Relationship between attachment style and symptom severity across the psychosis spectrum: A meta-analysis

Trauma and social pathways to psychosis: Examining the role of attachment, social rank and dissociation in a clinical sample

OBJECTIVES

The trauma and social pathways model of psychosis proposes interactions between trauma, attachment, social rank and dissociation in pathways to psychosis, though this model has yet to be empirically investigated. The primary aim of this study was to examine the overall predictive value of the trauma and social pathways model using regression analysis. A secondary aim was to delineate hypothesized pathways between trauma and positive symptoms of psychosis using serial mediation analysis.

METHOD

This was a cross-sectional study of people attending mental health services for a psychosis-related diagnosis (N = 71). Measures of trauma, positive symptoms of psychosis, attachment, social comparison and dissociation were completed.

RESULTS

A model of recurrent trauma, insecure attachment, social rank and dissociation predicted 23.2% of the variance in positive symptoms of psychosis. Recurrent trauma, attachment and dissociation contributed significantly to the model, while social rank did not. Further, serial mediation analysis indicated that the sequence of disorganized attachment and dissociation fully mediated the relationship between recurrent trauma and positive symptoms.

CONCLUSIONS

Results provide preliminary support for the trauma and social pathways model of psychosis, specifically as it relates to recurrent trauma, insecure attachment and dissociation. Results did not support the social rank component of this model, however. These findings provide clear targets for the development of next-wave psychological interventions that focus on trauma-related variables in psychosis. Future studies should replicate these findings with a larger clinical sample, and consider a measure of shame to further elucidate social processes in pathways to psychosis.

Autistic and schizotypal traits exhibit similarities in their impact on mentalization and adult attachment impairments: a cross-sectional study

BACKGROUND

Deficits in mentalizing and attachment occur in the autism and schizophrenia spectrum, and their extended traits in the general population. Parental attachment and the broader social environment highly influence the development of mentalizing. Given the similarities in the symptomatology and neurodevelopmental correlates of autism spectrum disorder (ASD) and schizophrenia (SCH), it is crucial to identify their overlaps and differences to support screening, differential diagnosis, and intervention.

METHODS

This cross-sectional study utilized questionnaire data from 2203 adults (65.1% female, mean age[SD] = 37.98[9.66]), including participants diagnosed with ASD, SCH, and those exhibiting subclinical traits to investigate the associations between mentalizing, attachment, and perceived social support during adolescence across the autistic and schizotypy spectrum.

RESULTS

It was revealed that both autistic and schizotypal traits have comparable effects on insecure adult attachment, primarily through challenges in mentalizing. The impact of mentalizing deficits on adult attachment slightly varies between autistic and schizotypal traits. Conversely, perceived social support during adolescence relates to improved mentalizing and secure adult attachment as a protective factor during development.

CONCLUSIONS

These outcomes highlight the significance of supportive therapeutic relationships and community care while suggesting directions for further research and collaborative treatments addressing ASD and SCH, considering the differential impact of mentalizing on adult attachment.

The revised Psychosis Attachment Measure: further psychometric evidence

PURPOSE

Disorganised attachment is a key concept in understanding the development of psychosis. However, existing questionnaires of adult attachment do not adequately measure this construct hindering future research into the psychosocial causes of psychosis. The most widely measure of adult attachment in people experiencing psychosis is the Psychosis Attachment Measure (PAM). The measure has recently been revised to include disorganised attachment items. This study develops previous research by providing a rigorous examination the psychometric properties of the revised questionnaire (PAM-R).

METHODS

A total of 407 participants with self-reported experiences of psychosis completed a battery of questionnaires which included the PAM-R and other measures which were conceptually related to the concept of disorganised attachment.

RESULTS

Confirmatory factor analysis (CFA) indicated a three-factor solution with factors corresponding to anxious, avoidant, and disorganised attachment. The majority of the fit statistics were acceptable with the exception of the RMSEA statistic. Internal consistency and test-retest reliability were good for all subscales. The disorganised subscale correlated in expected directions with other measures of attachment, dissociation, trauma, and psychotic experiences.

CONCLUSION

The PAM-R is a valid and reliable measure of adult attachment. It is a practical assessment tool for clinicians and researchers to measure insecure and disorganised attachment patterns that is acceptable to people experiencing psychosis.

Practitioner perspectives on the nature, causes and the impact of poor mental health and emotional wellbeing on children and young people in contact with children's social care: A qualitative study

BACKGROUND

Children and young people (CYP) who are in contact with social care are at higher risk of developing mental health difficulties compared to the general population. This has been attributed to their experience of significant childhood adversity. With an increased likelihood of experiencing poorer health outcomes which can persist into adulthood, it is crucial that key factors for their positive mental health development are identified.

OBJECTIVE

To identify factors associated with the poor mental health of CYP in contact with social care from the perspective of practitioners working in children's social care and mental health.

PARTICIPANTS AND SETTING

Social care and mental health practitioners; three Local Authorities across the North-East of England.

METHODS

Four focus groups were conducted with 23 practitioners between April and May 2022. A semi-structured topic guide exploring the nature and associated factors of mental health was used to focus discussion. Data were thematically analysed and informed by the four levels of the socio-ecological model.

RESULTS

Individual level risk factors were associated with the CYP's emotional health and included what practitioners described as the 'sense of shame'. Interpersonal level risk factors were most recurrent and included parental factors within the home environment. Community level risk factors consisted of characteristics of settings and institutions that increased the risk of the CYP developing mental health and wellbeing difficulties. Societal level risk factors included broader societal factors such as poverty. Practitioners maintained that certain protective factors possessed or developed by CYP including secure attachments, prevent the development of mental health difficulties.

CONCLUSIONS

Our current study provides strong evidence for the interlinkage between multiple levels of risk and their interacting impact on the CYP's mental health and emotional wellbeing. It is imperative that this, and the need to strengthen protective factors, whilst reducing risks are carefully considered for the development of effective support interventions for CYP in contact with social care.

Art and mentalizing in early intervention psychosis: rationale and therapist insights on a new psychoeducational course

In this paper, we explore the rationale for a combined art therapy and mentalization-based treatment (MBT) group course for those experiencing a first episode of psychosis (FEP). We discuss the theoretical background for how art and MBT theory can help us better understand and work with groups of individuals experiencing FEP, particularly focusing on avoidance and insecure attachment styles. We outline the delivery of a ten-week psychoeducational Art MBT course within an Early Intervention in Psychosis (EIP) Service and discuss our experiential insights into this new modality as co-therapists. We conclude by proposing that art therapy and mentalizing practice together offer an accessible, useful and practical group structure for EIP services, which could improve individuals' mentalizing capacity and overall social functioning.

Does insecure attachment lead to psychosis via dissociation? A systematic review of the literature

PURPOSE

Insecure attachment may constitute a vulnerability factor for psychosis, and dissociation may be a key mechanism in the development of auditory hallucinations specifically. While there is good evidence for the role of these processes in isolation, it is unclear whether dissociation accounts for the association between insecure attachment and psychosis. This systematic review takes a theory-driven approach to examine proposed causal relationships across the clinical and nonclinical literature.

