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Purpose: Insecure attachment may constitute a vulnerability factor for psychosis, and dissociation may be a key mechanism in the development of auditory hallucinations specifically. While there is good evidence for the role of these processes in isolation, it is unclear whether dissociation accounts for the association between insecure attachment and psychosis. This systematic review takes a theory‐driven approach to examine proposed causal relationships across the clinical and nonclinical literature. Methods: We searched five databases (PubMeD, Web of Science, PsycINFO, CINAHL and ETHOS) for published and unpublished research examining attachment, dissociation and psychosis. Two independent reviewers extracted the data and assessed the quality of all included studies. Results: We identified 242 potential articles and included 13 in the final review (2096 participants). We found that (1) disorganised attachment was consistently associated with dissociation and inconsistently associated with voices and paranoia, (2) dissociation was associated with voices and paranoia, and these links were stronger in clinical samples, and (3) dissociation played a role in the impact of insecure attachment on voice hearing and paranoia in clinical groups. Conclusions: This is the first review to synthesise the research examining attachment, dissociation, and psychosis. The evidence is consistent with proposed causal hypotheses and raises conceptual and measurement issues, for example, the need to clarify the relative contributions of different insecure attachment styles, and utilise behavioural/observational measures to strengthen study designs. Most importantly, we need experimental and longitudinal studies to confirm causal links and targets for treatment. [ABSTRACT FROM AUTHOR]

Objectives: Auditory hallucinations (such as hearing voices) are common in clinical and non‐clinical populations. Many people who hear voices also report early adversity and have an insecure attachment style. Current cognitive models suggest that dissociation mediates an association between disorganised attachment and auditory hallucinations, but this has not been tested experimentally. Design: We recruited a non‐clinical analogue sample highly predisposed to auditory hallucinations and utilised an experimental design to examine the impact of disorganised attachment imagery on hallucinatory experiences, and whether dissociation mediates an expected association. Methods: Participants completed self‐report measures of state auditory hallucinations and dissociation before and after random allocation to secure or disorganised attachment conditions. Results: Attachment imagery did not affect auditory hallucinations. Both secure and disorganised attachment conditions increased state dissociation. Secure attachment imagery reduced paranoia, but state dissociation did not mediate this effect. An exploratory analysis found that trait dissociation fully accounted for the association between trait‐disorganised attachment and hallucinatory experience while controlling for paranoia. Conclusions: Secure attachment imagery reduces paranoia but not auditory hallucinations and the impact on paranoia is not mediated by dissociation. Secure attachment imagery may be useful in reducing fears and distress associated with voices, rather than the frequency or severity of hallucinations. Disorganised attachment may increase hallucinatory experiences for people vulnerable to dissociation. Trait dissociation should be assessed in clinical settings and addressed where indicated as a means of targeting vulnerability to distressing voices. [ABSTRACT FROM AUTHOR]

Background: Previous research has shown a link between childhood sexual abuse (CSA) and more severe symptoms of psychosis. There is also evidence that self‐compassion is a key mechanism linking adverse childhood experiences and mental health problems such as post‐traumatic stress disorder and depression, but no research has examined these links in psychosis. Methods: We analysed existing cross‐sectional data, including 55 individuals with psychosis and 166 individuals from the general population. Participants completed standardized measures of CSA, self‐compassion, paranoia, positive psychotic symptoms and distress linked to psychosis. Results: The clinical group had higher scores on CSA and all psychosis measures, but we found no differences in self‐compassion between the groups. Higher levels of CSA correlated with lower self‐compassion and higher paranoia and positive symptoms in both groups. CSA also correlated with distress linked to psychosis in the non‐clinical group. Lower self‐compassion mediated the association between higher levels of CSA and more severe paranoia in both groups. In the non‐clinical group, lower self‐compassion also mediated the association between greater CSA and more positive psychotic symptoms and more severe distress. Conclusions: This is the first study to show that self‐compassion mediates the link between CSA and both paranoia and psychotic symptoms in adulthood. Self‐compassion may therefore be an important transdiagnostic candidate target in therapy to mitigate the impact of early adversity on paranoia in both clinical and non‐clinical groups. Limitations include the small clinical sample and inclusion of a cannabis‐using non‐clinical sample, though recent cannabis use did not impact self‐compassion levels. [ABSTRACT FROM AUTHOR]

