Attachment Theory and Personality Disorders

You may already have a sense of how your early relationship patterns persist into adulthood, particularly if you’ve already been part of the Attachment Project for some time. These patterns can also affect our personality development, as our early attachment relationships provide an internal working model – like a mental roadmap – of ourselves, the world, and how we fit into it.

Personality disorders are complex and influenced by lots of things, but our early attachment experiences do play a role. One 2007 study on 239 pairs of twins, which helps to separate environmental from genetic effects, found that attachment anxiety was associated with personality pathologies related to emotional dysregulation, while attachment avoidance was associated with personality pathologies related to inhibition – but more on this later¹.

In this article, we’ll broadly explain personality disorders, psychological research on how they link to attachment theory, and how we can use attachment theory to support people with personality disorders.

Key Takeaways:

• Attachment theory can help us to understand how personality disorders develop.
• Disorganized attachments show a strong correlation with borderline personality disorder.
• Some personality disorders share common traits with insecure attachment styles, though they are more extreme.
• Attachment patterns can contribute to personality disorders, but aren’t considered to cause them.
• Attachment-based therapy offers promising approaches for personality disorder treatment.

What Are Personality Disorders?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a tool used by mental health professionals to diagnose psychological disorders. Its current version (at the time of writing) is the 5th edition text revision, or the DSM-5-TR, published in 2022².

The DSM-5-TR describes personality disorders as:

“An enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”²

In other words, 4 characteristics form a personality disorder:

1. You feel and act in ways that are very unusual within your culture.
2. This pattern is consistent and doesn’t change over time.
3. It usually first started in adolescence or early adulthood (but can start earlier).
4. These experiences are distressing or stop you from doing what you need to do in daily life.

To diagnose a personality disorder, this pattern can affect 2 or more of:

• Cognition (the way you perceive others, events, and yourself)
• Emotions (range, intensity, stability, and appropriateness of emotional response)
• Social functioning
• Impulse control

The diagnostic criteria also specifies that this pattern is not better explained by the effects of another mental disorder, medical condition, or substance.

According to the DSM-5-TR, around 10.5% of the population have a personality disorder. There are 10 personality disorder diagnoses in the DSM-5-TR, grouped into 3 different clusters.

Cluster A: Odd or Eccentric

3.6% of the population are estimated to have a Cluster A personality disorder².

Paranoid Personality Disorder

Paranoid Personality Disorder is characterized by a distrust or suspicion of others and interpretation of others’ behavior as intentionally harmful. People with this disorder might refuse to answer personal questions, hold onto grudges, and read negatively into benign comments or even compliments.

Schizoid Personality Disorder

Schizoid Personality Disorder describes a pattern of detachment from social relationships and decreased range of emotions around others. People with Schizoid Personality Disorder might be indifferent to intimacy, prefer to spend time alone, and appear unaffected by compliments or criticism.

Schizotypal Personality Disorder

Schizotypal Personality Disorder is marked by discomfort with close relationships and anxiety in social situations, often associated with suspicion around others; this causes the anxiety to get worse rather than improve over the duration of a social occasion.

Cluster B: Dramatic, Emotional, or Erratic

4.5% of the population are estimated to have a Cluster B Personality Disorder².

Antisocial Personality Disorder

Antisocial Personality Disorder describes a disregard for the wellbeing, safety, and rights of others. People with Antisocial Personality Disorder might break laws, make impulsive decisions, and be quick to anger. This diagnosis cannot be made before the age of 18.

Borderline Personality Disorder

Borderline Personality Disorder, or BPD, is characterized by impulsivity, high emotions, and an intense fear of abandonment. People with BPD often struggle with unpredictable relationships and can quickly switch between idealizing and devaluing others.

Histrionic Personality Disorder

Histrionic Personality Disorder shows up as high emotions and “attention seeking”. People with Histrionic Personality Disorder tend to be dramatic and may behave in inappropriately sexual ways towards others; although it may seem like they know how to command a room, they can be very easily influenced and overly trusting of others.