METHODS

We searched five databases (PubMeD, Web of Science, PsycINFO, CINAHL and ETHOS) for published and unpublished research examining attachment, dissociation and psychosis. Two independent reviewers extracted the data and assessed the quality of all included studies.

RESULTS

We identified 242 potential articles and included 13 in the final review (2096 participants). We found that (1) disorganised attachment was consistently associated with dissociation and inconsistently associated with voices and paranoia, (2) dissociation was associated with voices and paranoia, and these links were stronger in clinical samples, and (3) dissociation played a role in the impact of insecure attachment on voice hearing and paranoia in clinical groups.

CONCLUSIONS

This is the first review to synthesise the research examining attachment, dissociation, and psychosis. The evidence is consistent with proposed causal hypotheses and raises conceptual and measurement issues, for example, the need to clarify the relative contributions of different insecure attachment styles, and utilise behavioural/observational measures to strengthen study designs. Most importantly, we need experimental and longitudinal studies to confirm causal links and targets for treatment.

Pathways from childhood trauma to aberrant salience: A structural equation approach to mentalization model

OBJECTIVE

The aim of this study was to explore the relationship between affective disturbances and aberrant salience in the context of childhood trauma, attachment, and mentalization in an analogue study.

METHODS

Using a cross-sectional design, an online community sample completed self-report measures of key variables. Structural equation modelling was used to test childhood trauma's influence on aberrant salience via a set of intermediate risk factors (depression, negative schizotypy, and insecure attachment). These intermediate risk factors were assumed to lead to the proximal risk factors of aberrant salience (i.e., disorganized schizotypy and disorganized attachment) depending on the vulnerability of mentalizing capacity to elevated stress.

RESULTS

The sample (N = 1263) was 78% female and aged between 18 and 35 years. The tested models closely fitted the observed data, revealing significant pathways from childhood trauma to aberrant salience via the hypothesized pathways. The direct effect of childhood trauma on aberrant salience was significant.

CONCLUSION

Findings suggest that the pathway to aberrant salience may be characterized by disorganization of self-state and intersubjectivity as a function of diminishment in mentalizing ability. This may relate to changes in attachment organization and socio-cognitive capacity, which could constitute possible risk factors signalling development of aberrant salience.

Attachment representations in 7-year-old children at familial high risk of schizophrenia or bipolar disorder: Associations with mental disorders and daily functioning: The Danish High Risk and Resilience Study, VIA 7-A population-based cohort study

BACKGROUND

Attachment quality may affect psychological functioning. However, evidence on attachment representations and their correlates in children born to parents with schizophrenia and bipolar disorder is sparse.

METHODS

We compared attachment representations in a Danish sample of 482 children aged 7 years at familial high risk of schizophrenia, bipolar disorder, and population-based controls and examined associations between attachment and mental disorders and daily functioning. Attachment representations were examined with the Story Stem Assessment Profile (SSAP). Mental disorders were ascertained in diagnostic interviews. Daily functioning was assessed with the Children's Global Assessment Scale.

RESULTS

We found no between-group differences in attachment. Higher levels of secure attachment were associated with decreased risk of concurrent mental disorders in the schizophrenia high-risk group. Higher levels of insecure and disorganized attachment were associated with increased risk of mental disorders across the cohort. Higher levels of secure and insecure attachment were associated with better and poorer daily functioning, respectively. In the current study, results regarding defensive avoidance could not be reported due to methodological limitations.

CONCLUSION

Familial high risk of schizophrenia (FHR-SZ) or bipolar disorder is not associated with less secure or more insecure attachment at age 7. Insecure and disorganized attachment representations index risk of mental disorders and poorer functioning. Secure attachment may be a protective factor against mental disorders in children at FHR-SZ. Validation of the SSAP is needed.

Being more satisfied with romantic relationship status is associated with increased mental wellbeing in people with experience of psychosis

Aims

Romantic relationships represent one of the most salient sources of social support. In general population studies, they are associated with both physical and psychological benefits. Research suggests that for people with psychosis, romantic relationships may also have a positive impact on a range of outcomes, but the reasons for these associations are still unclear. This study aims to investigate whether satisfaction with romantic relationships status is associated with better wellbeing outcomes in people with experience of psychosis and explore three possible psychological mediators of this relationship.

Methods

Participants who had previously sought support for psychosis (n = 190) completed an online survey including measures of relationship status satisfaction (the Satisfaction with Relationship Scale) as well as measures of psychotic symptoms (the CAPE-42), general well-being (Short Warwick-Edinburgh Mental Wellbeing Scale) and several psychological variables relevant to the pathway between romantic relationships and well-being outcomes, namely loneliness, internalised stigma, self-esteem and attachment.

Results

Fearful attachment and partner criticism were negatively associated with relationship status satisfaction. Having a partner was positively associated with relationship status satisfaction. Higher levels of relationship status satisfaction were associated with lower psychotic symptoms and higher mental wellbeing. This relationship was mediated by loneliness, internalised stigma, and self-esteem.

Conclusion

Mental health services should be mindful of the associations between romantic relationship satisfaction and wellbeing. Service users with a fearful attachment style may particularly benefit from support in this area.

Attachment Stability and Longitudinal Prediction of Psychotic-like Symptoms in Community Adolescents over Four Months of COVID-19 Pandemic

Background: The Friends and Family Interview (FFI) is assumed to be a valid method to study attachment stability and attachment-related psychopathological processes in adolescence, but no studies have yet tested the test-retest reliability of this interview or the longitudinal association of attachment patterns in response to the FFI from adolescents with symptoms such as psychotic-like experiences (e.g., hallucinations, bizarre behavior, dissociation, self-harm) that are known to have increased during the COVID-19 pandemic. Methods: This study involved 102 community adolescents (M = 14.64, SD = 1.63, 46% males) assessed twice: during a severe COVID-19-related lockdown (in Italy) (T1) and four months later (T2). Measures were the FFI (assessing attachment patterns: secure-autonomous, insecure-dismissing, insecure-preoccupied, and insecure-disorganized) and the thought problems scale of the Youth Self-Report to assess psychotic-like symptoms. Results: revealed high stability of four-way attachment classifications over four months (93.5%), with a modest yet significant link between higher disorganization at T1 and higher scores of thought problems at T2, p = 0.010. Conclusions: The FFI shows high test-retest reliability and can be a valid, age-adapted option to assess adolescents' attachment. Attachment disorganization should be further investigated as possibly related to psychotic-like experiences in community adolescents.

