Although there is considerable evidence that adversities in childhood such as social deprivation, sexual abuse, separation from parents, neglect and exposure to deviant parental communication are associated with psychosis in later life, most studies have considered broad diagnoses as outcomes In this review we consider evidence for pathways between specific types of adversity and specific symptoms of psychosis We present theoretical arguments for expecting some degree of specificity (although by no means perfect specificity) between different kinds of adversity and different symptoms of psychosis We review studies that have investigated social–environmental risk factors for thought disorder, auditory–verbal hallucinations and paranoid delusions, and consider how these risk factors may impact on specific psychological and biological mechanisms Communication deviance in parents has been implicated in the development of thought disorder in offspring, childhood sexual abuse has been particularly implicated in auditory–verbal hallucinations, and attachment-disrupting events (eg neglect, being brought up in an institution) may have particular potency for the development of paranoid symptoms Current research on psychological mechanisms underlying these symptoms suggests a number of symptom-specific mechanisms that may explain these associations Few studies have considered symptoms, underlying mechanisms and different kinds of adversity at the same time Future research along these lines will have the potential to elucidate the mechanisms that lead to severe mental illness, and may have considerable clinical implications

From adversity to psychosis: pathways and mechanisms from specific adversities to specific symptoms

Objective
This review sought to identify, summarise and critically evaluate studies that investigated attachment amongst individuals with psychosis.

Method
The following computerised databases searched were CINAHL < 1980 to December 2012; EMBASE < 1980 to December 2012; Ovid MEDLINE (R) < 1980 to December 2012; PsychINFO < 1980 to December 2012; and Google Scholar < 1980 to December 2012.

Results
We identified 22 papers describing 21 studies comprising 1453 participants, with a mean age of 35.0 years (range of 12–71 years), of whom 68.4% (n = 994) were male. Of our sample, 1112 (76.5%) had a diagnosis of schizophrenia. We found small to moderate associations between greater attachment insecurity (as reflected in anxiety and avoidance) and poorer engagement with services, more interpersonal problems, more avoidant coping strategies, more negative appraisals of parenting experiences and more severe trauma. We also found small to modest associations between attachment insecurity and more positive and negative symptoms and greater affective symptom problems.

Conclusion
Attachment theory may be useful as a means of understanding the developmental and interpersonal basis of recovery and adaptation in the context of psychosis. However, further research comprising more representative samples in their first episode and using prospective designs is required.

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A systematic review of attachment and psychosis: measurement, construct validity and outcomes

Objectives

It has been argued that attachment theory could enhance our knowledge and understanding of psychotic phenomenology.



Design

We systematically reviewed and critically appraised research investigating attachment and psychotic phenomenology in clinical and non-clinical samples.



Methods

We searched databases Pub Med, PsycINFO, Medline and Web of Science using the keywords. Attachment, Adult Attachment, Psychosis, Schizotypy and Schizophrenia and identified 29 studies assessing adult attachment in combination with psychotic phenomenology.



Result

The findings indicated that both insecure anxious and insecure avoidant attachment are associated with psychotic phenomenology. Insecurely attached individuals are more vulnerable to developing maladaptive coping strategies in recovering from psychosis. The importance of attachment experiences for processing social information, mentalization skills and developing social relationships, including therapeutic relationships, in samples with psychosis is also highlighted.



Conclusion

Attachment style is a clinically relevant construct in relation to development, course and treatment of psychosis.



Practitioner points

Understanding the role of attachment in symptoms may help to gain insight into the development or persistence of symptoms.
Associations between attachment and recovery style suggest that it may be helpful to improve attachment security in a context of therapeutic relationships or other social relationships before encouraging people to explore their experiences of psychosis.
Associations between insecure attachment and impaired mentalization skills may help in understanding interpersonal difficulties and this knowledge can be used to improve recovery.

Adult attachment and psychotic phenomenology in clinical and non‐clinical samples: A systematic review

Background A growing body of research has investigated associations between insecure attachment styles and psychosis. However, despite good theoretical and epidemiological reasons for hypothesising that insecure attachment may be specifically implicated in paranoid delusions, few studies have considered the role it plays in specific symptoms. Method We examined the relationship between attachment style, paranoid beliefs and hallucinatory experiences in a sample of 176 people with a diagnosis of schizophrenia spectrum disorders and 113 healthy controls. We also investigated the possible role of negative self-esteem in mediating this association. Results Insecure attachment predicted paranoia but not hallucinations after co-morbidity between the symptoms was controlled for. Negative self-esteem partially mediated the association between attachment anxiety and clinical paranoia, and fully mediated the relationship between attachment avoidance and clinical paranoia. Conclusions It may be fruitful to explore attachment representations in psychological treatments for paranoid patients. If future research confirms the importance of disrupted attachment as a risk factor for persecutory delusions, consideration might be given to how to protect vulnerable young people, for example those raised in children's homes.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291714002633

Insecure attachment is associated with paranoia but not hallucinations in psychotic patients: the mediating role of negative self-esteem.

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

OBJECTIVES: The study investigated associations between adult attachment and voice hearing. We hypothesized associations between insecure attachment, severity of voice hearing, and distress in relation to voices. We also hypothesized associations between attachment and the nature of relationships with voices. METHOD: Seventy-three participants with a diagnosis of schizophrenia spectrum disorders completed measures of anxiety and avoidance in attachment relationships and we coded experiences of voice hearing from interviews. RESULTS: There were modest but significant positive associations between attachment anxiety and both severity and distress in relation to voice hearing, but no associations between attachment avoidance and these dimensions. We found evidence of predicted associations between attachment avoidance and themes of rejection, criticism, and threat in relationships with voices. Contrary to predictions, there were no significant associations between anxious attachment and the theme of control in relationships with voices and no association between anxious attachment and the theme of threat. CONCLUSIONS: The study is promising in demonstrating some associations between attachment and the nature of relationships with voices. This suggests that the assessment of attachment styles may be a useful contribution in developing formulations of voice hearing.

An investigation of adult attachment and the nature of relationships with voices

The present study explored participants’ experiences of attending Hearing Voices Network groups. We interviewed 11 participants about their experiences of the groups using semistructured interviews. Interviews were transcribed and analysed using thematic analysis. Five themes emerged: (1) Discovery, relating to initial group attendance; (2) Group structure, consisting of the key ingredients of the group; (3) Acceptance, reflecting an acceptance of their experiences; (4) Hope, exploring hope in the group; and (5) Group benefits, focusing on benefits derived from the group. The study extends previous research about the role of peer facilitation in hearing voices and supports existing research on the importance of hope, acceptance and coping in recovery within voice-hearing.

Lauren Oakland

Papers

An investigation of adult attachment and the nature of relationships with voices

“Lifting the veil”: a qualitative analysis of experiences in Hearing Voices Network groups.