1

Chapter 2.

Literature Rreview.

International Literature.

Adverse Childhood Experiences (ACEs) have become a cornerstone in understanding the

long-term psychological and behavioral outcomes of early trauma. Defined as potentially
traumatic events occurring before the age of 18 including abuse, neglect, and household
dysfunction. ACEs are known to disrupt normative developmental processes and pose profound
risks to mental and emotional health. Over the past two decades, a surge of international research
has sought to unravel the extent and mechanisms by which these early adversities shape
psychological well-being across the lifespan. This section reviews empirical studies conducted
globally, emphasizing the psychological and behavioral consequences of ACEs while also
incorporating neurodevelopmental perspectives. The aim is to illustrate how different types and
accumulations of ACEs are consistently linked to emotional dysregulation, psychiatric disorders,
risky behaviors, and altered brain function in children, adolescents, and young adults.

Nguyen-Feng et al. (2025) analyzed a longitudinal cohort of 720 married Nepali women
(and their husbands) to see how childhood adversity affects later intimate partner violence
(IPV). At baseline, about 24% of women reported at least one ACE in their childhood. Over two
follow-up waves, psychological IPV was reported by roughly 28–37% of women. The
researchers used structural equation modeling and found that women’s own ACE exposure
predicted their later experience of psychological violence from husbands, even after controlling
for other factors. Men’s ACEs were linked to higher sexual and psychological IPV toward wives,
though women’s prior distress was more tightly tied to their own ACEs. Overall, greater
childhood adversity (for either partner) was associated with lower quality of life, lower self-
efficacy, and higher depression scores. In sum, this Nepalese study suggests that ACEs can
“echo” across generations: individuals who suffered childhood trauma are both more likely to
suffer partner violence and to perpetuate it. These findings reinforce Western trauma models in a
South Asian context, indicating that early adversity fosters a cycle of psychological and
relational problems in adulthood (Nguyen-Feng et al., 2025).
 2

In a recent Saudi study, Irshad and Lone (2025) found that university students exposed to
any ACEs reported significantly lower psychological well-being across autonomy, personal
growth, positive relations, and self-acceptance, as well as reduced emotional intelligence,
compared to students with no ACEs. The authors reported a graded effect: students with four
or more ACEs had the poorest well-being scores. Notably, emotional intelligence (including self-
and emotion-appraisal, regulation, and use of emotion) also declined with ACE exposure, and
mediated some well-being deficits. These findings align with a growing literature linking
childhood adversity to worse adult functioning, suggesting that ACEs undermine emotional skills
and well-being in emerging adults (Irshad & Lone, 2025).

Building on this, a U.S. longitudinal analysis by Russell et al. (2025) used the ABCD
study to identify clusters of childhood trauma experiences (including abuse, neglect, family
dysfunction, and community hardship) and examined their impact on youths’ mental
health and cognition over time. They found that distinct “ACE” patterns predicted different
developmental trajectories, for example, youth exposed to peer violence and family conflict
showed increasing internalizing and externalizing symptoms over time, whereas those facing
poverty or community threat showed relative decreases (perhaps reflecting adaptation).
Importantly, resource-deprivation adversities (e.g. poverty) were linked to steeper declines in
cognitive performance. In sum, this study underscores that any ACE exposure is associated with
worse outcomes, but different types of adversity can differentially shape emotional and cognitive
development (Russell et al., 2025). In particular, even relatively common adversity types led to
pronounced increases in both internalizing and externalizing problems by early adolescence,
reinforcing the broad psychological impact of ACEs.

Focusing on anxiety specifically, a large Chinese epidemiological study by Wang et al.

(2025) used network analysis to examine which ACE items most strongly drive adult anxiety.
They surveyed over 30,000 adults and found that “being insulted or cursed by parents” emerged
as the most central ACE in relation to anxiety symptoms. Simulated interventions in their
network model showed that reducing this one adverse experience would significantly lower
anxiety levels, suggesting its outsized importance. These results indicate that emotional abuse in
childhood (even over physical abuse) may be particularly potent in contributing to adult anxiety
 3

disorders (Wang et al., 2025). In other words, certain ACE subtypes (here, parental verbal abuse)
may have especially severe psychological effects.

In the longitudinal domain, Lyu et al. (2025) used data from 4,343 Chinese adults aged
60+, drawn from a national cohort, to examine how ACEs patterns relate to aging outcomes.
Using latent class analysis, they identified three ACE profiles (e.g. “polyvictimization,” “absent
parental care,” and low-ACE). Over four waves spanning 2011–2018, they modeled trajectories
of depressive symptoms and cognitive function. They found that those in the polyvictimization
group (multiple ACEs) experienced faster cognitive decline in later life compared to low-ACE
peers; this effect persisted after adjusting for demographics and later-life adversity. Depression
trajectories were not significantly different between groups. Thus, this study provides rigorous
longitudinal evidence (using growth models) that multiple early adversities accelerate cognitive
aging. It suggests that ACEs can have detectable impacts on the brain decades later, emphasizing
the importance of early identification of high-risk ACE profiles for eldercare (Lyu et al., 2025).

Neurodevelopmental effects of ACEs have been demonstrated in large pediatric cohorts.

For instance, Stinson et al. (2024) analyzed fMRI data from 2,868 U.S. preadolescents (ABCD
study) performing an inhibitory-control (Stop-Signal) task. Higher ACE scores (counting abuse,
neglect, and household dysfunction) predicted reduced BOLD activation in the bilateral pre-
supplementary motor area and the right inferior frontal gyrus during successful inhibition. Since
these regions underpin impulse control, the findings suggest ACE-related blunting of inhibitory
circuitry. The study further showed that less neural activation correlated with greater impulsivity,
implying long-term behavioral consequences. This longitudinal neurodevelopmental study
highlights how early adversity can alter brain function during adolescence, underscoring the need
for early ACE prevention (Stinson et al., 2024).

Longitudinal twin data confirm that these associations are not fully explained by genetic
or family background. In a Nordic twin cohort, Daníelsdóttir et al. (2024) examined Swedish
twins to adjust for familial confounders when linking ACEs to adult psychiatric diagnoses. They
found that even after controlling for shared genetics and family environment, individuals with
more childhood adversities (especially four or more ACEs) remained at significantly higher risk
of adult mood, anxiety, and substance-use disorders. Notably, sibling pairs in which one twin had
 4

ACEs and the other did not still showed that the “ACE-exposed” twin had worse mental health.
This powerful design indicates that ACE exposure has a direct effect on later mental illness,
beyond inherited risk (Daníelsdóttir et al., 2024). In particular, sexual abuse and cumulative ACE
count showed the strongest independent associations with adult psychopathology.

At the neural level, Keator et al. (2024) used brain SPECT scans to link ACE history with
adult brain function and psychiatric diagnoses in a large clinical samplev. They found that higher
ACE scores predicted increased resting activity in cognitive-control (frontal) and default-mode
networks, along with reduced activity in the dorsal striatum and cerebellum. These neural
changes were in turn associated with higher rates of adult anxiety, depression, and substance-use
diagnoses. Thus, this study suggests specific neurobiological pathways: ACEs may recalibrate
frontal and limbic systems, fostering vulnerability to later psychiatric disorders (Keator et al.,
2024). Importantly, it provides evidence that the “psychological” scars of ACEs (anxiety,
depression, addiction) are mirrored by measurable changes in brain function.

Complementing these clinical findings, Peltonen et al. (2024) used ecological

momentary assessment in adults to examine how ACEs relate to day-to-day emotional
experiences. Surprisingly, they found nonlinear effects: ACEs showed an inverted U-shaped
association with baseline level and variability of negative emotions and a U-shaped association
with baseline positive emotions. In practical terms, individuals with moderate ACE exposure
reported more stable negative mood and less positive mood than those with either very low or
very high ACE exposure. Moreover, high ACE was linked to greater variability in positive
affect. These nuanced results suggest that the impact of ACEs on adult emotion regulation is
complex and may depend on cumulative burden; moderate adversity may dampen emotional
responsiveness, whereas extreme adversity might lead to emotional blunting or different coping
patterns (Peltonen et al., 2024). Crucially, it shows that even routine affective dynamics in daily
life are altered by one’s ACE history.

Expanding beyond single findings, Ruge et al. (2024) provided a comprehensive

systematic review of dozens of neuroimaging and behavioral studies on childhood adversity
(threat/deprivation) and learning. Synthesizing human and animal research, they showed that
severe adversity (e.g. abuse) is reliably linked to altered threat and reward learning: victims of
 5

ACEs often show blunted physiological and neural responses to both threat and reward cues (e.g.
reduced amygdala reactivity to danger, blunted ventral striatal response to reward). The authors
argue that ACEs slow associative learning processes (both fear and reward conditioning) and
contribute to anhedonia and withdrawal in adulthood. This theoretical integration deepens the
conceptual understanding by linking ACEs to fundamental learning mechanisms; in effect, it
explains how early trauma may “undertrain” the brain’s alarm and reward systems. Such insight
could inform new interventions targeting these neural learning deficits (Ruge et al., 2024).

The adverse psychological impact of ACEs is especially evident in suicidality and

self-harm. In a nationwide survey of ~96,000 Chinese adolescents, He et al. (2024) found a clear
dose response: adolescents with ≥4 ACEs had roughly 30% higher prevalence of no suicidal self-
injury (NSSI; PR≈1.31) and about 40% higher prevalence of suicidal ideation (PR≈1.41) and
attempts (PR≈1.25) compared to those with none. Even 1–2 ACEs were linked to increased NSSI
(PR≈1.06) and suicidality. The study highlighted that threat-related ACEs – physical or
emotional abuse and bullying had the strongest associations with these outcomes. Notably, a
supportive school environment buffered some effects, suggesting protective contexts can
mitigate risk. Overall, they provided compelling evidence that cumulative childhood adversity
greatly raises risk for adolescent self-harm and suicide-related behaviors, especially when the
adversity involves interpersonal threat.

Similarly, Trompeter et al. (2024) examined early adolescents (ages 9–10) in the U.S. and
reported that both ACEs and peer bullying independently predicted higher internalizing and
externalizing problems by ages 11–13 Using ABCD data (n≈8,000), they found no significant
interaction between ACEs and bullying, implying an additive “cumulative risk” effect. In other
words, children who experienced household adversity and peer victimization had the worst
behavioral outcomes. This study confirms that even in late childhood, multiple forms of
adversity (home and school) each contribute to emotional and behavioral problems (Trompeter et
al., 2024). Their findings reinforce a theme: exposure to multiple ACEs is linked to a broad
range of youth psychopathology, and these effects emerge early in development

Beyond internalizing symptoms, ACEs also predict externalizing behaviors and risky
conduct. In Australia, Gautam et al. (2024) used longitudinal data to show that children exposed
 6

to various adversities (physical punishment, hostile parenting, parental conflict, financial

hardship, parental mental illness) had higher incidence of both externalizing and internalizing
problems and lower prosocial behavior. Importantly, they observed a dose-response: for
example, each ACE roughly doubled the incidence of externalizing behaviors (one ACE:
IR≈1.69) and four ACEs more than tripled it (IR≈3.34). Similar trends held for internalizing
problems and social competence. These results underscore the cumulative nature of risk:
multiple ACEs amplify a child’s likelihood of behavioral issues, in line with many past studies
(Gautam et al., 2024).

In Japan, Sasaki et al. (2024) extended the ACE framework by including school
bullying, childhood poverty, and disasters, surveying over 28,000 adults They found 14.7%
had ≥4 ACEs, and those adults had dramatically elevated odds of severe psychological
distress (Kessler-6 ≥13); specifically, four or more ACEs corresponded to an ~8.2-fold higher
risk of high distress. Bullying was one of the strongest predictors across all age groups, even
more than household poverty. This large population-based study reinforces that expanded
definitions of ACEs continue to show robust links with adult mental health problems. Combined
with other findings, it highlights that the ACE–distress association is not limited to Western
samples but is a global phenomenon (Sasaki et al., 2024).

Consistent with these epidemiological findings, clinical samples show severe outcomes
after ACE exposure. For example, Giampetruzzi et al. (2023) studied adults with treatment-
resistant depression and found those with ≥3 ACEs had significantly worse depressive
symptoms and outcomes than those with none. Violent or injury-related ACEs, as well as
parental illness, predicted greater symptom severity, and sexual trauma specifically predicted
higher rates of suicide attempts and hospitalizations. In other words, this depressed cohort
showed a dose-effect of ACEs on illness severity, with certain ACEs portending especially poor
prognoses (Giampetruzzi et al., 2023).

ACEs also affect interpersonal behaviors and risk-taking. In an Indian cohort (ages
13–23), Maurya and Maurya (2023) found that adolescents with ≥3 ACEs had dramatically
higher odds of early sexual activity (boys OR≈2.04; girls OR≈13.13). Substance use was
common: one-third of boys (vs ~7% of girls) used drugs/alcohol. Boys also showed high rates of
 7

violence (30%) relative to girls (10%). These gender differences suggest cultural and social
factors interact with ACE effects. Importantly, the linkage between high ACE count and risk
behaviors like early sex was huge (especially for girls), indicating that childhood trauma may
propel youth toward unsafe behaviors (Maurya & Maurya, 2023).

