Systematic review and framework synthesis of attachment injuries among romantic couples

Abstract

Attachment injuries in romantic relationships are increasingly recognized as significant relational traumas, yet existing literature lacks a comprehensive framework for understanding their traumatic sequelae. While traditionally viewed through an attachment theory lens alone, emerging evidence suggests these injuries may trigger symptom patterns consistent with post-traumatic stress disorder (PTSD). Following PRISMA guidelines, we systematically searched PsycINFO, MEDLINE/PubMed, JSTOR, and Scopus databases for English-language qualitative studies published between January 2000 and January 2025. Studies examining subjective experiences of attachment injuries, relational betrayals, or breaches of trust in romantic relationships were included. Quality was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Framework synthesis methodology was employed to map findings against the complex PTSD framework. Twelve qualitative studies (N = 207 participants) met the inclusion criteria. Attachment injuries were mapped to four distinct symptom clusters mirroring complex PTSD: (1) severe affect dysregulation characterized by intense emotional responses and grief; (2) persistent negative self-beliefs, including diminished self-worth and pervasive self-doubt; (3) persistent difficulties sustaining relationships extending beyond the original injury; and (4) classic PTSD symptoms of intrusion, avoidance, and hyperarousal. The most common triggers were infidelity (5 studies), pregnancy/child-rearing conflicts (4 studies), and pornography/sexual addiction disclosure (3 studies). However, significant gender bias (73.8% female participants) and cultural homogeneity (83% North American samples) limit generalizability. This review adds to the evidence that attachment injuries constitute a distinct form of relational trauma and offers an integrated attachment-trauma conceptualization. These findings can open new possibilities in how clinicians assess and treat attachment injuries, emphasizing the need for phase-based interventions that address trauma symptomatology alongside relational repair.

Keywords

attachment injuries complex PTSD qualitative research systematic review framework synthesis

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