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Objectives. Using the model of activation and dynamics of the attachment system (Shaver & Mikulincer, 2002) and dynamic stress-vulnerability models of psychosis (Ingmar & Luxton, 2005) as the analytical frameworks, the authors tested the hypothesis that the insecure attachment styles are differentially associated with the severity of psychopathological symptoms and emotional distress among outpatients with International Classification of Diseases, Tenth edition (ICD-10) diagnosis of schizophrenia.

Methods. Attachment styles were identified using the Relationship Questionnaire (Bartholomew & Horowitz, 1991) among 100 outpatients with an ICD-10 schizophrenia diagnosis. Current symptom severity was measured by the Positive and Negative Syndromes Scale (Kay, Fiszbein, & Opler, 1987) and emotional distress by the General Health Questionnaire (Goldberg & Williams, 1988). Univariate and multivariate analyses were performed to test the hypotheses.

Results. The preoccupied and fearful-avoidant attachment patterns were associated with higher scores of psychotic (delusions, suspiciousness/persecution, and hallucinatory behaviour) and affective (anxiety, tension, guilt feeling, and depression) symptoms, whereas the dismissing-avoidant style was associated with only anxiety. All the insecure attachment styles were associated with elevated emotional distress.

Conclusions. The findings support the hypothesis of a predisposing role of the preoccupied and fearful-avoidant styles in psychotic symptom formation and call for cognitive interpersonal interventions geared to reduce symptom and emotional distress severity.

Practitioner Points

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    Knowledge of certain attachment style would be valuable for:
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      individual prognosis predicting to what extent the patient with particular attachment style would be amenable to different forms of treatment;
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      enhancement of the therapeutic alliance and anticipating the types of alliance ruptures that might be diverse in different attachment styles;
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      prediction of recovery style, engagement with services, and hence therapeutic outcome.
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    Cognitive-behavioural techniques aimed at reducing sensitivity to interpersonal stress, alleviating emotional distress, and promoting well-being could be beneficiary, in particular, for patients with the preoccupied and fearful-avoidant attachment patterns that showed themselves most symptomatic and distressed.