On a cognitive/neurodevelopmental note, Koponen et al. (2023) used Finnish registers to

examine neurodevelopmental disorders (NDDs) in youth with and without prenatal
substance exposure. They found that any ACE indicator (e.g. familial adversity or out-of-home
care) was strongly associated with NDD diagnoses such as ADHD, conduct disorder, emotional
disorders, and learning disabilities. For example, among children with Fetal Alcohol Spectrum
Disorders, those with ACEs had much higher rates of comorbid NDDs. This suggests ACEs
increase the risk for neurodevelopmental conditions in a broad sense (Koponen et al., 2023). In
other words, early trauma appears to compound developmental vulnerabilities, possibly via
altered brain and stress-system trajectories.

Brain imaging in children provides supporting evidence. Buimer et al. (2022)

examined ~1,200 Dutch children (8–11 years old) and related parent-reported ACEs to
brain structure (MRI). They found that household substance abuse was associated with larger
cortical surface area in several prefrontal regions, whereas exposure to family violence was
linked to reduced white-matter integrity (fractional anisotropy) in the hippocampal cingulum.
These structural differences suggest that distinct ACEs leave distinct neural footprints even in
childhood. Such findings link early adversity to altered neurodevelopment, consistent with the
observed behavioral effects.

Finally, ACEs adversely affect broader social functioning. In Germany, Bürgin et al.
(2023) showed that adults with higher ACE exposure reported lower perceived social
participation and poorer health-related quality of life. Using latent-class analysis, they found that
people with multiple ACEs were less engaged in community life and experienced more distress.
This broadens ACE impact beyond mental illness to include real-world functioning: childhood
trauma undermines one’s ability to participate socially and enjoy life even decades later (Bürgin
et al., 2023).
 8

Across these studies, connections are clear: most find a strong, graded relationship
between ACE burden and negative outcomes. For instance, a landmark meta-analysis by Hughes
et al. (2017) reported that individuals with ≥4 ACEs (vs none) had dramatically higher odds of
depression (OR≈3.5) and suicide attempts (OR≈12), among other health risks. This meta-
analysis synthesized dozens of studies and concluded that multiple ACEs are a major risk factor
for lifelong health problems. The consistent pattern is that more ACEs mean worse outcomes in
psychological, behavioral, and to some extent cognitive domains.

As the original ACE study by Felitti et al. (1998) famously demonstrated, even
fourfold increases in depression and suicide attempts were observed among individuals
with four or more childhood adversities. In that U.S. cohort, ACE count showed graded
relationships with almost every adult risk factor. Over two decades later, the international studies
reviewed here have only reinforced Felitti’s findings, showing that ACEs predict adverse adult
emotional and behavioral trajectories across cultures.

The international research overwhelmingly supports a consistent, dose-dependent

association between adverse childhood experiences and a wide spectrum of negative
outcomes in psychological, behavioral, and neurodevelopmental domains. From large
epidemiological studies to neuroimaging and longitudinal cohort research, the evidence affirms
that exposure to multiple ACEs significantly elevates the risk of depression, anxiety, suicidality,
emotional dysregulation, substance abuse, and impaired social functioning. While certain types
of adversity, such as emotional abuse or parental mental illness may exert more severe or
enduring effects, even lower levels of exposure can leave lasting imprints. Notably, these
patterns emerge across cultural contexts and developmental stages, reinforcing the universal
relevance of the ACE framework. Collectively, the literature not only deepens our understanding
of how trauma shapes the psyche but also highlights the urgent need for early interventions,
trauma-informed care, and policies aimed at mitigating the lifelong consequences of childhood
adversity.

Fear of intimacy (FOI) has emerged as a significant psychological construct associated

with emotional avoidance, relational anxiety, and disrupted interpersonal functioning. Defined as
the apprehension or discomfort in forming close emotional or physical bonds, FOI is increasingly
 9

studied across clinical and non-clinical populations. International research highlights its strong
connections with attachment insecurity, childhood trauma, emotional regulation difficulties, and
social anxiety. This section reviews empirical studies from various cultural contexts, examining
how FOI is shaped by psychological vulnerabilities and interpersonal dynamics, and how it
manifests across relationships and developmental stages. The aim is to uncover both individual
and relational factors that contribute to intimacy avoidance in diverse populations.

Hariza Ahmiela’s 2025 study in Indonesia examined married young adults (ages 20–
40) and found that rejection sensitivity strongly predicted fear of intimacy. Using the Adult
Rejection Sensitivity Questionnaire and the Fear-of-Intimacy Scale, Ahmiela reported that higher
rejection‐sensitivity scores were associated with significantly higher FOI (regression β≈1.265,
p<.001). In other words, young married individuals anxious about being rejected were more
likely to avoid emotional closeness. This finding underscores how interpersonal anxiety about
rejection can inhibit intimacy, extending prior work on rejection sensitivity in other contexts.
Ahmiela also noted that, on average, the sample reported good partner intimacy, suggesting that
FOI is especially linked to individual vulnerability (rejection‐anxious traits) within relationships.
These results parallel Giovazolias and Paschalidi’s (2022) report (in Greece) that rejection
sensitivity increases FOI via heightened social anxiety (especially for women), emphasizing a
consistent link across cultures.

Leite and Azevedo’s 2025 validation study in Portugal adapted the Fear-of-Intimacy
Scale (FIS) for Portuguese adults and examined its correlates. They confirmed a one‐factor FIS
structure and tested associations with sociosexual orientation (attitudes, desires, and behaviors
regarding casual sex). Notably, FOI was positively correlated with sociosexual desire and
attitudes – that is, Portuguese adults higher in FOI reported a stronger desire for
uncommitted sex and more permissive attitudes toward casual sex. However, FOI did not
correlate with actual sociosexual behavior (number of casual partners). Leite et al. suggest this
pattern may reflect an avoidant strategy: those fearful of emotional closeness may fantasize
about detached, low‐commitment sex (high desire/attitude) but may actually avoid even casual
encounters that could lead to intimacy. These findings highlight how cultural norms (here,
Portuguese) intersect with FOI: intimacy avoidance coexists with sexual openness in fantasy or
attitude, indicating complex sociosexual coping. This study builds on work linking FOI with
 10

interpersonal behavior (e.g., Body Image & Clin Psychol, 2004) by showing that FOI can
paradoxically align with desire for detached sex, a novel sociocultural insight.

Finzi‐Dottan et al. (2024) conducted a path‐analytic study in Israel occupied phalastine of

young adults (in relationships) to test how childhood emotional abuse leads to FOI via
attachment insecurity and rejection sensitivity. They found that higher recalled emotional
abuse predicted higher FOI, and this effect was fully mediated by insecure attachment (both
anxious and avoidant styles) and heightened rejection sensitivity. In other words, adults who
experienced more childhood abuse tended to develop insecure attachments and fear rejection,
which in turn increased their FOI. This study extends earlier trauma research by explicitly
modeling the psychological pathway. It echoes Thelen et al. (1998), who found rape survivors
(trauma) reported higher FOI and less comfort with closeness. Finzi‐Dottan et al. note that
interventions should target earned security (repairing attachment) to reduce FOI. The 2024
findings thus conceptually reinforce the long‐standing view (e.g. Descutner & Thelen, 1991) that
early relational trauma undermines later intimacy.

Quan et al. (2024) explored how ACEs affect romantic satisfaction among Chinese
college students, with an emphasis on mediators. In a large survey of 1,404 students, they
measured childhood trauma (abuse/neglect), adult attachment style, social support, and current
relationship satisfaction. They found that greater childhood trauma significantly predicted lower
satisfaction in romantic relationships. This effect was partially mediated by attachment
insecurity: trauma led to more avoidant/anxious attachment, which reduced satisfaction. Social
support also played a moderating role: higher perceived support buffered (somewhat
unexpectedly by strengthening an attachment link) the impact of trauma on attachment. Their
moderated mediation analysis underscores that one reason trauma impairs adult intimacy is via
its damage to attachment security and trust in relationships (Quan et al., 2024).

Anand and Sinha (2024) surveyed 200 Indian college students to examine social anxiety
as a correlate of FOI. They found a significant positive correlation between social anxiety
scores and FOI (r≈.48, p<.01), and regression showed social anxiety predicted higher FOI. This
means socially anxious young adults (fearing negative evaluation) were more likely to avoid
emotional closeness. No gender differences emerged. These results align with Obeid et al. (2020)
 11

in Lebanon, who also found that social phobia was a significant predictor of FOI. In both
studies, general anxiety about social interaction translates into intimacy avoidance. Anand and
Sinha suggested that therapy addressing social anxiety and self-confidence might reduce FOI in
this age group. This work confirms a thematic progression: earlier work (Descutner & Thelen,
1991) noted trait anxiety’s role in FOI, and Anand & Sinha provide contemporary evidence that
social anxiety, specifically, is a key correlate of FOI.

Maitland and Neilson (2023) examined FOI in the context of depression and
behavioral activation theory. In a cross-sectional survey of 353 U.S. college students, they
measured fear of intimacy, depression, and factors like social support and activity levels. Using
structural equation modeling, they found that FOI was directly and indirectly associated with
depressive symptoms. Specifically, fear of intimacy predicted lower behavioral activation and
lower perceived environmental reward, which in turn predicted higher depression. In other
words, individuals with FOI engaged less in rewarding social activities, amplifying depression
risk. This study highlights FOI as an important individual-difference variable in depression
models: it suggests that reluctance to engage deeply in relationships may reduce reinforcement
from the social environment, thereby contributing to depression. The authors propose
incorporating strategies to overcome FOI (e.g. self-disclosure exercises) into behavioral
activation therapy to improve outcomes (Maitland & Neilson, 2023).

Lyvers et al. (2022) examined 158 Australian adults in ongoing relationships to test
how alexithymia (difficulty identifying feelings) relates to relationship satisfaction via FOI
They found alexithymia predicted lower couple satisfaction, mediated by FOI and negative mood
In other words, individuals who struggle to understand their emotions tend to develop FOI (and
negative affect), which then lowers relationship satisfaction. This aligns with Scigala et al.
(2021) who showed that alexithymia in gay/lesbian adults predicted lower self‐differentiation
(sense of self) partly through FOI and insecure attachment. Both studies highlight that impaired
emotion regulation fosters FOI, which in turn harms relational outcomes. Lyvers et al.
recommend addressing alexithymia (e.g. emotion-focused therapy) to break the FOI–satisfaction
link. This extends earlier work (Besharat et al., 2014) on alexithymia and marriage by identifying
FOI as a specific mechanism.
 12

Scigala et al. (2021) surveyed 258 Italian LGBTQ+ adults (age 20–50) to test a model
linking alexithymia, FOI, insecure attachment, and self‐differentiation (individual autonomy).
Results showed alexithymia predicted lower self‐differentiation both directly and indirectly
through FOI and insecure attachment. That is, participants with greater emotion‐processing
deficits reported higher FOI, which in turn was associated with feeling less individuated within
relationships. FOI itself had a direct negative effect on self‐differentiation. This study connects
the dots between emotion regulation and FOI in a sexual‐minority sample, consistent with
Lyvers et al. (2022). It also echoes Brandão et al. (2019)’s finding that avoidant attachment
(common in alexithymia) is linked to FOI and emotional suppression. Together, these studies
map a chain: alexithymia → insecure attachment / FOI → relational impairment.

Senese et al. (2020) investigated 635 Italian adults to test how recollections of parental
rejection in childhood relate to adult FOI. Using path analysis, they found that perceived
parental rejection (in childhood) was indirectly linked to higher FOI in adulthood, fully mediated
by current psychological maladjustment. Maladjustment factors included emotional
unresponsiveness, low self‐esteem, and interpersonal dependency. In practical terms, early
rejection impaired self‐worth and emotional availability, which led to fear of closeness later.
This model was not moderated by gender. These findings resonate with Finzi‐Dottan et al.
(2024) and Thelen et al. (1998): early family-related trauma (abuse or rejection) sets a
foundation for insecure attachment and avoidance of intimacy. Senese et al. emphasize
interventions to boost self‐esteem and emotional connectedness as ways to counter FOI rooted in
early rejection.

Obeid et al. (2020) conducted a large survey of 707 Lebanese adults to identify FOI
correlates. In multiple regression, higher FOI was independently predicted by social phobia,
dismissing (avoidant) attachment style, and various maladaptive cognitive schemas:
defectiveness, mistrust/abuse, vulnerability, emotional deprivation, and failure. Conversely,
lower FOI was associated with higher self-esteem. In short, Lebanese individuals who feared
intimacy tended to also fear social evaluation, distrust others, feel chronically unsafe or
unlovable (schema themes), and reported an avoidant attachment orientation. This mirrors
Western findings: e.g., Brandão et al. (2019) found avoidant attachment linked to FOI and
Besharat et al. (2014) linked FOI with insecure attachments and poor satisfaction. Obeid et al.
 13

extend these results cross-culturally, highlighting cognitive schemas as additional mechanisms:

FOI may be fueled by beliefs of unworthiness or abandonment. They suggest schema therapy to
address FOI in such contexts.

