Overcoming the civil wars: the role of attachment styles between the impact of war and psychological symptoms and post-traumatic growth among Libyan citizens

ABSTRACT

Background: Civil wars in Libya have impacted the mental health of the general population. The ways in which individuals cope with traumatic events are influenced by several psychological variables.

Objectives: The present study aimed to investigate how post-traumatic stress symptoms (PTSS) are associated with psychological symptoms and post-traumatic growth (PTG), and to evaluate the role of avoidant and anxious attachment dimensions as mediators in these associations, among Libyan citizens.

Method: Three-hundred participants (147 females; age 31.0 ± 8.4 years) completed the Impact of Event Scale – Revised, Experiences in Close Relationships, Patient Health Questionnaire, and Post-traumatic Growth Inventory – Short Form.

Results: The structural equation model revealed that insecure attachment dimensions mediated the association between PTSS and psychological symptoms and PTG. PTSS were positively associated with psychological symptoms, PTG, and both insecure attachment dimensions. Insecure attachment dimensions were positively associated with psychological symptoms and negatively with PTG.

Conclusion: The present findings contribute to growing empirical research on the roles of insecure attachment dimensions in the association between the impact of war, psychological symptoms, and PTG.

HIGHLIGHTS

• Insecure attachment dimensions mediated the association between the impact of war and psychological symptoms, as well as posttraumatic growth, among Libyan citizens.

• Higher psychological symptoms were negatively correlated with posttraumatic growth.

• Psychological interventions should consider insecure attachment dimensions, when evaluating the consequences of prolonged and repeated wars.

Antecedentes: Las guerras civiles acaecidas en Libia impactaron la salud mental de la población general. Las formas en la que las personas afrontan los eventos traumáticos están influenciadas por varias variables psicológicas.

Objetivo: El presente estudio tuvo como objetivo investigar cómo los síntomas de estrés postraumático (PTSS por sus siglas en inglés) se asocian con síntomas psicológicos y de crecimiento postraumático (PTG por sus siglas en inglés), y evaluar el papel de las dimensiones de apego evitativo y ansioso como mediadores en estas asociaciones, entre los ciudadanos libios.

Método: 300 participantes (147 mujeres) (31.0 ± 8.4) completaron la escala revisada del impacto de eventos, Experiencias en relaciones cercanas, el Cuestionario de salud y el Inventario de crecimiento postraumático versión abreviada.

Resultados: El modelo de ecuación estructural mostró que las dimensiones de apego inseguro mediaron la asociación entre PTSS y síntomas psicológicos y crecimiento postraumático. Los PTSS se asociaron positivamente con síntomas psicológicos, PTG y ambas dimensiones de apego inseguro. Las dimensiones de apego inseguro se asociaron positivamente con síntomas psicológicos y negativamente con PTG.

Conclusión: Los hallazgos actuales contribuyeron a la creciente investigación empírica para comprender los papeles de las dimensiones del apego inseguro en la asociación entre el impacto de la guerra, los síntomas psicológicos y PTG.

背景：利比亚发生的内战影响了普通民众的心理健康。个人应对创伤事件的方式受到多种心理变量的影响。

目的：本研究旨在调查利比亚公民中创伤后应激症状（PTSS）与心理症状和创伤后成长（PTG）之间的关系，并评估回避和焦虑依恋维度在这些关联中的中介作用。

方法：300 名参与者（147 名女性）（31.0±8.4）完成了修订版事件影响量表、亲密关系经历、患者健康问卷和创伤后成长调查问卷简表。

结果：结构方程模型显示，不安全依恋维度中介了 PTSS 与心理症状和创伤后成长之间的关联。 PTSS 与心理症状、PTG 以及两个不安全依恋维度呈正相关。不安全依恋维度与心理症状呈正相关，与 PTG 呈负相关。

结论：本研究结果有助于了解不安全依恋维度在战争影响、心理症状和 PTG 之间关联中的作用的实证研究的积累。

KEYWORDS:

• Post-traumatic stress symptoms
• attachment styles
• psychological symptoms
• post-traumatic growth
• war

PALABRAS CLAVE:

• Síntomas de estrés postraumático
• estilos de apego
• síntomas psicológicos
• crecimiento postraumático
• guerra

关键词:

• 创伤后应激症状、依恋风格、心理症状、创伤后成长、战争。

1. Introduction

Libya's civil wars (2011–2020) caused many deaths, injuries, refugees, insecurity, and financial crises (Daw et al., 2019). The Libyan citizens suffered from several psychological symptoms, such as anxiety, depression, and post-traumatic stress symptoms (PTSS), as a consequence of cumulative events (Abdulshafea et al., 2021).

