Attachment, Neurobiology, and Mentalizing along the Psychosis Continuum

Abstract

In this review article, we outline the evidence linking attachment adversity to psychosis, from the premorbid stages of the disorder to its clinical forms. To better understand the neurobiological mechanisms through which insecure attachment may contribute to psychosis, we identify at least five neurobiological pathways linking attachment to risk for developing psychosis. Besides its well documented influence on the hypothalamic-pituary-adrenal (HPA) axis, insecure attachment may also contribute to neurodevelopmental risk through the dopaminergic and oxytonergic systems, as well as bear influence on neuroinflammation and oxidative stress responses. We further consider the neuroscientific and behavioral studies that underpin mentalization as a suite of processes potentially moderating the risk to transition to psychotic disorders. In particular, mentalization may help the individual compensate for endophenotypical impairments in the integration of sensory and metacognitive information. We propose a model where embodied mentalization would lie at the core of a protective, resilience response mitigating the adverse and potentially pathological influence of the neurodevelopmental cascade of risk for psychosis.

Mentalization and Psychosis: A Rationale for the Use of Mentalization Theory to Understand and Treat Non-affective Psychotic Disorder

“…Hasson-Ohayon et al 2018;Mcleod et al 2014) and negative symptoms (Mcleod et al 2014;Weijers et al 2018). Debbané et al (2016) further expanded upon Frith's hypothesis by suggesting that patients with NAPD suffer specifically from problems with 'embodied' mentalizing. Embodied mentalizing involves the ability to consciously detect and identify sensory-affective signals coming from one's body and to critically think about them.…”

“…On the other hand, sensory-affective information or the viewpoint of others may not be used to update cognitive beliefs, resulting in delusional ideation the patient's current experience without forcing any single interpretation upon the patient. When using this stance, the therapist communicates that she is trying to interpret the patient's actions in line with her own subjective experience and that the patient is being treated as an intentional agent (Debbané et al 2016;Fonagy et al 2017). Feeling "mentalized about" in therapy is thought to make the patient feel safe enough to think about himself in relation to his social world and how he operates in it (Fonagy and Allison 2014), which aids the restructuring of the "organization of thinking into less rigid, delusional and pervasive patterns of reality testing" (Pereira and Debbané 2018).…”

“…Although MBT was originally designed for borderline personality disorder (BPD; Bateman and Fonagy 1999), given its focus on impaired mentalizing ability, it may be suitable for patients with NAPD as well. Recent articles have explored the applicability of MBT as a treatment for psychotic disorders or its prodromal states (Brent and Fonagy 2014;Weijers et al 2016;Debbané et al 2016) and the effectiveness of MBT for psychotic disorders is currently being examined in a randomized controlled trial (Weijers et al 2016). However, disorder-specific characteristics do warrant some different approaches in MBT when dealing with patients with NAPD.…”

“…Chief of these are that MBT specifically offers psycho-education prior to treatment to elaborate on mentalizing and its relation to attachment-processes and emotions. MBT has also been argued to pay more attention to the bodily aspect of emotional experience (Debbané et al 2016). From the therapist perspective, MBT-training provides specific clinical guides to assess emotional arousal in sessions, as well as how to work safely within the client-therapist relationship (Brent 2009, Debbané et al 2016).…”

“…MBT has also been argued to pay more attention to the bodily aspect of emotional experience (Debbané et al 2016). From the therapist perspective, MBT-training provides specific clinical guides to assess emotional arousal in sessions, as well as how to work safely within the client-therapist relationship (Brent 2009, Debbané et al 2016). On the other hand, MERIT arguably focuses more explicitly on the patient's agency, by explicitly making the patient set the agenda for each treatment session.…”