Acta Psychopathologica Open Access

Keywords

First episode psychosis; Trauma; Attachment; Anxious

Introduction

The goal of this literature review is to discover how attachment affects any trauma that is associated with first episode psychosis. Learning how attachment affects post-psychotic trauma can assist therapists in treatment plans for these individuals to attain better outcomes in the therapeutic setting. Discovering the different types of trauma that are associated with psychosis, as well as any traumas that may predict a psychotic episode. Additionally, this review may help in finding a more comprehensive method of care for post-psychosis.

Bowlby’s Theory of Attachment posits that early relationships have a major impact on interpersonal relationships in life [1]. The theory is that these early relationships form the internal working model of a person and that is the lens through which they view the world. This internal working model affects interpersonal relationships as well as social functioning of the person through their lifetime. Each study selected was chosen from keywords in the title, specifically because the role that attachment plays in the outcome of post-psychotic trauma is the research we wanted to discover. The theoretical implications are that when in individual or group therapy, clients that have had a psychotic episode may need to be guided through attachment work as well as processing their psychotic episode and the trauma that resulted from the episode. By working on attachment, the client may experience less post-psychotic shame as well as fewer negative symptoms of psychosis such as apathy, social withdrawal, or anhedonia. In short, working not only on the trauma but also on attachment, the client may be able to experience a fuller life. The results of this study may impact social work practice and policy, as current standards of care are evolving to trauma informed care as well as treatment of trauma such as trauma-focused cognitive behavioral theory, however attachment style may also be key in identifying roadblocks to recovery. Roadblocks to recovery are often maladaptive coping mechanisms and through the literature appear to be associated with insecurely attached clients, whether they are insecure avoidant/ambivalent or insecure anxious [2].

Attachment is the main theoretical model that was examined, and each of the articles utilized similar testing hypothesis, exploring how attachment style impacted the patient’s recovery post-psychosis. Attachment is thought by many to be key in discovering how people recover from trauma. Psychotic trauma is difficult to define through the existing literature, however because psychosis is (for the patient) impossible to explain what is happening and why and therefore can be considered traumatic for many people. However, defining any psychotic break as automatically traumatic is also not necessarily true, as all clients are different in their response to traumatic events.

The types of childhood attachment are: secure, avoidant, and insecure. Within avoidant and insecure there are two subsets of additional attachment models. As a child grows into an adult these basic models of attachment are how the world is viewed, and how someone may react to their stresses. Bowlby and Ainsworth have done significant work in the field of attachment; however their focus was on the attachment of children [3]. Research then developed the idea of adult attachment, and this literature review seeks to understand a link between attachment and post-psychotic trauma. Because the research is based on how a person may view their world and react to their stressors, attachment may be an important factor in the recovery of a psychotic state. Psychosis is a major stressor to the individual as well as their family. Recovering from that stress will depend on what kind of attachment the individual has to each part of the family unit. Attachment may matter in how people can resume their lives, post-psychosis. However, as with most therapy and theories, perhaps it will be individual specific.

Methods

A systematic review of the literature was conducted to examine the relation of attachment to post-psychotic trauma. OneSearch database from East Carolina University was utilized to search for articles reviewed. OneSearch is a comprehensive database of all available resources through East Carolina University. The keywords for this search were, “trauma,” “attachment,” and “first episode psychosis.” The authors limited articles to peer/ scholarly reviewed during the last 10 years (January 1, 2007 to March 1, 2017). Then the authors conduscted a face validity review by examining the titles and abstracts of the remaining articles to assure that they were germane to the three key words.

Results

As shown in Appendix 1, the research question for this literature review was “what is the effect of attachment style on postpsychotic trauma” with the anticipation of understanding better if and how attachment effects psychosis, and what modalities are preferred for treating patients with trauma related to their first episode of psychosis. As shown in Appendix 2, the results appeared consistent with the hypothesis that attachment does appear to matter in treating psychosis, especially as several of the studies showed that insecure attachment style can have a poor prognosis for a healthy recovery. The majority of these studies were clear and straightforward. Many of them had carefully considered conclusions with clear limitations and strengths and themes as shown in Appendix 3. Many of the studies that were in the “other” category appeared that they touched upon attachment and psychosis, but some missed the mark of having any clear conclusion.

