When safety fails: A narrative review on attachment in patients with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) has traditionally been conceptualized according to cognitive-behavioral and neurobiological domains. However, increasing attention has been directed toward its relational and developmental dimensions, particularly the potential role of attachment-related processes. This narrative review explored the relationship between attachment patterns and OCD, with the aim at synthesizing and commenting on the current empirical and clinical evidence, and on how disruptions in early attachment may contribute to the onset and maintenance of OCD. Increased attention has been given to the impact of relational and developmental dimensions, such as early attachment in OCD. The findings consistently suggest a higher prevalence of insecure attachment, especially anxious and disorganized patterns, among patients with OCD compared to healthy controls. Furthermore, specific attachment-related processes, such as impaired emotion regulation, increased need for control, and heightened sensitivity to responsibility appear to mediate the relationship between early attachment insecurity and obsessive-compulsive symptomatology. Clinical implications include the potential value of integrating attachment-based assessments and interventions into the treatment of OCD, especially in cases resistant to conventional cognitive-behavioral therapy and/or pharmacological treatments. Although limitations exist in terms of methodological heterogeneity and the predominance of cross-sectional designs, the reviewed evidence supports a multifactorial model of OCD in which attachment disturbances play a significant role. In conclusion, understanding OCD through the lens of attachment theory may provide a more comprehensive and developmentally informed perspective, opening new directions for research and therapeutic innovation.