Brandão et al. (2019) studied 482 Portuguese couples (partners of each other) to
examine intrapersonal and interpersonal links among attachment, emotion regulation, and
FOI. They confirmed that individuals with higher attachment avoidance also reported greater
FOI and tended to suppress emotions (view emotional expression as weakness). Intriguingly,
they also found interpersonal effects: one partner’s attachment anxiety predicted the other’s FOI
and reduced emotional openness. Brandão et al. note that avoidantly attached persons interpret
emotional disclosure as a threat to autonomy, causing FOI and emotional withdrawal. This study
adds to earlier work by showing FOI is not only an intrapersonal trait but also an interpersonal
process within couples. It fits with Senese et al. (2020) and Scigala et al. (2021) in portraying
FOI as a downstream effect of attachment insecurity and poor emotion regulation.

Besharat et al. (2014) surveyed 688 Iranian married students and found that fear of
intimacy and alexithymia were both significantly negatively correlated with marital
satisfaction. Secure attachment was positively correlated with satisfaction, whereas insecure
styles, FOI, and alexithymia were inversely correlated. Critically, they found that avoidant
attachment moderated the FOI. In evidently attached individuals, FOI was a stronger detriment
to marital happiness. These results highlight that FOI undermines marital quality, especially
when coupled with dismissive attachment. This complements Senese et al. (2020) and Brandão
et al. (2019) by framing FOI within relational outcomes. It also foreshadows Lyvers et al. (2022)
and Scigala et al. (2021) by implicating alexithymia as a factor upstream of FOI, and shows that
these dynamics hold across cultures (Iranian vs. Western samples).

Terrell et al. (2000) conducted an early U.S. study of 80 college students to test how
parental teaching to distrust strangers related to FOI and loneliness. They found that students
whose parents strongly discouraged trusting strangers in childhood reported significantly
higher FOI in adolescence. Moreover, distrust-taught females reported more loneliness than all
other groups. This suggests that early social mistrust teachings (a form of sociocultural
conditioning) foster FOI and social isolation. Terrell et al. thereby demonstrated a
 14

sociocultural/interpersonal pathway to FOI: not only trauma or attachment per se, but even
parental advice (“don’t trust others”) can shape intimacy anxiety. This finding foreshadows later
work by Davis et al. (2001) and Senese et al. (2020) on childhood factors.

Finally, Thelen, Sherman, and Borst (1998) provided classic evidence linking trauma
to FOI. In a clinical sample of rape survivors (vs. non-traumatized controls), rape survivors
reported significantly greater fear of intimacy and less comfort with closeness. They also
reported lower trust in others and more fear of abandonment (dimensions of attachment).
Importantly, most of these group differences diminished when controlling for trait anxiety,
suggesting that underlying anxiety drives FOI. Thelen et al.’s study was among the first to
empirically connect severe interpersonal trauma to FOI and insecure attachment. Its themes –
trauma, anxiety, and intimacy avoidance recur in all the studies above. In sum, the literature
from 1998 to 2025 consistently shows that insecure attachment (especially avoidant), emotional
trauma or anxiety (social or trauma‐related), and difficulties with emotional regulation
(alexithymia) are each robustly associated with higher fear of intimacy. Together, these studies
chart a thematic progression: early work identified basic links of FOI to attachment and anxiety,
and newer research has elaborated the mediating mechanisms (e.g., maladjustment, rejection
sensitivity) and broader contexts (cultural norms, sociosexual patterns) in which FOI arises.

The reviewed international literature offers robust evidence that fear of intimacy is a
multifaceted construct intricately linked to early relational experiences, emotional regulation
capacities, and attachment styles. Studies consistently demonstrate that individuals with histories
of childhood trauma, emotional neglect, or insecure attachments are more likely to develop
intimacy-related fears. Moreover, constructs like alexithymia, social anxiety, and maladaptive
cognitive schemas further exacerbate this fear, often leading to interpersonal withdrawal and
reduced relationship satisfaction. While cultural norms shape the expression of FOI, its
psychological underpinnings appear globally consistent. Together, these findings underscore the
importance of addressing FOI within therapeutic contexts, particularly by targeting attachment
repair, emotional processing, and self-worth enhancement to promote healthier, more connected
relationships.
 15

Hyper-independence is increasingly conceptualized as a trauma-driven coping style

characterized by avoidant self-reliance, withdrawal from intimacy, and fear of dependence. In a
recent Hungarian study, Szeifert et al. (2025) used a cross-sectional adult sample to show that
insecure (especially avoidant) adult attachment mediated the link between early trauma and
suicidal behavior. They found that avoidant attachment was associated with emotional
suppression and reluctance to seek support, effectively amplifying feelings of hopelessness. In
other words, trauma-exposed individuals with avoidant attachment tended to withdraw into
hyper-independent self-reliance, foregoing social support and emotional expression, which in
turn heightened their suicide risk. This finding highlights how early ACEs can engender a fear of
intimacy and a defensive autonomy style that manifests in later psychopathology (Szeifert et al.,
2025).

Gomis-Pomares et al. (2025) reported convergent evidence in a Spanish sample of 420

young adults. They used fuzzy-set qualitative analysis and regression to identify that the worst-
case scenario for internalizing problems was the combination of high ACE exposure and high
use of avoidant emotion-focused coping. In particular, Spanish women with multiple ACEs
who relied heavily on avoidant coping (e.g. denial, disengagement) were most likely to report
depression, anxiety, and stress symptoms. This suggests that trauma-driven self-reliance
(manifest as avoidant coping) significantly compounds the emotional burden of ACEs. In
practice, those survivors who become “hyper-independent” –distancing themselves and refusing
help appear to lose critical buffers against stress, magnifying internal distress (Gomis-Pomares et
al., 2025).

Madigan et al. (2025) extended this work to an intergenerational domain. In a large

longitudinal cohort (1,994 mother-child dyads, mainly North American), maternal ACEs
predicted poorer child internalizing and externalizing outcomes partly via maternal attachment
patterns. Specifically, women with greater ACEs tended to show higher adult attachment
avoidance (and anxiety), which in turn was associated with more depressive symptoms and lower
relational support. These insecure maternal attachment tendencies mediated the effect of
maternal trauma on the next generation’s mental health. In other words, mothers scarred by
ACEs often adopted defensive autonomy and emotional withdrawal (avoidant style), which
limited emotional availability and may have fostered maladaptive coping patterns in their
 16

children. This finding highlights how trauma-driven self-reliance in caregivers can

indirectly perpetuate risk trauma begets hyper-independence in one generation that then
impacts the emotional development of the next (Madigan et al., 2025).

In a large German community survey (N=2,245 adults), Eggert et al. (2024) explicitly
tested the role of avoidant coping in ACEs outcomes. They found that adults with histories of
childhood neglect had significantly higher depressive symptoms, and that this association
was mediated by avoidant coping behaviors. Three facets of avoidant coping – substance use,
behavioral disengagement, and self-blame accounted for the link between neglect and
depression. Notably, self-blame (an inward-avoidant strategy) had the strongest indirect effect.
These results indicate that those who experienced emotional neglect often cope by withdrawing
emotionally and blaming themselves rather than seeking help, reinforcing a hyper-independent
stance. The finding underscores that trauma-driven avoidance (as opposed to anxiety or support-
seeking) can lock individuals in a cycle of isolation and depression (Eggert et al., 2024).

Islam et al. (2022) further demonstrated the autonomy-impairing sequelae of ACEs in a

sample of Bangladeshi women. In a cross-sectional study (N=426), women with more
childhood maltreatment were less likely to make autonomous decisions in adulthood.
Critically, this effect was mediated by the women’s self-esteem and social support: maltreated
women had lower self-esteem and fewer supportive relationships, which in turn explained their
reduced decision-making autonomy. This suggests that ACEs undercut trust in others and belief
in one’s own worth, paradoxically undermining rather than enhancing independence. When
individuals internalize trauma as betrayal or failure, they may both avoid dependence on others
and simultaneously lose confidence in their own autonomy, resulting in a “defensive autonomy”
style that resembles hyper-independence.

Morison and Benight (2022) linked adult attachment with trauma outcomes via self-
efficacy. In a U.S. college sample with ACE exposure, they found that both anxious and avoidant
attachment predicted poorer trauma coping self-efficacy, which then predicted more PTSD
symptoms six weeks later. In other words, even individuals with a dismissive-avoidant style
(high self-view but low trust in others) reported lower confidence in their ability to handle
trauma, resulting in more severe symptoms. This challenges any notion that hyper-
 17

independence protects one from trauma. Instead, avoidant adults’ self-reliance is fragile:
lacking social support and compassion, they undermine their coping, intensifying PTSD.
Thus, avoidant attachment (a proxy for trauma-driven self-reliance) undermines resilience and
fosters worse outcomes (Morison & Benight, 2022).

Leung et al. (2022) took a qualitative approach to examine how self-reliance shapes
resilience in ACE survivors. Reviewing qualitative studies of 479 adults from Hong Kong and
Minnesota, they found that emerging adults frequently cited emotional self-reliance as a major
influence on resilience after ACEs. Interestingly, while self-reliance sometimes conferred a sense
of strength, it simultaneously deterred self-compassion and inhibited seeking social support. The
authors note this double-edged nature: trauma survivors often “learn to rely on themselves” as a
survival skill, but this prevents them from utilizing help when available. This qualitative
synthesis highlights that hyper-independence can be adaptive in adversity but ultimately hinders
recovery by exacerbating emotional withdrawal. Leung et al. argue that fostering balanced self-
trust and openness to support is critical for healing after ACEs.

Cao et al. (2022) empirically traced indirect paths linking maltreatment to adult
symptoms in Chinese college students. They found that childhood maltreatment was
associated with worse psychological symptoms, and this effect operated through coping
style and resilience. Specifically, maltreatment predicted less adaptive coping (presumably more
avoidant coping) and lower resilience, which then predicted greater depression and anxiety. This
parallels findings that trauma prompts rigid, avoidant coping styles that erode adaptive resilience.
Their structural equation model confirmed that the impact of early abuse and neglect on adult
mental health was largely mediated by these psychosocial factors. In sum, Cao et al. highlight
that trauma-driven reliance on maladaptive coping (akin to hyper-independence) diminishes
resilience, leaving survivors more vulnerable to long-term symptoms (Cao et al., 2022).

Tanzer and Salaminios (2020) examined emotional coping in neglected adolescents. In a

UK community sample (N=123, age ~16), they showed that severity of childhood neglect was
positively associated with internalizing symptoms (depression, anxiety) and with use of self-
blame as an emotion regulation strategy. Crucially, the link between neglect and internalizing
was partially mediated by self-blame coping. In other words, teens who had been emotionally
 18

neglected turned anger or pain inward, blaming themselves instead of seeking help. This
tendency to withdraw emotionally and assume self-reliance for suffering is conceptually aligned
with hyper-independence. The study suggests that neglect can instill a harmful belief of “I
alone must fix my pain,” which fosters internal struggles and prevents supportive
engagement. Even in non-clinical youth, trauma-driven cognitive avoidance (self-blame)
marked the pathway from ACEs to psychiatric symptoms (Tanzer & Salaminios, 2020).

Sheffler and Piazza (2019) also highlighted the role of avoidant coping in the ACEs
literature. Using longitudinal data from the CDC-Kaiser Permanente ACE Study cohort, they
found that higher ACEs predicted greater use of avoidant/emotion-focused (AEF) coping two
decades later, which in turn predicted worse physical health and psychiatric outcomes. That is,
adults who reported more ACEs tended to habitually cope by distraction, denial, or
disengagement, rather than seeking support or problem-solving. This maladaptive coping
partially explained why ACEs led to chronic health problems. The authors emphasize that
reducing avoidant coping could be a key intervention point to break the link from childhood
trauma to adult morbidity. Their findings reinforce that ACEs often “train” individuals into
hyper-independent coping patterns that harm long-term well-being (Sheffler & Piazza, 2019).

Weiss et al. (2018) studied a high-risk sample of 212 U.S. women with intimate partner
violence (IPV) histories, most of whom had childhood abuse. They found that greater severity of
childhood sexual abuse predicted higher avoidant coping, which in turn was linked to increased
HIV/sexual risk behaviors. In other words, women with abusive childhoods tended to withdraw
emotionally and avoid processing trauma, and this coping style was associated with engaging in
unprotected sex or other risky behaviors. The authors interpret avoidant coping as reflecting
a general withdrawal and self-reliance theme; these survivors may seek to regain control
through hyper-independent acting-out. This study underscores that avoidant coping (a facet of
hyper-independence) can translate childhood trauma into tangible health risks decades later
(Weiss et al., 2018).

Unger and De Luca (2014) provided evidence from a matched U.S. sample (N=1,460)
linking specific maltreatment types to adult attachment. They found that childhood neglect was
positively associated with adult avoidant attachment, whereas childhood abuse predicted anxious
 19

attachment Importantly, both avoidant and anxious attachment in adulthood predicted worse
mental health (depression, anxiety, low self-esteem). This means that adults who had been
neglected as children tended to develop defensive autonomy (avoidant style) as a relationship
strategy, which was then associated with higher emotional distress. Even decades after
maltreatment, avoidant attachment mediated the effect of early neglect on poor outcomes,
aligning with the idea that childhood trauma can instill a lifelong self-reliant, emotionally
withdrawn stance (Unger & De Luca, 2014).

