The relationship between attachment insecurity and experiences on the paranoia continuum: A meta‐analysis

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We searched five databases (PubMeD, Web of Science, PsycINFO, CINAHL and ETHOS) for published and unpublished research examining attachment, dissociation and psychosis.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.

Does disorganised attachment lead to auditory hallucinations via dissociation? An experimental study with an analogue sample

OBJECTIVES

Auditory hallucinations (such as hearing voices) are common in clinical and non-clinical populations. Many people who hear voices also report early adversity and have an insecure attachment style. Current cognitive models suggest that dissociation mediates an association between disorganised attachment and auditory hallucinations, but this has not been tested experimentally.

DESIGN

We recruited a non-clinical analogue sample highly predisposed to auditory hallucinations and utilised an experimental design to examine the impact of disorganised attachment imagery on hallucinatory experiences, and whether dissociation mediates an expected association.

METHODS

Participants completed self-report measures of state auditory hallucinations and dissociation before and after random allocation to secure or disorganised attachment conditions.

RESULTS

Attachment imagery did not affect auditory hallucinations. Both secure and disorganised attachment conditions increased state dissociation. Secure attachment imagery reduced paranoia, but state dissociation did not mediate this effect. An exploratory analysis found that trait dissociation fully accounted for the association between trait-disorganised attachment and hallucinatory experience while controlling for paranoia.

CONCLUSIONS

Secure attachment imagery reduces paranoia but not auditory hallucinations and the impact on paranoia is not mediated by dissociation. Secure attachment imagery may be useful in reducing fears and distress associated with voices, rather than the frequency or severity of hallucinations. Disorganised attachment may increase hallucinatory experiences for people vulnerable to dissociation. Trait dissociation should be assessed in clinical settings and addressed where indicated as a means of targeting vulnerability to distressing voices.

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.

Temporal pathways from attachment insecurity to paranoia in a heterogeneous clinical sample: An experience sampling study

INTRODUCTION

There has been growing interest in the role of attachment mechanisms in the onset and maintenance of paranoia. The latest systematic reviews of mixed samples of healthy individuals and psychiatric patients have revealed that increased trait attachment anxiety and avoidance are associated with experiencing paranoia, with trait attachment anxiety showing a stronger association. Few studies have examined attachment and paranoia in naturalistic conditions via the Experience Sampling Method.

OBJECTIVES

The present study examined whether experiences of attachment anxiety and avoidance fluctuate in the flow of daily life, and whether a within-person change in both attachment states precedes the experience of momentary paranoia, and negative and positive emotions.

METHODS

Thirty-seven clinical participants and twenty-six healthy controls were studied over six consecutive days using the Experience Sampling Method (ESM). An experience-in-close-relationships questionnaire (ECR-R 16 SF) was used to capture trait attachment dimensions. Several ESM items were used to capture momentary negative and positive affect, paranoia and attachment insecurity states.

RESULTS

The findings revealed that fluctuations in both attachment insecurity states were significantly higher in the clinical group. A prior elevated attachment anxiety and avoidance was followed by an increase in negative affect in the next moment and elevated attachment avoidance was additionally followed by a decrease in positive affect and an increase in paranoia.

CONCLUSION

Our findings reveal the specific temporal associations between momentary attachment insecurity states as predictors of change in emotions/affects and paranoia, along with evidence that state attachment avoidance has a superior impact on momentary affect and paranoia compared to state attachment anxiety. These results contrast with those of recent cross-sectional studies.

Do the diverse phenotypes of Prader-Willi syndrome reflect extremes of covariation in typical populations?

The phenotypes of human imprinted neurogenetic disorders can be hypothesized as extreme alterations of typical human phenotypes. The imprinted neurogenetic disorder Prader-Willi syndrome (PWS) features covarying phenotypes that centrally involve altered social behaviors, attachment, mood, circadian rhythms, and eating habits, that can be traced to altered functioning of the hypothalamus. Here, we conducted analyses to investigate the extent to which the behavioral variation shown in typical human populations for a set of PWAS-associated traits including autism spectrum cognition, schizotypal cognition, mood, eating, and sleeping phenotypes shows covariability that recapitulates the covariation observed in individuals with PWS. To this end, we collected data from 296 typical individuals for this set of phenotypes, and showed, using principal components analysis, evidence of a major axis reflecting key covarying PWS traits. We also reviewed the literature regarding neurogenetic syndromes that overlap in their affected traits with PWS, to determine their prevalence and properties. These findings demonstrate that a notable suite of syndromes shows phenotypic overlap with PWS, implicating a large set of imprinted and non-imprinted genes, some of which interact, in the phenotypes of this disorder. Considered together, these findings link variation in and among neurogenetic disorders with variation in typical populations, especially with regard to pleiotropic effects mediated by the hypothalamus. This work also implicates effects of imprinted gene variation on cognition and behavior in typical human populations.

