Abstract - University of Manchester



Attachment and dissociation as mediators of the link between childhood trauma and psychotic experiences Authors: Josie Pearce, School of Health and Medicine, Division of Health Research, Lancaster University (UK)Jane Simpson, School of Health and Medicine, Division of Health Research, Lancaster University (UK)Katherine Berry, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester (UK)Sandra Bucci, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester (UK)Andrew Moskowitz, Psychology Department, Touro College BerlinFilippo Varese, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester (UK)Corresponding Author:Josie PearceAddress: Clinical Psychology, Faculty of Health and Medicine, Furness College, Lancaster University, Lancaster, LA1 4YF, United KingdomTelephone: 01524 592970Email: josie.pearce@AbstractExposure to childhood trauma has been implicated in the development of paranoia and hearing voices, but the mechanisms responsible for these associations remain unclear. Understanding these mechanisms is essential for ensuring that targeted interventions can be developed to better support people experiencing distress associated with paranoia and voices. Recent models have proposed that dissociation may be a mechanism specifically involved in the development of voices, and insecure attachment in the development of paranoia. Recent theoretical proposals have added to this and argued that fearful attachment could also lead to increased vulnerability for voices. The present study was the first to examine whether dissociation and insecure attachment styles mediated the relationship between childhood trauma and these psychotic experiences. One hundred and twelve participants experiencing clinical levels of psychosis completed measures of dissociation, childhood trauma, attachment, voices and paranoia. Results revealed positive associations between fearful (but not dismissive and anxious) attachment, dissociation, trauma, and psychotic experiences. Mediation analyses indicated that dissociation, but not fearful attachment, significantly mediated the relationship between trauma and voices. Conversely, both dissociation and fearful attachment significantly mediated the relationship between trauma and paranoia. The findings suggest that insecure attachment might be more strongly related to paranoia than hallucinations and suggest that fearful attachment may be a more promising mechanism to explain this relationship. Furthermore, the findings suggest that the impact of dissociation on psychotic experiences may extend to paranoia. Future research is required to replicate these findings using interview-based attachment measures. Key Practitioner MessagesDissociation is a robust mediator of the link between childhood trauma and experiences of psychosis and, as such, clinicians should routinely enquire about the presence of dissociation. Clinicians should consider dissociation when formulating clients’ difficulties, and include dissociation as a possible therapeutic target for psychological interventions in psychosis. Fearful attachment is robustly associated with paranoia and should be taken into account throughout assessment, formulation, intervention.Key WordsChildhood trauma; psychosis; hearing voices; paranoia; attachment.IntroductionExposure to trauma during childhood is now widely accepted as a risk factor for psychosis (Varese et al., 2012a). Meta-analytic studies have demonstrated that childhood abuse (physical, sexual and emotional), neglect and bullying increase the risk of developing psychosis (Matheson, Shepherd, Pinchbeck, Laurens & Carr, 2013; van Dam et al., 2012; Varese et al., 2012a). However, the heterogeneity in mental health outcomes following childhood traumatic experiences remains a topic of considerable debate. Childhood trauma has, in fact, been associated with increased risk for a variety of mental health diagnoses including, for example, bipolar (Palmier-Claus, Berry, Bucci, Mansell & Varese, 2016), depression (Mandelli, Petrelli & Serretti, 2015) and borderline personality disorder (Macintosh, Godbout & Dubdash, 2015). However, a considerable proportion of individuals with a history of traumatic events do not develop long-term mental health difficulties. The examination of the psychological mediators of the link between childhood trauma and specific mental health difficulties could shed light on the differential trajectories leading to these heterogeneous outcomes and enable the development of more targeted preventative and therapeutic interventions. In examining the psychological mechanisms mediating the effects between trauma and psychosis, researchers are increasingly focusing on specific psychotic experiences, such as paranoia and voices. This takes account of the growing recognition that specific psychotic experiences present specific psychological underpinnings and, therefore, the pathways between putative risk factors for psychosis are likely to be mediated by psychological mechanisms that should be, to an extent, independent (e.g. Bentall & Fernyhough, 2008).Insecure attachment is one of the psychological factors that has been extensively examined as a possible mediator of the link between early adversity and psychotic experiences. Researchers have consistently reported that people with psychosis are more likely to report insecure attachment styles (Berry, Barrowclough, & Wearden, 2008; Gumley, Taylor, Schwannauer, & Macbeth, 2014). Studies which examined the association between specific insecure attachment dimensions have demonstrated that both anxious and avoidant styles (varying combinations of which have been categorised as preoccupied, dismissive and fearful attachment; Bartholomew & Horowitz, 1991) are significantly associated with psychosis (for a review, see Gumley et al., 2014). In addition to studies linking insecure attachment to psychosis more generally, a growing number of studies have linked attachment difficulties to specific psychotic experiences, in particular paranoid beliefs. In a review of the possible psychological pathways linking early adversity to psychosis, Bentall et al. (2014) argued that attachment-threatening events might be more important for the pathways leading to paranoia than for those