Does Insecure Attachment Lead to Psychosis via Dissociation?

Psychosis: Thinking and perceptions that differ significantly from commonly shared reality, including hallucinations, delusions, and disorganized thinking.

Insecure attachment: Attachment styles that develop from inconsistent, unavailable, or frightening caregiving, leading to anxiety about relationships, avoidance of closeness, or unpredictable behavior. These include anxious, avoidant, disorganized and fearful attachment styles.

Dissociation: A lack of normal integration of thoughts, feelings, memories, and experiences into conscious awareness and memory. Ranges from common zoning out to amnesia, depersonalization, and feeling split into multiple senses of self.

Disorganized attachment: Disorganised attachment is an unpredictable pattern of attachment behavior that develops in response to caregivers who are frightening.

Liotti (1992, 2009) conceptualized disorganized attachment as an early dissociative process. He proposed that in the context of frightening and confusing childhood caregiving relationships, distinct internal working models of attachment develop simultaneously yet separately (split off) from one another. This provides the foundation for dissociation later in adulthood.

Puckett, J., Sood, M., & Newman‐Taylor, K. (2024). Does insecure attachment lead to psychosis via dissociation? A systematic review of the literature. Psychology and Psychotherapy: Theory, Research and Practice.  https://doi.org/10.1111/papt.12521

Key Points

1. Disorganized attachment is consistently associated with dissociation in clinical and non-clinical samples.
2. Disorganized attachment is often associated with paranoia, but findings are mixed for voices and other psychotic experiences.
3. Dissociation is associated with both voices and paranoia, with stronger links in clinical samples.
4. Dissociation likely plays a role in the impact of insecure attachment on voice hearing and paranoia in clinical groups.

Rationale

Previous research demonstrates robust links between insecure attachment and psychosis across clinical and non-clinical populations (Carr, Hardy, & Fornells-Ambrojo, 2018; Gumley, Taylor, Schwannauer, & MacBeth, 2014; Korver-Nieberg, Berry, Meijer, & De Haan, 2014).

Dissociation is also associated with psychotic experiences such as hallucinations and paranoia (Longden, Branitsky, Moskowitz, Berry, Bucci, & Varese 2020; Pilton, Varese, Berry, & Bucci, 2015).

However, it remains unclear whether dissociation accounts for the association between insecure attachment and psychosis (Lavin, Bucci, Varese, & Berry, 2020).

This review takes a theory-driven approach to examining proposed causal relationships across the psychosis continuum.

Method

Search strategy and terms

The authors conducted a systematic literature review following the PRISMA guidelines. They comprehensively searched 5 databases (PubMeD, Web of Science, PsycINFO, CINAHL and British Library EThOS) using search terms for dissociation, attachment, and psychotic experiences.

The search, conducted in August 2023, included published empirical studies and unpublished dissertations examining attachment, dissociation and psychosis.

Reference lists of relevant reviews were hand-searched, and an independent researcher repeated the search process, to ensure a comprehensive set of studies for review.

Inclusion criteria

1. quantitative methodology,
2. standardized measure of attachment,
3. standardized measure of dissociation,
4. standardized measure

Exclusion criteria

1. were not published in English,
2. used qualitative methodology only
3. were books, book reviews, book chapters, conference extracts, case reports or other reviews.

Results

Associations between attachment and dissociation

• Disorganised attachment consistently positively associated with dissociation in both clinical and non-clinical samples (small to moderate correlations)
• Mixed evidence for associations between dissociation and anxious/avoidant attachment

Associations between attachment and psychosis/psychotic experiences

• Disorganised attachment often positively associated with paranoia (small to moderate correlations)
• Mixed findings linking disorganised attachment to hallucinations/other psychotic symptoms
• Some evidence of positive associations between anxious/avoidant attachment and psychotic experiences in nonclinical groups, but mixed evidence in clinical groups

Associations between dissociation and psychosis/psychotic experiences

• Dissociation positively associated with both hallucinations and paranoia in clinical and non-clinical groups (small to strong correlations)
• Links tend to be stronger in clinical compared to non-clinical groups

The evidence indicates dissociation is likely involved in impact of insecure attachment on voice hearing and paranoia among clinical samples.

Insight

This systematic review synthesizes the growing body of research examining attachment styles and dissociation among individuals with psychotic disorders and experiences.

The fairly consistent evidence linking disorganized attachment and dissociation to psychotic symptoms lends support to developmental models of psychosis (Liotti, 1992, 2009; Moskowitz et al., 2019).

These models propose that disorganized attachment stems from early relational trauma and confusing/frightening caregiving relationships.

This provides the foundation for dissociative tendencies later in life, which can be triggered by stress to produce psychotic experiences like hallucinations and paranoia.

The review raises important conceptual and measurement considerations in distinguishing between attachment patterns like anxious, avoidant, and disorganized in psychosis populations.

The mixed findings for anxious and avoidant attachment styles raise measurement questions around whether current self-reports accurately distinguish attachment patterns in psychosis or just proxy disorganized/fearful styles. Resolving these issues can clarify etiological models.

More work is needed to determine whether current self-report attachment measures accurately and reliably reflect these hypothesized distinct styles in clinical groups, or if patterns tend to co-occur in this context (Alexander, 1992; Paetzold et al., 2015).

Resolving these issues will further enhance our etiological models of psychosis.

Clinical Implications

The findings indicate insecure attachment and dissociation may be vulnerability factors for psychosis that can trigger symptoms. Clinicians should routinely assess for early adversity, attachment styles, and dissociation. Principles are provided for sensitively asking about childhood trauma (Read et al., 2008).