Victims of war may experience post-traumatic growth (PTG), which is theorized as an individual process that consists of finding new meanings and reconciling beliefs, leading to greater appreciation for life, improved relationships, increased personal strength, and a deeper sense of spirituality or meaning (Kılıç et al., 2016; Tedeschi & Calhoun, 2004).

Previous research has shown inconsistent associations between PTSS and PTG, finding positive (Cengiz et al., 2019), negative (Thomas et al., 2021), or non-significant correlations (Sleijpen et al., 2016). A possible explanation for this inconsistency could be that only a sufficiently severe trauma could activate the processing of traumatic events (Tedeschi & Calhoun, 2004). Moreover, it seems that other factors, such as individual and social factors, can affect this relationship (Ersahin, 2022; Volgin & Bates, 2016).

Attachment is a key construct in the field of traumatic stress and may be a critical factor to help understand the ways in which trauma relates to PTG (Gleeson et al., 2021). Insecure attachment dimensions – anxious and avoidant – could impact socioemotional adaptation in adults (Mikulincer & Shaver, 2019), and have been found to be a risk factor for psychological symptoms (Alonso et al., 2018). Individuals with higher levels of anxious attachment tend to overly rely on their relationships, fearing that others will be unavailable or abandon them (Ein-Dor & Hirschberger, 2016). These individuals may use hyperactivating strategies, such as crying or clinging, to regain proximity whenever the attachment figure seems unreachable (Mikulincer & Shaver, 2019). Individuals with high levels of avoidant attachment tend to distrust others’ motives and intentions, attempting to maintain emotional distance in relationships (Altavilla et al., 2021; Gleeson et al., 2021).

Following a traumatic event, the attachment style has been associated with the event-associated appraisals, which would consequently alter post-trauma trajectories (Arikan et al., 2016). A meta-analysis by Gleeson et al. (2021) showed that the attachment styles may affect PTG after the exposure to traumatic events. Secure attachment was positively associated with PTG while insecure attachment dimensions were negatively associated with PTG (Gleeson et al., 2021).

Considering the lack of studies the literature, the present study investigated the mediating role of attachment dimensions in the association between the impact of war and the severity of psychological symptoms and PTG among Libyan citizens. PTSS was expected to be positively associated with the severity of psychological symptoms and the PTG. Moreover, the avoidant and anxious attachments were hypothesized to positively mediate the associations between PTSS and psychological symptoms, and negatively mediate the link between PTSS and PTG.

2. Method

Three-hundred Libyans (58.4% females) completed an online survey posted on social media groups (Facebook, Instagram, and Twitter) of Libyan citizens. The inclusion criteria were being 18 years of age or older and Libyan. The Ethics Committee of the Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome approved the study. Table 1 shows the sociodemographic characteristics of the sample.

• The Arabic version of the Impact of Event Scale – Revised (IES-R) (Davey et al., 2015) was used to measure PTSS, evaluating avoidance, intrusion, and hyperarousal symptoms.

  Table 1. Demographic characteristics of the study sample (N = 300).

  Demographics		Frequency	Percentage (%)
  Gender	Male	153	51
  	Female	147	49
  Age (years)	Mean ± SD: 31.0 ± 8.37
  	Range: (18–63)
  Geographic location	Western region	225	75
  	Eastern region	17	5.7
  	Southern region	24	8
  	Middle region	34	11.3
  Family members	Mean ± SD: 4.85 ± 2.27
  	Range (0–13)
  Marital status	Single	171	57
  	Married	102	34
  	Engaged	17	5.7
  	Divorced	9	3
  	Widow	1	0.3
  Education	Primary	3	1
  	Secondary	33	11
  	Bachelor	168	56
  	Master or higher	96	32
  Occupation	Student	78	26
  	Unemployed	23	7.7
  	Housewife/household	22	7.3
  	Military	10	3.3
  	Private sector employee	64	21.3
  	Public sector employee	103	34.3
  Monthly income (Libyan dinars)	0	90	30
  	< 500	27	9
  	500–1000	75	25
  	1000–2000	60	20
  	2000–3000	22	7.3
  	> 3000	26	8.7

• The Arabic version of the Experiences in Close Relationships (ECR) scale (Lavy et al., 2012) was used to assess anxious and avoidant attachment orientations in a close relationship.

• The Arabic version of the Patient Health Questionnaire (PHQ) (Alhadi et al., 2017) was used to evaluate symptoms of depression, generalized anxiety, somatization, panic attack, eating disorder, and alcohol abuse.

• The Arabic version of the Post-traumatic Growth Inventory – Short Form (PTGI-SF) (Veronese & Pepe, 2019) was used to assess five dimensions of PTG: relationships with others, new possibilities, personal strength, spiritual change, and appreciation of life.

