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

Digital Interventions for Symptoms of Borderline Personality Disorder: Systematic Review and Meta-Analysis

BACKGROUND

Borderline personality disorder (BPD) is a mental health condition with insufficient care availability worldwide. Digital mental health interventions could reduce this treatment gap. Persuasive system design (PSD) is a conceptual framework outlining elements of digital interventions that support behavior change.

OBJECTIVE

This systematic review aims to characterize digital interventions targeting BPD symptoms, assess treatment efficacy, and identify its association with intervention features, including PSD elements.

METHODS

A systematic review of automated digital interventions targeting symptoms of BPD was conducted. Eligible studies recruited participants aged ≥18 years, based on a diagnosis of BPD or one of its common comorbidities, or as healthy volunteers. OVID Embase, OVID MEDLINE, OVID PsycINFO, and the Cochrane Central Register for Controlled Trials were searched on July 19, 2022, and February 28, 2023. Intervention characteristics were tabulated. A meta-analysis of randomized controlled trials (RCTs) determined treatment effects separately for each core symptom of BPD using Hedges g. Associations between the treatment effect and intervention features, including PSD elements, were assessed by subgroup analysis (Cochran Q test). Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the National Institutes of Health Quality Assessment Tool for pre-post studies.

RESULTS

A total of 40 (0.47%) publications out of 8520 met the inclusion criteria of this review, representing 6611 participants. Studies comprised examinations of 38 unique interventions, of which 32 (84%) were RCTs. Synthesis found that included interventions had the following transdiagnostic treatment targets: severity of BPD symptoms (4/38, 11%), suicidal ideation (17/38, 45%), paranoia (5/38, 13%), nonsuicidal self-injury (5/38, 13%), emotion regulation (4/38, 11%), and anger (3/38, 8%). Common therapeutic approaches were based on dialectical behavioral therapy (8/38, 21%), cognitive behavioral therapy (6/38, 16%), or both (5/38, 13%). Meta-analysis found significant effects of digital intervention for both symptoms of paranoia (Hedges g=-0.52, 95% CI -0.86 to -0.18; P=.01) and suicidal ideation (Hedges g=-0.13, 95% CI -0.25 to -0.01; P=.03) but not overall BPD symptom severity (Hedges g=-0.17, 95% CI -0.42 to 0.10; P=.72). Subgroup analysis of suicidal ideation interventions found that evidence-based treatments such as cognitive behavioral therapy and dialectical behavior therapy were significantly more effective than alternative modalities (Cochran Q=4.87; P=.03). The degree of human support was not associated with the treatment effect. Interventions targeting suicidal ideation that used reminders, offered self-monitoring, and encouraged users to rehearse behaviors were associated with a greater reduction in ideation severity.

CONCLUSIONS

Evidence suggests that digital interventions may reduce the symptoms of suicidal ideation and paranoia and that the design of digital interventions may impact the efficacy of treatments targeting suicidal ideation. These results support the use of transdiagnostic digital interventions for paranoia and suicidal ideation.

TRIAL REGISTRATION

PROSPERO CRD42022358270; https://tinyurl.com/3mz7uc7k.

Could an evaluative conditioning intervention ameliorate paranoid beliefs? Self-reported and neurophysiological evidence from a brief intervention focused on improving self-esteem

Introduction

Much research on the treatment of paranoia has involved cognitive-behavioural interventions that address explicit social cognition processes. However, much of human cognition is preverbal or implicit, raising the possibility that such social judgements are implicated in paranoia. One type of implicit social cognition that has been investigated concerning paranoia is implicit self-esteem with some evidence that it may be possible to change implicit self-esteem using techniques based on conditioning theory. Therefore, the primary purpose of this research is to further evaluate the potential of this approach. At the same time, as a secondary purpose, we introduce a novel way of measuring social cognition that, we argue, has utility for investigating the psychological processes involved in paranoia.

Method

We conducted two proof-of-concept studies of a novel brief intervention based on evaluative conditioning, targeting implicit cognition. The first study was conducted with a large non-clinical sample, while the second study included a small series of psychotic patients. As part of our proof-of-concept evaluation of the potential of evaluative conditioning, we attempted to probe for neurophysiological changes following the intervention using magnetoencephalography in an exploratory way in the clinical sample.

Results

Our results revealed that both non-clinical and clinical participants in the experimental group showed a significant change in how they evaluated themselves in the social cognition task, which could be related to the perception of social information in a less threatening way. In addition, clinical participants in the experimental group showed changes in brain activity during the social cognition task, particularly in regions involved in emotional reactivity and mentalization processes.

Discussion

Our results are encouraging, suggesting that implicit cognition is manipulable, that such manipulation affects underlying neurophysiological mechanisms, and that there may be an impact on paranoid symptoms. However, much more work is required to determine whether this approach can produce meaningful clinical change and be delivered in routine clinical settings. Finally, it is important to note that we are not claiming the clinical effectiveness of our intervention, which is in a very early stage of development. Our goal here is to demonstrate clinical possibilities that warrant further investigation.

Secure attachment imagery facilitates help-seeking and help-acceptance in psychosis

OBJECTIVES

People with psychosis delay accessing recommended treatments, resulting in poor healthcare outcomes and increased risk of relapse. Means of improving help-seeking and help-acceptance could reduce duration of untreated psychosis (DUP). This study examined the role of attachment style in help-seeking and help-acceptance in psychosis.

DESIGN

We used an experimental design to test the effect of attachment imagery priming on help-seeking and help-acceptance intentions, in a sample with self-reported psychosis. The independent variables were attachment imagery condition (secure vs. avoidant) and time (pre- vs. post-prime). The dependent variables were state paranoia, help-seeking intentions and help-acceptance intentions.