Association between Parents’ Relationship, Emotion-Regulation Strategies, and Psychotic-like Experiences in Adolescents

This study aimed to examine the association between the psychotic-like experiences (PLEs) and emotion-regulation (ER) strategies of adolescents and their parents’ relationship, and we hypothesized that the parents’ relationship moderates the link between ER strategies and PLEs. We recruited a total of 2708 first-year college students (1659 males and 1049 females) aged 15–20 years (mean = 17.9). Participants completed assessments of PLEs, their use of ER strategies, and reported their parents’ relationship as harmonious, conflicting, or divorced. Regression analyses indicated that the lower the use of the emotion-reappraisal strategy, the greater the use of the emotion-suppression strategy and that parental conflict or divorce predicted the number of PLEs endorsed and the level of distress from the PLEs. The parents’ relationship moderated the association between ER strategies and distress from PLEs. Among those who reported parental conflict or divorce, their lower use of the reappraisal strategy predicted their experiencing higher levels of distress from their PLEs. This study suggested the direct and interactive influence of the parents’ relationship and ER strategies on the presence of PLEs and PLE-related distress levels among adolescents, which may represent potential intervention targets.

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.

Pathways from insecure attachment to paranoia: the mediating role of emotion regulation

Background:

Paranoia is common across the clinical and non-clinical spectrum. Cognitive behavioural therapy for psychosis currently yields modest results, warranting research into symptom-specific maintenance factors to improve outcomes. There is strong evidence of a relationship between insecure attachment and increased paranoia, but little is known about the mediating mechanisms. Emotion dysregulation is associated with both insecure attachment and paranoia, and a candidate causal mechanism.

Aims:

This study aimed to determine if emotion dysregulation mediates the association between attachment and paranoia.

Method:

Sixty-two individuals with elevated paranoia were recruited from NHS services and community settings across the South of England. Mediation analyses were conducted on trait attachment, emotion regulation and paranoia variables, which were collected at one time point.

Results:

As predicted, emotion dysregulation mediated the relationship between attachment avoidance and paranoia, and between attachment anxiety and paranoia. Emotion suppression did not mediate the relationship between attachment avoidance and paranoia, possibly due to power. Attachment avoidance correlated with deactivating emotion regulation strategies (e.g. lack of emotional awareness) and attachment anxiety correlated with hyperactivating emotion regulation strategies (e.g. impulse control difficulties). Both deactivating and hyperactivating strategies correlated with paranoia.

Conclusion:

Emotion dysregulation is not routinely targeted in cognitive behavioural therapy for psychosis. This study suggests that incorporating emotion regulation strategies in therapy may improve clinical outcomes. Experimental studies are now required to support a causal argument, and pilot intervention studies should investigate if emotion regulation skills development (aligned with attachment style) is effective in reducing non-clinical and clinical paranoia.

The co-occurrence of multidimensional loneliness with depression, social anxiety and paranoia in non-clinical young adults: A latent profile analysis

INTRODUCTION

Loneliness is a negative experience arising from a mismatch between perceived and actual social relationships. Several dimensions of loneliness have been suggested, namely intimate, relational and collective loneliness. Loneliness has been linked to poorer mental health, with its co-occurrence with depression, social anxiety, and paranoia most widely reported. While expressions of these symptoms are heterogeneous across individuals in the non-clinical population, it remains unclear how these symptoms co-occur with one another and with various dimensions of loneliness. It is also of interest how trait factors such as core schemas about self/others may moderate these relationships between loneliness and co-occurring symptoms.

METHODS

A demographically diverse sample of young adults was recruited from multiple sources. The validated sample consisted of 2,089 participants (68.4% female), who completed an online survey consisting of questionnaires assessing levels of multidimensional loneliness, depression, social anxiety, paranoia, core schemas, and demographic characteristics. Latent profile analysis (LPA) was used to identify distinct profiles of loneliness and the three symptoms. Positive and negative core schemas about self and others were modeled as predictors of these profiles.