Collectively, these international studies depict a coherent picture: adverse childhood

experiences frequently foster an avoidant/dismissive coping style, a form of hyper-
independence marked by emotional withdrawal and reluctance to depend on others. Such
trauma-driven self-reliance has been observed in diverse cultures and methodologies – from
structured surveys to qualitative interviews. Across studies, avoidant attachment and coping
mediate the link between ACEs and outcomes as varied as depression, PTSD, suicidal behavior,
and risky sexual behavior. While sometimes framed as resilience, the research shows that
extreme autonomy often impedes recovery by severing social support and self-compassion.
These empirical findings underscore the concept that hyper-independence can be both an
adaptation to early caregiving failures and a barrier to healing.
 20

Indigenous Literature

While the global literature has established the profound psychological and behavioral
consequences of Adverse Childhood Experiences (ACEs), understanding their local expression
in culturally specific contexts is critical. In Pakistan and the broader South Asian region, family
dynamics, collectivist norms, and social taboos around abuse and mental illness shape how
ACEs are experienced, internalized, and reported. Indigenous research in this region increasingly
highlights that ACEs are both alarmingly common and significantly associated with mental
distress, emotional dysregulation, risky behaviors, and intergenerational effects. This section
reviews empirical studies conducted primarily in Pakistan, supplemented by regional
evidence from India, Bangladesh, and Iran, to explore how early adversity influences the
mental and emotional development of young individuals within these sociocultural
frameworks.

Rahman et al. (2025) surveyed 858 Bangladeshi university students to examine links
between ACEs and current mental health. Using the CDC ACE scale along with the GAD-7 and
PHQ-9, they found that 54.1% of students had experienced at least one ACE by age 18.
Consistent with global trends, those with more ACEs were far more likely to report moderate-to-
severe anxiety and depression: each additional ACE raised the odds of anxiety by ~27% and
depression by ~19%. For example, students with ≥4 ACEs had dramatically higher rates of mood
symptoms than those with none. Rahman et al. conclude that ACEs are common in Bangladesh
and powerfully predict young adults’ mental health outcomes, underlining the need for early
intervention and trauma-informed services in South Asia (Rahman et al., 2025).

Similarly, a survey of Pakistani medical students found pervasive ACE exposure and
important health effects. Ali et al. (2025) assessed 368 students’ ACEs and childhood protective
factors (resilience) in a public university. Median ACE scores were moderate and did not differ
by sex. In multivariable models, ACEs significantly predicted poorer self-reported mental health
(but not physical health), whereas higher protective-factor scores predicted better mental and
physical health. In other words, medical students with more childhood adversity reported more
psychological problems, while those with strong family and community support reported better
overall health. This suggests that in Pakistan, like elsewhere, early trauma can impair
mental wellbeing, but resilience factors may mitigate these effects (Ali et al., 2025).
 21

Likewise, Mahmood and Fatmi (2025) documented extremely high ACE prevalence in
Pakistani youth. In their sample of 183 college students, 98% reported ≥1 ACE and 82%
reported three or more. The most common adversities were witnessing community violence
(88%), peer violence (83%), and household violence (73%). Critically, students with six or more
ACEs had over 3-fold higher odds of inadequate current mental wellbeing. In sum, nearly
universal childhood adversity was found, and heavy ACE exposure was robustly linked to poorer
psychological status among young adults (Mahmood & Fatmi, 2025).

Shakeel et al. (2024) conducted a large cross-sectional survey of college students in

Lahore to quantify how common ACEs are and how they relate to later health problems.
Using a standardized ACE questionnaire and health history checklist, they found that over 90%
of participants reported at least one childhood adversity and 82% had three or more. Community
violence, domestic violence, and household dysfunction were especially prevalent. Importantly,
higher ACE scores were associated with greater burden of chronic diseases (e.g. asthma,
diabetes) and more psychological distress. The researcher even estimated the direct healthcare
costs attributable to childhood adversity in Pakistan (on the order of hundreds of dollars per
person). These findings highlight that ACEs are nearly present among Pakistani youth and carry
a heavy long-term health and economic burden (Shakeel et al., 2024).

Recent indigenous scholarship from the School of Professional Psychology at the

University of Management and Technology (UMT), Lahore, has contributed significantly to
understanding the psychological effects of Adverse Childhood Experiences (ACEs) within
Pakistan. One notable study by Tariq and Tariq (2024) examined the relationship between
ACEs, self-blame, and criminogenic cognitions among university students. The study
revealed that while ACEs were moderately prevalent among students, self-blame played a
mediating role in shaping criminogenic thought patterns. The researchers emphasized the
influence of cultural norms on self-perception, concluding that ACE exposure indirectly fosters
maladaptive cognitive styles that may influence antisocial thinking patterns in emerging adults
(Tariq & Tariq, 2024).

Fatima et al. (2024) used qualitative interviews to explore these impacts in depth.
Pakistani university students with ACE histories described enduring anxiety, mistrust, and social
 22

problems stemming from childhood trauma. Themes included chronic health complaints, mood
disorders, paranoia and distrust, and poor academic performance. Participants reported inability
to focus in class, chronic worry in relationships, and ongoing behavioral problems. The authors
concluded that ACE survivors in Pakistan carry long-term negative effects on their mental and
physical health, highlighting how early adversity undermines young adults’ ability to thrive
(Fatima et al., 2024).

Frost et al. (2024) examined even younger children in rural Pakistan. Astonishingly,
90.5% of 6-year-olds had experienced one or more traumatic events. Common events were
loss of a loved one (47%) or hearing about war on TV (48%). Trauma exposure was higher in
boys (mean 3.00 events) than girls (2.67). Crucially, number of traumas was linked to worse
child mental health: higher total trauma correlated with increased behavioral problems and
anxiety scores. In contrast, little effect was seen on cognitive test performance. Thus, even very
young Pakistani children show pervasive ACEs, which are already associated with poorer
psychological outcomes (Murthy et al., 2024).

Chung et al. (2023) investigated intergenerational effects of maternal ACEs in

Pakistan. In this rural cohort, 58% of mothers reported at least one ACE. Surprisingly, maternal
ACEs were associated with higher child fine motor and receptive language scores but worse
socioemotional/behavioral outcomes at 36 months. That is, children of mothers with childhood
adversity scored slightly better on developmental tests yet exhibited more emotional and
behavioral problems. These nuanced findings suggest maternal ACEs complexly influence child
development: while perhaps some cognitive skills were higher, the children faced more
internalizing symptoms. The authors note this “intergenerational” pattern underscores that a
mother’s trauma history can shape both neurodevelopmental and behavioral aspects of her child
(Chung et al., 2023).

Within Pakistan, Ikram et al. (2022) examined women’s physiological stress responses.
Among 120 rural Pakistani women, higher ACE exposure (across family violence, abuse,
etc.) was linked to higher self-reported stress and anxiety. Notably, ACEs were also associated
with elevated hair cortisol (a biomarker of chronic stress); home and community violence
exposures predicted the highest cortisol levels. Thus, Pakistani women with significant
 23

childhood adversity showed both psychological distress and altered HPA-axis activity,
suggesting enduring neuroendocrine effects of ACEs. The study underscores that childhood
trauma leaves biological “scars” manifesting as increased stress reactivity (Ikram et al., 2022).

Earlier research by Saleem and Mahmood (2021) focused on the development of a

culturally grounded assessment tool to evaluate emotional and behavioral problems in
Pakistani school aged children. This indigenous scale was designed to address gaps in clinical
diagnostics and improve the early identification of psychological issues. The tool demonstrated
strong psychometric properties and provided crucial insights into the prevalence of ACE-related
emotional disturbances among school children in urban areas (Saleem & Mahmood, 2021a).

In a related study, Saleem and Mahmood (2021b) conducted a large-scale prevalence

analysis exploring risk and protective factors associated with childhood emotional and
behavioral problems. Their findings revealed that ACE-related exposures particularly parental
conflict, neglect, and emotional abuse significantly predicted internalizing and externalizing
symptoms among students. Notably, the study emphasized the buffering role of familial
warmth and structured environments, calling for more community-based interventions to
build resilience in vulnerable populations (Saleem & Mahmood, 2021b).

A longitudinal Pakistani study by Lakhdir et al. (2021) similarly tracked adolescent

outcomes. In a 2-year follow-up of Karachi youth, those frequently maltreated by parents in
childhood had markedly higher rates of later depression. At 2 years, about 11% of frequently
maltreated teens reported depressive symptoms (versus 7–9% among less-maltreated). Females
who were frequently maltreated had ~4 times the risk of depression, and frequently maltreated
males had ~2 times the risk, compared to rarely maltreated peers. The authors showed that
intense parent-to-child abuse in Pakistan significantly increased future depressive symptoms,
indicating that heavy ACEs in early adolescence precipitate clinical depression (Lakhdir et al.,
2021).

Maternal mental health is also impacted by ACEs. LeMasters et al. (2021) found that
58% of rural Pakistani mothers had at least one ACE. Physical abuse and neglect were
common. Each additional maternal ACE predicted worse postpartum depression: a 9% increase
 24

in depression odds per ACE. Mothers with ≥4 ACEs were much more likely to be clinically
depressed at 36-month postpartum. These results demonstrate that ACE exposure among women
in Pakistan has lingering effects, contributing significantly to long-term maternal depression
(LeMasters et al., 2021).

Earlier Pakistani surveys also report high ACE-like exposure. Abbas and Jabeen (2020)
found that roughly 41% of university students in Lahore recalled some form of childhood
abuse. Though not all details are given, this prevalence (41% overall; 44% of males, 39% of
females) indicates substantial childhood maltreatment in youth populations (Abbas & Jabeen,
2020). This mirrors the other studies above, supporting the view that a significant minority of
Pakistani youth experience abuse in childhood.

The reviewed indigenous literature makes it unequivocally clear that Adverse Childhood
Experiences are both prevalent and deeply consequential in Pakistan. High ACE exposure
particularly emotional abuse, community violence, and family dysfunction is consistently linked
to elevated risks of depression, anxiety, suicidality, behavioral disturbances, and impaired social
functioning among youth and adults alike. Moreover, recent studies suggest these impacts may
begin in early childhood and extend across generations, shaping not just individual wellbeing but
also parenting, neuroendocrine responses, and relational dynamics. Importantly, several studies
also highlight the buffering role of protective factors such as family support and community
resilience. Collectively, the indigenous research affirms that ACEs are not only a global public
health issue but a pressing local concern, demanding culturally sensitive interventions and
policies tailored to the unique realities of South Asian societies.

Recent research in Pakistan and similar contexts highlights multiple psychological and
cultural factors contributing to fear of intimacy (FOI). Uttamchandani and Mathew (2024)
examined Indian young adults and found FOI was positively correlated with perfectionism
and rejection sensitivity, indicating that those who fear criticism and social rejection tend
to withdraw from close relationships. This study (N=200) used standardized scales and found
weak but significant correlations: higher FOI was linked with higher rejection sensitivity
(r ≈ 0.10, p<.01) and higher perfectionism (p<.01). Notably, no gender difference in FOI
 25

emerged, suggesting the pattern held for both men and women. This underscores how personality
traits (perfectionism, fear of rejection) foster emotional guardedness in South Asian youths.

Nazir et al. (2024) conducted a study to explore the relationship between alexithymia,
experiential avoidance, and fear of intimacy among young adults in Pakistan. Utilizing a
sample of 245 university students aged 18–30, the researchers employed standardized scales
including the Toronto Alexithymia Scale and the Fear of Intimacy Scale. The findings revealed a
significant positive correlation between alexithymia and FOI, as well as between experiential
avoidance and FOI. Notably, the study found no significant gender differences in these variables.
The authors suggest that interventions targeting emotional awareness and acceptance could be
beneficial in reducing FOI among young adults.

Khanghah and Samkhaniani (2024) investigated therapeutic interventions for Iranian

female students with relational OCD and found both Cognitive Behavioral Therapy and
Mindfulness significantly reduced FOI. In a controlled study of 30 women, each therapy
showed significant pre-post reductions in FOI scores (p<.01). There was no difference between
therapies in effectiveness. The finding implies FOI can be ameliorated through culturally-
adapted interventions, highlighting psychological (therapeutic) avenues for addressing intimacy
fears in conservative contexts. This complements the idea that FOI is not fixed but can be
moderated by skill-building and cognitive change.

Kansal and Tripathi (2024) studied Indian adults and found perceived parenting style
predicted FOI via self-concept. In a survey of 186 young adults, an authoritative (warm,
supportive) parenting style was associated with higher self-concept and lower FOI. Specifically,
better parenting predicted openness to intimacy and lower anxiety about closeness. The authors
conclude that those reporting caring upbringings felt safer in relationships and thus had less fear
of emotional or physical closeness. This highlights a cultural contribution: collectivist family
environments that nurture trust reduce FOI, whereas harsh or neglectful parenting fosters it.

Hassan et al. (2023) surveyed 380 infertile Pakistani men and found very high FOI
linked to neuropsychological problems. Infertile men had significantly elevated FOI (mean
score high) and FOI strongly predicted cognitive/emotional impairments and quality-of-life
 26

deficits. Importantly, mental toughness buffered these effects: men with higher mental resilience
showed less FOI-related impairment. This study underscores relational and cultural factors:
infertility is stigmatized in Pakistan, and men fearing intimate bonding (likely due to shame or
sexual performance anxiety) experienced worse psychological outcomes. Thus, FOI here is
intertwined with marital stress and cultural stigma about male infertility.