Narcissistic Personality Disorder

Narcissistic Personality Disorder describes a combined need for admiration from others and lack of empathy. People with Narcissistic Personality Disorder can have an unrealistic sense of importance, both inflating their own success and devaluing others, and may believe they’re owed greater recognition. They typically have cognitive empathy, meaning they can understand someone’s perspective, but not emotional empathy, meaning they can’t feel what someone else is feeling. They may not show it, but their self-esteem is very fragile and they can be highly sensitive to criticism.

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Cluster C: Anxious or Fearful

2.8% of the population are estimated to have a Cluster C Personality Disorder².

Avoidant Personality Disorder

People with Avoidant Personality Disorder are highly sensitive to being negatively perceived by others. They typically avoid social and work situations that require meeting new people or taking risks, find it difficult to try new things in front of people, and are very inhibited around others because of their fear of rejection.

Dependent Personality Disorder

Dependent Personality Disorder is characterized by a sense of needing to be taken care of, leading to intense fears of separation and “clinginess“. People with Dependent Personality Disorder can find it difficult to make decisions, disagree with others, and start projects on their own; this is rooted in a lack of confidence rather than a lack of motivation. Other people’s approval and reassurance are vital to them.

Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive Personality Disorder involves a constant worry over keeping in control through perfectionism and orderliness, and an incapability of being flexible and open. People with Obsessive-Compulsive Personality Disorder can be very strict on rules, have (sometimes impossibly) high standards, and spend lots of time checking and rechecking their work. This can have the opposite of the desired effect, causing projects and tasks to take a long time and problems working with others.

Personality Disorders vs. Personality Traits

Personality traits exist on a spectrum, and being especially high or low on any particular trait doesn’t constitute a personality disorder – even if you recognize some of the traits described above.

According to the DSM-5-TR:

“Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute personality disorders.”

In other words, only personality traits that are causing problems in someone’s life to the extent that they cannot function well can be considered part of a personality disorder.

Someone who is highly confident and unempathic when it helps them in the workplace doesn’t necessarily have Narcissistic Personality Disorder, or someone who can be a stickler for rules but lets things slide for the sake of efficiency or team cohesion doesn’t have Obsessive-Compulsive Personality Disorder.

Personality disorders have a serious impact on someone’s life and should not be taken lightly – if you suspect you have a personality disorder, a qualified mental health practitioner can help you to understand more about your experiences.

The Link Between Attachment Theory and Personality Disorders

Your personality is shaped by lots of things, including, to some extent, your genetics³. However, scientists estimate that more than half of your personality is influenced by your environment, and this includes your early attachment relationships.

If your caregiver responds to your needs reliably, you develop an internal working model of yourself as worthy of attention and others as trustworthy. However, if your caregiver is occasionally or consistently absent, you develop an internal working model of yourself as undeserving of love.

Difficulties relating to others are characteristic of personality disorders in all 3 clusters, and some studies have even found that early attachments can effectively alter your genes related to behavioral difficulties⁴. Bowlby himself believed that insecure attachment styles were at the core of personality disorders – so how does an insecure attachment style become a risk factor for personality disorders?

Insecure Attachment as a Risk Factor

Insecure attachment styles are a form of survival – in an environment where you need to be self-reliant, an avoidant attachment pattern helps you to succeed, while attachment anxiety can be an effective survival strategy in an unpredictable environment⁵.

Some psychologists suggest that the caregiver’s attachment behavior signals the social environment to the infant, which could explain why our attachment styles affect us so significantly – we’re not just responding to our caregiver’s behavior, but to the setting we were born into, which we understand through our caregiver’s behavior⁵.

This also shows how difficult it can be to untangle whether insecure attachments cause personality disorders, or whether both are caused by another third factor. For example, the 2007 twin study suggested that anxious attachment and emotional dysregulation share the same genetic influences¹.

The reality is that lots of factors, biological and environmental, likely play into both attachment and personality development, which in turn interact with each other and our environment, and even our genetics⁴. Because the relationships are quite complex, attachment insecurity doesn’t always lead to personality disorders – but it’s often closely linked.

By the same logic, personality disorders don’t always have to lead to attachment insecurity, but they can easily co-occur because of their shared traits and the difficulties that personality disorders cause in relationships. The same factors that support attachment security – secure, predictable, and safe environments – can also help to protect against the development of personality disorders.

