Matthias Schwannauer

Attachment states of mind, mentalization, and their correlates in a first-episode psychosis sample

OBJECTIVES Although there has been increased interest in applying attachment theory to the psychological understanding of psychosis, research to date has focused on self-reported attachment and psychotic symptomatology. This study presents evidence for applying attachment and mentalization constructs to understanding engagement and adaptation to first-episode psychosis (FEP), using a narrative based interview. DESIGN A cross-sectional cohort design was used. METHODS Thirty-four individuals with a first episode of psychosis were interviewed using the Adult Attachment Interview. Attachment classifications and reflective function scores were derived from the interview. Psychotic symptomatology, premorbid adjustment, duration of untreated psychosis, and psychological variables were also measured. RESULTS Attachment distribution was heterogeneous in the sample, although the majority of participants were classified dismissing of attachment. Mentalization scores were consistent with previous clinical samples. Attachment and mentalization were unrelated to psychotic symptomatology. CONCLUSIONS The current study demonstrates, albeit with a small clinical sample, the importance of assessing attachment and mentalization via narrative methods. The findings also have clinical implications for understanding the process of engagement and adaptation in FEP.

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

This review sought to identify, summarise and critically evaluate studies that investigated attachment amongst individuals with psychosis.

The association between attachment style, social mentalities, and paranoid ideation: an analogue study

OBJECTIVES The study was a novel exploration of possible associations between attachment status and psychotic phenomenology, applied within a social mentality framework (Gilbert, 1989, 2001). We hypothesized that attachment avoidance would be associated with higher endorsement of paranoid ideation. Consistent with social mentality theory, we hypothesized that higher levels of interpersonal problems would also be associated with higher paranoia scores and greater attachment avoidance. DESIGN An analogue cross-sectional cohort design was used. METHODS Two hundred and thirteen individuals completed self-report measures of current attachment style, interpersonal problems, paranoia, delusions, hallucinations, depression, and anxiety. RESULTS Confirmatory factor analysis of the attachment measure suggested a two-factor structure: attachment anxiety and avoidance. Covariance modelling suggested both attachment and a strategy of interpersonal distancing predicted paranoia. Hallucinatory phenomena were predicted by latent constructs representing interpersonal dependence and avoidance strategies. CONCLUSIONS The findings confirmed a two-factor dimensional model was the optimum model for attachment self-report data. The interaction of attachment theory and social mentalities appears to be a promising framework for exploring developmental aspects of psychotic phenomenology.

Negative beliefs about self and illness: a comparison of individuals with psychosis with or without comorbid social anxiety disorder

OBJECTIVE This study set out to investigate whether socially anxious individuals with psychosis will perceive more loss, entrapment, shame and humiliation, will blame themselves more for their illness and have lower self-esteem than non-socially anxious individuals with psychosis. METHOD Two groups of participants with psychosis with (n=19) and without (n=19) social anxiety disorder were matched on the basis of gender and diagnosis. RESULTS There were no differences between the two groups in terms of positive and negative symptoms. Participants with social anxiety had significantly higher levels of self-blame, entrapment, shame and lower self-esteem. Differences in entrapment, shame and self-esteem remained significant after controlling for depression. CONCLUSIONS Negative beliefs about self and psychosis may be associated with the development of concurrent social anxiety disorder. The clinical and research implications of the findings are discussed.

Metacognition, symptoms and premorbid functioning in a First Episode Psychosis sample

Significant metacognitive impairments are observed in chronic psychosis samples but metacognition is less understood in first episode psychosis (FEP). The current study explored correlations between metacognition, symptoms and premorbid functioning in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology, premorbid adjustment, and clinician rated service engagement were also measured. Lower scores for metacognitive understanding of others minds were significantly correlated with greater negative symptoms, poorer early adolescent social adjustment and poorer clinician rated help-seeking. Our findings suggest that FEP individuals with difficulties in understanding others minds have more social deficits and may be less able to make effective use of treatment.