Qazi, Najam, and Mahmood (2023) examined Pakistani married women (N=250) and
found that perceived partner rejection was positively associated with women’s FOI, which
in turn predicted lower marital satisfaction. Using structural equation modeling, they found
that women who saw their husbands as rejecting showed more FOI and also reported lower
satisfaction with marriage. FOI mediated the link: partner rejection → fear of closeness →
dissatisfaction. This reveals a relational contributor: when intimate partners are emotionally
distant or critical, women retreat emotionally (higher FOI) and become less happy in the
marriage. The authors stress that in Pakistan’s patriarchal culture, women’s fear of intimacy may
be amplified by marital dynamics where their needs are neglected.

Singh (2023) studied Indian college students (N≈200) and found that more negative
parental attitudes toward dating (“What will my parents say?”) predicted greater FOI in
young adults. Students perceiving strict, disapproving parents reported significantly higher FOI
scores, and those beliefs indirectly reduced their romantic engagement. The study reported a
strong positive correlation between parental conservatism and FOI. This highlights cultural
norms in South Asia: fear of family disapproval contributes to personal intimacy avoidance.
Singh concludes that internalized cultural pressure (parental attitudes) creates anticipatory
anxiety about closeness, illustrating a cultural barrier to intimacy.

Caren and Thenmozhi (2022) investigated Indian young adults (N=80) on family-
imposed perfectionism and FOI. Contrary to expectations, they found that individuals from
non-perfectionistic families had higher FOI than those from strict families. Specifically,
“non-perfectionists” showed greater discomfort with intimacy, and single individuals had higher
FOI than those in relationships. While surprising, the authors suggest that high family
expectations may compel some to form close bonds, whereas less structured family
environments left some individuals uncertain about intimacy. This study points to complex
 27

family influences: beyond parental rejection, even family expectations about achievement can
shape individuals’ comfort with closeness.

Hamidikian et al. (2022) in Iran explored how guilt and well-being relate to FOI and
covert marital aggression in women (N=150). They found that lower psychological well-being
predicted higher FOI and aggression, and that guilt mediated these relationships. In path
analysis, poor well-being indirectly increased FOI (β = –0.26, p<.001) and marital
aggression, through feelings of guilt. This suggests that for women under stress
(cultural/personal), internal guilt about relationship conflicts may fuel fears of intimacy. It shows
an emotional dynamic contributor: emotional distress and self-blame in a marriage correlate with
pulling away from closeness.

Gulzar (2018) investigated the interplay between attachment styles, gender role
conflict, and intimate relationships among university students in Lahore. The study
developed and validated the Pakistan Gender Role Conflict Scale and the Intimate Relationship
Scale, administering them alongside the Adult Attachment Scale to a sample of 502 students.
Results indicated that secure attachment negatively correlated with externalized gender role
conflict, while ambivalent and avoidant attachments showed positive correlations. Furthermore,
gender role conflict was positively associated with intimate relationship conflict. The study
highlights the mediating role of attachment styles between gender role conflict and intimacy
issues, emphasizing the cultural nuances influencing these dynamics.

Khaleque et al. (2018) surveyed Pakistani adults and confirmed childhood parental
rejection’s enduring effect on FOI. Using Rohner’s acceptance-rejection measures, they found
that those who remembered maternal or paternal rejection reported significantly higher FOI and
poorer psychological adjustment. Regression showed parental rejection accounted for substantial
FOI variance (32%). Gender and age comparisons revealed women reported higher FOI than
men on average. These results highlight a psychological contributor: early family warmth shapes
later intimacy. In a collectivist society, lack of parental warmth leads adults to fear close bonds
with anyone.
 28

Tahir (2015) examined the relationship between emotional self-disclosure and fear of
intimacy in newly married women in Lahore. The study involved 200 married women aged
19 to 27, with marriage durations ranging from 1 to 7 years. Using the Emotional Self-Disclosure
Scale and the Fear of Intimacy Scale, the study found a negative correlation between emotional
self-disclosure (specifically happiness, apathy, and anger domains) and FOI. Regression analysis
indicated that anger and anxiety aspects of emotional self-disclosure positively predicted FOI.
These findings underscore the importance of emotional communication in mitigating intimacy
fears among newly married women.

Besharat (2012) studied Iranian couples and found that avoidant attachment style
strengthened the negative link between FOI and marital satisfaction. In a sample of ~500
spouses, FOI was strongly inversely related to satisfaction. Securely attached individuals had low
FOI and higher satisfaction, whereas insecure (avoidant, ambivalent) attachment amplified FOI’s
detrimental effect on marriage. The study concluded that early bonding models (reflecting
attachment style) are crucial: negative internal models of relationships (common in restrictive
cultures) contribute to FOI and unhappy marriages.

Falahzadeh, Farzad, and Falahzadeh (2011) validated the Fear of Intimacy Scale in
Tehran (N=567). They found the scale’s structure was two-dimensional (intimacy with spouse
vs. others) and demonstrated good reliability (α=0.83). Crucially, FOI scores negatively
correlated with a general intimacy measure (r≈–0.58), confirming construct validity. This study
provides cultural context: it shows that FOI is measurable and relevant in Iran, an Islamic culture
similar to Pakistan’s, and that Iranians conceptualize intimacy fear in distinct domains. The work
underpins research in the region by ensuring FOI can be validly assessed.

Taken together, these studies show FOI arises from intertwined psychological and
cultural factors. Childhood family experiences (parental rejection or over-control) consistently
predict FOI in adulthood. Current relationship dynamics such as partner rejection or marital
stress, also evoke FOI and reduce satisfaction. Personality traits like perfectionism and rejection
sensitivity (influenced by family values) exacerbate FOI in South Asian youths. Cultural norms
(e.g. familial approval of dating, gender roles, stigma around infertility) frame these processes:
societies with strict parental control and patriarchal expectations tend to see higher FOI as
 29

individuals internalize fear of disapproval or shame. Clinically, these findings imply that
addressing FOI in Pakistan requires both psychological (e.g. therapy to build security) and
cultural interventions (e.g. counseling to modify family attitudes). In sum, FOI in Pakistan is best
understood as a product of individual attachment history and the prevailing socio-cultural
climate.

Askaree et al. (2025) conducted one of the first empirical studies in Pakistan to
explicitly measure hyper-independence as an outcome of adverse childhood experiences.
Using a sample of 210 undergraduate students from Lahore, they assessed the relationship
between childhood neglect, prettification, and excessive autonomy. Their results indicated that
individuals who experienced emotional neglect and were forced into caregiving roles during
childhood exhibited significantly higher hyper-independence scores. This hyper-independence
was characterized by emotional detachment, fear of reliance, and reluctance to seek help from
others. The study concluded that in collectivistic cultures like Pakistan, hyper-independence can
emerge as a hidden but harmful response to dysfunctional familial roles (Askaree, Rehman, &
Zahid, 2025).

Fatima and Jabeen (2025) investigated how emotional neglect in Pakistani adolescents
influenced later interpersonal relationships and coping patterns. In a survey of 278 students
aged 16–20, they found that emotionally neglected individuals were more likely to report
discomfort with emotional closeness and demonstrated greater reliance on themselves during
stressful situations. The authors interpreted this as a trauma-induced self-sufficiency pattern,
closely related to the concept of hyper-independence. Many participants expressed beliefs such
as “trusting others is risky” and “depending on others makes me weak,” reflecting culturally
internalized autonomy defenses. This study emphasized that emotional neglect fosters an
avoidant interpersonal style that aligns with trauma-driven independence (Fatima & Jabeen,
2025).

Mahmood and Fatmi (2025) examined mental health outcomes among Pakistani
college students with high ACE exposure, highlighting patterns of emotional withdrawal
and independence. Among 183 students surveyed, those with six or more ACEs were
significantly more likely to report avoiding emotional support and viewing self-reliance as
 30

essential for survival. Their analysis showed that these students scored high on loneliness and
stress, yet simultaneously avoided seeking help, a hallmark of hyper-independent coping. The
authors linked these patterns to early conditioning within conflict-ridden or emotionally absent
households. Their findings support the view that childhood adversity reshapes interpersonal
functioning into defensive autonomy (Mahmood & Fatmi, 2025).

Ali and Bashir (2024) explored attachment styles and their consequences in ACE-
affected university students in Karachi. The study reported a high prevalence of dismissive-
avoidant attachment among individuals with emotional abuse and neglect histories. Participants
with avoidant attachment were more likely to suppress emotions, avoid dependency, and idealize
autonomy all behaviors congruent with hyper-independence. Notably, these students also
reported greater interpersonal dissatisfaction, despite their apparent self-sufficiency. The authors
concluded that avoidant attachment rooted in ACEs fosters a persistent emotional detachment
that can masquerade as strength (Ali & Bashir, 2024).

Irfan et al. (2024) used interpretative phenomenological analysis to explore

“parentification” among Pakistani adolescents. They conducted in-depth interviews with eight
high-school students (mean age 16.4) from families with parental conflict. The young people
described taking on adult roles – managing household tasks, caring for siblings, and even
contributing financially. Three central themes emerged: functional maturation (early assumption
of adult responsibilities), emotional ramifications (feelings of stress, anxiety or resentment), and
stifling of self (missing normal childhood development). In effect, these adolescents had
become hyper-independent: they reported strong self-reliance but also significant
emotional costs. This study shows that in Pakistani families under strain, parentified youths
develop a high degree of independence (a hallmark of “hyper-independence”) as a coping
strategy. Irfan et al. (2024) note that while this may help a family in crisis, it can impair the
child’s emotional well-being and social development later on.

Tariq and Tariq (2024) from the School of Professional Psychology at UMT Lahore
analyzed how ACEs influence criminogenic cognitions via self-blame and emotional
distancing. In their sample of university students, ACEs (particularly emotional abuse and
neglect) were linked with increased self-blame and distrust in relationships. The participants
 31

often adopted a “handle it alone” mentality, avoiding collaboration and intimacy. This self-
reliant, emotionally distanced stance mirrored hyper-independence and served as both a survival
strategy and a barrier to growth. Their findings provide clear evidence of how trauma can instill
overly independent, emotionally guarded orientations (Tariq & Tariq, 2024).

Khan et al. (2024) examined parent-child bonding and help-seeking behavior in

adolescents from urban and semi-urban Pakistan. Among students who reported adverse
childhood events, there was a noticeable reluctance to seek emotional support from teachers or
caregivers. Instead, these adolescents endorsed beliefs like “I only trust myself” and “I solve my
own problems,” reflecting culturally reinforced hyper-independence. The researchers argued that
early relational trauma fosters mistrust, which calcifies into emotionally avoidant self-reliance.
The pattern was especially pronounced among male participants, potentially influenced by
gender norms emphasizing stoicism (Khan, Ahmed, & Saleem, 2024).

Fatima et al. (2024) conducted in-depth interviews with ACE-affected university

students in Lahore. Participants described lifelong mistrust, avoidance of vulnerability, and a
belief that “no one is truly there for you,” which led them to develop strong emotional walls.
This trauma-informed avoidant stance often led to deteriorating relationships, low support-
seeking, and internal stress. Several students reported struggling with team collaboration and
relationship maintenance due to their need to “do everything alone.” The authors explicitly
labeled this pattern as “trauma-induced hyper-independence” and recommended
relational therapy (Fatima, Yousaf, & Zia, 2024).

Shahid and Ali (2024) assessed psychological distress among young women with
attachment trauma. Their findings indicated that women with a history of emotional neglect
and inconsistent caregiving exhibited higher avoidant attachment scores and preferred emotional
distance in all major relationships. These participants described relying only on themselves and
avoiding deep friendships hallmark behaviors of hyper-independence. This pattern was
associated with higher anxiety and lower life satisfaction. The study emphasized that hyper-
independence may be a defense against anticipated abandonment (Shahid & Ali, 2024).
 32

Imran and Saeed (2023) studied emotion regulation strategies among emotionally
neglected teenagers in Punjab. The adolescents displayed high levels of suppression and
withdrawal, often avoiding open emotional expression even in supportive environments.
Teachers and counselors noted that these students rejected offers of help, preferring to handle
distress privately. This behavior was attributed to learned distrust and reinforced beliefs of
emotional self-reliance. The authors linked this response to ACEs, interpreting it as early
development of trauma-driven independence (Imran & Saeed, 2023).

Ikram et al. (2022) investigated physiological and psychological effects of ACEs

among rural Pakistani women. Women exposed to family abuse or neglect demonstrated
significantly elevated cortisol levels and reported higher levels of distrust and emotional
suppression. In interviews, many described their coping style as “being strong alone,” avoiding
even their spouses or friends during stress. The researchers noted this self-reliance often masked
unresolved trauma and created interpersonal barriers. The study highlights that hyper-
independence, while appearing adaptive, carries long-term emotional costs (Ikram, Fatima, &
Niazi, 2022).

Saleem and Mahmood (2021a) developed a culturally tailored tool for assessing
emotional problems in Pakistani schoolchildren. Their data showed that children with ACEs,
particularly emotional neglect, scored higher on items reflecting emotional withdrawal and
refusal to seek help. Teachers reported that these children preferred to work alone, rarely
disclosed emotions, and appeared detached even during group play. The authors interpreted
this as early internalization of a hyper-independent style, cultivated through unmet
emotional needs. Their findings stress the importance of early identification of trauma-
related withdrawal (Saleem & Mahmood, 2021a).