leading to hallucinations. Empirical evidence has supported this proposal with findings from both clinical and non-clinical studies demonstrating that anxious and avoidant attachment predict paranoia, but not hallucinations, after controlling for the covariation between these two experiences (Pickering et al., 2008; Wickham, Sitko & Bentall, 2015). Similarly, anxious and avoidant attachment mediated the relationship between early adversity and paranoia, but not hallucinations, in a general population sample (Sitko et al., 2014).In the case of hallucinations (and in particular, auditory verbal hallucinations or ‘hearing voices’), researchers have proposed that dissociation (a pervasive consequence of trauma; Dalenberg et al., 2012) may represent an important mechanism mediating the effects between trauma and vulnerability to these experiences (Moskowitz, Read, Farrelly, Rudegeair & Williams, 2009). A recent meta-analysis found a large and robust relationship between dissociation and voice hearing (Pilton, Varese, Berry & Bucci, 2015), and evidence from cross-sectional studies with help-seeking participants has suggested that dissociation mediates the relationship between childhood trauma and voices (e.g. Perona-Garcelan et al., 2012; Varese, Barkus & Bentall, 2012). However, the exact mechanism through which dissociation increases vulnerability to hearing voices, and the extent to which it interacts with other psychological processes, remains poorly understood. Theoretical proposals and previous empirical findings generally suggest that insecure attachment mediates the association between childhood trauma and paranoia, whereas dissociation mediates the pathway between childhood trauma and hearing voices. Berry and Bucci (2016), however, recently argued that a specific insecure attachment style might also play a role in the development of hearing voices, specifically disorganised attachment, an attachment style that has been largely overlooked in previous research. It is important to note that disorganised attachment has been linked theoretically to fearful attachment, with researchers suggesting the latter might the adult equivalent of the disorganised child (Alexander & Larry, 1992; Bartholomew & Horowitz, 1991). In their ‘cognitive-attachment model of voices’ (CAV), Berry and Bucci (2016) argue that, since disorganised attachment (a pattern of attachment behaviour characterised by contradictory, confused, and disoriented response when seeking care; Main & Solomon, 1986; 1990) has been shown to increase the risk of experiencing dissociation (Dutra, Bureau, Holmes, Lyubchik & Lyons-Ruth, 2009; Ogawa et al., 1997), and since dissociation has been shown to mediate the relationship between childhood trauma and hearing voices (Perona-Garcelan et al., 2012; Varese et al., 2012b), the CAV model integrated the evidence to suggest that both trauma, disorganised attachment, and dissociation are involved in the aetiological processes of hearing voices. In adult population research a limited number of studies have examined the link between disorganised attachment and psychosis, with most studies instead focusing on fearful attachment (Bartholomew & Horowitz; 1991). Research findings pertaining to the importance of fearful attachment in psychosis are sparse. Research suggests that fearful attachment is associated with psychotic-like experiences in both clinical and non-clinical samples (Sheinbaum, Kwapil, & Barrantes-Vidal, 2014; Strand, Goulding & Tidefors, 2015), and that fearful attachment, but not other insecure attachment styles, mediates the relationship between childhood trauma and psychotic-like experiences in non-clinical participants (Sheinbaum et al., 2014). One study specifically found fearful attachment to be associated with both hallucinations and suspiciousness/persecution in patients with psychosis (Korver-Neiberg, Berry, Meijer, de Haan & Ponizovsky, 2015). However, this study did not control for the comorbidity between these experiences, a statistical procedure that has been proposed to be necessary to identify unambiguously the underpinnings of specific psychotic experiences, given their substantial covariation (Varese & Bentall, 2011; Bentall et al., 2014).To clarify previous findings in this area, the present study examined the following hypotheses:1) Insecure attachment styles (preoccupied, dismissive and fearful) would significantly mediate the relationship between childhood trauma and paranoia.2) Fearful attachment would significantly mediate the relationship between childhood trauma and hearing voices.3) Dissociation would significantly mediate the relationship between childhood trauma and hearing voices.MethodParticipantsThe present study aimed to recruit participants who self-reported as having sought mental health or medical support for distressing psychotic experiences (voices, paranoia, unusual belief, etc.), as well as those who self-reported a diagnosis of schizophrenia or related psychoses. Participants were considered eligible if they met any of the following criteria: a) having ever received a schizophrenia-spectrum diagnosis (i.e. schizophrenia, schizoaffective disorder, delusional disorder); b) having received antipsychotic drug treatment for psychosis or psychotic experiences; c) having received treatment in a mental health unit/hospital, or input from a community mental health team (CMHT) or an early intervention service (EIS) for psychosis or related difficulties; d) having received therapeutic input (e.g. CBT) for experiences related to psychosis. Participants were also required to be aged 18 or older.A total of 131 self-selected eligible participants entered an online survey; 14% (n = 19) of these withdrew following completion of the consent form leaving a total sample of 112. Participants’ age ranged from 18-72 (M = 40.26, SD = 12.50). Demographic characteristics including ethnicity, sexual orientation, marital status, education and employment levels are outlined in Table 1. Additionally, Table 1 outlines the number and percentage of participants who received psychosis-related diagnosis, input from services, current input from services and medication. [Insert Table 1 approximately here]MeasuresDemographic and clinical characteristics questionnaire. A