Katherine Berry

Attachment theory: A framework for understanding symptoms and interpersonal relationships in psychosis.

We investigated associations between adult attachment, symptoms and interpersonal functioning, including therapeutic relationships in 96 patients with psychosis. Using a prospective design, we also assessed changes in attachment in both psychiatrically unstable and stable groups. We measured attachment using the Psychosis Attachment Measure (PAM) and interpersonal problems and therapeutic relationships were assessed from both psychiatric staff and patient perspectives. Avoidant attachment was associated with positive symptoms, negative symptoms and paranoia. Attachment ratings were relatively stable over time, although changes in attachment anxiety were positively correlated with changes in symptoms. Predicted associations between high levels of attachment anxiety and avoidance and interpersonal problems were supported, and attachment avoidance was associated with difficulties in therapeutic relationships. Findings suggest that adult attachment style is a meaningful individual difference variable in people with psychosis and may be an important predictor of symptoms, interpersonal problems and difficulties in therapeutic relationships over and above severity of illness.

Reviewing evidence for the cognitive model of auditory hallucinations: The relationship between cognitive voice appraisals and distress during psychosis

Individuals who hear voices during psychosis may be vulnerable to increased distress. Cognitive models place emphasis on the role of subjective and cognitive appraisals of voices in influencing different emotional reactions. This paper systematically reviewed literature investigating the relationship between appraisals of voices and distress. The review included 26 studies, published between 1990 and 2008. Several types of appraisals were found to be linked to higher levels of distress in voice hearers, including voices appraised as malevolent, voices appraised as high in supremacy, voices appraised to have personal acquaintance with the individual, and attitudes of disapproval and rejection towards voices. However, results from cognitive therapy trials did not consistently report significant improvements in voice related distress post-intervention. One explanation for this finding is that mediating variables, such as social schemata, exist within the appraisal-distress relationship, variables which were not targeted in the cognitive therapy trials. Areas for future investigation may include developing a greater understanding of mediating variables, such as social schemata, within the appraisal-distress relationship, carrying out interventions aimed at addressing these mediating variables using randomized controlled trial designs, and understanding the relationship between positive affect and voice appraisals.

Attachment styles, earlier interpersonal relationships and schizotypy in a non-clinical sample.

OBJECTIVES This paper investigates associations between adult attachment style, relationships with significant others during childhood, traumatic life-events and schizotypy. DESIGN Relationships between attachment and hypothesized correlates were investigated in a cross-sectional design using an analogue sample. The reliability of the attachment and trauma measures was investigated using a test-retest design. METHODS Three hundred and four students completed the self-report version of the Psychosis Attachment Measure (PAM), maternal and paternal versions of the Parental Bonding Instrument, the Attachment History Questionnaire, a measure of trauma and the Oxford-Liverpool Inventory of Feelings and Experiences scale through an internet website. RESULTS As predicted, there were statistically significant associations between insecure attachment in adult relationships and experiences of negative interpersonal events. Both earlier interpersonal experiences and adult attachment style predicted schizotypy, and adult attachment style emerged as an independent predictor of positive schizotypal characteristics. CONCLUSIONS The findings support associations between adult attachment style and previous interpersonal experiences and between adult attachment and schizotypy. The PAM is a reliable and valid instrument that can be used to explore attachment styles in analogue samples and associations between attachment styles and psychotic symptoms in clinical samples.

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

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.

PTSD symptoms associated with the experiences of psychosis and hospitalisation: a review of the literature.

There is evidence of high rates of PTSD in people with psychosis, but the influence that symptoms or hospitalisation have on PTSD in individuals with psychosis is less clear. This paper reviewed studies investigating the prevalence of PTSD induced as a result of the experience of psychosis and hospitalisation and factors that might influence its development. The review included 24 studies, published between 1980 and 2011. Studies showed high levels of PTSD resulting from the trauma of symptoms and/or hospitalisation, with prevalence rates for actual PTSD resulting from these traumas varying from 11% to 67%. In line with studies of PTSD related to other traumatic events, there were inconsistent associations between PTSD and severity of positive and negative symptoms, but there were consistent associations between affective symptoms and PTSD. There were also inconsistent associations between hospital experiences and PTSD. Consistent with the general PTSD literature, there was some evidence that psychosis-related PTSD was associated with trauma history. There was also some emerging evidence that psychological variables, such as appraisals and coping style may influence psychosis-related PTSD. The review highlights the need for further research into psychological mechanisms that could increase vulnerability to psychosis-related PTSD and treatment approaches.