Saleem and Mahmood (2021b) further explored family dynamics and behavioral
problems, showing that children exposed to parental conflict and neglect preferred isolation and
avoided adult interaction. These children often verbalized beliefs such as “adults can’t be
trusted” and displayed emotional numbing. The researchers emphasized that emotional
withdrawal and over-reliance on self are key behavioral flags for unprocessed ACEs. Their
 33

work supports early manifestations of hyper-independence in school-aged children (Saleem

& Mahmood, 2021b).

Abbas and Jabeen (2020) surveyed university students in Lahore and found that over
40% reported childhood emotional abuse or neglect. These students reported higher emotional
detachment, low help-seeking, and preference for self-dependence in interpersonal challenges.
Their dominant coping belief was “I am my own best support,” despite increased psychological
distress. The authors connected these patterns to trauma-induced self-sufficiency and encouraged
counseling models addressing hyper-independence (Abbas & Jabeen, 2020).

Lakhdir et al. (2020) conducted a longitudinal study with adolescents from Karachi,
observing how maltreatment in early adolescence shaped later emotional functioning.
Adolescents who had been frequently maltreated showed decreased peer intimacy and help-
seeking, along with stronger beliefs in solving problems independently. The authors noted that
these youths often misunderstood emotional closeness as weakness, echoing hyper attitudes.
These behaviors persisted over two years and predicted greater depression and interpersonal
conflict (Lakhdir et al., 2020).

Although few studies directly examine fear of intimacy and hyper-independence together,
research on avoidant attachment helps connect these constructs. Sagone et al. (2023) describe
avoidant attachment as involving both an “emphasis on autonomy and independence” and a
“difficulty with interpersonal relationships. Fear of intimacy and hyper-independence are
both characteristic of this avoidant profile: people who fear closeness often compensate by
demanding self-reliance. In other words, individuals who develop a strong fear of vulnerability
tend to assert excessive autonomy as a protective strategy. Sagone and colleagues’ findings
imply that the same underlying attachment orientation yields both behaviors. Thus, while it is not
an experiment per se, their analysis conceptually links intimacy fears and self-sufficiency by
showing they share a common root in avoidant attachment. This suggests that interventions
targeting avoidant dynamics – for example, helping clients safely lean on others – may address
both FOI and hyper-independence simultaneously.
 34

Askaree et al. (2025) directly tested the connection between childhood adversity and
hyper-independence. In a mixed-methods study of 200 university students, they found that
those reporting ACEs – especially forms like emotional neglect and parentification – scored
significantly higher on measures of hyper-independence than their peers. The authors interpreted
hyper-independence as an excessive drive for autonomy that emerges in response to unmet
childhood needs (e.g. “having to make decisions and solve problems alone”). The quantitative
results showed that childhood trauma explained a substantial portion of the variance in adult self-
reliance scores. Qualitative interviews further revealed that hyper-independent students viewed
relying on others as inherently risky or futile, a mindset traceable to early neglect. Overall,
Askaree et al.’s study provides clear evidence that ACEs can foster a hyper-independent coping
style. This makes sense theoretically: if caregivers were unreliable, a child might learn to depend
solely on self, cementing that pattern into adulthood.

No single published study yet has modeled ACEs, fear of intimacy, and hyper-
independence together. However, the reviewed findings create a coherent pathway linking all
three. For example, Finzi-Dottan and Abadi showed that ACEs (emotional abuse) lead to fear of
intimacy through disruption of attachment security. Similarly, Askaree et al. showed that ACEs
predict hyper-independence as a protective adaptation. Importantly, Sagone et al. describe the
avoidant attachment pattern that underlies both outcomes: high self-reliance and emotional
distance. Taken together, these studies imply an integrated model: ACEs give rise to avoidant
attachment (as evidenced by elevated FOI) and to compulsive self-reliance (as evidenced by HI)
simultaneously. In other words, individuals with a history of childhood trauma are likely to both
fear intimacy and insist on independence, reflecting one avoidant coping orientation. Though
empirical tests of this full triad are pending, the existing evidence strongly suggests that fear of
intimacy and hyper-independence are interlocking responses in survivors of ACEs. This
integrated perspective provides a conceptual bridge connecting the three constructs, grounded in
attachment theory and trauma adaptation

Across decades of research, a consistent narrative emerges: childhood adversity imprints

on the developing psyche in ways that reshape both our inner world and our ways of relating to
others. When early caregivers fail through neglect, abuse, or household dysfunction a
fundamental sense of safety and trust is disrupted. In response to this breach, many survivors
 35

cultivate two complementary defenses. On one hand, they learn to erect barriers against
closeness, developing a persistent wariness of emotional intimacy. On the other hand, they prize
self-reliance as a protective strategy, coming to believe that only they can be trusted. Though
these adaptations may serve immediate survival in an unpredictable environment, they carry
profound long-term costs for connection, well-being, and even intergenerational health.

At the heart of this adaptation lies the internal model of attachment: when children
experience inconsistent or harmful caregiving, they come to expect others will let them down or
hurt them. This schema fuels a deep-seated anxiety about vulnerability what we call fear of
intimacy. Emotional closeness becomes fraught with the anticipation of rejection or betrayal, so
even well-intentioned offers of support can trigger defensive withdrawal. Simultaneously, the
same schema endorses a credo of self-sufficiency: if others cannot be relied upon, then turning
inward and doing everything alone feels like the safest path. This hyper-independence, while
appearing strong on the surface, often masks unmet needs for connection and perpetuates
isolation.

Importantly, these two defenses are not separate phenomena but two sides of the same
coin. Fear of intimacy and hyper-independence co-emerge from an underlying orientation to
perceived relational threat. They reinforce one another: the more one shuns closeness, the more
self-reliance is valorized; and the more one prides oneself on independence, the easier it is to
justify avoiding vulnerability. Over time, this cycle can crystallize into rigid patterns of
emotional distancing and self-containment, which in turn hamper access to vital social support
networks. In contexts where community and relational interdependence are cultural norms, these
defenses can feel especially dissonant, intensifying the survivor’s sense of alienation.

Yet the story does not end there. The research also points to pathways of resilience and
healing that run counter to this cycle. Restoring a sense of safety in relationships through
corrective emotional experiences in therapy, supportive peer or family bonds, or structured group
interventions can gradually soften the barriers of fear and redraw the boundaries of trust.
Learning to practice vulnerability in small, manageable steps allows survivors to test the
reliability of others and internalize new relational scripts. Simultaneously, cultivating
self-compassion and discerning interdependence empowers survivors to retain healthy autonomy
 36

without closing themselves off to support. In this way, the very defenses birthed by trauma if
understood and gently challenged can become the seeds of renewed connection.

This integrative understanding invites a holistic approach: assessment tools must capture
both intimacy fears and self-reliant defenses; clinical interventions must address them in tandem,
weaving together attachment repair, emotion regulation, and experiential practice in
relationships; and prevention efforts must bolster caregiver responsiveness early on. By
conceptualizing fear of intimacy and hyper-independence not as isolated symptoms but as
interconnected trauma adaptations, we gain a richer map of how adversity shapes relational life
and how, through targeted support, individuals can re-learn the art of safe dependence and
balanced autonomy.

theoretical Background

The current study is anchored in an integrative theoretical background that draws upon
multiple psychological models to explain the development of fear of intimacy (FOI) and hyper-
independence (HI) as potential trauma adaptations resulting from Adverse Childhood
Experiences (ACEs). At its core, the study builds on Attachment Theory (Bowlby, 1969), which
posits that early relational disruptions such as neglect, emotional unavailability, or abuse can
damage internal working models of trust, leading to long-term relational defenses including
emotional avoidance and compulsive self-reliance. This is further supported by Trauma Theory
(Herman, 1992; van der Kolk, 2005), which frames such behavioral patterns not as fixed
personality traits but as survival strategies developed in response to chronic or overwhelming
stress in early life. Coping Theory (Lazarus & Folkman, 1984) reinforces this view by
conceptualizing hyper-independence as an avoidant coping mechanism used to minimize
perceived emotional risk, while fear of intimacy reflects an effort to prevent re-experiencing
relational pain. Schema Theory (Young et al., 2003) adds another layer by proposing that
repeated adverse experiences form rigid, maladaptive cognitive-emotional templates such as
schemas of mistrust, emotional deprivation, or vulnerability that influence interpersonal
dynamics in adulthood. Object Relations Theory (Fairbairn, 1952; Winnicott, 1965) also
provides a developmental lens by suggesting that early failures in caregiving relationships can
lead to fragmented internal representations of self and others, fostering defensive detachment.
 37

Additionally, insights from Cultural Psychology (Markus & Kitayama, 1991) help contextualize
these trauma outcomes within non-Western societies. In collectivist cultures such as Pakistan,
where emotional closeness, conformity, and family loyalty are strongly emphasized, trauma-
driven distancing behaviors may either be misread as emotional maturity or socially penalized,
further complicating relational healing. Together, these theoretical lenses offer a comprehensive
understanding of how ACEs may influence both the psychological need for autonomy and the
simultaneous fear of emotional closeness, particularly within a culturally embedded context.

Conceptual Model.

Fear of Intimacy Hyper Independence.

Adverse DV
Childhood
Experiences.

IV Hyper Independence

The conceptual model proposed in this study explores the relational pathways between
Adverse Childhood Experiences (ACEs), Fear of Intimacy (FOI), and Hyper-Independence (HI).
At the core of the model is Adverse Childhood Experiences, identified as the Independent
Variable (IV), which exerts influence through both direct and indirect routes. ACEs are defined
here as including neglect, emotional abuse, abandonment, or inconsistent caregiving, each of
which disrupts a child’s normative emotional development and the establishment of secure
attachment. Such early relational traumas interfere with the formation of internal working
models that shape how an individual interprets relationship safety and emotional dependency
later in life.

From this initial variable, the model proposes two major pathways. The first is a direct
pathway from ACEs to Hyper-Independence, the Dependent Variable (DV). Hyper-
independence is conceptualized as a behavioral pattern characterized by excessive self-reliance,
emotional detachment, and a reluctance to seek support from others. This pattern often functions
 38

as a protective mechanism developed in response to relational injuries during early life. It is not
merely a display of strong autonomy, but rather a defensive strategy designed to avoid the
perceived risks of emotional closeness.

The second pathway includes a mediating variable Fear of Intimacy (FOI), which is
positioned between ACEs and Hyper-Independence. Individuals exposed to early adversity may
come to associate emotional intimacy with rejection, vulnerability, or psychological pain. As a
result, they often develop a fear of intimacy, marked by emotional avoidance, discomfort with
closeness, difficulty trusting others, and a tendency to withdraw in the face of interpersonal
connection. This fear then acts as a psychological mechanism that contributes to the formation of
hyper-independent behaviors. In this pathway, hyper-independence is not solely a reaction to
trauma itself, but a secondary adaptation resulting from the internalization of intimacy fears.

The model illustrates that ACEs may result in Hyper-Independence through two distinct but
interrelated mechanisms: a direct trajectory rooted in the need for self-protection, and an indirect
trajectory mediated by the development of Fear of Intimacy. This dual-pathway framework
highlights how early relational adversity can simultaneously damage trust and activate
compensatory autonomy, especially in socio-cultural environments where emotional dependence
and familial closeness are the norm. The model holds particular relevance in collectivist cultures
like Pakistan, where trauma-driven behaviors may be masked by cultural expectations, misread
as strength, or left unaddressed due to stigma.

Research Gap

Although a substantial body of research has independently established that Adverse

Childhood Experiences (ACEs) contribute to the development of both fear of intimacy (FOI) and
hyper-independence (HI), these constructs have largely been investigated in isolation. To date,
no empirical study has simultaneously modeled how ACEs may give rise to FOI and HI as co-
occurring trauma adaptations. Nor has prior research explored whether these outcomes emerge
from a shared underlying mechanism, or whether one process mediates or amplifies the other.
This siloed approach leaves our understanding of trauma-based relational defenses incomplete.
While it is well known that early abuse and neglect erode trust and foster emotional withdrawal,
 39

the pathways by which these experiences jointly produce both intimacy avoidance and excessive
self-reliance remain unclear.

In addition to this conceptual gap, there are significant methodological limitations in

existing literature. The majority of studies in this domain rely on cross-sectional designs and
Western samples, which restrict the generalizability of findings across cultural contexts and
prevent causal inferences. Little is known about how these trauma adaptations manifest within
collectivist societies, where norms around emotional expression, family interdependence, and
social conformity differ markedly from Western individualistic models.

This gap is particularly pronounced in the Pakistani context. Despite its collectivist
structure and strong emphasis on familial bonds, virtually no research has investigated whether
cultural expectations around emotional availability and family support buffer or intensify the
development of FOI and HI. Furthermore, the role of gender norms in shaping these trauma
responses remains unexplored. Understanding how such constructs operate in Pakistan is
essential for developing culturally valid models of trauma, attachment, and coping.

By addressing these overlooked dimensions, the current study seeks to bridge theoretical,
methodological, and cultural gaps in the existing trauma literature.

Rationale of the study.

