For more than half a century, attachment theory has explained the effects of maternal deprivation and the negative impact of traumatic events on a child's psychophysical growth; however, the literature has not yet been able to demonstrate what the correlation is between attachment style and the onset of a specific psychopathological personality picture. This narrative review focuses on the newly proposed psychometric instrument (Perrotta Evolutionary Attachment Questionnaire, PEA-Q1), for adolescents (14-17 years) and adults (18-90 years), which can fill this gap and can help the therapist shed light on the deeper childhood aspects of the patient undergoing clinical psychotherapy.

Since the 1950s Bowlby, Ainsworth and numerous researchers in the international scientific context have studied how the bond between a child and his significant figures develops. Beginning with the effects of maternal deprivation, the properties of attachment bonding, different attachment styles and continuity with relationship patterns in the adult have been studied. The resulting data have been systematized into "attachment theory," one of the foundational pillars of the current psychological sciences. Formulated initially by the British psychoanalyst John Bowlby, later, one of his students, Mary Ainsworth expanded these studies by describing three attachment styles: secure, ambivalent and avoidant; finally, in the late 1980s, researchers Main and Solomon introduced the last category: disorganized. (Perrotta, 2019a/b; Hazan, 1987)

Attachment theory describes how early relationships, in childhood, structure "Internal Working Models" (IWMs) in the child, that is, those operational models of the world and oneself in it, with the help of which he perceives events, predict the future and constructs his plans. In the operational model of the world that everyone builds for himself, a key feature is the notion we have of who the attachment figures are, and how they can be expected to respond. Similarly, in the operating model of self that each of us constructs, a key feature is our notion of how acceptable or unacceptable we are in the eyes of our attachment figures. These are early schemas that contain information about the self, the other, and the self-other relationship. From the IWMs developed in childhood, therefore, comes the attachment style that each of us expresses in relationships. They remain active throughout the life cycle operating outside of awareness. It is precisely this that determines their relative stability, but it is important to consider that each individual develops multiple IWMs as a result of the different significant relationships experienced, and each pattern is precisely because they are based on real, personal experiences and are subject to continuous reorganization, which continues throughout adult life. (Perrotta, 2020a; Santrock, 2017; Van Ijzendoorn, 1997; Bowlby, 1992/1989)

Mary Ainsworth (1965/1978/1982) later succeeded in supporting Bowlby's theory with empirical data, and first identified three distinct attachment patterns through a specially devised situation in the laboratory: the "Strange Situation Procedure" (SSP). Ainsworth, from observing groups of children who were reunited with their mothers after being separated, identified a first group of children who exhibited positive feelings toward their mothers, a second group who exhibited markedly ambivalent relationships, and a third group had non-expressive, indifferent or hostile relationships with their mothers. (Warren, 1997; Weiss, 1982; Vanghn, 1979)

At a later stage, Main and Solomon (1985/1990) introduced a fourth category, relating to children who, upon reunification with their mothers, exhibited behaviors that could not be attributed to any of the three described patterns. In this category, children were disoriented and confused in both intentions and behaviors. Therefore, this pattern was called disorganized/disoriented attachment (Carlson, 1998; Fonagy, 1996; Lyons-Ruth, 1987).

There are thus 4 adults "attachment styles" into which each of us falls (Espugnatore, 2023; Pastore, 2019; Perrotta, 2019a):

