothesized moder-
ated mediation. As hypothesized, self-worth mediated the relationship
between attachment and PTSD in survivors exposed to IPT, but the mediating
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2054 Journal of Interpersonal Violence 27(10)
effect was not observed in survivors exposed to NIPT. Consistent with previ-
ous research, insecure attachment may lead IPT survivors to believe that they
are accountable for the occurrence of the traumatic event. These individuals
are also likely to engage in characterological self-blame and attribute the
occurrence of trauma to some enduring, negative self-trait, which in turn
results in diminished self-worth and increased risk for developing PTSD
(Foa, Feske, Murdock, Kozak, & McCarthy, 1991; Silver, Boon, & Stones,
1983). Insecure individuals may also be inclined to rely heavily on affect,
rather than cognition, in directing their behaviors and have a highly sensitive
emotional system (Crittenden, 1997). Their inability to process trauma-
related information adaptively may in turn cause them to falsely perceive
internal and external stimuli as ongoing threats, which is a prominent symp-
tom of PTSD (Ehlers & Clark, 2000).
Self-worth has also been associated with a greater sense of efficacy to
mobilize resources for effective trauma-related coping (Benight & Bandura,
2004; Bradley et al., 2005). For that reason, secure individuals may be more
likely than insecure individuals to seek social support following trauma,
which has been shown to alleviate adverse effects on self-worth and thwart
the development of PTSD (Brewin, Andrews, & Valentine, 2000; Cuneo &
Schiaffino, 2002; Ozer et al., 2003). In addition, self-worth has also been
found to be implicated in dissociation (Lilly, 2011), which often co-occurs
with PTSD following trauma. More specifically, Lilly proposed that dissocia-
tion may be used as a tactic in traumatic situations to defend against strong
threats to ones sense of self-worth. As observed in trauma survivors with
PTSD, dissociative symptoms may also likely arise from feelings of being
damaged or trauma-related guilt.
Several limitations in the present study need to be addressed in future
studies. First, the use of a cross-sectional design in the present study makes it
difficult to determine the direction of causality. Although the current study
modeled insecure attachment and diminished self-worth as precursors of
posttraumatic stress symptoms, it is possible that insecure attachment and
diminished self-worth are instead outcomes of posttraumatic stress symp-
toms. Further studies using a longitudinal design that assess attachment and
self-worth prior to and following a traumatic event are warranted to examine
this relationship further. Second, it is important to distinguish exposure to
childhood from later IPT in future studies, considering that attachment style
and self-worth are developmental variables, and thus, may be more related to
childhood trauma. Third, the use of a convenient college sample poses chal-
lenges in generalizing the current findings to a wider range of trauma survi-
vors. A sample of college students who are exposed to trauma may be
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Lim et al. 2055
unrepresentative of trauma survivors at large because being able to attend
college may be indicative of a relatively better psychological adjustment
or having experienced less trauma, compared to other trauma survivors in
clinical setting, in the community, or who dropped out of college following
trauma. Fourth, self-selection bias could also influence the composition of
the sample in this study. Participants were given a number of options for
research studies in which to participate, and those who chose to participate in
this study may represent a skewed sample of trauma survivors. In particular,
individuals who have been exposed to severe or chronic traumatic events
may likely avoid participating in trauma-related studies. Fifth, to generate a
more holistic and accurate understanding of posttrauma functioning, it may
be necessary to take into account all possible adverse mental health outcomes
associated with trauma exposure. Sixth, it is difficult to gauge clinical signifi-
cance of the outcome variables because the measures we used do not provide
such information. For example, although there is some evidence that a cutoff
score of 28 on the PDS (Coffey et al., 1998) may reflect the potential pres-
ence of a PTSD diagnosis, there are no norms for scores on the PDS that
suggest clinically meaningful differences. Lastly, the use of self-reports may
also introduce recall bias and socially desirable responding.
Despite these limitations, the study represents an important contribution to
the field of trauma recovery and mental health. Research has shown that inse-
cure attachment is a risk factor in developing emotional difficulties following
trauma. It is important to clarify this link between attachment and PTSD
because attachment denotes a more enduring, distal factor that may be resis-
tant to change. More important, a better understanding of the underlying eti-
ology contributing to this association, which in this case implicates a negative
working model of the self, can help design and tailor prevention and interven-
tion strategies offered to trauma survivors.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publica-
tion of this article.
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Bios
Ban Hong (Phylice) Lim is currently a second year doctoral student in the clinical
psychology program at Northern Illinois University. She earned her B.A. in
Psychology in 2010 from University of Kansas. Broadly speaking, her interests
include a) exploring factors impacting mental health sequeale following trauma, b)
examining the different types of traumatic events on mental health sequeale, c) under-
standing factors impacting the occurrences and reoccurrences of intimate partner
violence, and d) exploring how the abovementioned contextual factors facilitate or
hinder survivors recovery from the violence.
Lauren A. Adams completed her BA in psychology at Northern Illinois University
in 2011. She has completed research in the area of intimate partner violence, revic-
timization, and mental health outcomes. She completed an internship as an advocate
at a local domestic violence shelter in DeKalb, Illinois. She plans to attend graduate
school and pursue a career as a counselor.
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Lim et al. 2061
Michelle M. Lilly began as an assistant professor at Northern Illinois University in
the fall of 2009. She earned her doctorate in clinical psychology and womens studies
at the University of Michigan in 2008 and completed a postdoctoral fellowship at the
Psychological Clinic in Ann Arbor, Michigan. Her research has focused predomi-
nantly in the following areas: intimate partner violence, PTSD, and the mediating role
of ethnicity, coping, world assumptions, and religiosity. She has also done research in
the area of police work and the role that gender plays in predicting mental health
outcomes.
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