Attachment Style and Self-Experience: The Association Between Attachment Style and Self-Reported Altered Self-Experience in Patients With Psychotic Disorders, Unaffected Siblings, and Healthy Controls

ABSTRACT

The present study aimed to examine the cross-sectional association between attachment style and self-reported disturbed self-awareness (disturbed sense of mineness of experiences) and depersonalization (disturbed sense of first-person perspective) in patients with psychotic disorders, unaffected siblings, and healthy controls. Data pertain to a subsample of the GROUP (Genetic Risk and Outcome of Psychosis) study. We found positive associations between anxious attachment and disturbed self-awareness and depersonalization across participants with different psychosis vulnerability. We also found a positive association between avoidant attachment and depersonalization, although on a trend level. Findings indicate that attachment style is associated with self-reported disturbed self-awareness and depersonalization over and above the influence of psychotic or depressive experiences in people across the vulnerability spectrum of psychosis. This supports the importance of attachment style, self-awareness, and depersonalization as potential targets in prevention and treatment interventions in patients with psychotic disorders or those with increased vulnerability.

The association between attachment style and social functioning in patients with non-affective psychotic disorders, unaffected siblings and healthy controls

OBJECTIVE

In patients with psychotic disorders, insecure attachment styles and impaired social functioning are highly prevalent. Our aim was to explore the multi-cross-sectional and longitudinal associations between attachment style and social functioning.

METHODS

This study was performed in a subsample of 119 patients with non-affective psychotic disorders, 128 unaffected siblings and 66 healthy controls within the Genetic Risk and Outcome of Psychosis (GROUP) Study. Attachment style (using the Psychosis Attachment Measure) and three social functioning domains, namely withdrawal, interpersonal behaviour and pro-social activities as measured with the Social Functioning Scale (SFS) were assessed on two moments in time. Generalized linear mixed models and linear regression models were used. Bonferroni correction for multiple testing was applied.

RESULTS

In the patient group, a significant negative association was found between avoidant attachment and pro-social functioning. In the sibling and control group, we found significant negative associations between avoidant attachment and the social functioning domains withdrawal and interpersonal behaviour. We also found a significant negative association between anxious attachment and the social functioning domain withdrawal in siblings. Higher levels of insecure anxious attachment at baseline predicted a reduction of the social functioning domain interpersonal behaviour in siblings over a period of three years on a trend level.

CONCLUSIONS

Findings indicate that levels of insecure attachment are elevated in patients with psychotic disorders and have a negative association with social functioning in both patients, siblings and controls. These findings warrant specific attention for attachment style in the treatment of patients with psychotic disorders and individuals with an increased vulnerability for developing psychosis.

The role of insecure attachment and psychological mechanisms in paranoid and depressive symptoms: An exploratory model

Attachment theory is considered an important theoretical framework for understanding the ontogenesis of psychopathology. In this regard, insecure attachment styles have been associated with the development and maintenance of paranoid and depressive symptoms. Furthermore, different psychological processes (i.e., self-esteem and experiential avoidance) have been identified as mediating mechanisms between the relationship of insecure attachment and these symptoms. Nowadays, there is a more positive view in psychology focusing on factors that contribute to well-being, although little is known about the role of these psychological well-being variables as mediators between insecure attachment and psychopathology. For thus, the aim of this study was to test one explorative structural equation model of insecure attachment on paranoid and depressive symptoms through psychological mediating mechanisms to elucidate the processes involved in each of them. To evaluate the model, 141 individuals with severe psychiatric conditions participated in the study. The results revealed good model fit, highlighting that avoidant attachment has a direct and indirect effect on the symptoms, while anxious attachment has only an indirect effect through mediating mechanisms. On the other hand, lower levels of self-acceptance and environmental mastery have been identified as important processes associated with paranoid and depressive symptoms. However, less positive relationships were a significant mediating mechanism only for paranoid ideation symptoms. These results have important clinical implications by shedding light on the relationship between insecure attachment, paranoid and depressive symptoms, and the psychological mediating mechanisms involved in this relationship, which may be considered key variables in clinical treatments.

How does attachment style affect psychosis? A systematic review of causal mechanisms and guide to future inquiry

PURPOSE

The link between attachment and psychosis is now well established, but less is known about the causal mechanisms underlying this relationship. This systematic review synthesises the studies that examine mediating mechanisms in the attachment and psychosis relationship, in both clinical and non-clinical samples.

METHOD

We conducted a database search (PsychINFO, MEDLINE, Web of Science) to identify all eligible studies irrespective of publication status, the language of article or article date. We assessed methodological quality and completed a narrative synthesis given the heterogeneity of studies to date.

RESULTS

We identified 17 papers, comprising 3,672 participants. The relationship between attachment and psychosis is mediated by four variables or groups of variables. There is good evidence for the causal role of affective factors (affective dysregulation and affective disturbances) and cognitive factors (e.g., self-beliefs and self-esteem and beliefs about symptoms). Affective factors differed by attachment style. Tentative evidence was found for the role of duration of untreated psychosis and baseline negative symptoms.

CONCLUSIONS

Cognitive and affective factors mediate the relationship between attachment style and psychosis. Whilst cognitive factors are routinely targeted in recommended psychological interventions for psychosis, affective factors and attachment style are less commonly considered. Psychological therapies may be improved by calibrating cognitive and affective interventions by attachment style, which should be subjected to experimental and then field studies to assess the impact on clinical and recovery outcomes.

PRACTITIONER POINTS

The relationship between attachment and psychosis is now well established, and studies have started to examine mediating mechanisms. Affective and cognitive factors mediate the attachment-psychosis relationship. Affective factors differ by attachment style. There is limited evidence for the duration of untreated psychosis and negative psychotic symptoms as mediating mechanisms, and research replication is needed. Cognitive factors are routinely targeted in recommended psychological therapies for psychosis, but affective factors and attachment style are less commonly considered. Research should be conducted into the effectiveness of psychological therapies which calibrate cognitive and affective interventions, according to attachment style.

How does insecure attachment lead to paranoia? A systematic critical review of cognitive, affective, and behavioural mechanisms

Background

The relationship between attachment and paranoia is now well established. There is good theoretical reason and evidence to indicate that attachment style affects cognitive, affective, and behavioural processes which, in turn, contribute to the maintenance of paranoia, but this research has not been integrated. We critically and systematically review research that examines relevant cognitive, affective, and behavioural processes, which may explain how attachment insecurity leads to paranoia and constitute key targets in psychotherapeutic interventions for people with psychosis.

Method

We conducted three systematic searches across six databases (PsycINFO, CINAHL, Medline, Web of Science, Embase, and Google Scholar), from inception to September 2021, to investigate key cognitive, affective, and behavioural processes in the attachment–paranoia association.

Results

We identified a total of 1930 papers and critically reviewed 16. The literature suggests that negative self‐ and other‐beliefs, inability to defuse from unhelpful cognitions, and use of maladaptive emotion regulation strategies mediate the association between attachment insecurity and paranoia in people with psychosis/psychotic experience. Attachment‐secure people with psychosis are more likely to seek help and engage with services than attachment‐insecure people.