1. "Secure". The child with secure attachment uses the caregiver as a secure base for exploring the world. He protests at separation but allows himself to be comforted and overcomes the separation. When the parent returns, he approaches him and asks to be comforted again. This attachment style develops when the caregiver has been consistently attentive to the child's requests and supportive in times of stress. He has implemented, technically, what Aisworth called "sensitive caregiving", meaning that he has responded appropriately to his child's needs, using optimal modes of communication. This has enabled him to develop self-confidence in himself and others; over time he will be marked by increasing autonomy and confidence in his abilities. The child perceives himself as worthy of being loved and others as generally willing to help him in difficult times.
2. "Insecure-Eviting". In this attachment style, the child is generally disinterested in the caregiver figure. He explores the world regardless of the caregiver's presence: he does not involve the caregiver in play when he is there, does not complain when he leaves and continues to play the moment he returns. The exploration system is hyperactivated, at the expense of the affiliative system. The child learns early on to be autonomous and to manage his own emotions: he does not rely on others, as he feels they are not available to him. The caregiver has often been emotionally unavailable and this has led the child to think that, in general, people are predisposed to turn away from him and not help him when needed. As a result, he does not express his distress because he thinks it would be useless to.
3. "Insecure-Ambivalent". This attachment style is, on the contrary, often determined by excessive affective stimulation from the caregiver. The parent is responsive to the child's needs; however, he is not attuned to the child's emotional state: he moves closer or farther away based on his own needs rather than those of the child. He or she turns out, therefore, to be sometimes too invasive or extremely assent. This lack of consistency does not allow the child to know what to expect from either the caregiver or others, who are unpredictable and centered only on their well-being. The child does not explore and always stays close to the mother, who may disappear so as not to return (hypo-activated exploration system); when left alone with the stranger he is inconsolable, but when the caregiver returns he does not show happiness to see him and enacts contradictory behaviors, such as approaching and showing aggression and then pulling away and crying. In both insecure attachments, whether avoidant or ambivalent, the child develops self-representation as "unlovable and unworthy of help".
4. "Disorganized". The last attachment style, the disorganized style, was introduced later by 3 other authors, Main, Kaplan and Cassidy, starting from the studies of Bowlby and his assistant Ainsworth. It is the style that characterizes children who live in contexts of parental maltreatment and/or abuse, or who have experienced psychophysical trauma. These are situations in which the caregiver is simultaneously both the safe base and a danger to the child. This creates a strong affective and cognitive conflict for him, which he does not know how to handle at all: he does not understand how to behave, let alone how to ask for help. The attachment style is therefore very confusing: the child, at the moment of reunion with the parent, may initially show contentment and go to him, only to freeze and not speak (freezing phenomenon) or show hostile and contrary attitudes and behaviors. 

The DSM 5-TR (APA, 2022), the manual that encompasses all pathological forms recognized by the American Psychological Association, in its latest edition, counts 2. Both present inappropriate attachment modes compared to what is expected for developmental age, but symptomatically they are the opposite of each other (Fabiano, 2021; Atkinson, 2019; Hornor, 2019; Greenberg, 1993): 

1. "Reactive Attachment Disorder". It is generally a pattern of inhibited behavior. The child does not seek comfort from others even though he often experiences negative emotions, with moments of unwarranted sadness and irritability. In addition, he or she does not respond to any attempts at consolation from adults. 
2. "Disinhibition Disorder in Social Relationships": pattern of socially uninhibited behavior. The child seeks inappropriate physical and verbal contact; and shows excessive willingness to interact with adults, even strangers. This can be particularly dangerous, as he may agree to stray with a stranger. All this is associated with poor caregiver control. Attachment disorders are caused by an extremely poor affective context that does not allow the child to develop a real attachment bond. The primary caregiver is absent, or several succeed one after another: the child is neglected because there is no one to comfort him or her. Delays in cognitive development and language are often associated with these diagnoses.

There are many tests of attachment style in adults. Often self-report instruments, whose fundamental limitation is to measure only what you are aware of. For this reason, accurate measurement requires a broader psychodiagnostic assessment with an experienced clinician. (Bartholomew, 1995/1997) 

One of the earliest psychometric instruments developed was Bartholomew and Horowitz's (1995) "Relationship Questionnaire", which allowed one to identify the style in which one identifies most and the degree to which one falls into each style. Again, the Attachment Story Completion Task (ASCT), assessed attachment representations through the presentation of 5 stories on attachment issues, of which the child had to provide narrative completion through the use of a series of dolls representing the main characters in the family. Then there are Q-sort methods, such as the Attachment Q-sort (Perrotta, 2019b), which allows for the detection and assessment of some simple attachment behaviors of the child in the natural environment, covering a wider period than the SS (up to 5 years) and possibly being applied to dyads other than the mother-child dyad (thus also assessing multiple attachments). The Separation Anxiety Test - SAT (Perrotta, 2019b) detects children's responses to stimuli of a semiprojective nature because it follows the assumption that the child projects onto a series of attachment-activating stimuli in his or her mental organizations in this regard. This test consists of 6 photographs depicting various separation situations, which are shown to the subject telling him or her what feelings the character in the picture experiences and what strategies he or she will implement to cope with the situation. For adults, on the other hand, George, Kaplan and Main's (1985) Adult Attachment Interview (AAI) is used, which is also used for adolescent mothers, being careful, however, to keep in mind the possible underestimation of existing difficulties or the attempt to appear to live up to the proposed situations (degree of social desirability). The AAI is probably the best psychometric test most widely used in adults and written in a semi-structured questionnaire in which interviews are recorded and graded according to various parameters. The Adult Attachment Interview has made it possible to define 3 internal representative models of the self and attachment figures in adulthood and consequently allows a classification of adults into as many categories (Dazzi, 2010):