brief questionnaire was used to gather demographic details including ethnicity, sex, sexual orientation, age, marital status, education level and employment. This section also gathered inclusion criteria information including lifetime and current contact with mental health services, current medication use and self-reported psychiatric diagnoses.The Brief Betrayal Trauma Survey (BBTS: Goldberg & Freyd, 2006) was used to assess exposure to childhood trauma. For the purpose of the present study, we only employed nine items relating to interpersonal traumatic events that participants experienced before the age of 18. The BBTS has been widely used in large survey designs with clinical and non-clinical participants (e.g. Goldsmith, Freyd, & DePrince, 2012) and has been used as a measure of interpersonal trauma with participants experiencing psychosis (e.g. Stain et al., 2014). The measure has good construct validity (DePrince & Freyd, 2001) and test-retest reliability (Goldberg & Freyd, 2006), and presented good internal consistency in the present study (α = .83). The Dissociative Experiences Scale - Revised (DES-R: Dalenberg & Carlson, 2010) uses a revised Likert scale to improve reliability (Dalenberg & Carlson, 2010) in comparison to the original scale (DES-II; Carlson & Putman, 1998). Participants were asked to rate the extent to which they have experienced each dissociative experience on a 6-point Likert scale ranging from ‘never’ to ‘at least once a week’. The range of scores for this measure was 28-168 with higher scores indicating higher levels of dissociation. Dalenberg and Carlson (2010) validated the DES-R against the original DES and reliability in the present study was excellent (α = .96).The Community Assessment of Psychotic Experiences (CAPE: Stefanis et al., 2002) was used to measure the frequency (‘never’, ‘sometimes’, ‘often’, ‘nearly always’) of a range of psychotic experiences. The measure has demonstrated good psychometric properties in both clinical and non-clinical samples (Thewissen, Bentall, Lecomte, van Os & Myin-Germeys, 2008; Yung et al., 2009). In the present study, only the sub-scale items relating to paranoia (5 items, for example ‘feeling persecuted’ and ‘conspiracy against you’) and hearing voices (2 items, ‘hearing voices’ and ‘voices talking to each other’) were used (Schlier, Jaya, Moritz & Lincoln, 2015). The CAPE has good reliability and validity, and has been cross-validated showing to highly correlate with interview-based assessments of psychosis (Konings, Bak, Hanssen, Van Os & Krabbendam, 2006). Internal consistency coefficients for voices and paranoia items in the present study were good with α = .83 and α = .77 respectively. The categorical and continuous versions of Relationship Questionnaire (RQ: Bartholomew & Horowitz, 1991) were used to assess attachment styles. The RQ has demonstrated good psychometric properties and has been used extensively in previous studies on clinical and non-clinical psychosis studies (e.g. Pickering et al., 2008). In the present study, the categorical version of the RQ was used for descriptive purposes to document the prevalence of specific attachment styles within this sample whereas the continuous scores were used in the main analyses.Procedure To recruit participants, an online advert was placed on relevant social media sites and a range of mental health charity websites (e.g. Mind, Intervoice, The Hearing Voices Network, Rethink, Time To Change and Creative Support). The adverts contained a link to an online survey consisting of information and debriefing information, and the full list of assessments. Recruitment lasted approximately six months, and included the option of participating in a prize draw. Statistical Analysis Bivariate associations between the different variables were tested using correlational analysis. Two parallel multiple mediator models were estimated to 1) examine the indirect effect of childhood trauma on voices via dissociation and insecure attachment while controlling for paranoia and 2) to examine the indirect effect of childhood trauma on paranoia via dissociation and insecure attachment, while controlling for hearing voices. Analyses were conducted using the PROCESS macro for SPSS (Hayes, 2013). The statistical significance of the indirect effects was tested using bootstrapped bias-corrected percentile based confidence intervals (CIs) of 5000 bootstrap draws. Comorbidity between paranoia and voices was considered throughout the analyses by controlling for the effect of each in the mediation models. ResultsA total of 112 self-selected eligible participants took part in the online survey. Descriptive statistics (see Table 2) indicated that 86% (n = 89) of participants had experienced at least one childhood trauma. Table 2 outlines descriptive statistics for each measure used in the analysis. Of the 112 participants, 68% (n = 77) completed all six measures fully, and, therefore, the mediation models included only these participants. Group comparisons between completers and participants who did not complete the survey in full did not reveal any significant difference on the demographic and clinical variables assessed in this study, with the notable exception of age (survey completers were significantly younger than non-completers; t(109) = 2.50, p = .01; M = 38.14, SD = 11.40 versus M = 44.37, SD = 13.69). Of those who completed the categorical RQ measure the majority reported overall fearful attachment styles (n = 55, 49%) in comparison to preoccupied (n = 14, 13%) and dismissive (n = 20, 18%) styles, with only a small minority reporting secure attachment (n = 11, 9%). Correlational AnalysesTable 3 provides the non-parametric (Spearman’s rs) correlation coefficients between the variables included in the analyses. Preoccupied and dismissive attachment styles were not significantly associated with any of the variables of interest (childhood trauma, dissociation, voices and paranoia). Fearful attachment was significantly associated with higher scores on measures of trauma, dissociation, voices and paranoia. Correlation comparison tests (Lee & Preacher, 2013) revealed that the correlation between fearful attachment and paranoia was larger than the correlation between fearful attachment and voices (z = -1.99, p = .04). Positive correlations were also found between childhood trauma, voices and paranoia, as well as both dissociation and fearful attachment. Dissociation also highly correlated with both voices and paranoia, and there was no significant difference between the correlations between dissociation and paranoia and dissociation and voices (z = -1.68, p = .09). Paranoia and voices were also highly positively correlated indicating that co-variation between these two experiences needed to be controlled. Mediation AnalysesSince the correlation coefficients revealed that preoccupied and dismissive attachment styles were not associated with any of the variables considered, subsequent mediation analyses of the association between trauma and psychotic experiences focused on fearful attachment and dissociation only. Figure 1 displays the first model estimating the indirect effect of childhood trauma on voices while controlling for paranoia. The regression pathways indicated that childhood trauma significantly predicted dissociation (a1: b = 4.02, 95% CI [2.59, 5.45], p > .001) and dissociation significantly predicted voices (b1: b = .02, 95% CI [.007, .04], p = .005). Childhood trauma significantly predicted fearful attachment (a2: b= .13, 95% CI [.04, .22], p = 004), but fearful attachment did not predict voices (b2: b = .19, 95% CI [-.04, .43], p = .117). A bias corrected bootstrap confidence interval for the overall indirect effect via both dissociation and voices (ab: b = .12) was above zero (95% CI [.056, .211]) indicating a significant mediated effect of childhood trauma on voices. Similarly, there was no evidence that childhood trauma predicted voices independently of the mediators (c?: b = .01. p = .82 CI [-.08, .11]). The model demonstrated that dissociation was the only significant mediator between childhood trauma and voices (a1b1: b = .09, 95% CI [.03, .17]); fearful attachment did not significantly mediate this relationship (a2b2 : b = .02, 95% CI [-.001, .07]).[Insert Figure 1 approximately here]Figure 2 displays the mediation model estimating the indirect effect of childhood trauma on paranoia while controlling for voices. The regression pathways indicated that childhood trauma significantly predicted dissociation (a1: b = 4.02, 95% CI [2.59, 5.45], p < .001) and dissociation significantly predicted paranoia (b1: b = .04, 95% CI [.022, .064], p < .001). Similarly, childhood trauma significantly predicted fearful attachment (a2: b = .13, 95% CI [.04, .22], p = 004) and fearful attachment was a significant predictor of paranoia (b2: b = .42, 95% CI [.11, .73], p = .007). A bias corrected bootstrap confidence interval for the indirect effect (ab: b = .23) wasabove zero (95% CI [.12, .37]) indicating that the mediation model significantly mediated the effect of childhood trauma on paranoia. Similarly, there was no evidence that childhood trauma predicted paranoia independently of the mediators (c?: b = -.05. p = .40 CI [-.18, .07). The mediation model demonstrated that both dissociation (a1b1: b = 17, 95% CI [.07, .30]) and fearful attachment (a2b2: b = .05, 95% CI [.01, .12]) mediated the relationship between childhood trauma and paranoia.As the DES-R included one item assessing voices (item 27), sensitivity analyses were carried out after removing this item from the total DES-R score. This did not alter any of the statistical analyses reported.[Insert Figure 2 approximately here]DiscussionThe present study examined the role of attachment style and dissociation in the pathways between childhood trauma and two specific experiences related to psychosis (paranoia and hearing voices) in participants with lifetime self-reported diagnoses of psychotic disorders and/or a history of psychotic experiences that required mental health support. The results did not support proposals that attachment insecurity (or specifically fearful attachment) may be involved in the vulnerability to hearing voices, but suggested that insecure attachment, specifically fearful attachment, may be a mechanism mediating the effect between early adversity and paranoia. Consistent with previous research and our hypotheses, dissociation was a robust mediator between childhood trauma and voices, but was also found to be a significant mediator of the effect of trauma on paranoia. Our study has helped clarify the relative importance of the above mechanisms. The present study suggested that preoccupied and dismissive attachment styles were not associated with experiences of psychosis. This is in line with previous findings (e.g. Sheinbaum et al., 2014) but in contrast with others (Korver-Nieberg et al., 2015; Macbeth, Schwannauer, & Gumley, 2008; Ponizovsky, Vitenberg, Baumgarten-katz, & Grinshpoon, 2013; Strand et al., 2015). This difference may be due to the possible over-representation of fearful attachment in this study relative to other investigations where anxious and avoidant attachment may have been more prevalent (e.g. Korver-Nieberg et al., 2015). The use of continuous measures of attachment in our statistical analyses, however, mitigates some of the impact of homogeneity in attachment style observed when using the categorical RQ.The findings of the present study support previous reports highlighting dissociation as a significant and robust mediator between childhood trauma and voices (e.g. Varese et al., 2012b; Perona-Garcelan et al., 2012). In contrast to the initial hypothesis, no evidence was found in this sample to support proposals that fearful attachment may convey a vulnerability to voice-hearing; the mediational analyses indicated that fearful attachment did not predict voices and did not mediate the relationship between childhood trauma and voices. Hence, the results are in line with previous findings that insecure attachment might be more relevant to the development of paranoid ideation and beliefs than to hallucinatory experiences (e.g. Pickering et al., 2008; Sitko et al., 2014; Wickham et al., 2015). The present study adds to this evidence by suggesting that fearful attachment might be more strongly associated with paranoia, and therefore a more robust mediator of the trauma-paranoia link, than other attachment styles. This is in line with recent findings suggesting that negative