METHODS

We used an online research platform to recruit people with psychosis (n = 61). Participants were randomly allocated to the secure or avoidant attachment priming condition. All completed measures of state paranoia, help-seeking, and help-acceptance, before and after priming.

RESULTS

In comparison with the avoidant condition, secure attachment imagery resulted in reduced paranoia and increased help-seeking and acceptance intentions, all with large effect sizes.

CONCLUSIONS

This is the first study to use an experimental design to assess the role of attachment style in help-seeking and help-acceptance in a clinical sample. Attachment style is causally linked to behavioural intentions that contribute to DUP. Clinicians should assess attachment and help-seeking and acceptance, highlight these in formulation, and prioritise in treatment planning. Interventions that enhance help-seeking and acceptance could improve access to recommended treatments and reduce DUP.

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.

Experimental studies of paranoid thinking in clinical and nonclinical populations: a systematic review and meta-analysis

Paranoia is common in clinical and nonclinical populations, consistent with continuum models of psychosis. A number of experimental studies have been conducted that attempt to induce, manipulate or measure paranoid thinking in both clinical and nonclinical populations, which is important to understand causal mechanisms and advance psychological interventions. Our aim was to conduct a systematic review and meta-analysis of experimental studies (non-sleep, non-drug paradigms) on psychometrically assessed paranoia in clinical and nonclinical populations. The review was conducted using PRISMA guidelines. Six databases (PsycINFO, PubMed, EMBASE, Web of Science, Medline and AMED) were searched for peer-reviewed experimental studies using within and between-subject designs to investigate paranoia in clinical and nonclinical populations. Effect sizes for each study were calculated using Hedge's g and were integrated using a random effect meta-analysis model. Thirty studies were included in the review (total n = 3898), which used 13 experimental paradigms to induce paranoia; 10 studies set out to explicitly induce paranoia, and 20 studies induced a range of other states. Effect sizes for individual studies ranged from 0.03 to 1.55. Meta-analysis found a significant summary effect of 0.51 [95% confidence interval 0.37-0.66, p < 0.001], indicating a medium effect of experimental paradigms on paranoia. Paranoia can be induced and investigated using a wide range of experimental paradigms, which can inform decision-making about which paradigms to use in future studies, and is consistent with cognitive, continuum and evolutionary models of paranoia.

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 emotion regulation strategies mediate the attachment-paranoia association? An experimental study of repeated attachment imagery priming and stress buffering

OBJECTIVES

Paranoia describes unfounded interpersonal threat beliefs. Secure attachment imagery attenuates paranoia, but limited research examines mechanisms of change and no studies examine how secure imagery may be implemented most effectively in clinical practice. In this study, we tested: (a) the causal impact of secure, anxious, and avoidant attachment imagery on paranoia and anxiety, (b) whether emotion regulation strategies mediate these relationships, and (c) whether secure imagery buffers against social stress.

DESIGN

We utilized a longitudinal, experimental design.

METHOD

A general population sample with high non-clinical paranoia (N = 265) completed measures of paranoia, anxiety, and emotion regulation strategies. Participants were randomly allocated to secure, anxious, or avoidant conditions and repeated an imagery prime for four days prior to a social stress task.

RESULTS

Relative to anxious and avoidant imagery, secure imagery decreased state paranoia and anxiety. These associations were not mediated by state emotion regulation strategies, and secure imagery did not buffer against stress. Exploratory analyses on trait variables revealed that: (a) hyperactivating strategies mediated the association between attachment anxiety and paranoia, and (b) suppression mediated the association between attachment avoidance and paranoia.

CONCLUSIONS

Secure attachment imagery reduces state paranoia and anxiety and could be incorporated into psychotherapies to attenuate clinical paranoia. Measurement of state emotion regulation was problematic. Attachment imagery does not buffer stress; further research is required to test whether secure imagery facilitates recovery from stress. Attachment style is likely to account for trait paranoia via attachment-congruent emotion regulation strategies. Research is now needed to determine if these strategies can be targeted to alleviate paranoia in clinical populations.

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.

Adult attachment anxiety is associated with night eating syndrome in UK and US-based samples: Two cross-sectional studies

Previous research has shown that "attachment anxiety" is a robust predictor of disinhibited eating behaviours and that this relationship is underpinned by difficulties in managing emotion. Night eating syndrome (NES), a proposed eating disorder characterized by evening hyperphagia, nocturnal awakenings to eat, and morning anorexia, is also associated with eating to manage emotion. Across two studies (N = 276 &N = 486), we considered a relationship between attachment anxiety and NES. In Study 1, we hypothesised (pre-registered) that attachment anxiety would predict NES score and that this relationship would be mediated by disinhibited eating. Participants were asked to complete questionnaire measures of attachment orientation, disinhibited eating (emotional and uncontrolled eating) and NES. Our parallel mediation model confirmed a direct relationship between attachment anxiety and NES (p < .001) and showed an indirect path via both emotional (95% CI: 0.15-0.63) and uncontrolled eating (95% CI: 0.001-0.36). In Study 2, we showed that fear of negative evaluation of eating significantly mediated a reversed relationship between attachment anxiety and NES (95% CI: 0.02-0.04). Finally, across both studies we used a novel tool to assess "eating to cope". We showed a relationship with emotional eating but failed to show a robust relationship with NES. Attachment orientation may represent a potential intervention target for night eating syndrome. Future research should consider a longitudinal approach to strengthen our understanding of directionality amongst these factors.