1. "Secure-Autonomous Adults" ("F", free): these are individuals who show consistent evaluations in the narration of their experiences, even in the presence of a difficult childhood or one marked by traumatic events. They demonstrate free access to childhood memories, have no biases and do not make a selection of what is reported. They present awareness of the past and easily recount even unpleasant events.
2. "Distancing Adults" ("Ds", dismissing): these are individuals who tend to provide generalized descriptions of their parents but fail to support these definitions with specific memories. If a memory of a difficult experience is present, it is attributed little or no weight in life. They have a cheap and sparse narrative style of their childhood experiences, and from their accounts, it is difficult to identify underlying emotions
3. "Concerned Adults" ("E", entangled): these are subjects still stuck with memories of early experiences with their parents whom they describe extensively but in an inconsistent and confused manner. Their narratives suggest a role reversal with their parents, who are therefore not a secure base. They present a serious difficulty in defining emotions.
4. "Unresolved Adults" ("U", unresolved): these are individuals who have not resolved attachment-related traumatic experiences, may present coherent in their narratives, but make decidedly implausible statements about the causes and consequences of traumatic events, such as the loss of an attachment figure.
5. "Unclassifiable" ("CC", cannot classify): used to describe interview transcripts that do not fully meet the criteria for inclusion in one of the three "core" attachment categories.

2.1. Preamble 

For more than half a century, attachment theory has been explaining the effects of maternal deprivation and the negative impact of traumatic events on a child's psychophysical growth; however, the literature has not yet been able to demonstrate what the correlation is between attachment style and the onset of a specific psychopathological personality picture. This dyscrasia is explained by the multifactorial nature of psychopathological disorders (Perrotta, 2020b), in that the current dysfunctional personality profile is the consequence of one or more psychologically stressful or traumatizing events, unresolved and reinforced over time to maintain active destructive and/or self-destructive power. It is therefore unlikely that identifying the specific childhood attachment style can determine with certainty the corresponding psychopathological development, as so many other factors such as life experiences (a), education received and stimuli from the family environment (b), extended social context such as school and friendship (c), physical health status (d), genetically based neurobiological predispositions (e) and behavioral reinforcers to certain cognitive states (f) are needed. 

In the writer's opinion, however, identifying with a good probability of correctness of the adult attachment style (derived from IWMs) helps to better frame the current personality profile, both in its functional and dysfunctional components. 

A theory (Perrotta Evolutive Attachment Theory, PEA-t) and its model (Perrotta Evolutive Attachment Model, PEA-m) were developed to proceed with this task, to fill the main clinical gaps in modern attachment theory, use the new psychometric instrument based on these assumptions (Perrotta Evolutive Attachment Questionnaire, PEA-Q1). 

2.2. Perrotta Evolutive Attachment Theory (PEA-t) 

Attachment theory (AT), as also reflected in the contributions of researchers in the last three decades, succeeds admirably in explaining the properties of the attachment bond, the different styles identified, and the continuity with relationship patterns in the adult through the use of the concept of internal operating model, but despite efforts to adapt this theory to modern clinical practice this theory fails to explain the correlations, in a comprehensive manner, with personality profiles, because the basic approach was not clinical but evolutionary, that is, the purpose was to explain the effects of maternal deprivation and childhood trauma but not to correlate them with their possible psychopathological evolution. PEA-t, shares with TA the concept of "subjective infant attachment", as an individual's internal dynamic system on a cognitive-behavioral basis and concerning his or her ability to form deep emotional and/or sentimental bonds with the human and animal figures who care for them during life, and the concept of "internal working model", as the container of mental representations from which "attachment behaviors" then originate throughout the subject's developmental stage, i.e., the behaviors we put into practice during our human relationships; unlike AT, however, PEA-t seeks to address the need for clinical correlation with the individual personality profile, thus making some corrections (explicated in the corresponding model, PEA-m) that might facilitate this [Table 1]. 