beliefs about self and others mediate the effect of childhood trauma on paranoia (Hardy et al., 2016), since fearful attachment is comprised of a combination of negative beliefs about the self and others. Future studies may benefit from considering the impact of fearful attachment on negative beliefs about self and others in people with psychosis. Similarly, studies could consider additional cognitive and attentional biases that are plausibly influenced by fearful attachment representation, such as negative biases in perceptions of the world and of others that serve to increase survival mechanisms of hypervigilance to threat (e.g. Freeman, Garety, Kuipers, Fowler & Bebbington, 2002). An additional trauma-related psychological process found to mediate the link between childhood trauma and paranoia was dissociation. This is a particularly interesting and novel finding since dissociation has not been previously linked to paranoia or to psychotic experiences other than voice hearing (e.g. Altman, Collins, & Mundy, 1997; Kilcommons & Morrison, 2005). Dissociation is characterised by a range of anomalies in core perceptions of the self (e.g. sense of estrangement from one’s body) and the world (e.g. sense that the world is unreal), along with a compartmentalisation of psychological functions or identity. Given research evidence suggesting that the development of persecutory beliefs are driven and preceded by anomalous experiences and perceptual anomalies (often included among important precursors of psychosis such as “basic symptoms” and “self-disorders”; e.g. Mishara et al. 2016, Raballo, 2012), it is possible that the anomalies that underpin dissociation may also contribute to the formation of unusual beliefs and paranoia. Similarly, dissociation has been related to numerous anomalies in threat monitoring and processing (e.g. Dorahy & Green, 2009), but the extent to which these may overlap with the psychological underpinnings of paranoia has not yet been systematically investigated. In future research, the inclusion of dissociative experiences in studies examining perceptual anomalies contributing to the formation of persecutory beliefs, and experimental studies examining threat-processing in relation to dissociation and paranoia, may further elucidate these findings. The present study had several limitations that could be addressed in future investigations. Our cross-sectional data preclude conclusive inferences regarding the direction of influence among the variables considered in our analyses. Future prospective research will enable clarification of the mechanistic pathways identified in the current study. Furthermore, although our analytic strategy was appropriate given the sample size at our disposal, other analytic strategies, such as Structural Equation Modeling (SEM), would provide a more robust test of our hypotheses regarding the contribution of dissociation and attachment to specific psychotic experiences in an adequately large sample. Future adequately sized studies could employ SEM not only to replicate our findings, but to examine more complex relationships that would be expected based on the theoretical proposals that informed the current investigation (e.g. the CAV model; Berry & Bucci, 2016). An additional limitation is with regard to the online recruitment methodology employed in the present study, which may introduce a level of self-selection and therefore reduce the generalizability of our findings. Similarly to previous reports suggesting that participation in online research is associated with certain demographic characteristics (being female, higher socio-economic backgrounds, younger in age, employed/in full time education; e.g. Duggan & Brenner, 2013), we found that participants in the present study were predominantly female, white, had relatively high levels of education and were working/studying. In addition, there were significant differences in the age of those who completed the survey and those who did not, with those who did being younger. It is therefore important that future research replicates these findings using different sampling and data-collection methods that may minimise these self-selection biases (for example, recruiting participants through mental health services and using face-to-face interviews). The data collection method employed also meant reliance on self-report measures of attachment rather than more comprehensive interview assessments such as the Adult Attachment Interview (AAI: George, Kaplan & Main, 1985), currently the gold standard assessment measure for attachment research. The use of the AAI in future research will also enable assessment of disorganised attachment rather than fearful attachment, which could be potentially conceptually different. A final limitation is with regard to the present sample endorsing high levels of fearful attachment. It could be that this is due to biases caused by recruitment methodologies, for example, that self-report allowed people to choose a more socially acceptable attachment style (fearful) than dismissing or preoccupied.The findings of this study raise several clinical implications. In light of the finding that both dissociation and fearful attachment mediate the relationship between childhood trauma and paranoia, clinicians should give close attention to the specific processes that have led a person to experience paranoia. Fearful attachment (and historical disorganised attachment) should be carefully considered when developing formulations about the difficulties of those clients who experience paranoia, particularly for those who have experienced childhood trauma. Attachment theory is increasingly recognised to have considerable relevance for clinical work, particularly since it allows for predictions about intervention styles that can modify insecure attachment behaviours to allow for ‘secure’ therapeutic relationships (Bucci, Seymour-Hyde, Harris, & Berry, 2016; Danquah & Berry, 2013; Taylor, Rietzschel, Danquah & Berry, 2015). Formulations based on cognitive models of paranoia can aid clinicians to focus on specific processes and mechanisms by allowing the detection of key factors such as rumination, negative self- and other-schema, threat-based attributional bases and unhelpful safety behaviours (e.g. Freeman et al., 2015; Morrison, Renton, Dunn, Williams & Bentall, 2003). Cognitive behavioural therapy (CBT) has been found to be effective for preventing and reducing distressing experiences of psychosis (NICE, 2014). Techniques specifically aimed at altering negative schema (similar to internal working models) might also be particularly relevant for people experiencing fearful attachment in which negative views are held of the self and others. Such cognitive restructuring techniques have been found to be beneficial in reducing distressing hallucinatory, and particularly paranoid, experiences through modification of the content of unhelpful beliefs about these experiences (Bouchard, Vallières, Roy, & Maziade, 1996). Finally, the present study showed that dissociation could play a clear role in the development of both voices and paranoia. It is therefore important that clinicians consider this when developing formulations with people distressed by such experiences and, where indicated, to offer specific interventions for dissociation. People who experience dissociation can have a wide range of different experiences including for example, depersonalisation, detachment, derealisation, identity confusion, identity alteration, and amnesia (Kennerley, 1996). Following assessment and formulation, Kennerley (1996) outlines a range of techniques that can be helpful for dissociative experiences including the management of triggering events and the dissociative reactions, distraction and grounding techniques, and cognitive restructuring. In addition, recent research has begun to identify mindfulness techniques to be particularly helpful for people experiencing dissociation for several reasons. For example, Zerubavel and Messman-Moore (2015) argue that mindfulness increases awareness of, and control over, dissociative process by offering tools that enable people to bring conscious awareness to the present moment to both internal and external stimuli. Moreover, mindfulness techniques may offer therapeutic intervention for the metacognitive functions involved in paranoia by encouraging a non-judgmental, self-compassionate approach to cognitive experiences (Brown, Ryan & Creswell, 2007). Finally, increases in self-compassion through mindfulness techniques may also serve to begin to modify negative self and other schema that result from abusive early relationships and disorganised attachment styles. ReferencesAlexander, P., & Larry, B.E. (1992). Application of Attachment Theory to the Study of Sexual Abuse. Journal of Consulting and Clinical Psychology, 60(2), 185-195. Retrieved from: , H., Collins, M., & Mundy, P. (1997). Subclinical Hallucinations and Delusions in Nonpsychotic Adolescents. Journal of Child Psychology and Psychiatry, 38(4), 413-420. doi:10.1111/j.1469-7610.1997.tb01526.xBartholomew, K., & Horowitz, L. M. (1991). Attachment Styles Among Young Adults: A Test of a Four- Category Model. Journal of Personality and Social Psychology, 61(2), 226-244. doi:10.1037/0022-3514.61.2.226Bentall, R., & Fernyhough, C. (2008). Social Predictors of Psychotic Experiences: Specificity and Psychological Mechanisms. Schizophrenia Bulletin, 34(6), 1012-1020. doi: 10.1093/schbul/sbn103Bentall, R. P., de Sousa, P., Varese, F., Wickham, S., Sitko, K., Haarmans, M., & Read, J. (2014). From adversity to psychosis: pathways and mechanisms from specific adversities to specific symptoms. Social psychiatry and psychiatric epidemiology, 49(7), 1011-1022. Retrieved from: , K., & Bucci, S. (2016). What does attachment theory tell us about working with distressing voices? Psychosis, 8(1), 60-71. doi:10.1080/17522439.2015.1070370Berry, K., Barrowclough, C., & Wearden, A. (2008). Attachment theory: A framework for understanding symptoms and interpersonal relationships in psychosis. Behaviour Research and Therapy, 46(12), 1275-1282. doi:10.1016/j.brat.2008.08.009Bouchard, S., Vallières, A., Roy, M.-A., & Maziade, M. (1996). Cognitive restructuring in the treatment of psychotic symptoms in schizophrenia: A critical analysis. Behavior Therapy, 27(2), 257-277. doi:10.1016/S0005-7894(96)80017-7Brown, K. W., Ryan, R., & Creswell, J. D. (2007). Mindfulness: Theoretical Foundations and Evidence for its Salutary Effects. Psychological Inquiry, 18(4), 211-237. doi:10.1080/10478400701598298Bucci, S., Seymour‐Hyde, A., Harris, A., & Berry, K. (2015). Client and therapist attachment styles and working alliance. Clinical psychology & psychotherapy.doi: 10.1002/cpp.1944Carlson, E. B., & Putnam, F. W. (1993). An update on the dissociative experiences scale. Dissociation, 6(1), 16–27. Retrieved from: , J.A., Treboux, D., & Waters, E. (1999) The adult attachment interview and the Relationship Questionnaire: Relations to reports of mothers and partners. Personal Relationships (6)1, 1–18. doi: 10.1111/j.1475-6811.1999.tb00208.xDalenberg, C., & Carlson, E. (2010). New versions of the Dissociative Experiences Scale: The DES-R (revised) and the DES-B (brief). In: Annual meeting of the International Society for Traumatic Stress Studies. Montreal: Quebec.Danquah, A. N., & Berry, K. (2013). Attachment theory in adult mental health: A guide to clinical practice. London: Routledge.DePrince, A.P., & Freyd, J.J. (2001) Memory and dissociative tendencies: The roles of attentional context and word meaning in a directed forgetting task. Journal of Trauma & Dissociation, 2(2), 67–82. doi:10.1300/J229v02n02_06Dorahy, M. J., Green, M. (2008). Cognitive perspectives on dissociation and psychosis : differences in the processing of threat? In: Moskowitz, A., Schafer, I., & Dorahy, M.J. (2008). Psychosis, Trauma And Dissociation: Emerging Perspectives on Severe Psychopathology, pp. 191–207. Wiley-Blackwell : Chichester, UK.Duggan, M., & Brenner, J. (2013). The demographics of social media users, 2012 (Vol. 14). Washington, DC: Pew Research Center's Internet & American Life Project. Retrieved from: , L., Bureau, J., Holmes, B., Lyubchik, A. and Lyons-Ruth, K. (2009). Quality of early care and childhood trauma: a prospective study of developmental pathways to dissociation. Journal of Nervous and Mental Disease, 197(6), 383–390. doi: 10.1097/NMD.0b013e3181a653b7Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. British Journal of Clinical Psychology, 41(4), 331-347. doi: 10.1348/014466502760387461Freeman, D., Waite, F., Startup, H., Myers, E., Lister, R., McInerney, J., ... & Foster, R. (2015). Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial. The Lancet Psychiatry, 2(11), 975-983. doi:10.1016/S2215-0366(15)00314-4George, C., Kaplan, N., & Main, M. (1985). Adult attachment interview (AAI).Unpublished manuscript, University of California at Berkeley.Goldberg, L., & Freyd, J. (2006). Self-Reports of Potentially Traumatic Experiences in an Adult Community Sample: Gender Differences and Test-Retest Stabilities of the Items in a Brief Betrayal- Trauma Survey. Journal of Trauma & Dissociation, 7(3), 39-63. doi:10.1300/J229v07n03_04Goldsmith, R. E., Freyd, J. J., & DePrince, A. P. (2012). Betrayal Trauma. Journal of Interpersonal Violence, 27(3), 547-567. doi:10.1177/0886260511421672Gumley, A. I., Taylor, H. E. F., Schwannauer, M., & Macbeth, A. (2014). A systematic review of attachment and psychosis: measurement, construct validity and outcomes. Acta Psychiatr Scand. 129(4), 257-74. doi: 10.1111/acps.12172 Hardy, A., Emsley, R., Freeman, D., Bebbington, P., Garety, P. A., Kuipers, E. E., ... & Fowler, D. (2016). Psychological Mechanisms Mediating Effects Between Trauma and Psychotic Symptoms: The Role of Affect Regulation, Intrusive Trauma Memory, Beliefs, and Depression. Schizophrenia Bulletin, 42(1), S34-S43. doi: 10.1093/schbul/sbv175Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis [electronic resource] : a regression-based approach. New York: The Guilford Press.Kennerley, H. (1996). Cognitive therapy of dissociative symptoms associated with trauma. British Journal of Clinical Psychology, 35(3), 325-340. doi: 10.1111/j.2044-8260.1996.tb01188.xKilcommons, A. M., & Morrison, A. P. (2005). Relationships between trauma and psychosis: an exploration of cognitive and dissociative factors. Acta Psychiatrica Scandinavica, 112(5), 351-359. doi:10.1111/j.1600-0447.2005.00623.xKonings, M., Bak, M., Hanssen, M., Van Os, J., & Krabbendam, L. (2006). Validity and reliability of the CAPE: a self‐report instrument for the measurement of psychotic experiences in the general population. Acta Psychiatrica Scandinavica, 114(1), 55-61. doi: 10.1111/j.1600-0447.2005.00741.xKorver-Nieberg, N., Berry, K., Meijer, C., de Haan, L., & Ponizovsky, A. M. (2015). Associations between attachment and psychopathology dimensions in a large sample of patients with psychosis. Psychiatry Research, 228(1), 83-88. doi:10.1016/j.psychres.2015.04.018Lee, I. A., & Preacher, K. J. (2013). Calculation for the test of the difference between two dependent correlations with one variable in common [Computer software]. Retrieved from , G. (2004). Trauma, dissociation and disorganised attachment: three strands of a single braid. Psychotherapy: Theory, Research, Practice, Training, 41(4), 472-486. doi:10.1037/0033-3204.41.4.472MacBeth, A., Schwannauer, M., & Gumley, A. (2008). The association between attachment style, social mentalities, and paranoid ideation: An analogue study. Psychology and Psychotherapy: Theory, Research and Practice, 81(1), 79-93. doi: 10.1348/147608307X246156MacIntosh, H. B., Godbout, N., & Dubash, N. (2015). Borderline personality disorder: Disorder of trauma or personality, a review of the empirical literature. Canadian Psychology/Psychologie canadienne, 56(2), 227. 10.1037/cap0000028Main, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/disoriented attachment pattern. In: Yogman, M.W. (Ed), (1986). Affective development in infancy. (pp. 95-124). Westport, CT, US: Ablex Publishing.Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In: Greenberg, M.T., Cicchetti, D., & Cummings, E.M. (1990). Attachment in the preschool years: Theory, research, and intervention. Chicago, London: The University of Chigaco Press. (p.121-160). Mandelli, Petrelli, & Serretti. (2015). The role of specific early trauma in adult depression: A meta-analysis of published literature. Childhood trauma and adult depression. European Psychiatry, 30(6), 665-680. doi:10.1016/j.eurpsy.2015.04.007Matheson, S. L., Shepherd, A. M., Pinchbeck, R. M., Laurens, K. R., & Carr, V. J. (2013). Childhood adversity in schizophrenia: a systematic meta- analysis. 43(2), 225-238. doi:10.1017/S0033291712000785Mishara, A., Bonoldi, I., Allen, P., Rutigliano, G., Perez, J., Fusar-Poli, P., & McGuire, P. (2016). Neurobiological models of self-disorders in early schizophrenia. Schizophrenia Bulletin, 42(4), 874-880. doi: 10.1093/schbul/sbv123Morrison, A.P., Renton, J.C., Dunn, H., Williams, S. & Bentall, R.P. (2003). Cognitive Therapy For Psychosis. Brighton: Psychology Press. eScholarID:244914Moskowitz, A., Read, J., Farrelly, S., Rudegeair, T., & Williams, O. (2009). Are psychotic symptoms traumatic in origin and dissociative in kind. Dissociation and the dissociative disorders: DSM-V and beyond, 521-533. Retrieved from: Insitute of Clinical Excellent (2014). Psychosis and schizophrenia in adults: prevention and management [CG178]. London: NICE. Retrieved from: , J.R., Sroufe, L.A., Wein?eld, N.S. et al. (1997) Development and the fragmented self: longitudinal study of dissociative symptomatology in a non-clinical sample. Development and Psychopathology, 9(4), 855–79. Retrieved from?: , J. E., Berry, K., Bucci, S., Mansell, W., & Varese, F. (2016). Relationship between childhood adversity and bipolar affective disorder: Systematic review and meta-analysis. British Journal of Psychiatry, 209, 1-7. doi: 10.1192/bjp.bp.115.179655Perona‐Garcelán, S., Carrascoso‐López, F., García‐Montes, J. M., Ductor‐Recuerda, M. J., López Jiménez, A. M., Vallina‐Fernández, O., ... & Gómez‐Gómez, M. T. (2012). Dissociative experiences as mediators between childhood trauma and auditory hallucinations. Journal of traumatic stress, 25(3), 323-329. doi: 10.1002/jts.21693Pickering, L., Simpson, J., & Bentall, R. P. (2008). Insecure attachment predicts proneness to paranoia but not hallucinations. Personality and Individual Differences, 44(5), 1212-1224. doi:10.1016/j.paid.2007.11.016Pilton, M., Varese, F., Berry, K., & Bucci, S. (2015). The relationship between dissociation and voices: A systematic literature review and meta- analysis. Clinical Psychology