There were 17,642 results for the three keywords. Limiting by “peer reviewed/ scholarly articles) the search rendered 1311 articles. The next limiter was time, so the search was changed to include January 1, 2007 to March 1, 2017. This search resulted in 738 articles. Then two authors conducted a face validity review by examining the title and abstract of each article to ensure fit into the literature review. Twenty-eight articles met all criteria. The qualifying studies are listed in Appendix 1, which include the themes: early trauma, attachment style, social anxiety disorder, mentalization, and a group of other articles that were singular in theme. These themes emerged following a thorough review of the articles that were selected. The theme with the most number of articles were about attachment (n=12). The second most prevalent theme included articles written on early trauma (n=6). Following that, the most prevalent theme concerned mentalization (n=4). Social Anxiety Disorder was the fourth most prevalent theme (n=2). The “other” category, “outliners,” had one article each on mindfulness, symptomatology, metacognition, recovery, coping, and personality disorder. The research questions for this study, how many articles relate to attachment and does effect does attachment have on postpsychotic trauma seemed to be resolved in that the 28 resulting articles attachment style appear to shape the way a person sees the world, so to experience something as life-changing as psychosis, attachment likely changes the way the person views it. The authors eliminated articles from the 709 articles did not fit the search parameters, based on their title and abstract. Because of the specificity of the question, there was not as much current research on the topic. In fact, the studies that are in the “other” category are not necessarily written about attachment, but may have some information about the link between attachment and post-psychotic trauma. The evidence appears to support links between the way a person copes with psychosis and attachment style. While insecurely attached patients may show higher prevalence of paranoia, it is not indicative of every person. The experience of psychosis is highly personal and while attachment may play a role, it is not to be considered that it is the only factor in the recovery of psychosis.

Many of the studies were written by similar groups of people with similar research aims, and several of the studies cited each other, which may indicate homogeneity within the sample. However, with these limitations, the link between attachment and recovery from psychosis can likely be inferred. These studies carefully consider the link between the two ideas and many come to the conclusion that it is likely there is a relationship.

Appendix 1 shows each study in alphabetical order with how many participants of the study in the “N” column, the assessments or tests used to get results, and study outcomes. Many of the studies used similar assessments with some of the common ones being the Positive and Negative Syndrome Scale (PANSS), Adult Attachment Interview (AAI), and Psychosis Attachment Measure (PAMS). These instruments have been shown to be reliable for the purposes for which they were developed. Some of the studies utilized self-report, or created their own assessment tool. While not uncommon, most of those studies also listed their assessment tool or self-report as a limitation. One study listed the Adult Attachment Interview (AAI), as a limitation due to the invasive nature of the test itself. Appendix 3 discusses each study within its theme. The major themes of this literature review were: attachment style, early trauma, mentalization, and “other.” In the “other” category were outliers that did not have much to do with the other themes. Additionally, some of these outliers had titles and abstracts that did not indicate the actual purpose of the study so they were included with the literature review [4].

Some articles (n=12) discussed attachment style and psychotic trauma in this sample [5]. Each of the articles emphasized that attachment style does have an impact on how patients recover from psychosis. While mindfulness was not the next highest category, it is important to mention second, because it could provide a difference in the delivery of therapeutic modality. By using mindfulness, a practitioner may be able to assess the patient more quickly, and by providing a corrective emotional experience the patient may learn that it is possible to trust. All of the research is interwoven in that each piece affects another part of the research. Therefore, utilizing mentalization in combination with other therapy modalities may result in a more effective recovery for a patient no matter their attachment style. It is important to note that patients that are insecurely attached, whether it is avoidant or anxious appear that they are more likely to have a difficult recovery from psychosis. Securely attached patients appear to use that secure attachment as a resiliency factor in their recovery. Also of note is that each study mentioned that ultimately, it depends on the person that is being treated. Attachment style may make some symptoms more prevalent, but that it is not safe to assume that it is totally true. However, the studies clearly support that it is important to discuss attachment in the therapeutic setting and provide a corrective emotional experience as that may help with trust for the patient.