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The Role of Childhood Trauma and Disrupted Bonding

Traumatic experiences can affect our attachments and the way we feel about ourselves and the world at any age, including in childhood. Studies have found correlations between childhood trauma and personality development, including and in some cases especially emotional neglect⁵, ⁶.

In one recent study, childhood maltreatment was found to double the risk of personality disorders⁷. The kind of maltreatment experienced can influence the kind of traits that develop; physical abuse has been associated with higher risk of Antisocial PD symptoms, for instance, while sexual abuse has been associated with higher risk of BPD symptoms⁸.

However, it’s also noted that children are resilient, so traumatic childhoods don’t always lead to personality disorders – in fact, in most cases, they don’t.

Which Attachment Patterns Connect to Different Personality Disorders?

You might have noticed that some of these personality disorder traits are already similar to the characteristics of insecure attachment. It makes sense, then, that they tend to correlate – but this still doesn’t mean that one causes the other.

It also doesn’t mean that if you have an insecure attachment style, then you must have a personality disorder. Rather, it means that some of the traits we see in personality disorders are extreme expressions of the same traits that exist along a broad spectrum within attachment insecurity.

Below, we’ll explore how each insecure attachment style connects to different personality disorders as it’s explained in psychological literature.

Anxious Attachment and Personality Disorders

The anxious, or anxious-preoccupied, attachment style is marked by a heightened sensitivity to rejection and fear of abandonment. When this is extreme, making sure others stick around can overshadow our other priorities.

The anxious-preoccupied attachment style has been associated with Histrionic, Dependent, and Avoidant Personality Disorders⁴.

Avoidant Attachment and Personality Disorders

The avoidant, or dismissive-avoidant, attachment style is characterized by a need for independence that grows from a mistrust in others. In its most extreme form, it could lead someone to a distinct lack of interest in others or mistrust so extreme we lose connection with reality.

The avoidant attachment style has been found to correlate with Narcissistic, Antisocial, Schizoid, and Paranoid Personality Disorders⁴.

DISCOVER YOUR ATTACHMENT STYLE

Fearful-Avoidant Attachment and Personality Disorders

The fearful-avoidant attachment style is characterized by both high attachment avoidance and high attachment anxiety. Often confused with attachment disorganization, the two share traits but are actually different experiences (more on disorganized attachment below).

Fearful-avoidant attachment is associated with Paranoid, Schizotypical, Avoidant, Borderline, Obsessive-Compulsive, and Narcissistic Personality Disorders⁴.

Disorganized Attachment and Personality Disorders

When we’re repeatedly frightened by our caregiving environment, such as witnessing anger in our caregiver, enduring a major separation, or suffering abuse, we can develop attachment disorganization.

Disorganized attachment is often confused with the fearful-avoidant attachment style, but in this case, we refer to Main & Solomon’s original understanding of disorganization as an additional classification on top of the three infant attachment styles⁹.

A disorganized attachment system has been associated particularly with Borderline Personality Disorder. Both are commonly – though not in all instances – linked with a history of trauma, intense emotions, and a disrupted sense of self.

If we already find it difficult to understand our own and others’ intentions and feelings because of attachment disorganization, this could contribute to difficulties with others that we experience in BPD.

The Dark Triad and Attachment Patterns

The Dark Triad is a group of 3 personality traits first grouped together by Paulhus and Williams in 2002¹⁰. Paulhus and Williams argued that narcissism, psychopathy, and Machiavellianism were different but overlapping traits, stating:

“To varying degrees, all three entail a socially malevolent character with behavior tendencies toward self-promotion, emotional coldness, duplicity, and aggressiveness.”

They defined these traits as:

• Narcissism: grandiosity, entitlement, dominance, superiority.
• Psychopathy: high impulsivity, thrill-seeking, low empathy, low anxiety.
• Machiavellianism: manipulation of others, coldness.

While just being high on these traits doesn’t lead to a clinical diagnosis, they have been linked strongly with Cluster B personality disorders¹¹. Dark Triad traits have also been linked with attachment insecurity: specifically, high secondary psychopathy (psychopathy arising from distress and anxiety) and low narcissism predict attachment anxiety, while high Machiavellianism, high primary psychopathy (psychopathy without anxiety) and high secondary psychopathy predict attachment avoidance¹².