1. Clinicians and multidisciplinary teams should routinely assess for early life adversity as this can inform case formulation and treatment planning.
2. Psychologists specifically should evaluate attachment styles and dissociation and discuss the likely role of dissociation in increasing hallucination risk and possibly protecting against paranoia in the context of anxious attachment patterns.
3. For clients with insecure attachment styles, clinicians should prioritize consistent and boundaried therapeutic relationships and techniques to engender feelings of security.
4. Managing dissociation through psychoeducation and grounding skills may also be beneficial.
5. Trauma-focused approaches should be considered where early adversity and dissociation are central issues.
6. At a service or systems level, standardized care pathways for psychosis should specify timelines for evaluating trauma, attachment and dissociation.
7. Internal auditing processes could monitor implementation across community and inpatient teams.

References

Alexander, P. C. (1992). Application of attachment theory to the study of sexual abuse. Journal of Consulting and Clinical Psychology, 60(2), 185–195.

Berry, K., Varese, F., & Bucci, S. (2017). Cognitive attachment model of voices: Evidence base and future implications. Frontiers in Psychiatry, 8, 111.

Carlson, E. A. (1998). A prospective longitudinal study of attachment disorganization/disorientation. Child Development, 69(4), 1107–1128.

Carr, S. C., Hardy, A., & Fornells-Ambrojo, M. (2018). Relationship between attachment style and symptom severity across the psychosis spectrum: A meta-analysis. Clinical Psychology Review, 59, 145–158.

Gumley, A. I., Taylor, H. E. F., Schwannauer, M., & MacBeth, A. (2014). A systematic review of attachment and psychosis: Measurement, construct validity and outcomes. Acta Psychiatrica Scandinavica, 129, 257–274.

Hardy, A. (2017). Pathways from trauma to psychotic experiences: A theoretically informed model of posttraumatic stress in psychosis. Frontiers in Psychology, 8, 697.

Keen, N., Hunter, E., & Peters, E. (2017). Integrated trauma-focused cognitive-behavioural therapy for post-traumatic stress and psychotic symptoms: A case-series study using imaginal reprocessing strategies. Frontiers in Psychiatry, 8, 92.

Korver-Nieberg, N., Berry, K., Meijer, C. J., & De Haan, L. (2014). Adult attachment and psychotic phenomenology in clinical and non-clinical samples: A systematic review. Psychology and Psychotherapy: Theory, Research and Practice, 87(2), 127–154.

Lavin, R., Bucci, S., Varese, F., & Berry, K. (2020). The relationship between insecure attachment and paranoia in psychosis: A systematic literature review. British Journal of Clinical Psychology, 59(1), 39–65.

Liotti, G. (1992). Disorganized/disoriented attachment in the etiology of the dissociative disorders. Dissociation, 5(4), 196–204.

Liotti, G. (2009). Attachment and dissociation. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and dissociative disorders: DSM-V and beyond (pp. 53–65). Routledge.

Longden, E., Branitsky, A., Moskowitz, A., Berry, K., Bucci, S., & Varese, F. (2020). The relationship between dissociation and symptoms of psychosis: A meta- analysis. Schizophrenia Bulletin, 46(5), 1104–1113.

McGonagle, G. (2017). Does fearful attachment and dissociation mediate the relationship between Trauma and voice-hearing in psychosis? [Unpublished doctoral dissertation]. University of Manchester.

Moskowitz, A., M. J. Dorahy, & I. Schäfer (Eds.) (2019). Psychosis, trauma and dissociation: Evolving perspectives on severe psychopathology. John Wiley & Sons.

Ogawa, J. R., Sroufe, L. A., Weinfield, N. S., Carlson, E. A., & Egeland, B. (1997). Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Development and Psychopathology, 9(4), 855–879.

Paetzold, R. L., Rholes, W. S., & Kohn, J. L. (2015). Disorganized attachment in adulthood: Theory, measurement, and implications for romantic relationships. Review of General Psychology, 19(2), 146–156.

Pearce, J., Simpson, J., Berry, K., Bucci, S., Moskowitz, A., & Varese, F. (2017). Attachment and dissociation as mediators of the link between childhood trauma and psychotic experiences. Clinical Psychology & Psychotherapy, 24(6), 1304–1312.

Pilton, M., Varese, F., Berry, K., & Bucci, S. (2015). The relationship between dissociation and voices: A systematic literature review and meta-analysis. Clinical Psychology Review, 40, 138–155.

Read, J., Fink, P. J., Rudegeair, T., Felitte, V., & Whitfield, C. L. (2008). Child maltreatment and psychosis: A return to a genuinely integrated bio-psycho-social model. Clinical Schizophrenia & Related Psychoses, 2(3), 235–254.

Read, J., & Gumley, A. (2008). Can attachment theory help explain the relationship between childhood adversity and psychosis? In J. Schwarz (Ed.), Attachment: New directions in psychotherapy and relational psychoanalysis (pp. 1–35). Karnac Books.

Sitko, K. (2015). Dissociation moderates the association between attachment and paranoia [Unpublished doctoral dissertation]. University of Liverpool.

Williams, J. (2017). Psychological mechanisms of the relationship between early adversity and psychosis [Unpublished doctoral dissertation]. University of Manchester.

Keep Learning

1. How might clinicians adapt psychological therapies for psychosis based on these findings regarding attachment and dissociation? What cautions might apply?
2. What are the arguments for and against attempting to alter attachment styles in therapy? How might this goal relate to symptom reduction?
3. Could changes in societal approaches to early parenting potentially impact rates of disorganized attachment and later dissociation in the population? What evidence is needed to support this idea?