Discussion and Conclusion

Summary of findings

The evidence presented appears to be overwhelming that the trauma associated with psychosis must be discussed within the therapeutic setting. The trauma associated with hospitalization is not to be discounted [5,6] and should also be discussed in the therapeutic setting. Additionally, a client’s attachment style will affect the therapeutic alliance [7]. Moreover, there are relatively few studies that examine attachment style in post-psychotic trauma, although the few studies that have been completed are evidence that more examination should be done.

Limitations

Limitations to this study are the small number of studies (n=30). Further, there are few studies that examine attachment’s role in post-psychotic trauma with first episode psychosis (n=12) [8- 10]. Ultimately, this is an area that needs further research due to the clear connection between attachment type and recovery, particularly when a patient has insecure avoidant or anxious attachment. Additionally, many of the limitations of the studies utilized stated that while attachment might matter, ultimately it will depend on the individual and more factors than can be controlled in one study.

Application to social work policy and practice

Considering the professional training and skill versatility of social workers, they may be in unique positions to successfully work with patients coping with post-psychotic trauma [11,12]. Social Workers have the ability to create correctional relational experiences and utilize mentalization to foster a therapeutic alliance so that post-psychotic trauma can be processed and reduced. Utilizing mentalization and fostering that skill with the patient may assist patients in recovery [7]. Another important application to Social Work practice is that trauma informed care is necessary, particularly in the severely and persistently mentally ill population, as many of these articles underscore how past trauma affects recovery post-psychosis. Mentalization-based therapy may be an important type of therapy to include when treating those with a psychotic spectrum disorder, because it has the potential to aid the patient in reality based thought.

References

1. Bowlby J (1973) Separation: anxiety & anger. Attachment and Loss (2^nd edn.). International psycho-analytical library no. 95, London: Hogarth Press.
2. KorverNieberg N, Berry K, Meijer CJ, Haan L (2014) Adult attachment and psychotic phenomenology in clinical and nonclinical samples: A systematic review. Psychol Psychother Theor Res Pract 87: 127-154
3. Bretherton I (1992) The origins of attachment theory: john bowlby and mary ainsworth. Dev Psychol 28: 759-775.
4. Berry K, Barrowclough C, Wearden A (2009) Adult attachment, perceived earlier experiences of care giving and trauma in people with psychosis. J Ment Health 18: 280-287.
5. Gumley AI, Taylor HEF, Schwannauer M, MacBeth A (2014) A systematic review of attachment and psychosis: measurement, construct validity and outcomes. Acta Psychiatr Scand 129: 257-274.
6. Berry K, Ford S, Jellicoe-Jones L, Haddock G (2015) Trauma in relation to psychosis and hospital experiences: the role of past trauma and attachment. Psychol Psychother Theor Res Pract 88: 227-239
7. Debbané M, Benmiloud J, Salaminios G, Solida-Tozzi A, Armando M, et al. (2016) Mentalization-based treatment in clinical high-risk for psychosis: a rationale and clinical illustration. J Contemp Psychother 46: 217-225.
8. Lambert M, Conus P, Lambert T, McGorry PD (2003) Pharmacotherapy of first-episode psychosis. Expert Opin Pharmacother 4: 717-50.
9. Franz L, Carter T, Leiner AS, Bergner E, Nancy J, et al. (2010) Stigma and treatment delay in first-episode psychosis: a grounded theory study. Early Interv Psychiatry 4: 47-56.
10. Kane JM, Schooler NR, Marcy P, Correll CU, Brunette MF, et al. (2015) The RAISE early treatment program for first-episode psychosis: background, rationale, and study design. J Clin Psychiatry 76: 240-246.
11. Arango C (2015) First-episode psychosis research: time to move forward (by Looking Backwards). Schizophr Bull 41: 1205-1206.
12. McgorrY PD, Killackey E, Yung A (2008) Early intervention in psychosis: concepts, evidence and future directions. World Psychiatry 7: 148-156.

Appendix 1: Matrix for systematic literature review (n=28).

Searches engines: OneSearch database from East Carolina University libraries.

Appendix 2: Synthesis of keywords for systematic literature review (SLR).

Appendix 3: Synthesis and themes of key articles (n=28).