Conclusions

Attachment styles impact help‐seeking behaviours in people with psychosis and are likely to influence paranoia via self‐ and other‐beliefs, cognition fusion, and emotion regulation – these candidate mechanisms may be targeted in psychological therapy to improve clinical outcomes for people with psychosis, characterized by paranoia.

Practitioner points

Insecure attachment is likely to lead to paranoia via negative beliefs about self and others, cognitive fusion, and use of maladaptive emotion regulation strategies. These mechanisms can be targeted in psychotherapeutic interventions for psychosis, such as cognitive behaviour therapy, to improve clinical and recovery outcomes.

People with psychosis who are attachment‐secure are more likely to seek help and engage with services than those who are attachment‐insecure (particularly avoidant). Attachment style can be assessed to predict service engagement and help‐seeking behaviours in people with psychosis.

Attachment styles are important predictors of key cognitive, affective, and behavioural processes in people with psychosis. These processes can be assessed and incorporated into individualised formulations, and then targeted in therapy to effect psychotherapeutic change.

The relationship between attachment styles, psychopathology and quality of social interaction: A study on a clinical sample

The aim of this study is to examine the differences between four attachment styles in relation to symptoms of psychopathology and the quality of social interaction, as well as to determine the role of attachment and psychopathology in predicting positive and negative social exchange. A total of 57 participants from the neuropsychiatric department of the Service for Specialist-Consultative Health Activities of the Health Centre in Novi Sad took part in the research. Respondents were mostly female (61%), aged 17 to 68 (M=40.13, SD=12.35). The Relationship Questionnaire (RQ) was used for attachment styles assessment. Psychopathological symptoms were measured using the Cornell Index (CI-N4), and the quality of social relationships was evaluated via the Network of Relationship Inventory (NRI). The highest rate of symptoms was detected in subjects with a preoccupied style, followed by those whose style was identified as fearful. The same two styles showed the least positive social exchange. Statistically significant differences on most scales from CI-N4 were found mainly between the secure and preoccupied subjects, while subjects with the avoidant pattern did not demonstrate significant differences in psychopathology and social functioning compared to secure participants. Secure affective attachment and low aggressive-antisocial indicators (impulsiveness, aggression, and paranoia) were the most important predictors of positive social exchange. Understanding psychopathological manifestations of different insecure attachment styles can contribute to the efficiency of psychodiagnostic and psychotherapeutic processes. Furthermore, the fact that insecure attachment and aggressive-antisocial factor predominantly compromise positive social interaction can facilitate goal setting during psychological treatment within the clinical spectrum.

Insecure attachment as a transdiagnostic risk factor for major psychiatric conditions: A meta-analysis in bipolar disorder, depression and schizophrenia spectrum disorder

Insecure attachment has been suggested as a major risk factor for mental health problems as well as a key element for the development and trajectory of psychiatric disorders. The aim of this meta-analysis was to assess whether insecure attachment constitutes a global transdiagnostic risk factor in bipolar disorder, depression, and schizophrenia spectrum disorders. We conducted a PRISMA-based systematic quantitative review to explore the prevalence of insecure attachment among patients of three representative psychiatric disorders - major depression, schizophrenia spectrum disorders and bipolar disorder - in comparison with healthy controls (HC) from a transdiagnostic point of view. Effect sizes on differences of anxious, avoidant and insecure prevalence were calculated based on 40 samples including a total of n = 2927 individuals. Overall, results indicated a large effect on prevalence of insecure attachment across all disorders compared to HC (k = 30, g = 0.88, I² = 71.0%, p < 0.001). In a transdiagnostic comparison, the only difference was found in avoidant attachment, which was significantly lower (p = 0.04) compared to HC in the schizophrenia spectrum disorder subgroup (k = 10, g = 0.31, I² = 76.60%, p < 0.0001) than the depression subgroup subgroup (k = 12, g = 0.83, I² = 46.65%, p < 0.0001). The lack of further transdiagnostic differences between three distinct psychiatric disorders corroborates insecure attachment as a general vulnerability factor to psychopathology. Our findings warrant further investigations, which should explore the pathways from attachment insecurity towards psychopathology. Insecure attachment likely has implications on assessment, prediction and treatment of psychiatric patients.

Protective Factors Associated With Post-traumatic Outcomes in Individuals With Experiences of Psychosis

Trauma and trauma-specific mental health difficulties (e.g., post-traumatic stress disorder) are highly prevalent in people with psychosis. However, not everyone develops post-traumatic symptoms, and some people even experience post-traumatic growth (PTG) following trauma. It is important to identify which protective factors are associated with less severe trauma symptoms and/or positive outcomes to inform the development and implementation of interventions fostering these variables. Eighty-five patients with experiences of psychosis took part in a cross-sectional study. They were administered questionnaires measuring exposure to traumatic events, symptoms of PTSD and complex PTSD and potential protective factors assumed to be associated with lower vulnerability for post-traumatic symptoms and higher post-traumatic growth (trait resilience, secure attachment, social support, adaptive coping, optimism, general self-efficacy). Multiple hierarchical regression showed that some of these protective factors, in particular optimism, were associated with lower post-traumatic symptoms, explaining 21% of the variance in complex PTSD symptoms and 16% of the variance in PTSD symptoms. However, the hypothesized protective factors, in particular resilience and adaptive coping, explained a considerably larger proportion of variance in PTG (44%). Our results suggest that whilst these variables provide only moderate protection from the vulnerability to experience post-traumatic stress, they may play an important role in allowing people to find meaning despite multiple traumas and subsequently lead more fulfilling lives. Therapies targeting the emotional and psychological consequences of trauma in people with psychosis might benefit from the integration of intervention strategies to enhance these additional psychological protective factors, which in turn may lead to positive treatment outcomes beyond the mere reduction of post-traumatic stress symptoms.

Interpersonal attachment, early family environment, and trauma in hoarding: A systematic review

The formation of intense emotional attachments to objects, difficulty parting with possessions, and the extreme accumulation of clutter are key features of Hoarding Disorder (HD). Although substantial literature implicates processes such as dysfunctional beliefs and maladaptive emotional cycles in HD, little is known about the vulnerability factors that lead to their development and hoarding symptomatology. The current review sought to systematically collate and integrate findings from studies investigating the relationship between hoarding symptoms and three proposed vulnerability factors: i) interpersonal attachment, ii) early family environment, and iii) traumatic or adverse life events. A comprehensive search of the databases PsycInfo, PubMed, and Scopus identified a total of 39 studies for inclusion. The results presented a complex pattern that supported the presence of relationships between insecure attachment, cold and controlling family experiences, and exposure to adverse life events with increased hoarding severity. However, the specificity of these factors to HD over other clinical groups remains unclear and findings are limited by the heterogenous and small number of studies. We conclude by discussing the clinical implications and limitations of these findings and propose new directions for future research.

