MacBeth, Angus M.
The function of attachment in first episode psychosis: a theoretical integration and clinical investigation.
PhD thesis, University of Glasgow.
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Section I - Introduction:
The thesis explores the value of attachment theory as a framework for understanding the onset of, and adaptation to the experience of psychosis. The first section of the thesis establishes the clinical and theoretical context from which this line of enquiry arises, starting with a brief historical overview of the clinical approaches towards psychosis, including the diagnosis of schizophrenia, as a nosological entity (Chapter 1). Particular attention is drawn to the role of affect in psychosis, following Bleuler’s (1911/1950) conceptualisation of the splitting of cognitive and affect processes in the diagnosis of schizophrenia.
The late 20th century growth of early intervention for psychosis, a psychologically informed service model, is discussed, in order to contextualise the service model explored for the second empirical study in the thesis. The parameters of the onset of psychotic difficulties, and subsequent adaptation to the experience of psychosis are then discussed (Chapter 2).
Following this, the current literature on premorbid (i.e. before the onset of psychotic difficulties) functioning in psychosis and duration of untreated psychosis (DUP) is reviewed. The data finds no significant relationship between DUP and premorbid adjustment, and suggests that the role of social and academic functioning has been undervalued, particularly with regard to negative symptomatology and quality of life, with poorer adjustment relating to increased negative symptomatology and poorer quality of life. The importance of adolescent premorbid functioning is also highlighted. As premorbid adjustment concerns functioning prior to the onset of psychotic symptomatology, the review suggests scope for a reappraisal of the role of psychodevelopmental factors in psychosis (Chapter 3).
This forms the rationale for viewing attachment theory as a theory par excellence in forwarding a psychodevelopmental understanding of psychosis, particularly given the relevance of contemporary perspectives on attachment theory (focussing on insecure attachment representations) in aiding the understanding of psychopathology in general (Chapter 4).
Concluding the first section, a theoretical integration offers a framework for applying the principles of attachment theory, and the related constructs of mentalisation and affect regulation (e.g. Fonagy, Gergely, Jurist & Target, 2002) to the study of psychosis (Chapter 5). In particular the relevance of attachment and mentalisation to help-seeking, adaptation to psychosis and psychotic phenomenology is highlighted. It was hypothesised that secure attachment would associate with shorter DUP and better engagement, compared to insecure attachment classifications. Higher levels of mentalisation (operationalised as Reflective Function, RF) were also hypothesised to associate with shorter DUP, better help-seeking and better adjustment. Secure attachment was hypothesised to associate with higher RF.
Section II – First Empirical study
The second section of the thesis (Chapter 6) presents a short test of the theoretical validity of applying attachment theory to psychosis, using an analogue study to investigate the role of attachment in the phenomenology of paranoia and hallucinations. The results suggest attachment and a strategy of interpersonal distancing predict higher levels of paranoia, whereas hallucinatory phenomena were predicted by latent constructs representing interpersonal dependence and avoidance strategies (including attachment anxiety and avoidance).
Section III – Second Empirical study
The third section of the thesis builds on the first study by exploring the role of attachment in a clinical sample of individuals in the first year of treatment for a first episode psychosis, recruited from early intervention services in Glasgow and Edinburgh. The study utilises a cross-sectional cohort design (Chapter 7). The sample is characterised in terms of symptomatology, quality of life, DUP, help-seeking, premorbid adjustment, psychological variables, attachment states of mind (using the AAI) and mentalisation (Chapters 8).
Premorbid adjustment and DUP are included to facilitate investigation of the relationships outlined in Chapter 3. Levels of psychotic symptomatology and the median DUP were all comparable with contemporary FEP cohort studies. Contrary to the findings of Chapter 3, results of the study with regard to premorbid adjustment suggest that this construct is significantly correlated with DUP, particularly in the social domain, in the direction of poorer adjustment associating with longer DUP,. Poorer premorbid social adjustment was significantly associated with greater negative symptoms and greater general psychopathology. Poorer premorbid adjustment was not associated with help-seeking, but was associated with poorer engagement with services after initiation of treatment. Longer DUP was not associated with greater positive symptomatology, or poorer engagement, but was associated with more help-seeking (Chapter 9).
Attachment and mentalisation (RF) was investigated in a sub-sample of the main cohort. In contrast to chronic psychosis samples, both secure and insecure Attachment classifications were found in the FEP sample. Both secure and insecure/preoccupied attachment classifications were associated with higher RF. Attachment and RF were not related to psychotic symptomatology. However, higher RF was associated with poorer psychological quality of life. No significant relationships emerged between attachment and premorbid adjustment, DUP or help-seeking. No relationships between these variables emerged for RF. Attachment (but not RF) was significantly related to engagement, with secure attachment being associated with better engagement, and insecure/preoccupied attachment being associated with poorer engagement (Chapter 10).
Section IV – Discussion
The thesis represents a comprehensive assessment of theoretical links between attachment and psychosis, encompassing both phenomenological and clinical variables. The analogue study demonstrates the validity of the link between attachment and psychotic phenomenology, albeit limited by the use of self report measures of attachment. The clinical study is the first characterisation in Scotland of an FEP sample recruited from an early intervention cohort. The limitations of the clinical study are discussed in terms of small sample size, risk of Type I and II errors, and possible selection bias with regard to the attachment sub-sample. The low incidence of Unresolved attachment representations is also acknowledged. Theoretical implications of both studies are discussed in terms of the repositioning affect as an important factor in psychosis and the role of psychodevelopmental factors (including attachment, mentalisation and premorbid adjustment) in influencing onset and adaptation to psychosis. Clinical implications are discussed with regard to possible links with recovery trajectories, integrating attachment principles into treatment, and links to primary prevention of mental health problems in general (Chapter 11).
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