Specific feature of modern                           attachment theory (AT)	Specific feature of “Perrotta Evolutionary Attachment Theory” (PEA-t)	Equality/ Difference      AT         PEA
Studies the properties of attachment bonding, different styles, and continuity with relational patterns in the adult	Studies the properties of attachment bonding, different styles, and continuity with relational patterns in the adult
Studies the individual's internal operating patterns to explain his or her emotional-behavioral profile	Studies the individual's internal operating patterns to explain his or her emotional-behavioral profile
Explains the correlation between attachment style and psychopathological personality profile	Explains the correlation between attachment style and psychopathological personality profile
To childhood attachment, identifies the structural and functional components of the personality profile	To childhood attachment, identifies the structural and functional components of the personality profile
Identifies 4 attachment styles, to functional and dysfunctional personality dynamics	Identifies 4 attachment styles, to functional and dysfunctional personality dynamics
For each attachment style, identify the specific subtypes, of functional and and dysfunctional personality dynamics	For each attachment style, identify the specific subtypes, of functional and and dysfunctional personality dynamics

Table 1: Comparison table on the characteristics of the two theories compared. The symbol marked with the green tick indicates that both theories have the same characteristic, while the symbol marked with the red cross indicates that the two theories diverge on that specific characteristic.

2.3. Perrotta Evolutive Attachment Model (PEA-m) 

The explanatory model (Perrotta Evolutive Attachment Model, PEA-m) of PEA-t introduces 2 correctives to AT, namely:

1. Identifies "4 specific attachment styles" (and their specific sub-types) [Table 2], starting from AT but based on Kernberg's triadic model of personality organization (Espugnatore, 2023; Perrotta, 2019b): 
2. Secure. The developing-age individual, whether adolescent or adult, tends to have healthy relationships with friends, family members, and partners. He is secure and present to himself, has a good knowledge of his emotional dimension and emotional states, and tends to have clear, precise and non-confusing or painful bonds. The "secure" style is justified by 12 pairs of specific functional characteristics: coherence-fidelity (a1); envelopment-openness (a2); protectiveness-reservedness (a3); generosity-altruism (a4); helpfulness-gentility (a5); balance-rationality (a6); welcoming-sociability (a7); sensitivity-empathy (a8): courage-adventure (a9); energy-heat (a10); responsibility-reliability (a11); imagination-eclecticity (a12).
3. Neurotic (or insecure). The developing individual, whether adolescent or adult, tends to have unstable relationships, whether with friends, family members, or partners. He or she is doubtful, anxious and phobic, is not present to himself or herself concerning his or her emotional plane, does not have a good grasp of his or her emotional dimension and emotional states, and tends to have bonds marked by fear, doubt and fear of not being enough, of not deserving love, and of sabotaging his or her chances to self-assert his or her own discomfort and unstable position. The "neurotic" (or insecure) style is justified by 4 pairs of specific dysfunctional traits: fearful-avoidant (b1); fearful-sabotant (b2); hypervigilant-controlling (b3); angry-impulsive (b4).
4. Dramatic (or ambivalent). The developmental individual, whether adolescent or adult, tends to have unstable relationships, whether with friends, family members, or partners. He or she is doubtful, questions relationships even in the absence of objective danger, is not present to himself or herself for his or her emotional plane, lacks a good grasp of his or her emotional dimension and emotional states, and tends to have bonds marked by fear of abandonment or the need to overprotect himself or herself, tends to sabotage his or her chances to deresponsibilize himself or herself and blame others. The "dramatic" style is justified by 4 pairs of specific dysfunctional characteristics: passive-cool (c1); ambiguous-ambivalent (c2); idealizing-devaluing (c3); omnipotent-destructive (c4).
5. Fragmented. The developmental individual, whether adolescent or adult, tends to have unstable and destructive relationships, whether with friends, family members, or partners. He is suspicious and paranoid, is not present to himself for his emotional plane, lacks good knowledge of his emotional dimension and emotional states, and tends to have bonds marked by fear of suffering, thus sabotaging his chances of success in the first person. The "fragmented" style is justified by 4 pairs of specific dysfunctional characteristics: suspicious-aggressive (d1); withdrawn-defensive (d2); paranoid-hyper protective (d3); unresolved-disorganized (d4).

Table 2: Table of characteristics of attachment styles and subtypes, with specific descriptions.