Attachment as a framework to facilitate empowerment for people with severe mental illness

OBJECTIVES

Recovery and empowerment have evolved into key objectives in the treatment and care of people with severe mental illness (SMI), and interest has grown in the role of social relationships in recovery. This study is the first to explore whether attachment styles are related to levels of empowerment, and secondly, whether attachment anxiety and attachment avoidance are associated with lower empowerment levels, independently of quality and frequency of social contact.

DESIGN

We used a cross-sectional design.

METHODS

In a sample of 157 participants with SMI in outpatient care, associations between attachment (Revised Adult Attachment Scale), self-reported social functioning, and empowerment (Netherlands Empowerment List) were assessed.

RESULTS

Attachment anxiety and attachment avoidance were both associated with lower levels of empowerment. A stepwise multiple regression analysis showed that the prediction of empowerment was significantly improved by adding attachment anxiety and attachment avoidance to quality and frequency of social contact. Attachment anxiety, attachment avoidance, and quality of social contact were significant predictors; frequency of social contact was not.

CONCLUSIONS

Although our design does not allow causal conclusions, our results highlight the importance of interpersonal processes and behaviours as routes to improving empowerment for people with SMI. A promising approach might thus consist of securing attachment bonds with significant others so that the self and the other are perceived as reliable resources. Our findings also feature the importance of reciprocity and equality in social relationships. Taken together, our study emphasizes the value of social, contextualized interventions in recovery work for people with SMI.

PRACTITIONER POINTS

Working towards attachment safety in interpersonal relations may be important in recovery-oriented treatment and care for people with severe mental illness (SMI). Helping people with SMI to recognize and change how they tend to relate themselves to others may promote engagement and effectiveness of recovery-oriented treatment and care. Reciprocity and equality in social relationships as vital complements to the more one-sided nature of 'standing alongside' and offering support may be important requisites for empowerment.

Mistrust and negative self-esteem: Two paths from attachment styles to paranoia

OBJECTIVES

Paranoia is known to be associated with insecure attachment, with negative self-esteem as a mediator, but this pathway is insufficient to explain the paranoid individual's beliefs about malevolent others. Mistrust is a likely additional factor as it is a core feature of paranoid thinking also associated with insecure attachment styles. In this study, we tested whether mistrust - operationalized as judgements about the trustworthiness of unfamiliar faces - constitutes a second pathway from insecure attachment to paranoia.

DESIGN

The design of the study was cross-sectional.

METHODS

A nationally representative British sample of 1,508 participants aged 18-86, 50.8% female, recruited through the survey company Qualtrics, completed measurements of attachment style, negative self-esteem, and paranoid beliefs. Usable data were obtained from 1,121 participants. Participants were asked to make trustworthiness judgements about computer-generated faces, and their outcomes were analysed by conducting signal detection analysis, which provided measures of bias (the tendency to assume untrustworthiness in conditions of uncertainty) and sensitivity (accuracy in distinguish between trustworthy and untrustworthy faces).

RESULTS

Results using structural equation modelling revealed a good model fit (RMSEA = .071, 95% CI: 0.067-0.075, SRMR = .045, CFI = .93, TLI = .92). We observed indirect effects through bias towards mistrust both for the relationship between attachment anxiety and avoidance (β = .003, 95% CI: 0.001-0.005,p < .001) and attachment anxiety and paranoia (β = .003, 95% CI 0.002-0.006, p < .001). We observed an indirect effect through negative self-esteem only for the relationship between attachment anxiety and paranoia (β = .064, 95% CI: 0.053-0.077, p < .001). Trust judgements and negative self-esteem were not associated with each other.

CONCLUSIONS

We find that a bias towards mistrust is associated with greater paranoia. We also find indirect effects through bias towards mistrust between attachment styles and paranoia. Finally, we reaffirm the strong indirect effect through negative self-esteem between attachment anxiety and paranoia. Limitations of the study are discussed.

PRACTITIONER POINTS

When working with individuals suffering from paranoia, clinicians should consider not only explicit, deliberative cognitive processes of the kind addressed in cognitive behaviour therapy (e.g. cognitive restructuring) but also the way in which their patients make perceptual judgements (e.g., their immediate reactions on encountering new people) and consider interventions targeted at these judgements, for example, bias modification training. Assessment and clinical interventions for people should consider the role of trust judgements and the way in which they combine with low self-esteem to provoke paranoid beliefs. Psychological interventions targeting paranoid beliefs should focus on both attachment anxiety and attachment avoidance.

Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis

AIM

The moderate association between therapeutic alliance (TA) and psychological therapy outcome is well established. Historically, the field has not focused on people with a severe mental illness. This is the first review to conduct a meta-analysis of associations between TA and therapeutic engagement as well as outcome in psychological therapy for psychosis.

ELIGIBILITY CRITERIA

Eligible studies conducted a quantitative investigation of the relationship between TA during a psychological therapy and outcome at a subsequent time-point.

METHOD

A systematic review examined the relationship between TA and engagement as well as outcome measures within psychological therapy for psychosis. Correlational meta-analyses using an aggregate random effects model were conducted.

RESULTS

Twenty-four studies were eligible for inclusion (n = 1,656) of which 13 were included in the meta-analyses. Client- and therapist-rated TA were associated with engagement in therapy (r_{client (c)}  = 0.36, p = .003; r_{therapist (t)}  = 0.40, p = .0053). TA was also associated with reduction in global (r_c  = 0.29, p = .0005; r_t  = 0.24, p = .0015) and psychotic symptoms (r_c  = 0.17, p = .0115; r_t  = 0.30, p = .0003). The systematic review identified no evidence or limited evidence for a relationship between TA during therapy and depression, substance use, physical health behaviours, global as well as social functioning, overall mental health recovery, and self-esteem at follow-up. Although number of studies was small, TA was related to a reduced risk of subsequent hospitalization in 40% of analyses (across two studies) and improved cognitive outcome in 50% of analyses (across three studies).

CONCLUSIONS

The observed TA-therapy engagement and TA-outcome associations were broadly consistent with those identified across non-psychotic diagnostic groups. Well-powered studies are needed to investigate the relationship between TA and process as well as outcome in psychological therapy for psychosis specifically.

PRACTITIONER POINTS

This is the first review to conduct a meta-analytic synthesis of the association between therapeutic alliance (TA) and both engagement and change in outcome in psychological therapies for psychosis. TA (as rated by therapist and client) was associated with the extent of therapeutic engagement as well as reduction in global mental health symptoms and psychotic symptoms. The significant associations between TA and engagement as well as change in outcome identified in the current review are broadly consistent with those observed across non-psychotic diagnostic groups. We consider factors that could impact upon the dynamic and potentially interdependent relationships between TA and therapeutic techniques, including attachment security and severity of paranoid ideation.

Attachment styles moderate Theory of Mind differences between persons with schizophrenia, first-degree relatives and controls

OBJECTIVES

Theory of Mind (ToM) plays a role in social functioning and is impaired in patients with schizophrenia and to a lesser degree in first-degree relatives, compared to healthy controls. This study investigates whether attachment styles moderate these observed group differences in ToM.