The Beliefs about Paranoia Scale: Preliminary Validation of a Metacognitive Approach to Conceptualizing Paranoia

This study reports the development of a self-report measure to assess metacognitive beliefs about paranoia in non-patients. We aimed to test the specific hypotheses that positive beliefs about paranoia would predict frequency of paranoia, and that negative beliefs about paranoia would predict distress associated with delusional ideation. Three-hundred and seventeen non-patient participants were asked to complete questionnaires assessing beliefs about paranoia, paranoia, dimensions of delusional ideation and trait anxiety. The results showed that four empirically distinct subscales were measured by the beliefs about paranoia scale (negative beliefs about paranoia, beliefs about paranoia as a survival strategy, general positive beliefs and normalising beliefs). The scales possessed acceptable internal consistency and were associated with the measures of paranoia, delusional ideation and anxiety. Consistent with predictions, it was found that beliefs about paranoia as a survival strategy were associated with frequency of paranoia, and negative beliefs were associated with distress associated with delusional ideation. These findings suggest that a metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat may have some utility. The clinical implications of the findings are also discussed.

Metacognitive functioning predicts positive and negative symptoms over 12 months in first episode psychosis

The negative symptoms of schizophrenia are a major source of impairment and distress but both pharmacological and psychological treatment options provide only modest benefit. Developing more effective psychological treatments for negative symptoms will require a more sophisticated understanding of the psychological processes that are implicated in their development and maintenance. We extended previous work by demonstrating that metacognitive functioning is related to negative symptom expression across the first 12 months of first episode psychosis (FEP). Previous studies in this area have either been cross-sectional or have used much older participants with long-standing symptoms. In this study, forty-five FEP participants were assessed three times over 12 months and provided data on PANSS rated symptoms, premorbid adjustment, metacognitive functioning, and DUP. Step-wise linear regression showed that adding metacognition scores to known predictors of negative symptoms (baseline symptom severity, gender, DUP, and premorbid academic and social adjustment) accounted for 62% of the variance in PANSS negative symptom scores at six months and 38% at 12 months. The same predictors also explained 47% of the variance in positive symptoms at both six and 12 months. However, exploration of the simple correlations between PANSS symptom scores and metacognition suggests a stronger univariate relationship between metacognition and negative symptoms. Overall, the results indicate that problems with mental state processing may be important determinants of negative symptom expression from the very early stages of psychosis. These results provide further evidence that metacognitive functioning is a potentially relevant target for psychological interventions.

Psychological Processes Mediate the Impact of Familial Risk, Social Circumstances and Life Events on Mental Health

Background Despite widespread acceptance of the ‘biopsychosocial model’, the aetiology of mental health problems has provoked debate amongst researchers and practitioners for decades. The role of psychological factors in the development of mental health problems remains particularly contentious, and to date there has not been a large enough dataset to conduct the necessary multivariate analysis of whether psychological factors influence, or are influenced by, mental health. This study reports on the first empirical, multivariate, test of the relationships between the key elements of the biospychosocial model of mental ill-health. Methods and Findings Participants were 32,827 (age 18–85 years) self-selected respondents from the general population who completed an open-access online battery of questionnaires hosted by the BBC. An initial confirmatory factor analysis was performed to assess the adequacy of the proposed factor structure and the relationships between latent and measured variables. The predictive path model was then tested whereby the latent variables of psychological processes were positioned as mediating between the causal latent variables (biological, social and circumstantial) and the outcome latent variables of mental health problems and well-being. This revealed an excellent fit to the data, S-B χ2 (3199, N = 23,397) = 126654·8, p<·001; RCFI = ·97; RMSEA = ·04 (·038–·039). As hypothesised, a family history of mental health difficulties, social deprivation, and traumatic or abusive life-experiences all strongly predicted higher levels of anxiety and depression. However, these relationships were strongly mediated by psychological processes; specifically lack of adaptive coping, rumination and self-blame. Conclusion These results support a significant revision of the biopsychosocial model, as psychological processes determine the causal impact of biological, social, and circumstantial risk factors on mental health. This has clear implications for policy, education and clinical practice as psychological processes such as rumination and self-blame are amenable to evidence-based psychological therapies.

The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis

Summary Background Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. Methods We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. Findings Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohens d=1·11; p<0·0001), paranoia (−2·22, −2·98 to −1·45, Cohens d=0·19; p<0·0001), and hallucinations (−1·58, −1·98 to −1·18, Cohens d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported. Interpretation To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision. Funding Wellcome Trust.

Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up

BACKGROUND Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses. AIMS To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months. METHOD The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis. RESULTS Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months. CONCLUSIONS Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.