Does Insecure Attachment Lead to Psychosis via Dissociation? A Systematic Review of the Literature, 2024

Link: https://doi.org/10.1111/papt.12521

Authors: Puckett, J., Sood, M. & Newman-Taylor, K.

Quotes and Thoughts:

“There is now broad agreement that experiences traditionally associated with psychosis occur on a clinical/nonclinical continuum and are maintained by similar psychological processes (van Os et al., 2009).”

—Nice! Stress-Vulnerability model, continuum model, trauma based model. So nice to see more research normalizing this.

“.... anxious (preoccupied) attachment typically follows inconsistent caregiving, resulting in negative beliefs about the self, hyperactivation (escalation) of emotion to access care, and ambivalence in close relationships; avoidant (dismissive) attachment typically follows physically or emotionally absent caregiving, resulting in negative beliefs about others, deactivation (suppression) of emotion, excessive self-reliance and avoidance of close relationships (Mikulincer & Shaver, 2010). A fourth style, disorganised attachment, describes an unpredictable combination of anxious and avoidant patterns (Main & Solomon, 1990), and is thought to develop in response to frightening, confused or inconsistent caregiving, possibly due to caregivers' own unresolved trauma (Main & Hesse, 1990). Similarly, fearful attachment describes high levels of both anxious and avoidant patterns – a desire for close relationships alongside fear and avoidance of others (Bartholomew & Horowitz, 1991).”

—It’s unfortunate that the only one that mentions the caregiver may have their own unresolved difficulty is with disorganised attachment. We all go through things and that impacts how we can be there for others. I hope someday the descriptions can offer more compassion within each category.

“A series of reviews and meta-analyses now convincingly demonstrate an association between insecure attachment and psychotic experiences in adulthood, in clinical and non-clinical populations (Berry et al., 2007; Carr et al., 2018; Gumley et al., 2014; Korver-Nieberg et al., 2014; Lavin et al., 2020; Murphy et al., 2020). What is less clear is how insecure attachment leads to psychosis, in terms of child development and mechanisms involved. Dissociation has been posited as a likely causal process in the relationship between insecure attachment and psychosis.”

“Dissociation is associated with trauma in clinical and non-clinical populations (Dalenberg et al., 2012), and may be a direct consequence of trauma, or function to avoid or reduce associated physical and emotional pain (Dorahy & van der Hart, 2007; Ogawa et al., 1997). Systematic and meta-analytic reviews demonstrate robust associations between dissociation and both hallucinations and paranoia across the clinical/non-clinical psychosis continuum (Longden et al., 2020; Pilton et al., 2015).”

–It’s important to remember that there are lots of different types of trauma so please don’t immediately jump to blaming the family or implying they were traumatic. 

“Liotti (1992, 2009) conceptualises disorganised attachment as an early dissociative process; in the context of frightening and confusing early relationships, distinct internal working models develop simultaneously and separately (‘split off’) from one another, and this provides a foundation for dissociation in adults. In this way, dissociation can be conceptualised as part of personality development and adaptive in enabling the child to maintain a relationship with a potentially damaging caregiver (Gumley & Liotti, 2019; Liotti, 1992, 2009; Moskowitz et al., 2019). When a child is both drawn towards and fearful of their caregiver, the fight or flight system is activated as well as the attachment system, urging the child to approach and to withdraw, resulting in a confused and confusing set of responses. Importantly, longitudinal research shows that disorganised attachment in childhood predicts dissociation in adulthood (Carlson, 1998; Ogawa et al., 1997).”

–The term “potentially damaging caregiver” again implies brutality or coldness or trauma intensity. However so many things can interfere with the caregiver being able to have the support and energy themselves to be able to give care.

“The evidence suggests that insecure attachment, typically following early interpersonal adversity, constitutes a vulnerability factor for psychosis (Gumley et al., 2014; Read & Gumley, 2008), and that dissociation may be a key causal mechanism for both voices and paranoia (Longden et al., 2020; Moskowitz & Corstens, 2007).”

“In this model, voices are conceptualised as dissociated trauma-related memories experienced as external due to poor source monitoring. Where voices are malevolent or threatening (e.g. ‘we're going to get you’), paranoia may arise from associated appraisals (e.g. ‘they're going to get me’).”

–It’s important to be respectful to the individuals with lived experience who do not agree with this theory. We want to be respectful and not assume that it fits for all people.  Offering the information that this fits for some people allows the listener to still disagree or hold a different perspective while hearing the information.

“In summary, insecure attachment and dissociation are likely to contribute to the development of psychosis. This review addresses the hypothesis that early relational trauma predisposes a disorganised attachment style, which increases proneness to dissociation in response to stressors, in turn triggering psychotic experience. Previous reviews have found associations between attachment and psychosis (Lavin et al., 2020) and dissociation and psychosis (Longden et al., 2020)....”

“We selected English language publications of studies that utilised: (1) quantitative methodology, (2) a standardised measure of attachment, (3) a standardised measure of dissociation, and (4) a standardised measure of psychosis/psychotic-type experiences or recruited a sample with psychosis/psychotic-type experiences.”

–Nice to see the focus on standardized measures for the ease in comparison. 

“Disorganised attachment is consistently associated with dissociation in clinical and non-clinical samples, typically with small to moderate correlations. Findings are mixed for anxious and avoidant attachment.