METHODS

This cross-sectional study included a sample of 51 patients, 23 first-degree relatives, and 49 controls who completed assessments of anxious and avoidant attachment (Psychosis Attachment Measure), ToM (Reading the Mind in the Eyes Test), and estimated cognitive ability. Patients' symptoms were assessed with the Positive and Negative Syndrome Scale.

RESULTS

Patients differed from controls and relatives in ToM performance but not in attachment avoidance or attachment anxiety. Attachment anxiety showed an interaction with group over ToM. The interaction was significant only between patients and controls but not between patients and relatives or relatives and controls. Post-hoc analysis showed that patients and controls showed differential ToM performance at average and high attachment anxiety. In patients, symptom levels did not moderate the association between attachment and ToM.

CONCLUSIONS

Attachment anxiety is related to poorer levels of ToM in patients, suggesting this may have a contributory role in schizophrenia. The findings stress the need for longitudinal research into the directionality of the relationship between ToM and attachment anxiety.

PRACTITIONER POINTS

Relationships with significant others might be a factor that influences the way in which social information is processed by persons with a diagnosis of a psychotic disorder. In patients, higher levels of attachment anxiety - that is, low self-worth, fear of abandonment and rejection, continuous vigilance of threat-related cues - were associated with a lower ability to understand the mental states of others. However, at lower levels of attachment anxiety, their ToM performance was comparable to that of relatives and controls. This effect was not influenced by symptom severity. Further research is required to confirm the potential influence of attachment insecurity on ToM ability as the latter is strongly related to patient's functional outcomes.

Machine learning-based ability to classify psychosis and early stages of disease through parenting and attachment-related variables is associated with social cognition

Background

Recent views posited that negative parenting and attachment insecurity can be considered as general environmental factors of vulnerability for psychosis, specifically for individuals diagnosed with psychosis (PSY). Furthermore, evidence highlighted a tight relationship between attachment style and social cognition abilities, a key PSY behavioral phenotype. The aim of this study is to generate a machine learning algorithm based on the perceived quality of parenting and attachment style-related features to discriminate between PSY and healthy controls (HC) and to investigate its ability to track PSY early stages and risk conditions, as well as its association with social cognition performance.

Methods

Perceived maternal and paternal parenting, as well as attachment anxiety and avoidance scores, were trained to separate 71 HC from 34 PSY (20 individuals diagnosed with schizophrenia + 14 diagnosed with bipolar disorder with psychotic manifestations) using support vector classification and repeated nested cross-validation. We then validated this model on independent datasets including individuals at the early stages of disease (ESD, i.e. first episode of psychosis or depression, or at-risk mental state for psychosis) and with familial high risk for PSY (FHR, i.e. having a first-degree relative suffering from psychosis). Then, we performed factorial analyses to test the group x classification rate interaction on emotion perception, social inference and managing of emotions abilities.

Results

The perceived parenting and attachment-based machine learning model discriminated PSY from HC with a Balanced Accuracy (BAC) of 72.2%. Slightly lower classification performance was measured in the ESD sample (HC-ESD BAC = 63.5%), while the model could not discriminate between FHR and HC (BAC = 44.2%). We observed a significant group x classification interaction in PSY and HC from the discovery sample on emotion perception and on the ability to manage emotions (both p = 0.02). The interaction on managing of emotion abilities was replicated in the ESD and HC validation sample (p = 0.03).

Conclusion

Our results suggest that parenting and attachment-related variables bear significant classification power when applied to both PSY and its early stages and are associated with variability in emotion processing. These variables could therefore be useful in psychosis early recognition programs aimed at softening the psychosis-associated disability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00552-3.

Dissociation and insecure attachment as mediators of the relation between childhood emotional abuse and nonclinical paranoid traits

Background: Research suggests dissociation and insecure attachment serve as explanatory mechanisms in the pathway from childhood trauma to paranoia. However, past work has not examined these mechanisms concurrently in nonclinical populations. Objective: The current study sought to examine dissociation and insecure attachment as parallel mediators of the association between childhood emotional abuse and paranoid traits. Furthermore, a serial mediation model with insecure attachment preceding dissociation in the explanatory pathway was explored. Methods: Eighty-nine nonclinically ascertained young adults were assessed for childhood emotional abuse, dissociation, attachment styles, and paranoid traits. Parallel and serial mediation models were tested. Results: The association of childhood emotional abuse with both interview-based and self-reported paranoid traits was significantly mediated by dissociation and preoccupied attachment. Fearful attachment was a significant mediator in the model for self-reported paranoid traits. No evidence for a serial mediation effect was found. Conclusions: The present findings extend support for dissociation and attachment insecurity as mechanisms underlying the link between childhood emotional maltreatment and paranoid traits. Longitudinal research is needed to inform whether insecure attachment contributes to dissociation along the pathways to paranoid traits.

Self-reported interpersonal and educational/vocational difficulties in young adults with a history of transient psychotic experiences: findings from a population-based study

BACKGROUND

Psychotic experiences (PEs) are not uncommon in young people and are associated with both psychopathology and compromised global functioning. Although psychotic experiences are transient (short-lived, self-resolving and non-recurring) for most people who report them, few studies have examined the association between early transient PEs and later functioning in population samples. Additionally, studies using self-report measures of interpersonal and educational/ vocational difficulties are lacking. The aim of this study was to examine the relationship between transient psychotic experiences and self-reported interpersonal and educational/vocational difficulties in adolescence and young adulthood.

METHODS

Participants were 103 young people from a longitudinal population-based study cohort of mental health in Ireland. They attended for baseline clinical interviews in childhood (age 11-13) and were followed up in young adulthood (age 19-25). Participants who reported psychotic experiences at baseline but not at follow-up were classified as having transient psychotic experiences. Data from both time-points were used to examine the association between transient psychotic experiences and self-reported interpersonal and educational/ vocational difficulties in young adulthood using poisson regression modelling.

RESULTS

Young people with a history of transient psychotic experiences reported significantly higher interpersonal (adj IRR: 1.83, 95%ileCI: 1.10-3.02, p = .02) and educational/vocational (adj IRR: 2.28, 95%ileCI: 1.43-3.64, p = .001) difficulties during adolescence. However, no significant differences in interpersonal (adj IRR: 0.49, 95%ileCI: 0.10-2.30, p = .37) or educational/vocational (adj IRR: 0.88, 95%ileCI: 0.37-2.08, p = .77) difficulties were found in young adulthood. Self-reported interpersonal and educational/vocational difficulties in young people both with and without a history of transient psychotic experiences decreased between adolescence and young adulthood.

CONCLUSIONS

Young people with transient psychotic experiences have increased interpersonal and educational/vocational difficulties in adolescence but these may not persist into the young adult years. This finding indicates that early psychotic experiences may not confer high risk for long-term interpersonal or educational/vocational deficits among young people who experience these phenomena transiently.