The Role of Expressed Emotion in Relationships Between Psychiatric Staff and People With a Diagnosis of Psychosis: A Review of the Literature

The concept of expressed emotion (EE) has been extended to the study of staff-patient relationships in schizophrenia. A comprehensive review of the literature identified a total of 27 studies investigating EE in this group published between 1990 and 2008. The article aims to assess whether the concept of EE is a useful and valid measure of the quality of professional caregiver and patient relationships, given that staff may be less emotionally invested in relationships than relatives. In doing so, it summarizes methods of measuring EE, the nature of professional EE compared with familial EE, associations between high EE and patient outcomes, associations between EE and both patient and staff variables, and intervention studies to reduce staff high EE. The available evidence suggests that the Camberwell Family Interview is an acceptable measure of EE in staff-patient relationships, although the Five Minute Speech Sample may provide a less resource intensive alternative. However, in contrast to familial research, neither the EE status on the Camberwell Family Interview nor the Five Minute Speech Sample show a robust relationship with outcomes. The presence or absence of a positive staff-patient relationship may have more predictive validity in this group. There is relatively consistent evidence of associations between staff criticism and poorer patient social functioning. Consistent with findings in familial research, staff attributions may play a key role in driving critical responses, and it may be possible to reduce staff high EE by modifying negative appraisals.

Adult attachment styles and psychosis: an investigation of associations between general attachment styles and attachment relationships with specific others

BackgroundIf attachment theory is to help inform our understanding of relationship difficulties in people with psychosis, it is first important to understand the composition of attachment networks in this group and how attachment style measured with reference to relationships in general actually relates to attachment in relationships with specific others.MethodWe examined attachment networks and associations between general attachment style and attachment in relationships with parents and psychiatric staff in a sample of 58 patients with psychosis. We assessed attachment dimensions of anxiety and avoidance using the Psychosis Attachment Measure (PAM) and an adapted version of the instrument asking about relationships with specific others.ResultsPatients reported a median of two attachment relationships. Both attachment anxiety and avoidance measured with reference to close relationships in general were positively correlated with attachment in key worker and parental relationships, although levels of attachment anxiety and avoidance did vary across relationships.ConclusionFuture research should determine factors influencing variations in attachment working models in samples of people with psychosis, as it may be possible to help individuals with insecure attachment styles develop more positive relationships with others.

Changes in attachment representations during psychological therapy

Abstract Objectives: This review systematically examines research that investigates changes in adult attachment representations during psychological therapy. Method: Studies from two adult attachment approaches are reviewed (interview and self-report) with the aim of concluding whether psychotherapy can improve attachment representations. To guide the interpretation of findings, the methodological quality of studies is assessed. Results: The results suggest that attachment security increases following therapy, whereas attachment anxiety decreases following therapy. Findings are unclear with regard to attachment avoidance. Improvements are observed across different methodologies, patient groups, therapeutic approaches, and therapy settings. Findings also appear to be consistent across different levels of study quality. Conclusions: Overall, research supports the suggestion that attachment styles may alter during the course of psychotherapy, but further controlled trials are required to confirm this conclusion.

The relationship between dissociation and voices: A systematic literature review and meta-analysis

There are an increasing number of studies exploring the association between voice-hearing (auditory verbal hallucinations) and dissociative experiences. The current study provides a systematic literature review and meta-analytic synthesis of quantitative studies investigating the relationship between voice-hearing and dissociation. A systematic search identified and included 19 clinical studies, comprising 1620 participants, and 12 non-clinical studies, comprising 2137 participants, published between 1986 and 2014. Nineteen of these studies provided sufficient data to be included within the meta-analysis. The narrative review findings suggested that dissociative experiences may be implicated in voice-hearing, and may potentially be a mediating factor within the well-established trauma and voice-hearing relationship. Similarly, the meta-analytic findings suggested that the majority of the identified studies showed a significant positive relationship between dissociative experiences and voice-hearing. The magnitude of the summary effect was large and significant (r=.52), indicating a robust relationship between these two phenomena. However, considerable heterogeneity within the meta-analytic results and methodological limitations of the identified studies were evident, highlighting areas for future investigation. As the majority of the studies were cross-sectional by design, we recommended future research to include longitudinal designs with a view to exploring directional effects. Additionally, future studies should control for potential confounding factors. Clinical implications of the findings were also considered.

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

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.