Objectives: Paranoia describes unfounded interpersonal threat beliefs. Secure attachment imagery attenuates paranoia, but limited research examines mechanisms of change and no studies examine how secure imagery may be implemented most effectively in clinical practice. In this study, we tested: (a) the causal impact of secure, anxious, and avoidant attachment imagery on paranoia and anxiety, (b) whether emotion regulation strategies mediate these relationships, and (c) whether secure imagery buffers against social stress. Design: We utilized a longitudinal, experimental design. Method: A general population sample with high non‐clinical paranoia (N = 265) completed measures of paranoia, anxiety, and emotion regulation strategies. Participants were randomly allocated to secure, anxious, or avoidant conditions and repeated an imagery prime for four days prior to a social stress task. Results: Relative to anxious and avoidant imagery, secure imagery decreased state paranoia and anxiety. These associations were not mediated by state emotion regulation strategies, and secure imagery did not buffer against stress. Exploratory analyses on trait variables revealed that: (a) hyperactivating strategies mediated the association between attachment anxiety and paranoia, and (b) suppression mediated the association between attachment avoidance and paranoia. Conclusions: Secure attachment imagery reduces state paranoia and anxiety and could be incorporated into psychotherapies to attenuate clinical paranoia. Measurement of state emotion regulation was problematic. Attachment imagery does not buffer stress; further research is required to test whether secure imagery facilitates recovery from stress. Attachment style is likely to account for trait paranoia via attachment‐congruent emotion regulation strategies. Research is now needed to determine if these strategies can be targeted to alleviate paranoia in clinical populations. [ABSTRACT FROM AUTHOR]

Background: The relationship between attachment and paranoia is now well established. There is good theoretical reason and evidence to indicate that attachment style affects cognitive, affective, and behavioural processes which, in turn, contribute to the maintenance of paranoia, but this research has not been integrated. We critically and systematically review research that examines relevant cognitive, affective, and behavioural processes, which may explain how attachment insecurity leads to paranoia and constitute key targets in psychotherapeutic interventions for people with psychosis. Method: We conducted three systematic searches across six databases (PsycINFO, CINAHL, Medline, Web of Science, Embase, and Google Scholar), from inception to September 2021, to investigate key cognitive, affective, and behavioural processes in the attachment–paranoia association. Results: We identified a total of 1930 papers and critically reviewed 16. The literature suggests that negative self‐ and other‐beliefs, inability to defuse from unhelpful cognitions, and use of maladaptive emotion regulation strategies mediate the association between attachment insecurity and paranoia in people with psychosis/psychotic experience. Attachment‐secure people with psychosis are more likely to seek help and engage with services than attachment‐insecure people. Conclusions: Attachment styles impact help‐seeking behaviours in people with psychosis and are likely to influence paranoia via self‐ and other‐beliefs, cognition fusion, and emotion regulation – these candidate mechanisms may be targeted in psychological therapy to improve clinical outcomes for people with psychosis, characterized by paranoia. Practitioner points: Insecure attachment is likely to lead to paranoia via negative beliefs about self and others, cognitive fusion, and use of maladaptive emotion regulation strategies. These mechanisms can be targeted in psychotherapeutic interventions for psychosis, such as cognitive behaviour therapy, to improve clinical and recovery outcomes.People with psychosis who are attachment‐secure are more likely to seek help and engage with services than those who are attachment‐insecure (particularly avoidant). Attachment style can be assessed to predict service engagement and help‐seeking behaviours in people with psychosis.Attachment styles are important predictors of key cognitive, affective, and behavioural processes in people with psychosis. These processes can be assessed and incorporated into individualised formulations, and then targeted in therapy to effect psychotherapeutic change. [ABSTRACT FROM AUTHOR]