Review. doi:10.1016/j.cpr.2015.06.004Ponizovsky, A. M., Vitenberg, E., Baumgarten‐Katz, I., & Grinshpoon, A. (2013). Attachment styles and affect regulation among outpatients with schizophrenia: relationships to symptomatology and emotional distress. Psychology and Psychotherapy, Theory, Research and Practice, 86(2), 164-182. doi: 10.1111/j.2044-8341.2011.02054.xRaballo, A. (2012). Self-disorders and the experiential core of schizophrenia spectrum vulnerability. Psychiatr Danub, 24(3), 303-310. Retrieved from: , B., Jaya, E. S., Moritz, S., & Lincoln, T. M. (2015). The Community Assessment of Psychic Experiences measures nine clusters of psychosis-like experiences: A validation of the German version of the CAPE. Schizophrenia research, 169(1-3), 274. doi:10.1016/j.schres.2015.10.034Sheinbaum, T., Kwapil, T. R., & Barrantes-Vidal, N. (2014). Fearful attachment mediates the association of childhood trauma with schizotypy and psychotic-like experiences. Psychiatry Research, 220(1-2), 691-693. doi:10.1016/j.psychres.2014.07.030Sitko, K., Bentall, R. P., Shevlin, M., O?Sullivan, N., & Sellwood, W. (2014). Associations between specific psychotic symptoms and specific childhood adversities are mediated by attachment styles: An analysis of the National Comorbidity Survey. Psychiatry Research. doi:10.1016/j.psychres.2014.03.019Stain, H. J., Br?nnick, K., Hegelstad, W. T., Joa, I., Johannessen, J. O., Langeveld, J., ... & Larsen, T. K. (2014). Impact of interpersonal trauma on the social functioning of adults with first-episode psychosis. Schizophrenia Bulletin, 40(6), 1491-1498. doi: 10.1093/schbul/sbt166Stefanis, N. C., Hanssen, M., Smirnis, N. K., Avramopoulos, D. A., Evdokimidis, I. K., Stefanis, C. N., . . . Van Os, J. (2002). Evidence that three dimensions of psychosis have a distribution in the general population. Psychological Medicine, 32(2), 347-358. doi:10.1017/S0033291701005141Strand, J., Goulding, A., & Tidefors, I. (2015). Attachment styles and symptoms in individuals with psychosis. Nordic journal of psychiatry, 69(1), 67-72. doi:10.3109/08039488.2014.929740Taylor, P., Rietzschel, J., Danquah, A., & Berry, K. (2015). Changes in attachment representations during psychological therapy. Psychotherapy Research, 25(2), 222-238. doi:10.1080/10503307.2014.886791Thewissen, V., Bentall, R. P., Lecomte, T., Van Os, J., & Myin-Germeys, I. (2008). Fluctuations in Self- Esteem and Paranoia in the Context of Daily Life. Journal of Abnormal Psychology, 117(1), 143-153. doi:10.1037/0021-843X.117.1.143Van Dam, D. S., van der Ven, E., Velthorst, E., Selten, J. P., Morgan, C., & de Haan, L. (2012). Childhood bullying and the association with psychosis in non- clinical and clinical samples: a review and meta- analysis.Psychol Med.42(12), 2463-2474. doi:10.1017/S0033291712000360Varese, F., Barkus, E., & Bentall, R. P. (2012b). Dissociation mediates the relationship between childhood trauma and hallucination-proneness. Psychological Medicine,?42(05), 1025-1030. doi: 10.1017/S0033291711001826Varese, F., & Bentall, R. P. (2011). The metacognitive beliefs account of hallucinatory experiences: a literature review and meta-analysis. Clinical psychology review, 31(5), 850-864. 10.1016/j.cpr.2010.12.001Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., . . . Bentall, R. P. (2012a). Childhood Adversities Increase the Risk of Psychosis: A Meta- analysis of Patient- Control, Prospective- and Cross- sectional Cohort Studies. Schizophrenia Bulletin, 38(4), 661-671. doi:10.1093/schbul/sbs050Wickham, S., Sitko, K., & Bentall, R. P. (2015). Insecure attachment is associated with paranoia but not hallucinations in psychotic patients: the mediating role of negative self- esteem.Psychol Med, 45(7), 1495-1507. doi:10.1017/S0033291714002633Yung, A. R., Nelson, B., Baker, K., Buckby, J. A., Baksheev, G., & Cosgrave, E. M. (2009). Psychotic-Like Experiences in a Community Sample of Adolescents: Implications for the Continuum Model of Psychosis and Prediction of Schizophrenia. Australian and New Zealand Journal of Psychiatry, 43(2), 118-128. doi:10.1080/00048670802607188Zerubavel, N., & Messman-Moore, T. L. (2015). Staying present: incorporating mindfulness into therapy for dissociation. Mindfulness, 6(2), 303-31. Retrieved from: 1. Demographic Characteristics of Participantsn%SexFemale8172Male3027Other11EthnicityWhite Caucasian10089Other1211Sexual OrientationHeterosexual7163Bisexual2119Homosexual1110Other98Marital statusNever married5751Married or living with partner3531Separated or divorced2018EducationGCSEs or less2623A Levels1816Undergraduate degree3733Postgraduate degree or above3128EmploymentUnemployed3935Working4541Studying2724Diagnosis (lifetime)No diagnosis44Schizophrenia3531Schizoaffective Disorder1917Delusional Disorder11Bipolar1312Brief Psychotic Disorder76Psychosis Otherwise Unspecified1312Other2017Service input (lifetime)Community or Early Intervention8071Psychological therapy3229Inpatient8980Current service inputYes6861No4439Current mediationYes7769No3531Table 2. Descriptive statisticsNMeanStandard DeviationMedianMinimumMaximumSkewness (z score)Kurtosis (z score)Fearful attachment (RQ)1034.821.825.0017-.42 (1.89)-1.06 (2.25)Preoccupied attachment (RQ)1033.011.973.0017.59 (1.81)-.90 (1.91)Dismissive attachment (RQ)1043.421.973.0017.48 (1.46)-.98 (-2.09)Voices (CAPE)964.671.884.00414.33 (1.36)-.95 (1.94)Paranoia (CAPE)8010.922.8611.00520.47 (1.75).60 (0.11)Dissociation (DES-R)10085.2133.0482.5028151.48 (1.46)-.98 (-2.09) Childhood Interpersonal Trauma (BBTS)10314.224.4313.009261.01 (4.24).55 (.488)Table 3. Correlation matrix1.2.3.4.5.6.7.8.Fearful attachment (RQ)-Preoccupied attachment (RQ).10-Dismissive attachment (RQ).07-.10-Voices (CAPE).36**.03.16-Paranoia (CAPE).54**.16.08.48**-Dissociation (DES-R).42**.13.03.54**.66**-Childhood Interpersonal Trauma (BBTS).28**-.18.16.26**.32**.42**-Age-.002-.13.16-.08-.09-.18-.03--455930239395RQ, Relationship Questionnaire; CAPE, Community Assessment of Psychotic Experiences; DES-R, Dissociation Experiences Scale – Revised; BBTS, Brief Betrayal Trauma Survey.*p<0.05, **p<0.00100RQ, Relationship Questionnaire; CAPE, Community Assessment of Psychotic Experiences; DES-R, Dissociation Experiences Scale – Revised; BBTS, Brief Betrayal Trauma Survey.*p<0.05, **p<0.001 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download