1. Identifies the structural and functional structure of the "Individual Attachment Profile" (IAP) [Figure 1]:
2. The structural framework consists of 4 components: (a1) "emotional stability" (ES), represented by items no. 16, 17, 18, 22, 23, 24, 31, 32, 33, 46, 47, 48, 55, 56, 57, 67, 68 and 69, to be understood as the structural component that explains the subject's ability to maintain healthy and stable emotional-emotional relationships; (a2) "bonding strength" (BS), represented by items no. 1, 2, 3, 13, 14, 15, 28, 29, 30, 37, 38, 39, 40, 41, 42, 49, 50 and 51, to be understood as the structural component that explains the subject's ability to have healthy and lasting emotional-sentimental relationships; (a3) the "ability to love" (AL), represented by items no. 4, 5, 6, 7, 8, 9, 34, 35, 36, 43, 44, 45, 52, 53, 54, 58, 59, and 60, to be understood as the structural component that explains the subject's ability to experience healthy and fulfilling emotional-sentimental relationships in a functional sharing context; (a4) the "confidence in the future" (CF), represented by items no. 10, 11, 12, 19, 20, 21, 25, 26, 27, 61, 62, 63, 64, 65, 66, 70, 71, and 72, to be understood as the structural component that explains the subject's ability to accrue hopeful beliefs about the good outcome of emotional-sentimental relationships.
3. The functional framework consists of 2 axes of operation: (b1) the axis of safety-insecurity (or strength-weakness), represented by items no. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 25, 26, 27, 28, 29, 30, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 61, 62, 63, 64, 65, and 66, to be understood as the axis of functioning related to the energetic perspective of the attachment profile (how much emotional energy is available to the person to invest on emotional-sentimental relationships); (b2) the axis of organization-disorganization (or efficiency-inefficiency), represented by items no. 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 31, 32, 33, 34, 35, 36, 49, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 67, 68, 69, 70, 71, and 72, to be understood as the axis of functioning related to the potential perspective of the attachment profile (how much emotional capacity in terms of efficiency is available to the person to invest on emotional-sentimental relationships).

Figure 1: Table of characteristics of attachment styles and subtypes, with specific descriptions.

The Perrotta Evolutive Attachment Questionnaire (PEA-Q1), in 72 items with L0-5 response, was developed to have a psychometric instrument capable of identifying attachment style in adolescents and adults, investigating structural and functional dimensions of the individual profile. Validation studies are in progress. The questionnaire was structured for a target age range of 14 years to 90 years, based on the Perrotta Integrative Clinical Interviews 3 (PICI-3), section A (adolescents and adults) (Perrotta, 2024), and it is preferable that it take place in the presence of the administering therapist, and who already has prior clinical knowledge of the subject underwriting the responses, to avoid cognitive distortion or active manipulation by the subject. [Appendix 1]

Having administered the questionnaire, in a single solution and without a time limit, the administering therapist will proceed to scoring the score, according to the following rules of interpretation: 

1. For each question (item) the corresponding answer must be marked with a value from 0 to 5 (0 = no, never, not at all, 5 = yes, always, almost always). Missing answers or values greater than 5 or less than 0 are not allowed. The scores for items 1 to 36 will be reported exactly as assigned by the experimental subject, while the scores for items 37 to 72 will be reversed, and therefore if it is 0 the adjusted score will become 5, if 1 the adjusted score will be 4, if 2 the adjusted score will be 3, if 3 the adjusted score will be 2, if 4 the adjusted score will be 1, and if 5 the adjusted score will be 0.
2. Based on the scores obtained, the therapist should assign each style sub-style (4 for each style, for a total of 16 sub-styles) the category score summation as shown in Table 3. 

Table 3: Matching of items for individual subtypes of attachment style.

1. Having made the score assignments, adjusted for the inversion of items 37 to 72, the therapist can make the assignments to define the scores for all structural and functional categories identified by the questionnaire, as shown in Table 4.

Table 4: Matching of items for individual subtypes of attachment style.

1. Having obtained all the correct scores, for each category, the therapist can report the outcome of the questionnaire according to the following rating scales, which will be subject to possible revision after the conclusion of the questionnaire validation study, as shown in Table 5. 

Table 4: Matching of items for individual subtypes of attachment style. Total score (Difference between the score of the safe style and the summation of the other dysfunctional styles).

This narrative review on the topic of attachment theory has produced a new psychometric proposal (Perrotta Evolutionary Attachment Questionnaire, PEA-Q1), to be administered to adolescents (14-17 years) and adults (18-90 years), which may be able to fill the gap of a lack of a technical instrument on evolutionary attachment and correlations with psychopathological disorders, thus helping the therapist to shed light on the deeper childhood aspects of the patient in psychotherapy. Validation studies of this tool are underway to test its stability, efficiency, and effectiveness in terms of diagnostics.