Can Attachment-Based Therapy Help Personality Disorders?

Therapies that use attachment theory, such as Mentalization-Based Therapy (MBT), can be helpful for personality disorders – in fact, MBT was developed specifically with BPD in mind. Bowlby theorized that psychotherapy, or talk therapy, serves to provide us with a secure base, which could be the first we’ve ever experienced⁴.

From this secure base and with the modeling of a secure attachment, we can learn how to have secure attachments to others and slowly change our internal working models. While secure attachment styles aren’t necessarily the “cure” to personality disorders, building attachment security can help with some of the symptoms – particularly those associated with intense social anxiety, fear of rejection, or avoidance of others.

Conclusion

Attachment theory gives us a useful framework to understand how our early environments influence our personality development. The relationship between attachment and personality is complex, but the links between attachment anxiety, attachment avoidance, and certain personality disorders have been demonstrated in scientific research.

If you’re interested in support with symptom management for personality disorders, attachment-based therapy like MBT could help you to build a more secure attachment style. If you’re struggling with a personality disorder, other kinds of therapy are also available – it’s important to find the right treatment for you, and this can look different for everybody.

Frequently Asked Questions

Can you have a personality disorder without insecure attachment?

It is possible to have a personality disorder and a secure attachment style, but many personality disorders are characterized by extreme versions of the same difficulties we experience with insecure attachment styles and lead to challenging relationships with others. Due to this overlap, insecure attachments are very common in personality disorders.

Which attachment style is most linked to personality disorders?

Different attachment styles are linked to different personality disorders. According to a 2015 review (Levy et al.), fearful-avoidance is related to the highest number of personality disorders.

Can secure attachment develop if you have a personality disorder?

If you have a personality disorder, developing a secure attachment style can be difficult, but it is possible. Attachment-based therapies can help.

Are personality disorders caused by bad parenting?

Personality disorders are caused by lots of factors. While parenting does play a role, and experiencing difficult caregiver relationships is a risk factor, having a personality disorder doesn’t necessarily mean your parents did a bad job.

Do all people with insecure attachment develop personality disorders?

Having an insecure attachment style doesn’t mean you’ll develop a personality disorder, although there may be a slightly higher risk because of their shared experiences.

How early can personality disorders be detected?

Personality disorders start in adolescence or early adulthood, and some can’t be diagnosed until the age of 18.

References

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2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text rev. Arlington, VA: American Psychiatric Publishing; 2022.
3. Vukasović T, Bratko D. Heritability of personality: A meta-analysis of behavior genetic studies. Psychological bulletin. 2015 Jul;141(4):769.
4. Levy KN, Scala J, Temes CM, Clouthier TL. An integrative attachment theory framework of personality disorders. 2015.
5. Yöyen EG. Relationship between childhood trauma and personality typology. Balkan and Near Eastern Journal of Social Sciences. 2017;3(1):123-9.
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7. Wang WL, Hung HY, Chung CH, Hsu JW, Huang KL, Chan YY, Chien WC, Chen MH. Risk of personality disorders among childhood maltreatment victims: A nation-wide population-based study in Taiwan. Journal of affective disorders. 2022 May 15;305:28-36.
8. Johnson JG, Cohen P, Brown J, Smailes EM, Bernstein DP. Childhood maltreatment increases risk for personality disorders during early adulthood. Archives of general psychiatry. 1999 Jul 1;56(7):600-6.
9. Main M, Solomon J. Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. Attachment in the preschool years: Theory, research, and intervention. 1990;1:121-60.
10. Paulhus DL, Williams KM. The dark triad of personality: Narcissism, Machiavellianism, and psychopathy. Journal of research in personality. 2002 Dec 1;36(6):556-63.
11. Vossen TJ, Coolidge FL, Segal DL, Muehlenkamp JJ. Exploring the dark side: Relationships between the dark triad traits and cluster B personality disorder features. Journal of Psychiatry and Psychiatric Disorders. 2017;1(6):317-26.
12. Brewer G, Bennett C, Davidson L, Ireen A, Phipps AJ, Stewart-Wilkes D, Wilson B. Dark triad traits and romantic relationship attachment, accommodation, and control. Personality and Individual Differences. 2018 Jan 1;120:202-8.