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

Abstract

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.

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

“…Both attachment insecurity states had a separate effect when controlling for each other. These results support the evidence of attachment insecurity impacting the experience of daily negative emotions, which is strongly related to the use of maladaptive emotion regulation (ER) strategies (Ludwig et al, 2020;Partridge et al, 2022aPartridge et al, , 2022bSood et al, 2022a). Specific associations were found for elevated within-person state attachment avoidance, which led to a subsequent decrease in positive affect and an increase in paranoid thinking.…”

“…Both attachment insecurity states had a separate effect when controlling for each other. These results support the evidence of attachment insecurity impacting the experience of daily negative emotions, which is strongly related to the use of maladaptive emotion regulation (ER) strategies (Ludwig et al, 2020; Partridge et al, 2022a, 2022b; Sood et al, 2022a).…”

“…Research on trait attachment outlined the affective and cognitive factors as possible mechanisms by which attachment insecurity leads to the development and maintenance of paranoia (Partridge et al, 2022a(Partridge et al, , 2022bSood et al, 2022a). Cognitive behavioural therapy (CBT) is a recommended evidence-based treatment for psychosis (NICE, 2014).…”

“…Research suggests that insecure attachment can increase vulnerability to experiencing paranoia via negative self-esteem, the anticipation of threats and the perception that others are more powerful (Martinez et al, 2021;Pickering et al, 2008;Wickham et al, 2015); dysfunctional emotion regulation strategies including things such as blaming others, hyperactivating negative emotions, catastrophizing, rumination, self-preoccupation, self-criticism and impulse control difficulties (Ascone et al, 2020;Hajdúk & Heretik, 2016;Mikulincer & Florian, 1998) and also deactivating emotion regulation strategies including the non-acceptance of emotional responses, a lack of emotional awareness and a lack of emotional clarity (Partridge et al, 2022a(Partridge et al, , 2022b.…”

Measuring Dysfunctional Interpersonal Beliefs: Validation of the Interpersonal Cognitive Distortions Scale among a German-speaking Sample

“…Dysfunctional interpersonal beliefs (DIBs), such as expecting social rejection (e.g., "people will reject me") or interpersonal exploitation (e.g., "people will harm me"), have been proposed to constitute important characteristics of various mental disorders. DIBs are especially common in psychosis (e.g., Partridge et al, 2022), social phobia (e.g., Gkika et al, 2018), posttraumatic stress disorder (e.g., Sharp et al, 2012), depression (e.g., Evraire & Dozois, 2011), and borderline personality disorder (e.g., Baer et al, 2012). Even across short periods of time, DIBs have been shown to encourage the development and maintenance of depressive symptoms (Kirchner et al, 2022).…”