Adult attachment and prolonged grief: A systematic review and meta-analysis

Diagnoses characterized by severe, persistent and disabling grief have recently been added to the ICD-11 and DSM-5-TR as prolonged grief disorder. Adult attachment is widely assumed critical in the development, persistence, and treatment of prolonged grief, yet a meta-analysis on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42021220511) searching PsycInfo, Web of Science, and PubMed (final search: August 2022) to identify and summarize quantitative research examining relationships between adult attachment (i.e., attachment anxiety, attachment avoidance, secure attachment, disorganized attachment) and prolonged grief symptoms. Thirty-one studies including 8347 bereaved adults were included. Attachment anxiety (r = 0.28, 95 % CI:0.23–0.32, k = 15) and attachment avoidance (r = 0.15, 95 % CI:0.05–0.26, k = 15) related positively to prolonged grief symptoms concurrently. We found no evidence of publication bias but did detect heterogeneity in effect sizes. Ten longitudinal analyses showed no evidence that insecure attachment styles increase prolonged grief symptoms. Attachment anxiety predicted better therapy outcomes. Insecure attachment styles are concurrently positively related to prolonged grief symptoms but do not increase grief severity. The role of adult attachment in contemporary grief theories may need reconsideration. Intensive longitudinal research should aim to clarify how dynamic changes in attachment to the deceased and others relate to changes in prolonged grief symptoms.