ارتباط بین ابعاد دلبستگی و آسیب شناسی روانی در یک نمونه بزرگ از بیماران مبتلا به روان پریشی

Attachment theory is a powerful theoretical framework that complements and extents current models psychosis. We tested the hypothesis that attachment anxiety and avoidance are differentially associated with the severity of positive, negative and general psychopathology symptoms in patients with a diagnosis of psychosis. Five hundred patients with DSM-IV or ICD-10 diagnoses of psychotic disorders (schizophrenia, schizoaffective or non-affective psychosis) from independent samples from Netherlands, United Kingdom and Israel completed the Relationship Questionnaire. Psychopathology was assessed with the Positive and Negative Syndromes Scale. We used both categorical and dimensional approach to attachment data, which were analyzed using ANOVA with post-hoc tests, Pearson׳s correlations and multiple regression analysis. The conservative level of statistical significance was established (p<0.001) to control for multiple testing. After adjustment for possible confounders, attachment anxiety predicted severity of positive symptoms as well as affective symptoms. Both attachment anxiety and avoidance were associated with severity of hallucinations and persecution Contrary to predictions, attachment avoidance was not associated with overall scores for negative symptoms, although there was some evidence of relatively weaker association between avoidance and social and emotional withdrawal.

The role of trauma in the development of psychosis is well-established and there is now growing interest in elucidating the mechanisms through which trauma exerts its influence (Read and Bentall, 2012). It has been argued that attachment theory is a powerful theoretical framework that both complements and usefully extents current models of the development and persistence of psychosis (Korver-Nieberg et al., 2014, Gumley et al., 2014a and Gumley et al., 2014b). Insecure attachment styles may develop as a result of suboptimal caregiving in earlier life and are associated with later difficulties in regulating affect, poorer interpersonal functioning and negative beliefs about the self and others (Mikulincer and Shaver, 2012). They are hypothesised to increase vulnerability to the development of psychosis and are associated with worse outcomes in terms of symptom severity and course of illness (Korver-Nieberg et al., 2014; Gumley et al., 2014a and Gumley et al., 2014b). Conversely, secure attachment, which is associated with a positive self-image, a capacity to manage distress, comfort with autonomy and in forming relationships with others is hypothesised to be an important protective factor in the context of mental disorder (Mikulincer and Shaver, 2012). There are different methods of assessing and conceptualising attachment styles in adulthood. Bartholomew and Horowitz (1991) describe a four category model of adult attachment and have developed a brief self-report questionnaire to assess an individual׳s attachment style. As shown in Fig. 1, the four categories of attachment (secure, preoccupied, dismissing and fearful) can also be conceptualised as dimensions, either in cognitive terms as beliefs about self and others, or in affective terms as anxiety and avoidance. The dimensions of attachment anxiety and avoidance have been found to underlie a number of other self-report measures of attachment (Brennan et al., 1998). Bartholomew and Horowitz׳s (1991) model of adult attachment. Fig. 1. Bartholomew and Horowitz׳s (1991) model of adult attachment. Figure options As different types of insecure attachment are associated with different methods of regulating distress and self-other beliefs, it is possible that attachment styles may be differentially associated with specific symptom profiles. Preoccupied attachment or higher attachment anxiety is associated with hyper-activating coping strategies (excessive proximity seeking) that results in difficulties in regulating negative affect as well as sensitivity to threat (Mikulincer and Shaver, 2012). Conversely, dismissing or high avoidant attachment is associated with deactivating coping strategies that result in a blocking of conscious emotions, withdrawal from others and impaired mentalization (Mikulincer and Shaver, 2012). Fearful attachment is associated with both high levels of anxiety and avoidance or ‘disorganisation’ of the attachment system. Previous research has generated mixed findings in relation to associations between symptoms profiles and insecure attachment patterns (Berry et al., 2008, Ponizovsky et al., 2007, Ponizovsky et al., 2013, Korver-Nieberg et al., 2014 and Korver-Nieberg et al., 2013). However, two recent reviews of the psychosis and attachment literature conclude that there is good evidence that dismissing-avoidant attachment is associated with positive symptoms and to a lesser extent negative symptoms (Korver-Nieberg et al., 2014, Gumley et al., 2014a and Gumley et al., 2014b). There is also some evidence that preoccupied/anxious attachment is associated with positive and affective symptoms, but not negative symptoms. The role of fearful attachment has been relatively less well researched, but a related concept of disorganised attachment has been implicated as a potential risk factor for the development of psychosis (Harder, 2014). Although there is a growing consensus of the importance of attachment theory to the understanding of psychosis, there are limitations in the existing literature including small sample sizes, different ways of conceptualising and assessing attachment and cultural differences in attachment patterns. Accordingly, the aims of this study are to explore associations between attachment style and symptoms of psychosis in a large cross-cultural sample of patients who all completed the Bartholomew and Horowitz׳s (1991) Relationship Questionnaire (RQ) to assess attachment (we refer to Fig. 1 for a description of the attachment prototypes as assessed with the RQ). Consistent with previous research and theoretical formulations (Korver-Nieberg et al., 2014, Gumley et al., 2014a, Gumley et al., 2014b and Harder, 2014), we hypothesised that preoccupied attachment (or high attachment anxiety) would be associated with positive and affective symptoms of psychosis, and dismissing attachment (or high avoidant attachment) would increase vulnerability to both negative and positive symptoms. Further, we hypothesised that fearful attachment would be implicated in positive, affective and negative symptoms, whereas secure attachment would be negatively correlated with positive, affective and negative symptoms. Our primary aim was to investigate associations between attachment and symptom domains. However, in line with a single-symptom approach to understanding psychosis, we specifically investigated associations between attachment and two of the key positive symptoms of psychosis: hallucinations and paranoia. In line with previous studies, we predicted positive associations between all types of insecure attachment and both more severe hallucinations and more severe persecution.