Adult Attachment and Personal, Social, and Symptomatic Recovery From Psychosis: Systematic Review and Meta-Analysis

Despite growing evidence for the role of attachment in psychosis, no quantitative review has yet been published on the relationship in this population between insecure attachment and recovery in a broad sense. We therefore used meta-analytic techniques to systematically appraise studies on the relationship between attachment and symptomatic, social and personal recovery in clients with a psychotic disorder. Using the keywords attachment, psychosis, recovery and related terms, we searched six databases: Embase, Medline Epub (OVID), Psycinfo (OVID), Cochrane Central (trials), Web of Science, and Google Scholar. This yielded 28 studies assessing the associations between adult attachment and recovery outcome in populations with a psychotic disorder. The findings indicated that insecure anxious and avoidant attachment are both associated with less symptomatic recovery (positive and general symptoms), and worse social and personal recovery outcomes in individuals diagnosed with a psychotic disorder. The associations were stronger for social and personal recovery than for symptomatic recovery. Attachment style is a clinically relevant construct in relation to the development and course of psychosis and recovery from it. Greater attention to the relationship between attachment and the broad scope of recovery (symptomatic, social, and personal) will improve our understanding of the illness and efficacy of treatment for this population.

The Two-Dimensional Model of Behavioral Systems and the "Problematic" Activation Style

We describe a two-dimensional model of activation of the behavioural systems according to which four prototypical activation styles can be identified within a system by positioning an individual on two main dimensions. A functional style, characterized by primary strategies of activation, a hyperactivated style, by hyperactivation strategies, an inhibited style, by deactivating strategies, and a fourth style, the problematic style, characterized by coexistence of hyperactivating and deactivating strategies. Here, we focus on the problematic style representing a dysfunctional expression of the behavioral systems leading to chaotic and unpredictable behaviors, and also relating to higher rates of psychopathology and reduced ability to participate to therapy. The present model could help the clinician to identify problematic behavioural activations undermining the therapeutic process.

The relationship between attachment and functioning for people with serious mental illness: a systematic review

AIMS

Functional impairment is a hallmark feature of severe mental health problems (SMI). Attachment theory is a key psychological theory of interpersonal functioning and difficulties in attachment are common in SMI and may help explain functioning problems in SMI. This systematic review aimed to synthesise and critically appraise existing literature exploring associations between adult attachment style and functioning in SMI samples.

METHOD

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines we systematically searched five databases using strings of terms relating to both attachment and social functioning. Inclusion criteria were samples diagnosed with SMI and validated measure tools.

RESULTS

Ten studies met inclusion criteria. Considerable heterogeneity was found across studies in relation to construct measurement, sample size, and gender distribution. However, as predicted there was some evidence to suggest that secure attachment is associated with better functioning, and insecure attachment (specifically anxious style) is associated with impairments in functioning.

CONCLUSION

Findings highlight the importance of considering attachment in relation to functional outcome when working with people with SMI, particularly when assessing, formulating, and delivering psychological interventions.

The role of insecure attachment and cognitive biases in the social functioning of schizophrenia spectrum patients

OBJECTIVE

The study investigates the relationship between cognitive biases and attachment styles and social functioning.

METHOD

Fifty-three patients (28 females, age M = 41.73, SD = 11.71) with the diagnosis of schizophrenia participated in the study. We measured attachment styles, cognitive biases, and social functioning using self-report questionnaires. Relationships among variables were investigated with correlational and regression analyses.

RESULTS

Correlation analysis indicated that social engagement, interpersonal behavior, pro-social activities, and independence-performance significantly correlate with both attachment styles and cognitive biases. However, in regression analysis, after controlling for attachment styles, only subjective cognitive problems turned out to be a significant predictor of social functioning.

CONCLUSIONS

These preliminary findings might suggest that both attachment styles and cognitive biases are associated with social functioning. Nonetheless, when considered together it might suggest attachment styles have a higher contribution than cognitive biases to social engagement, interpersonal behavior, and pro-social activities decline in schizophrenia spectrum disorders.

An attachment perspective on the risk for psychosis: Clinical correlates and the predictive value of attachment patterns and mentalization

BACKGROUND

In a longitudinal design, the present study examined: (a) the nature of attachment patterns and reflective functioning (RF) in individuals at ultra-high risk for psychosis (UHR); (b) the association between RF and subclinical psychotic symtoms; and (c) the psychosis-predictive value of attachment patterns, RF, and the interaction between these factors.

METHOD

The sample comprised 57 UHR subjects and 53 clinical controls (non-UHR). UHR subjects were followed over a mean period of 14 months (SD = 2.7; range 11-19), during which time 11.5% developed psychosis. Attachment patterns and RF were measured. Hierarchical logistic regression was used to examine the predictive value of variables in the transition to psychosis.

RESULTS

At baseline, significant differences were found between groups in secure attachment patterns and RF. RF was negatively associated with the attenuated psychotic symptoms described by the Unusual Thought Content/Delusional Ideas, Suspiciousness/Persecutory Ideas, and Disorganized Communication subscales. Moreover, poor mentalization was related to an increased likelihood of developing a psychotic disorder (OR = 0.427, 95% CI [0.188, 0.970]); conversely, no predictive effects of the attachment variables and their interaction with RF on the transition to psychosis were found. Notably, an optimal threshold value of RF = 1.25 was found to distinguish UHR subjects who made the transition to psychosis from those who did not develop this pathology.

CONCLUSION

The results suggest that aberrant mentalizing patterns can predict the development of psychosis. Clinical implications of these results for the development of preventive treatments are discussed.

Childhood trauma, attachment and negative schemas in relation to negative auditory verbal hallucination (AVH) content

Auditory verbal hallucinations (AVHs, or hearing voices) are particularly characterized by negative content such as criticism and threats. The extent of negative content is a major predictor of distress, yet there is limited research on what contributes to the content of AVHs. The current study aimed to assess the relationships between childhood trauma, attachment styles (anxious and avoidant) and negative self schemas as plausible mechanisms underlying negative AVH content. Structural equation modelling was used to test a theoretical model, including these constructs, in a transdiagnostic sample of 140 people with AVHs. Findings indicated that collectively, emotional trauma during childhood, insecure anxious attachment and negative self schemas predicted the proportion of negative AVH content experienced by voice hearers. Whereby, trauma predicted attachment, which predicted schemas and in turn negative AVH content. This study marks an important step towards understanding the underlying mechanisms involved in negative AVHs. The results highlight the importance of recognising early experiences of trauma, adult attachment styles and self schemas in developing formulations and effective treatments for negative and distressing AVHs. Psychological interventions that target these underlying mechanisms of negative AVHs may lead to a reduction in negative content, thereby reducing voice related distress.

Early risk and protective factors and young adult outcomes in a longitudinal sample of young people with a history of psychotic-like experiences

AIM

Psychotic-like experiences (PEs) have been associated with childhood adversity and psychopathology. However, few studies have examined the dynamic interplay between risk and protective factors and later life outcomes in people with PEs. This study aimed to explore and compare patterns of early adverse and protective experiences and young adult outcomes in a sample of young people with a history of PEs.

