At-risk mental state for psychosis in help-seeking young people: an investigation into underlying affective and interpersonal risk factors
Semedo, Daniela Sofia De Freitas
Background: Considering recent advances in the field of early detection and intervention in young people with increased levels of psychotic symptoms seeking help, this thesis proposes that early attachment insecurity triggers an inability to regulate emotional distress, to engage in positive interpersonal interactions with others, to use adaptive coping mechanisms and to manage social support appropriately. These constructs appear to be linked to psychosis; however, considering continuity between subthreshold psychotic symptoms and the later development of psychosis, it is vital to understand if these underlying affective and interpersonal mechanisms increase the risk of psychosis in help-seeking young people. Objectives: This study was cross-sectional and investigated the following research questions: 1) Does attachment insecurity signpost the risk of developing psychosis? 2) Do coping strategies, interpersonal difficulties, social support and emotional distress have an indirect effect on the relationship between attachment insecurity and the risk of developing psychosis? Methods: A total of 76 help-seeking young people were recruited from Community Mental Health Services in Edinburgh. All participants completed a number of questionnaires exploring their coping strategies, interpersonal problems, perceived social support and emotional distress. A semi-structured interview was undertaken, to assess their socio-demographic background. The Comprehensive Assessment of At-Risk Mental States was administered and coded to assess their risk of psychosis and associated psychopathology, while path analysis was used to analyse the data and to address the research questions. Results: The profile of help-seeking young people in this sample (n=76) was made up of individuals with a moderate degree of difficulties in relation to coping strategies employed to manage stress and interpersonal problems dealing with others, moderate levels of emotional distress and discrepancies between their ideal and received social support. From the total help-seeking sample, the attachment dimensions anxiety and avoidance were relatively high. These young people were found to have had mild, psychotic-like experiences, especially in the domains associated with unusual thought content and perceptual abnormalities. When considering the subgroup of help-seeking young people with an at-risk mental state (ARMS) (n=46), the results revealed that this group had high levels of difficulties in interpersonal relationships, relied on non-productive coping strategies, presented emotional distress levels of clinical importance and also had discrepancies in their ideal and received social support. From the subsample of help-seeking young people with an ARMS the attachment dimensions anxiety and avoidance were reasonably high. These young people were found to have had moderately severe psychotic experiences, especially in the domains associated with unusual thought content and perceptual abnormalities. Path analysis revealed that attachment insecurity directly predicted psychotic symptoms in the total sample but not in the subgroup of young people with an ARMS. Emotional distress played a partially moderating role between attachment insecurity and the severity and distress associated with disorganised speech and perceptual abnormalities in the total sample but not when considering only those with an ARMS, while interpersonal problems did not mediate the relationship between attachment insecurity and the risk of psychosis in either group. Discrepancies between ideal and received social support fully mediated the relationship between attachment insecurity and the distress associated with disorganised speech in the total sample but not when considering those with an ARMS. The tendency to use less adaptive coping strategies was found to mediate directly the relationship between attachment anxiety and the distress associated with perceptual abnormalities in young people with an ARMS, albeit not in the total sample. Discussion: The clinical and theoretical implications of these results are discussed within the clinical staging model for intervention in psychosis. The findings strongly indicate that clinicians should take into consideration the mechanisms of attachment, coping strategies and social support, as well as the deleterious effects of associated emotional distress, when working with young people with increased levels of psychotic symptoms.