“The most consistent finding is for an association between disorganised attachment and paranoia. There is some evidence for associations between both anxious and avoidant attachment and psychotic experiences in the non-clinical samples, but the evidence is mixed in the clinical groups.”

“These studies indicate that dissociation is associated with both voices and paranoia, and that these links may be stronger in clinical samples.”

“Berry et al. (2018) showed that attachment avoidance and dissociation predicted voice hearing predisposition (controlling for age and negative affect) – individuals with higher levels of attachment avoidance and/or dissociation were more prone to voice hearing.” 

“Dissociation is likely to play a role in the impact of insecure attachment on AHs and paranoia in clinical groups.”

“We selected studies measuring attachment, dissociation and psychosis in clinical and non-clinical samples. We found that (1) disorganised attachment is consistently associated with dissociation in clinical and non-clinical groups (with mixed evidence for associations with anxious and avoidant attachment), (2) disorganised attachment is often associated with paranoia (with mixed evidence for the impact on voices, and the impact of anxious and avoidant attachment on psychotic experiences), (3) dissociation is associated with both voices and paranoia, and these links are likely to be stronger in clinical samples, (4) dissociation is likely to play a role in the impact of insecure attachment on voice hearing and paranoia in clinical groups.”

“These findings indicate that disorganised attachment, which often results from early interpersonal trauma, predisposes dissociation in adulthood, which can in turn trigger voices and paranoia (see Figure 2). This is consistent with developmental (Liotti, 1992, 2009) and mechanistic models (Berry et al., 2017) of psychosis that highlight the role of dissociation in the association between disorganised attachment and psychosis. The finding that disorganised attachment is consistently associated with dissociation, and that dissociation is associated with both voices and paranoia, particularly in clinical samples, suggests that both disorganised attachment and dissociation are causally linked to psychosis.”

“ Our results support the suggestion that disorganised attachment leads to voice hearing via dissociation (Berry et al., 2017), and raise interesting questions about the (possibly protective) function of dissociation in the relationship between attachment insecurity and paranoia (cf. Longden et al., 2020).”

“While disorganised and fearful attachment are often used interchangeably, these categories come from different classification systems and there is some disagreement regarding assumed equivalence (cf. Paetzold et al., 2015).”

–Interesting.

“Our findings indicate that insecure attachment is likely to be a vulnerability factor for psychosis, and that dissociation may mediate this effect and trigger psychotic experiences on a day-to-day basis.  Importantly, this applies to paranoia (and possibly negative symptoms) as well as voices.”

“Psychologists and psychological therapists: When formulating, discuss the function of dissociation for the individual, which probably increases likelihood of voices, and possibly decreases paranoia (in the context of anxious attachment)”

“Psychologists and psychological therapists: Prioritise means of managing dissociation where relevant, for example, psychoeducation and grounding skills”

“Clinicians and MDTs: Prioritise consistent and boundaried therapeutic relationships for people with insecure attachment and find ways to facilitate ‘felt security’”

“Clinicians and MDTs: Consider trauma-focused approaches where early adversity and dissociation dominate the presentation”

“We recommend that clinicians routinely ask about early and later adversity (Read et al., 2005, 2008; Read & Gumley, 2008). Read et al. (2008) provide a list of principles for asking about childhood trauma and responding to people's answers. These include asking everyone, asking at initial assessment (unless the person is in crisis), not seeking details, affirming it was helpful to tell, checking current emotional state, safety and support, and offering follow-up (Read et al., 2008).”

“In the case of psychological assessment and therapy, relevant early experience, attachment style and dissociation can be named in the formulation and linked to psychosis symptoms to facilitate understanding. For people with insecure attachment, it is important to foster a sense of felt security through therapeutic interactions that are consistent, reliable and boundaried (cf. Mikulincer et al., 2013).”

“In terms of treatment planning, clinicians should teach people to manage their dissociation, e.g. through psychoeducation and grounding skills (Newman-Taylor & Sambrook, 2013; Paulik et al., 2022), and address trauma directly where early adversity and dissociation dominate the presentation (Hardy, 2017; Keen et al., 2017; Paulik et al., 2019; van den Berg et al., 2020).”

“Routine assessment and formulation of attachment style and dissociation are likely to improve clinical outcomes for people with psychosis, particularly for those with a history of early relational trauma.”

Discussion Topics:

What pieces of the article stand out to you?

Did you find yourself drawn to any specific wording?

Did all of the different types of attachment make your head spin a bit? It definitely did mine :-)

Look Ups:

Previous reviews have found associations between attachment and psychosis (Lavin et al., 2020) and dissociation and psychosis (Longden et al., 2020)....”

“Seven self-report measures of attachment were used across the 13 studies (see Table 1). About half (n = 6) used the Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991), indicating some consistency in the field. The majority (10) measured trait dissociation using the Dissociative Experiences Scale-II (DES-II; Carlson & Putnam, 1993), a level of consistency that facilitates comparisons across studies. Eleven tools measured psychotic experiences, with the Community Assessment of Psychotic Experiences (CAPE; Konings et al., 2006) used most frequently (n = 4).”

“Felt security can also be targeted directly with brief imagery tasks (Newman-Taylor, 2020; Newman-Taylor et al., 2021; Pitfield et al., 2020; Sood et al., 2021, 2022a, 2022b; Sood & Newman-Taylor, 2020).”