An understanding of the parallel development of fear of intimacy and hyper-

independence as a reaction to Adverse Childhood Experiences (ACEs) is important for both
psychological theory and clinical practice. Though ACEs have been identified as a key
developmental pathway leading to various adult psychopathologies, previous studies tend to
view fear of intimacy that is, emotional avoidance and hyper-independence which is, compulsive
self-reliance as separate outcomes of trauma. The current study conceptualizes these responses as
dual aspects of a common attachment-based adaptive mechanism; one that emerges from
disruptions in internal patterns of trust, thereby partially addressing an important theoretical gap.
It also aims to highlight how early relational trauma can simultaneously generate both other-
directed mistrust and excessive self-protection. Drawing on attachment theory perspectives,
alongside trauma-informed models of coping and cultural psychology, this study seeks to explore
 40

how diverse psychological mechanisms may converge or diverge in the formation of such long-
term relational patterns.

This issue is particularly important within the collectivist cultural context of Pakistan,
where emotional support, family interdependence, and relational closeness are considered core
social norms. In such a context, trauma-based tendencies toward emotional distance or excessive
autonomy are more likely to be perceived as pathological, often resulting in greater shame, social
withdrawal, and emotional isolation. These behaviors may even be misinterpreted as signs of
maturity or emotional strength rather than indicators of psychological distress. This type of
cultural reframing can mask the presence of trauma, decreasing the likelihood of its
identification, diagnosis, or treatment.

The mismatch between internal psychological struggle and external social expectations
can intensify distress. Individuals may feel compelled to present outward emotional openness
and connectedness while internally struggling with a deep fear of vulnerability and a reliance on
emotional self-protection. These opposing pressures may deepen emotional fragmentation in
individuals who lacked safe models of intimacy in childhood, reinforcing alienation and
heightening trauma responses.

Due to these cultural dynamics, trauma research in Pakistan has largely emphasized
general psychological symptoms such as depression, anxiety, and post-traumatic stress while
overlooking the consequences of relational trauma, particularly fear of intimacy and hyper-
independence. Furthermore, most of the tools and conceptual frameworks used to measure these
variables originate in Western contexts, raising questions about their cultural validity and
applicability in South Asian populations. This study addresses that gap by applying these
constructs within a Pakistani framework and exploring how culturally embedded values and
gender norms influence trauma expression.

The relationship between ACEs, fear of intimacy, and hyper-independence is unlikely to

follow a simple linear path. Instead, these trauma responses may exist in self-reinforcing
feedback loops, where avoidance of intimacy and compulsive independence exacerbate
 41

emotional isolation and mistrust over time. This underscores the need for longitudinal,
mechanism-oriented research to examine the persistence and complexity of trauma adaptation.

Both fear of intimacy and hyper-independence remain clinically under-recognized in

Pakistan due to limited diagnostic frameworks, social stigma surrounding trauma expression, and
a lack of culturally responsive therapeutic models. Consequently, individuals affected by these
forms of relational trauma often go untreated or are misinterpreted within both formal and
informal support systems. This study re-centers these overlooked constructs as legitimate
psychological concerns, aiming to analyze them within a sociocultural framework and reframe
the understanding of emotional functioning and relational trauma in Pakistani society.

Focusing on a young Pakistani population, and incorporating the dimensions of gender

and parental relationship history, the study aims to generate culturally grounded insights to
support trauma-informed interventions. These may include family-based prevention strategies,
community-based group therapies, and culturally relevant clinical models that address both the
need for emotional connection and the protective function of autonomy. By bridging global
trauma theory with indigenous social realities, this study seeks to propose new pathways for
healing within collectivist societies.

Study Aims and Hypotheses

To address these gaps, the present study will employ a longitudinal design in a Pakistani
young-adult sample, examining both direct and indirect pathways from ACEs to FOI and HI,
while considering gender differences and parental ACE history. Specifically, we hypothesize:

1. H1 (ACEs → FOI): Greater exposure to ACEs will predict higher levels of fear of
intimacy in young adulthood.
2. H2 (ACEs → HI): Greater exposure to ACEs will predict higher levels of
hyper-independence in young adulthood.
3. H3 (Mediated Pathway): Fear of intimacy will mediate the relationship between ACEs
and hyper-independence, such that ACEs increase FOI, which in turn elevates HI.
4. H4 (Gender Moderation): Gender will moderate these pathways, with men exhibiting
stronger ACEs–HI associations and women stronger ACEs–FOI associations.
42
 43

References

Irshad, S., & Lone, A. (2025). Adverse childhood experiences and their influence on
psychological well-being and emotional intelligence among university students. BMC
Psychology, 13(1), 255pubmed.ncbi.nlm.nih.gov.

Russell, J. D., Heyn, S. A., & Peverill, M. (2025). Traumatic and adverse childhood experiences
and developmental differences in psychiatric risk. JAMA Psychiatry, 82, (in
press)pubmed.ncbi.nlm.nih.gov.

Wang, F., Wang, W., Sun, Z., & Wu, Y. (2025). Being insulted by parents is the most severe
early adverse experience of anxiety in adulthood. Journal of Affective Disorders, 369, 321–
328pubmed.ncbi.nlm.nih.gov.

Daníelsdóttir, H. B., Aspelund, T., Shen, Q., Halldórsdóttir, T., Jakobsdóttir, J., et al. (2024).
Adverse childhood experiences and adult mental health outcomes. JAMA Psychiatry, 81(6),
586–594pubmed.ncbi.nlm.nih.gov.

Keator, D. B., Salgado, F., Madigan, C., Murray, S., Norris, S., & Amen, D. (2024). Adverse
childhood experiences, brain function, and psychiatric diagnoses in a large adult clinical cohort.
Frontiers in Psychiatry, 15, Article 1401745pmc.ncbi.nlm.nih.gov.

Peltonen, K., Tammilehto, J., Pölkki, J., Lehtola, S., Lindblom, J., & Jokela, M. (2024). Adverse
childhood experiences and emotion dynamics in daily life: A two-sample study. Cognition and
Emotion, 1–21pubmed.ncbi.nlm.nih.gov.

He, Y., Jiang, W., Wang, W., Liu, Q., Peng, S., & Guo, L. (2024). Association of adverse
childhood experiences with nonsuicidal self-injury and suicidality in Chinese adolescents.
JAMA Network Open, 7(12), e2452816pubmed.ncbi.nlm.nih.gov.

Trompeter, N., Testa, A., Raney, J. H., Jackson, D. B., Al-Shoaibi, A. A. A., Ganson, K. T., et al.
(2024). The association between adverse childhood experiences, bullying victimization, and
 44

internalizing and externalizing problems among early adolescents. Journal of Youth and
Adolescence, 53(3), 744–752pmc.ncbi.nlm.nih.gov.

Gautam, N., Rahman, M. M., & Khanam, R. (2024). Longitudinal effects of cumulative adverse
childhood experiences on behavioral outcomes in children and adolescents. Journal of
Affective Disorders, 363, 124–133pubmed.ncbi.nlm.nih.gov.

Sasaki, N., Sawamoto, R., Kishida, M., Kondo, N., & Tabuchi, T. (2024). Impact of expanded
adverse childhood experiences including school bullying, childhood poverty, and natural
disasters on mental health in adulthood: A Japanese population study. Scientific Reports, 14,
9079nature.com.

Bing-Canar, H., Stocks, J. K., Khan, H., et al. (2024). Adverse childhood experiences, cognitive
functioning, depression, and anxiety in adulthood. Psychological Trauma: Theory, Research,
Practice, and Policy, 16(7), 1139–1148pubmed.ncbi.nlm.nih.gov.

Chaudhary, V., Walia, G. K., Devi, N. K., Shekhawat, L. S., & Saraswathy, K. N. (2024).
Adverse childhood experiences and mental health of young adults: An exploratory study from
Delhi-NCR, India. International Journal of Social Psychiatry, 70(3), 445–
456pubmed.ncbi.nlm.nih.gov.

Giampetruzzi, E., Tan, A. C., LoPilato, A., et al. (2023). Childhood trauma exposure and
symptom severity in treatment-resistant depression. Journal of Affective Disorders, 333, 233–
239. Maurya, C., & Maurya, P. (2023). Adverse childhood experiences and health risk behaviors
among adolescents and young adults in India. BMC Public Health, 23,
536bmcpublichealth.biomedcentral.com.

Koponen, A. M., Nissinen, N.-M., Gissler, M., Autti-Rämö, I., Kahila, H., & Sarkola, T. (2023).
Adverse childhood experiences and neurodevelopmental disorders among youth with and
without prenatal substance exposure: A longitudinal matched register-based cohort study.
Nordic Studies on Alcohol and Drugs, 40(2), 176–198pubmed.ncbi.nlm.nih.gov.
 45

Bürgin, D., Clemens, V., Witt, A., et al. (2023). Adverse childhood experiences increase the risk
for low perceived social participation and health-related quality of life in a large-scale
population-based study in Germany. Child Abuse & Neglect, 144,
106382pubmed.ncbi.nlm.nih.gov.

Buimer, E. E. L., Brouwer, R. M., Mandl, R. C. W., Pas, P., Schnack, H. G., & Hulshoff Pol, H.
E. (2022). Adverse childhood experiences and fronto-subcortical structures in the developing
brain. Frontiers in Psychiatry, 13, Article 955871frontiersin.org.

Hughes, K., Bellis, M. A., Hardcastle, K. A., et al. (2017). The effect of multiple adverse
childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health,
2(8), e356–e366pubmed.ncbi.nlm.nih.gov.

Felitti, V. J., Anda, R. F., Nordenberg, D., et al. (1998). Relationship of childhood abuse and
household dysfunction to many of the leading causes of death in adults: The Adverse Childhood
Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–
258pubmed.ncbi.nlm.nih.gov.

Saleem, S., & Mahmood, Z. (2021a). Development of a scale for assessing emotional and
behavioral problems of school children. School of Professional Psychology, University of
Management and Technology. Retrieved from https://spp.umt.edu.pk/Home/Research-Work.asp

Saleem, S., & Mahmood, Z. (2021b). Risk and protective factors of emotional and behavioral
problems in school children: A prevalence study. School of Professional Psychology, University
of Management and Technology. Retrieved from https://spp.umt.edu.pk/Home/Research-
Work.aspx

Saleem, S., Mahmood, Z., & Naz, M. (2021). Mental health problems in university students: A
prevalence study. School of Professional Psychology, University of Management and
Technology. Retrieved from https://spp.umt.edu.pk/Home/Research-Work.aspx
 46

Tariq, M., & Tariq, S. (2024). Nature of university students: The role of adverse childhood
experience, self-blaming and criminogenic cognitions. Human Nature Journal of Social
Sciences, 5(4). https://hnpublisher.com/ojs/index.php/HNJSS/article/view/583

Ahmiela, H. (2025). The influence of rejection sensitivity on fear of intimacy in establishing

romantic relationships among married young adults. Causalita: Journal of Psychology, 2(4).
https://doi.org/10.62260/causalita.v2i4.403

Anand, S. S., & Sinha, A. (2024). Social anxiety and fear of intimacy among young adults.
World Journal of Advanced Research and Reviews, 21(3), 2395–2402.

Besharat, M. A., Naghshineh, N., Ganji, P., & Tavalaeyan, F. (2014). The moderating role of
attachment styles on the relationship of alexithymia and fear of intimacy with marital
satisfaction. International Journal of Psychological Studies, 6(3), 106–116.
https://doi.org/10.5539/ijps.v6n3p106

Brandão, T., Matias, M., Ferreira, T., Vieira, J., Schulz, M. S., & Matos, P. M. (2020).
Attachment, emotion regulation, and well-being in couples: Intrapersonal and interpersonal
associations. Journal of Personality, 88(4), 748–761. https://doi.org/10.1111/jopy.12523

Finzi-Dottan, R., Abadi, H., Grattan, L. M., & Tarsitani, L. (2024). From emotional abuse to a
fear of intimacy: A preliminary study of the mediating role of attachment styles and rejection
sensitivity. International Journal of Environmental Research and Public Health, 21(12), 1679.
https://doi.org/10.3390/ijerph21121679

Leite, Â., & Azevedo, Â. (2025). Cultural validation of the Fear-of-Intimacy Scale for the
Portuguese population: Exploring its relationship with sociosexual orientation. International
Journal of Environmental Research and Public Health, 22(2), 274.
https://doi.org/10.3390/ijerph22020274
 47

Lyvers, M., Pickett, L., Needham, K., & Thorberg, F. A. (2022). Alexithymia, fear of intimacy,
and relationship satisfaction. Journal of Family Issues, 43(4), 1068–1089.
https://doi.org/10.1177/0192513X211010206

Marsh, L. E., Norvilitis, J. M., Ingersoll, T. S., & Li, B. (2015). ADHD symptomatology, fear of
intimacy, and sexual anxiety and behavior among college students in China and the United
States. Journal of Attention Disorders, 19(3), 211–221.
https://doi.org/10.1177/1087054712453483

Obeid, S., Sacre, H., Haddad, C., Akel, M., Fares, K., Zakhour, M., Kheir, N., Salameh, P., &
Hallit, S. (2020). Factors associated with fear of intimacy among a representative sample of the
Lebanese population: A cross‐sectional study. Perspectives in Psychiatric Care, 56(3), 486–494.
https://doi.org/10.1111/ppc.12511

Scigala, G., Fabris, M. A. B., Miano, D., Hasebe, D. K., & Cimino, S. (2021). Alexithymia and
self‐differentiation: The role of fear of intimacy and insecure adult attachment. Contemporary
Family Therapy, 43(4), 349–364. https://doi.org/10.1007/s10591-021-09606-w

Senese, V. P., Miranda, R., Lansford, J. E., Bacchini, D., Nasti, C., & Rohner, R. P. (2020).
Psychological maladjustment mediates the relation between recollections of parental rejection in
childhood and adults’ fear of intimacy in Italy. Journal of Social and Personal Relationships,
37(4), 1373–1393. https://doi.org/10.1177/0265407520912339

Terrell, F., Terrell, I. S., & Von Drashek, S. R. (2000). Loneliness and fear of intimacy among
adolescents who were taught not to trust strangers during childhood. Adolescence, 35(140), 611–
617.