Data analyses are reported in the Supplementary material.

3. Results

Since the data were not normally distributed according to the Kolgorov–Smirnov test, Spearman’s correlation was applied. The Spearman’s correlation results are presented in Table 2.

Table 2. Descriptive statistics and correlations for the study variables.

Variable	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	Mean	SD	K–S test
																				S	p
1. Sex^a	–																	1.59	0.50	.35	< .001
2. Age^b	−.05	–																31	8.37	.08	0.03
3. Family members	.13*	−.13*	–															4.85	2.27	.14	< .001
4. Total IES	.08	.06	−.07	–														5.4	2.98	.04	0.81
5. Avoidant attachment	.13*	−.18**	.01	.15**	–													70.2	18.0	.05	0.48
6. Anxious attachment	−.08	−.07	−.03	.33***	.15*	–												66.8	22.1	.04	0.60
7. Generalized anxiety	.08	−.13*	−.02	.58***	.30***	.47***	–											9.53	6.21	.09	.008
8. Major depression	.13*	−.20***	.04	.54***	.32***	.46***	.84***	–										10.8	7.36	.09	.01
9. Somatization	.35***	−.07	.08	.46***	.25***	.27***	.63***	.70***	–									10.6	7.11	.08	.04
10. Panic disorder	.20***	−.06	.06	.47***	.15**	.29***	.57***	.56***	.62***	–								4.62	5.29	.28	< .001
11. Eating disorder	.07	−.13*	.04	.13*	.12*	.20***	.23***	.30***	.31***	.27***	–							1.12	1.71	.34	< .001
12. Alcohol abuse	−.39***	.07	−.23***	.13*	−.02	.13*	.12*	.07	−.01	.01	.09	–						0.29	0.86	.58	< .001
13. Personal strength	.14*	.06	−.06	.01	−.08	−.20***	−.15*	−.16**	−.01	−.07	−.05	−.04	–					7.48	2.52	.14	< .001
14. New possibilities	.17**	.08	−.03	.16**	−.05	−.15**	−.07	−01	−.04	−.04	.01	−.08	.63***	–				6.94	2.85	.15	< .001
15. Relating to others	−.00	.20***	.02	.04	−.45***	−.13*	−.20***	−.24***	−.18**	−.11	−.01	.01	.50***	.51***	–			6.17	2.69	.11	< .001
16. Spiritual growth	.18**	.09	.01	.08	−.07	−.20***	−.07	−.07	.01	−.01	−.06	−.10	.44***	.50***	.41***	–		7.19	2.51	.14	< .001
17. Appreciation for life	.20***	.11	−.08	.15**	.04	−.12*	−.06	−.04	.05	−.02	−.06	−.03	.57***	.61***	.38***	.47***	–	6.54	2.78	.15	< .001
18. Total PTGI	.18**	.15**	−.05	.13*	−.15**	−.21***	.13*	−.16**	−.06	−.07	−.06	−.07	.77***	.83***	.71***	.71***	.80***	34.4	10.6	.12	< .001

Note: ^aOne male, two females. ^bAge range 18–63 years.

IES = Impact of Event Scale; PTGI = Post-traumatic Growth Inventory; K-S = Kolgorov–Smirnov.

*p < .05, **p < .01, ***p < .001.

The goodness of fit of the structural equation model (SEM) was tested on the whole sample (Figure 1). The association of PTSS with PTG and psychological symptoms, both directly and indirectly through avoidant and anxious attachment dimensions, was tested. The model showed an adequate fit [χ² = 94.3, p = 229; df = 85; χ²/df = 1,109; goodness of fit index (GFI) = 0.98; comparative fit index (CFI) = 0.99; Tucker–Lewis index (TLI) = 0.99; root mean square error of approximation (RMSEA) = 0.019, 95% confidence interval 0.000–0.038; standardized root mean square residual (SRMR) = 0.‏019]. Moreover, all of the manifest variables loaded significantly on the respective latent variables.

Figure 1. Goodness of fit of the structural equation model with unstandardized coefficients. Post-traumatic stress symptoms = Impact of Event Scale – Revised total score subscales (intrusion + avoidance + anxious subscales). Insecure attachment = anxious attachment; avoidant attachment. Psychological symptoms = Patient Health Questionnaire subscales: generalized anxiety; depression; somatization; panic attack; eating disorder; alcohol abuse. Post-traumatic growth = personal strength; new possibilities; relating to others; spiritual growth; appreciation for life.