RESULTS

Five distinct profiles were identified. Profile 1 had low levels across all symptoms and dimensions of loneliness (n = 1,273, 60.9%). Profiles 2-5 were elevated on dimensions of loneliness, and were heightened in depression (n = 189, 9.0%), social anxiety (n = 206, 9.9%), paranoia (n = 198, 9.5%), and all symptoms (n = 223, 10.7%), respectively. Relative to Profile 1, the other four profiles scored higher on negative-self (adjusted ORs = 1.36-1.49, ps < 0.001) and negative-other schemas (adjusted ORs = 1.24-1.44, ps < 0.001), and lower on positive-self (adjusted ORs = 0.82-0.85, ps < 0.001) and positive-other schemas (adjusted ORs = 0.81-0.90, ps < 0.001).

CONCLUSION

More marked intimate, relational and collective loneliness were evident across profiles that had heightened depression, social anxiety and/or paranoia, suggesting that loneliness may serve as a general risk factor for these psychopathologies. Our findings shed light on the heterogeneity of the co-occurrence of loneliness and various mental health difficulties in non-clinical young adults. Core schemas are suggested to be putative psychological mechanisms underlying their co-occurrence and even development.

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.

How does attachment imagery for paranoia work? Cognitive fusion and beliefs about self and others mediate the impact on paranoia and anxiety

OBJECTIVES

Paranoia describes unfounded and distressing interpersonal threat beliefs. Secure attachment imagery has been shown to attenuate paranoia and anxiety in non-clinical and clinical groups, but little is known about the differential effects of anxious and avoidant imagery or mechanisms of change. In this study, we tested the impact of secure, anxious, and avoidant attachment imagery on paranoia, anxiety, and help-seeking intentions. We also examined hypothesized mechanisms of change, specifically whether cognitive fusion and negative self- and other-beliefs mediate these relationships.

DESIGN

This study utilized an experimental, cross-sectional design.

METHODS

A large (N = 303), international general population sample with high levels of non-clinical paranoia completed a series of measures before and after engaging in secure, anxious, or avoidant imagery.

RESULTS

Relative to anxious and avoidant attachment imagery, secure attachment imagery reduced paranoia and anxiety and increased help-seeking intentions. Cognitive fusion and negative self- and other-beliefs mediated the impact of attachment imagery on paranoia and anxiety, but not help-seeking.

CONCLUSIONS

In line with attachment and cognitive theory, secure attachment imagery is effective in reducing paranoia and anxiety and works by reducing cognitive fusion and negative self- and other-beliefs. These novel findings suggest that the secure imagery task could be incorporated into cognitive and behavioural therapies to reduce distressing interpersonal threat beliefs and associated negative affect, and increase help-seeking intentions.

PRACTITIONER POINTS

When working with people experiencing paranoia, secure attachment imagery may be effective in reducing state paranoia and anxiety and improving help-seeking intentions. Attachment imagery works by influencing beliefs about self and others, and the degree to which people are fused with their beliefs. In clinical practice, the rationale for the imagery task fits well with psychological models of paranoia and the secure imagery task can be introduced as a way to cope when struggling with distressing beliefs about self and others, and feeling overwhelmed by these fears.

The Impact of Repeated Attachment Priming on Paranoia, Mood and Help-Seeking Intentions in an Analogue Sample

Attachment security priming effects therapeutic change in people with depression and anxiety. Preliminary studies indicate that visualising secure attachment memories also reduces paranoia in non-clinical and clinical groups, probably due to a decrease in cognitive fusion. Benefits to clinical populations depend on the sustainability of these effects and the impact on help-seeking behaviours. The combination of paranoia and an insecure-avoidant attachment style is likely to be a particular barrier to help seeking. We used a longitudinal experimental design to test the impact of repeated attachment priming on paranoia, mood and help-seeking intentions and whether cognitive fusion mediates these effects. Seventy-nine people with high levels of non-clinical paranoia, aged 18-50 years (M = 20.53, SD = 4.57), were randomly assigned to a secure or insecure-avoidant priming condition. Participants rehearsed the visualisation prime on four consecutive days and were assessed on standardised measures of paranoia, positive and negative affect, help-seeking intentions and cognitive fusion. A series of mixed-model analyses of variance showed that security priming decreases paranoia, negative affect and cognitive fusion and increases positive affect and help seeking, compared to insecure-avoidant priming. Examining the impact of primed attachment (rather than measured attachment style) allows us to draw conclusions about the causal processes involved; mediation analyses showed indirect effects of the primes on paranoia and negative affect through cognitive fusion. With a growing understanding of (1) the impact of security priming on paranoia, affect and help-seeking behaviours, (2) causal mechanisms and (3) sustainability of effects, security priming may be developed into a viable intervention for clinical populations.

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.