METHOD

Longitudinal qualitative data spanning nine years were collected from a general population sample of seventeen young adults who had reported PEs in early adolescence. A qualitative comparative case study design was used to explore patterns of early life experiences and young adult outcomes.

RESULTS

Four archetypal profiles of early life experiences and later outcomes were identified. Qualitative differences between types of early adverse experiences and the quality of attachment relationships were dominant discriminating factors between low-risk and at-risk archetypes for poor young adult outcomes. Experiences of multiple adversities, which included childhood trauma and occurred in the absence of secure attachment relationships was associated with the poorest young adult outcomes. The presence of secure attachment relationships was protective, even among individuals who had experienced adversity.

CONCLUSIONS

Not all young people who report PEs have high levels of adversity. Those who experience multiple early adversities, childhood trauma and insecure attachment relationships are at highest risk for reoccurring PEs and poor young adult outcomes. Developing trusted attachment relationships and engaging in corrective experiences may be protective and could promote positive outcomes in youth with PEs.

Attachment as a mechanism between childhood maltreatment and subclinical psychotic phenomena: Results from an eight-year follow-up study

We previously reported that fearful attachment mediated associations of childhood maltreatment with subclinical psychotic phenomena. At an eight-year follow-up, we aimed to replicate and extend this finding by examining the mediating role of disorganized attachment. Participants were 169 young adults who completed baseline and eight-year follow-up questionnaires. Physical/emotional maltreatment was prospectively associated with paranoid beliefs and positive schizotypy. For paranoid beliefs, fearful and disorganized attachment were significant mediators in separate models, whereas only disorganized was significant when examining all attachment styles concurrently. For positive schizotypy, no mediation was found. Findings support psychological models of paranoia and may inform intervention efforts.

Similar psychosis risks in adoptees and immigrants

BACKGROUND

There is a consensus that adoptees and immigrants both experience more mental health problems than their peers. The two groups share many risk factors for psychosis, but an increased risk for psychotic illness has only been demonstrated for immigrants.

AIMS

The aim of this review is to describe psychosis risk factors in adoptees, with a focus on difficulties with identity formation, identification with in-groups, attachment to parents, and coping with loss and with discrimination.

METHOD

The literature in these five areas is reviewed as it pertains to adoption and psychosis.

RESULTS

There are no clear findings because the relevant studies have not been done, but the literature suggests that adopted children face challenges very similar to those of immigrants to a new country.

CONCLUSION

The immigration field and the adoption field have much to learn from each other. It is recommended that a prevention strategy analogous to increased neighbourhood ethnic density be implemented with adoptees - that they be intentionally exposed from early childhood and throughout adolescence to age peers who share a similar background and with whom they can readily identify. It is also recommended that immigrants be welcomed into their host country with the same open arms as adoptive parents welcome their new children.

Looking at Intergenerational Risk Factors in Schizophrenia Spectrum Disorders: New Frontiers for Early Vulnerability Identification?

Offspring of individuals with serious mental illness (SMI) constitute a special population with a higher risk of developing psychiatric disorders, which is also highly prevalent among referrals to child and adolescent mental health services (CAMHS). They often exhibit more or less subclinical conditions of vulnerability, fueled by mutually potentiating combinations of risk factors, such as presumed genetic risk, poor or inadequate affective and cognitive parenting, and low socio-economic status. Despite this evidence, neither specific preventive programs for offspring of parents with SMI are usually implemented in CAMHS, nor dedicated supportive programs for parenting are generally available in adult mental health services (AMHS). Needless to say, while both service systems tend to focus on individual recovery and clinical management (rather than on the whole family system), these blind spots add up to frequent gaps in communication and continuity of care between CAMHS and AMHS. This is particularly problematic in an age-range in which an offspring's vulnerabilities encounter the highest epidemiological peak of incident risk of SMI. This paper offers a clinical-conceptual perspective aimed to disentangle the complex intertwine of intergenerational risk factors that contribute to the risk of developing SMI in offspring, taking schizophrenia spectrum disorders as a paradigmatic example.

The relationship between insecure attachment and paranoia in psychosis: A systematic literature review

Objectives

Paranoia is a key symptom in psychosis and associated with a range of poor outcomes. Earlier life experiences increase vulnerability to paranoid thinking, and attachment theory has been proposed as a key model in explaining this causal pathway. Previous reviews highlight evidence of associations between insecure attachment styles and overall severity of psychotic symptoms. Studies report on associations between insecure attachment and paranoia, but to date, this literature has not been adequately synthesized. The aim of the current review was to report the strength and consistency of associations between paranoia and insecure attachment across published studies, and provide systematic appraisal of study quality.

Method

We carried out a systematic review of electronic databases using search terms to capture concepts of adult attachment, paranoia, and psychosis. We pre‐registered the review protocol and followed PRISMA guidelines.

Results

Significant associations were reported in 11 out of 12 studies between an insecure attachment and paranoia, with associations remaining significant in studies that controlled for comorbid symptoms. The strongest, most commonly reported relationship was between an anxious attachment style and paranoia.

Conclusions

The findings support the proposed role of attachment insecurity in the development and maintenance of paranoia in psychosis and highlight the need to address insecure attachment representations in the treatment of paranoia.

Practitioner points

There is consistent evidence of associations between insecure attachment style and paranoia.

Insecure anxious attachment is more consistently associated with paranoia than an insecure avoidant attachment.

Associations between attachment and paranoia remain significant when key confounders are controlled for in the analyses.

Interventions that address insecure attachment representations and promote a more secure attachment are likely to help reduce paranoia.

The role of attachment anxiety in the relationship between childhood trauma and schizophrenia-spectrum psychosis

Childhood trauma (CT) is a comprehensive concept encompassing experiences of sexual, physical, and emotional abuse, and neglect during childhood and adolescence. Patients with schizophrenia-spectrum psychosis (SSP) display higher rates of CT than healthy controls. Among the potential mediators of this association, insecure attachment has gained attention and empirical validation. The present study aimed to extend existing knowledge on this field by exploring the role of the two attachment dimensions, attachment anxiety and attachment avoidance, in the CT-SSP association. A clinical sample of 63 SSP inpatients was compared to a healthy control group on CT and attachment style measures. Correlations between CT, attachment dimensions and psychopathology were sought. Mediation analyses were also performed to examine whether attachment anxiety and/or attachment avoidance mediated the CT-SSP association. Patients displayed higher rates of CT and insecure attachment than controls. Attachment anxiety and severity of Mother Antipathy were linked to severity of hallucinations. Attachment anxiety was recognized as the sole mediator of the CT-SSP association. Our findings suggest that individuals with severe CT and increased attachment anxiety represent a risk population warranting early clinical attention, regular monitoring and tailored therapeutic interventions aimed at reducing the psychological impact of trauma.