PTSS was positively associated with PTG (R² = .12, β = .24, p < .001), psychological symptoms (R²= .52, β = .52, p < .001), avoidant attachment (R²= .03, β = .17, p < .004), and anxious attachment (R²= .12, β = .35, p < .001). Avoidant attachment was negatively associated with PTG (β = −.21, p < .001) and positively associated with psychological symptoms (β = .19, p < .001). Anxious attachment was negatively associated with PTG (β = −.28, p < .001) and positively associated with psychological symptoms (β = .28, p < .001). Finally, PTG was negatively associated with psychological symptoms (β = −.18, p < .004).

Concerning the indirect effects, PTSS, through avoidant attachment, was negatively associated with PTG (β = −.03, p < .30) and positively with psychological symptoms (β = .03, p < .001). Lastly, PTSS, through the anxious attachment style, was negatively associated with PTG (β = −.10, p < .002) and positively associated with psychological symptoms (β = .10, p < .001).

4. Discussion

The main finding of this study was that the insecure attachment dimensions positively mediated the association between PTSS and psychological symptoms. This result is consistent with the literature, which noted the role of the risk factor of the insecure attachment dimension for different psychological symptoms (Besser & Neria, 2010). People with insecure attachment dimensions tend to show lower self-esteem, and more difficulties trusting others, reflecting on their internal state, and regulating their feelings (Altavilla et al., 2021). Moreover, insecure attachment styles are associated with a reduced use of adaptive strategies (Mikulincer & Shaver, 2019). The present findings suggest that these characteristics could have exacerbated the consequences of the Libyan wars.

The SEM revealed that insecure attachment dimensions negatively mediated the association between PTSS and PTG, suggesting that these dimensions could negatively affect the emotional and cognitive processing of PTG. Prior research found that people with an avoidant attachment dimension tend to self-isolate and minimize their painful experiences, by using deactivating strategies (Arikan et al., 2016), whereas people with anxious attachment dimensions tend to use hyperactivating strategies, trying ineffectively to obtain social support (Mikulincer & Shaver, 2019). It could be hypothesized that the tendency to inhibit the negative feelings associated with traumatic events, as well as the ineffective attempts to obtain support from others, could negatively influence the elaborative processing of PTG (Ein-Dor & Hirschberger, 2016; Volgin & Bates, 2016).

In the present study, the direct effects of insecure attachment dimensions on psychological symptoms and PTG seemed to highlight their potential role as risk factors. This result, according to the literature, seems to confirm the existence of a positive relationship between insecure attachment dimensions and psychopathology (Alonso et al., 2018) and a negative association with PTG (Arikan et al., 2016). Moreover, insecure attachment dimensions seem to be associated with higher levels of distress, which would interfere with the sense of mastery and control over the traumatic events (Arikan et al., 2016). Furthermore, the tendency to have negative expectations of others could hinder the PTG (Gleeson et al., 2021).

It is worth noting that the present study observed that the impact of war trauma was directly and positively associated with insecure attachment dimensions. Despite the evidence of stability in attachment dimensions (Mikulincer & Shaver, 2019), prolonged trauma may alter individuals’ basic trust in others, with significant changes in attachment dimensions (Solomon et al., 2008).

In the present study, the impact of war trauma was directly and positively associated, on the one hand, with psychological symptoms, confirming the devastating impact of war on mental health (Abdulshafea et al., 2021), and, on the other hand, with PTG. The latter result could be clarified considering previous findings in which the association between the severity of trauma and the PTG was influenced by the trauma type (Shakespeare-Finch & Lurie-Beck, 2014). In individual traumas, the severity of the event was associated with lower levels of PTG, whereas in collective traumas it was associated with higher levels of PTG (Kılıç et al., 2016). It is possible that in collective traumas it is easier to communicate with others about the events, facilitating the emotional and cognitive processes which sustain the PTG. In contrast, in individual traumas, several psychological reactions, such as feeling guilty and ashamed, could lead to the avoidance of social communication about the trauma. Consequently, this would interfere with its elaboration and with PTG.

Despite these findings, the cross-sectional nature of the study did not allow us to draw causal conclusions among the variables. Moreover, a social desirability bias could have affected the answers to the self-report measures. Longitudinal studies, which use more objective measures, could clarify the directions of the associations found in this study.

In conclusion, this study contributes to growing empirical research into understanding the roles of insecure attachment styles in the association between the impact of war trauma, psychological symptoms, and PTG. In a war context, screening programmes that identify the most vulnerable individuals should be implemented to develop targeted interventions. People with avoidant attachment dimensions could benefit from interventions that promote emotional sharing. Moreover, interventions that improve emotional regulation skills could be beneficial for individuals with anxious attachment dimensions. Lastly, the collective sharing of the event may be particularly indicated, considering its positive effects on PTG and mental health.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The data sets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request.

Additional information

Funding

This work was supported by Italian Ministry of Foreign Affairs MAECI Study Program [Prot. N. 2167].