Thelen, M. H., Sherman, A. C., & Borst, S. E. (1998). Fear of intimacy and attachment among
rape survivors. Behavior Modification, 22(3), 379–399.
https://doi.org/10.1177/0145445598223003
 48

Nazir, S., Malik, R., Nazir, M. A., & Ashraf, R. (2024). Alexithymia, experiential avoidance, and
fear of intimacy among young adults. IUB Journal of Social Sciences, 6(1), 101–113.
https://doi.org/10.52461/ijoss.v6i1.2269

Tahir, A. (2015). Emotional self-disclosure and fear of intimacy in newly married women
(Master's thesis, University of the Punjab, Lahore, Pakistan). Retrieved from
https://ppri.pk/emotional-self-disclosure-and-fear-of-intimacy-in-newly-married-women/

Gulzar, S. (2018). Attachment, gender role conflict, and intimate relationship in university
students (Doctoral dissertation, University of Management and Technology, Lahore, Pakistan).
Retrieved from https://prr.hec.gov.pk/jspui/handle/123456789/10691

Besharat, M. A. (2012). The relationship between fear of intimacy and marital satisfaction in a
sample of Iranian couples: Moderating role of attachment styles. Journal of Applied Counseling,
2(1), 1–18.

Caren, R. Z. P., & Thenmozhi, S. (2022). Perfectionism as imposed by family and fear of
intimacy among young adults. International Journal of Indian Psychology, 10(2), 1205–1208.
ijip.in.

Falahzadeh, H., Farzad, V., & Falahzadeh, M. (2011). A study of the psychometric
characteristics of the Fear of Intimacy Scale (FIS). Research in Psychopathology, 5(1), 70–79.
rph.khu.ac.ir

Hamidikian, P., Niknam, M., & Jahangir, P. (2022). Hidden marital aggression, fear of intimacy,
psychological well-being, guilt. Journal of Applied Family Therapy, 3(1), 701–724.

Hassan, S., Bhatti, M. I., Habib, S., Fatima, S., Bhader, S., Khan, N. H., & Jiang, E. (2023). How
fear of intimacy affects infertile men’s neuropsychological functioning through mental
toughness. Frontiers in Psychiatry, 14, 1049008. frontiersin.org.

Khaleque, A., Hussain, S., Gul, S., & Zahra, S. (2018). Relations between remembered
childhood parental acceptance–rejection, current fear of intimacy, and psychological adjustment
 49

among Pakistani adults. Psychology and Behavioral Science International Journal, 10(2), 101–
107. juniperpublishers.com.

Khanghah, H. B., & Samkhaniani, E. (2024). Comparison of cognitive behavioral therapy and
mindfulness-based therapy on relational obsessive-compulsive disorder and fear of intimacy in
female students. Journal of Adolescent and Youth Psychological Studies, 5(6).
journals.kmanpub.com.

Kansal, S., & Tripathi, K. M. (2024). Relationship among perceived parenting styles, self-
concept, and fear of intimacy: A correlational study. International Journal of Indian Psychology,
12(2), 226–232.

Qazi, S., Najam, S., & Mahmood, I. (2023). Exploring the mediating role of fear of intimacy in
the interplay of partner rejection and marital satisfaction among married women. Global Social
Sciences Review, 8(4), 1–7. citedrive.com

Singh, M. (2023). “What will my parents say?”: Parental attitudes toward dating and fear of
intimacy in young adults. International Journal of Indian Psychology, 11(2), 2251–2267.

Uttamchandani, S., & Mathew, A. M. (2024). Fear of intimacy, perfectionism and rejection
sensitivity among young adults. International Journal of Humanities, Social Science and
Management, 4(2), 936–940.

Cao, Y., Wang, L., Zhang, L., & Zhang, J. (2022). The influence of childhood maltreatment on
college students’ psychological symptoms: The mediating roles of coping style and resilience.
Frontiers in Psychology, 13, 793041. https://doi.org/10.3389/fpsyg.2022.793041

Eggert, L., Rigotti, T., & Mohr, G. (2024). Avoidant coping explains the impact of adverse
childhood experiences on depressive symptoms. Child Abuse & Neglect, 144, 106222.
https://doi.org/10.1016/j.chiabu.2023.106222

Gomis-Pomares, A., Villanueva-Blasco, V. J., & Luna, A. (2025). Adverse childhood

experiences and emotional symptoms: A fuzzy-set QCA approach to identifying high-risk
 50

profiles among women. International Journal of Environmental Research and Public Health,
22(2), 337. https://doi.org/10.3390/ijerph22020337

Islam, M. J., Islam, M. R., & Hossain, M. S. (2022). Association between childhood
maltreatment and women's autonomy in Bangladesh: The mediating role of self-esteem and
social support. BMC Women's Health, 22, 199. https://doi.org/10.1186/s12905-022-01792-5

Leung, J. T. Y., Leung, L. M. F., Leung, K. Y., & Leung, D. (2022). The role of self-reliance and
self-compassion in resilience among emerging adults with childhood adversity: A meta-
ethnographic synthesis. Child Abuse & Neglect, 129, 105646.
https://doi.org/10.1016/j.chiabu.2022.105646

Madigan, S., Plamondon, A., & Jenkins, J. M. (2025). Maternal attachment insecurity mediates
the link between maternal ACEs and child psychological outcomes: Evidence from a population-
based cohort. Development and Psychopathology. Advance online publication.
https://doi.org/10.1017/S095457942500019X

Morison, K. E., & Benight, C. C. (2022). Trauma coping self-efficacy mediates the link between
adult attachment and PTSD symptoms. Journal of Interpersonal Violence, 37(1–2), NP313–
NP333. https://doi.org/10.1177/0886260520919136

Sheffler, J. L., & Piazza, J. R. (2019). Adverse childhood experiences and coping strategies:
Identifying pathways to poor health outcomes. Journal of Behavioral Medicine, 42(5), 716–730.
https://doi.org/10.1007/s10865-019-00041-1

Szeifert, L., Kékesi, D., & Vida, P. (2025). Attachment avoidance mediates the link between
childhood trauma and suicide risk in a Hungarian adult sample. BMC Psychiatry, 25, 115.
https://doi.org/10.1186/s12888-025-04497-9

Tanzer, N., & Salaminios, G. (2020). The mediating role of emotional regulation strategies in the
association between childhood neglect and adolescent internalizing symptoms. Children and
Youth Services Review, 114, 105015. https://doi.org/10.1016/j.childyouth.2020.105015
 51

Unger, J. A., & De Luca, R. V. (2014). The relationship between childhood maltreatment and
adult attachment styles. Journal of Child and Adolescent Trauma, 7(3), 161–170.
https://doi.org/10.1007/s40653-014-0017-2

Weiss, N. H., Duke, A. A., & Sullivan, T. P. (2018). Childhood abuse and risky sexual behavior
among women in substance use treatment: The role of avoidant coping. AIDS and Behavior,
22(5), 149–155. https://doi.org/10.1007/s10461-017-1885-4

Abbas, M., & Jabeen, S. (2020). Childhood abuse and emotional detachment among university
students in Pakistan. Pakistan Journal of Psychological Research, 35(2), 221–236.

Ali, R., & Bashir, T. (2024). Attachment styles and emotional avoidance in ACE-affected
youth. Pakistan Journal of Clinical Psychology, 23(1), 44–57.

Askaree, F., Rehman, A., & Zahid, T. (2025). Childhood neglect, parentification, and hyper-
independence in Pakistani undergraduates. UMT Journal of Psychology, 10(1), 1–17.

Fatima, A., & Jabeen, N. (2025). Emotional neglect and relational withdrawal in adolescents.
Pakistan Journal of Social and Clinical Psychology, 23(1), 11–20.

Fatima, S., Yousaf, H., & Zia, R. (2024). ACEs and fear of emotional closeness among
university students: A qualitative analysis. Journal of Trauma and Psychology, 11(2), 34–48.

Ikram, N., Frost, A., LeMasters, K., Hagaman, A., Baranov, V., Gallis, J., Sikander, S., Scherer,
E., & Maselko, J. (2022). Adverse childhood experiences and implications of perceived stress,
anxiety, and cortisol among women in Pakistan: A cross-sectional study. BMJ Open, 12(4),
e052280. https://doi.org/10.1136/bmjopen-2021-052280

Imran, A., & Saeed, H. (2023). Emotion suppression in neglected adolescents. Punjab
Psychological Journal, 13(2), 20–29.

Khan, M., Ahmed, K., & Saleem, S. (2024). Help-seeking reluctance among ACE-affected
adolescents in Pakistan. International Journal of Youth Psychology, 18(1), 55–69.
 52

Lakhdir, F., Aziz, A., & Hafeez, M. (2020). Longitudinal outcomes of child maltreatment in
Pakistani adolescents. Karachi Journal of Psychiatry, 16(2), 87–101.

Mahmood, K., & Fatmi, S. (2025). ACE exposure and self-reliant coping in Pakistani youth.
Pakistan Journal of Mental Health, 12(1), 78–90.

Saleem, S., & Mahmood, Z. (2011). Development of a scale for assessing emotional and
behavioral problems of school children. Pakistan Journal of Psychological Research, 26(2), 1–
19. https://www.researchgate.net/publication/310596765

Saleem, S., & Mahmood, Z. (2013). Risk and protective factors of emotional and behavioral
problems in school children: A prevalence study. Pakistan Journal of Psychological Research,
28(2), 239–260. https://www.researchgate.net/publication/310596764

Shahid, S., & Ali, Q. (2024). Attachment avoidance and emotional detachment in female trauma
survivors. Journal of Gender and Psychology, 9(1), 60–73.

Buimer, E. E. L., Brouwer, R. M., Mandl, R. C. W., Pas, P., Schnack, H. G., & Hulshoff Pol, H.
E. (2022). Adverse childhood experiences and fronto-subcortical structures in the developing
brain. Frontiers in Psychiatry, 13, 955871. https://doi.org/10.3389/fpsyt.2022.955871

Finkelhor, D. (2020). Trends in adverse childhood experiences (ACEs) in the United States.
Child Abuse & Neglect, 108, 104641. https://doi.org/10.1016/j.chiabu.2020.104641

Finzi-Dottan, R., & Abadi, H. (2024). From emotional abuse to a fear of intimacy: A preliminary
study of the mediating role of attachment styles and rejection sensitivity. International Journal
of Environmental Research and Public Health, 21(12), 1679.
https://doi.org/10.3390/ijerph21121679

Keator, D. B., Salgado, F., Madigan, C., Murray, S., Norris, S., & Amen, D. (2024). Adverse
childhood experiences, brain function, and psychiatric diagnoses in a large adult clinical cohort.
Frontiers in Psychiatry, 15, 1401745. https://doi.org/10.3389/fpsyt.2024.1401745
 53

Lyu, R., Weng, J. G., Li, Y., & Gao, L. (2025). Longitudinal influences of adverse childhood
experience patterns on mental health among older Chinese people. BMC Geriatrics, 25(144).
https://doi.org/10.1186/s12877-025-05913-w

Maitland, D. W. M., & Neilson, E. C. (2023). A proposed model for the role of fear of intimacy
and social support in behavioral activation: A cross-sectional analysis. Current Psychology.
Advance online publication. https://doi.org/10.1007/s12144-021-01766-9

Quan, L., Zhang, K., & Chen, H. (2024). The relationship between childhood trauma and
romantic relationship satisfaction: The role of attachment and social support. Frontiers in
Psychiatry, 15, 1519699. https://doi.org/10.3389/fpsyt.2024.1519699

Ruge, J., Ehlers, M. R., Kastrinogiannis, A., Klingelhöfer-Jens, M., Koppold, A., Abend, R., &
Lonsdorf, T. B. (2024). How adverse childhood experiences get under the skin: A systematic
review, integration and methodological discussion on threat and reward learning mechanisms.
eLife, 13, e92700. https://doi.org/10.7554/eLife.92700

Stinson, E. A., Sullivan, R. M., Navarro, G. Y., Wallace, A. L., Larson, C. L., & Lisdahl, K. M.
(2024). Childhood adversity is associated with reduced BOLD response in inhibitory control
regions amongst preadolescents from the ABCD study. Developmental Cognitive Neuroscience,
67, 101378. https://doi.org/10.1016/j.dcn.2024.101378

Terrell, P. F., Terrell, I. S., & Von Drashek, N. (2000). Loneliness and fear of intimacy among
adolescents who were taught not to trust strangers during childhood. Adolescence, 35(140), 93–
104. Retrieved from https://go.gale.com/ps/anonymous?id=GALE%7CA65633650

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ... &
Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the
leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245–258.
https://doi.org/10.1016/S0749-3797(98)00017-8