Objectives: Paranoia describes unfounded and distressing interpersonal threat beliefs. Secure attachment imagery has been shown to attenuate paranoia and anxiety in non‐clinical and clinical groups, but little is known about the differential effects of anxious and avoidant imagery or mechanisms of change. In this study, we tested the impact of secure, anxious, and avoidant attachment imagery on paranoia, anxiety, and help‐seeking intentions. We also examined hypothesized mechanisms of change, specifically whether cognitive fusion and negative self‐ and other‐beliefs mediate these relationships. Design: This study utilized an experimental, cross‐sectional design. Methods: A large (N = 303), international general population sample with high levels of non‐clinical paranoia completed a series of measures before and after engaging in secure, anxious, or avoidant imagery. Results: Relative to anxious and avoidant attachment imagery, secure attachment imagery reduced paranoia and anxiety and increased help‐seeking intentions. Cognitive fusion and negative self‐ and other‐beliefs mediated the impact of attachment imagery on paranoia and anxiety, but not help‐seeking. Conclusions: In line with attachment and cognitive theory, secure attachment imagery is effective in reducing paranoia and anxiety and works by reducing cognitive fusion and negative self‐ and other‐beliefs. These novel findings suggest that the secure imagery task could be incorporated into cognitive and behavioural therapies to reduce distressing interpersonal threat beliefs and associated negative affect, and increase help‐seeking intentions. Practitioner points: When working with people experiencing paranoia, secure attachment imagery may be effective in reducing state paranoia and anxiety and improving help‐seeking intentions.Attachment imagery works by influencing beliefs about self and others, and the degree to which people are fused with their beliefs. In clinical practice, the rationale for the imagery task fits well with psychological models of paranoia and the secure imagery task can be introduced as a way to cope when struggling with distressing beliefs about self and others, and feeling overwhelmed by these fears. [ABSTRACT FROM AUTHOR]

Cannabis use can increase severity of symptoms and risk of relapse for people with psychosis. Childhood sexual abuse and high schizotypy increase the risk further. The mechanisms involved remain unclear, and this limits psychological therapies. In three linked studies, we examined the role of two candidate mechanisms – external attribution and cognitive fusion. Study 1 examined these processes in a general population sample and showed that paranoia, psychotic-type experiences, and linked distress were higher in cannabis-users, and mediated by cognitive fusion but not external attribution. Study 2 examined the impact of established risk factors in general population cannabis-users and showed that external attribution and cognitive fusion partially or fully accounted for the effects of childhood sexual abuse and schizotypy on paranoia, psychotic-type experiences and linked distress. Study 3 examined these same processes in a clinical population of people with psychosis and found that external attribution and cognitive fusion partially or fully accounted for the impact of gender, age of first use, sexual abuse and schizotypy. External attribution and cognitive fusion may be key mechanisms in the maintenance of cannabis-related paranoia and account for the impact of established risk factors. We present a cognitive model incorporating these processes to inform clinical practice. [ABSTRACT FROM AUTHOR]

Attachment security priming effects therapeutic change in people with depression and anxiety. Preliminary studies indicate that visualising secure attachment memories also reduces paranoia in non-clinical and clinical groups, probably due to a decrease in cognitive fusion. Benefits to clinical populations depend on the sustainability of these effects and the impact on help-seeking behaviours. The combination of paranoia and an insecure-avoidant attachment style is likely to be a particular barrier to help seeking. We used a longitudinal experimental design to test the impact of repeated attachment priming on paranoia, mood and help-seeking intentions and whether cognitive fusion mediates these effects. Seventy-nine people with high levels of non-clinical paranoia, aged 18–50 years (M = 20.53, SD = 4.57), were randomly assigned to a secure or insecure-avoidant priming condition. Participants rehearsed the visualisation prime on four consecutive days and were assessed on standardised measures of paranoia, positive and negative affect, help-seeking intentions and cognitive fusion. A series of mixed-model analyses of variance showed that security priming decreases paranoia, negative affect and cognitive fusion and increases positive affect and help seeking, compared to insecure-avoidant priming. Examining the impact of primed attachment (rather than measured attachment style) allows us to draw conclusions about the causal processes involved; mediation analyses showed indirect effects of the primes on paranoia and negative affect through cognitive fusion. With a growing understanding of (1) the impact of security priming on paranoia, affect and help-seeking behaviours, (2) causal mechanisms and (3) sustainability of effects, security priming may be developed into a viable intervention for clinical populations. [ABSTRACT FROM AUTHOR]