Emotion regulation in psychosis: exploring psychobiological markers and piloting an attachment and compassion-focused intervention

Abstract

“Non-affective” psychotic disorders are in fact associated with a high rate of emotional disorders. A number of attachment-based models of impairments in emotion regulation and mentalization in psychosis have been put forward. The present thesis aimed to explore psychobiological markers of emotion regulation in order to develop and pilot a novel psychological intervention. The portfolio consists of six peer-reviewed published articles. Four studies were conducted involving 167 psychosis patients and 66 community controls resulting in four original articles, a theory paper and a metaanalysis. Paper 1- 3 explored emotion regulation using different methods (self-report, hormonal, attachment-based narrative). Paper 4 lays out a compassion-focused model for promoting emotional recovery from psychosis. Paper 5 presents data from a feasibility trial of Group Compassion Focused Therapy. Paper 6 presents an updated attachment- and compassion-focused model of emotion regulation and mentalization in the context of a meta-analysis of effects of intranasal oxytocin on symptoms and social cognition in psychosis. Childhood trauma – especially emotional abuse - was strongly associated with dissociation in psychosis patients compared to non-psychotic community controls – most strongly in chronic patients (Paper 1). Psychosis patients with childhood trauma showed significantly lower basal cortisol levels indicative of impaired stress regulation than those without childhood trauma (Paper 2). Impaired emotion regulation operationalised as attachment-based mentalisation was associated with problematic adolescent development and emotional and interpersonal adaptation to a first episode of psychosis in qualitative interviews. A novel attachment-based model for improving emotion regulation in psychosis by way of strengthening the caregiving/ receiving and affiliation system through Compassion Focused Therapy (CFT) was put forward (Paper 4). A feasibility trial showed that group CFT was safe, well-accepted and associated with greater clinical improvement and greater increases in compassion compared to treatment as usual. Increases in compassion in CFT were associated with reductions in shame, perceived social marginalisation, fear or relapse and depression (Paper 5). A metaanalysis of oxytocin administration as a biological way of strengthening the care-giving/receiving and affiliation system in psychosis was conducted yielding medium effects despite significant heterogeneity (Paper 6). Findings replicated the strong association between childhood trauma and dissociation in psychosis patients relative to controls highlighting the importance of emotional abuse and suggesting underlying difficulties with regulating distress related to early interpersonal trauma. Lower basal cortisol in patients with childhood trauma appeared to support the presence of emotion regulation difficulties due to early interpersonal trauma on a physiological level. Qualitative findings helped to generate hypotheses about inhibitors and facilitators of recovery and targets for intervention including the moderating role of mentalization. A novel attachment- and compassion-focused model was outlined and successfully piloted yielding important signals of change such as increases in compassion, which appear to reduce depression and social marginalisation in particular. This model helped account for inconsistencies in oxytocin studies of psychosis. In summary, findings extend existing research on emotion regulation in psychosis by supporting links to early interpersonal trauma and attachment and offer a promising novel attachment-and compassion-focused psychological intervention and a comprehensive biopsychosocial framework for further improving emotion regulation and mentalization in people with psychosis.