EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 2021, VOL. 12, 1888539 https://doi.org/10.1080/20008198.2021.1888539 BASIC RESEARCH ARTICLE Dissociation and insecure attachment as mediators of the relation between childhood emotional abuse and nonclinical paranoid traits Yoki Linn Mertens a, Anna Racioppi b , Tamara Sheinbaum c , Thomas Kwapil d,e and Neus Barrantes-Vidal b,f,g a Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands; bDepartament de Psicologia Clínica i de la Salut, Universitat Autònoma de Barcelona (Edifici B), Barcelona, Spain; cDepartment of Psychology, University of Southern California, Los Angeles, CA, USA; dDepartment of Psychology, University of Illinois at Urbana-Champaign, Champaign, IL, USA; eDepartment of Clinical Psychology, University of North Carolina at Greensboro, Greensboro, NC, USA; fDepartament de Salut Mental, Sant Pere Claver – Fundació Sanitària, Barcelona, Spain; gCenter for Biomedical Research in Mental Health (CIBERSAM), Madrid, Spain ABSTRACT ARTICLE HISTORY Background: Research suggests dissociation and insecure attachment serve as explanatory Received 12 May 2020 mechanisms in the pathway from childhood trauma to paranoia. However, past work has Revised 11 January 2021 not examined these mechanisms concurrently in nonclinical populations. Accepted 29 January 2021 Objective: The current study sought to examine dissociation and insecure attachment as KEYWORDS parallel mediators of the association between childhood emotional abuse and paranoid Paranoia; dissociation; traits. Furthermore, a serial mediation model with insecure attachment preceding dissocia­ attachment style; childhood tion in the explanatory pathway was explored. trauma; schizotypy Methods: Eighty-nine nonclinically ascertained young adults were assessed for childhood emotional abuse, dissociation, attachment styles, and paranoid traits. Parallel and serial PALABRAS CLAVE mediation models were tested. Paranoia; Disociación; Estilo Results: The association of childhood emotional abuse with both interview-based and self- de apego; trauma infantil; Esquizotipia reported paranoid traits was significantly mediated by dissociation and preoccupied attach­ ment. Fearful attachment was a significant mediator in the model for self-reported paranoid 关键词 traits. No evidence for a serial mediation effect was found. 偏执; 解离; 依恋风格; 童 Conclusions: The present findings extend support for dissociation and attachment insecur­ 年期创伤; 精神分裂症 ity as mechanisms underlying the link between childhood emotional maltreatment and paranoid traits. Longitudinal research is needed to inform whether insecure attachment HIGHLIGHTS contributes to dissociation along the pathways to paranoid traits. • Dissociation and insecure attachment mediate the effect of childhood Disociación y apego inseguro como mediadores de la relación entre emotional abuse on paranoid traits. abuso emocional infantil y rasgos paranoides en población no clínica • Research on etiological Antecedentes: La investigación sugiere que la disociación y el apego inseguro sirven como trajectories in nonclinical mecanismos explicativos en el camino del trauma infantil a la paranoia. Sin embargo, cohorts may offer valuable trabajos anteriores no han examinado estos mecanismos concurrentemente en poblaciones insights into the no clínicas. traumagenic model of paranoia. Objetivo: El estudio actual buscó examinar la disociación y el apego inseguro como mediadores paralelos de la asociación entre el abuso emocional infantil y los rasgos para­ noides. Además, se exploró un modelo de mediación en serie con apego inseguro como precedente de la disociación en la vía explicativa. Métodos: Ochenta y nueve adultos jóvenes no evaluados clínicamente fueron medidos en cuanto a abuso emocional infantil, disociación, estilos de apego y rasgos paranoides. Se probaron modelos de mediación en paralelo y en serie. Resultados: La asociación del abuso emocional infantil con rasgos paranoides tanto basa­ dos en entrevistas como auto-reporte fue mediada significativamente por la disociación y el apego preocupado. El apego temeroso fue un mediador significativo en el modelo de rasgos paranoides auto-reportados. No se encontró evidencia de mediación en serie. Conclusiones: Los presentes hallazgos apoyan a la disociación y la inseguridad del apego como mecanismos subyacentes a la asociación entre el maltrato emocional infantil y los rasgos paranoides. Una investigación longitudinal sería necesaria para explorar si el apego inseguro contribuye a la disociación en la vía del desarrollo de los rasgos paranoides. 解离和不安全依恋作为童年期情感虐待与非临床偏执特质之间关系的中 介因子 背景: 研究表明, 解离和不安全依恋是从童年期创伤到偏执症的解释机制。但是, 以往的工 作并未在非临床人群中同时考查这些机制。 目的:本研究试图将解离和不安全依恋作为童年期情感虐待与偏执特质之间联系的平行中 介因子。此外, 探索了在解释路径中不安全依恋在解离之前的链式中介模型。 CONTACT Neus Barrantes-Vidal Neus.Barrantes@uab.cat Departament de Psicologia Clínica i de la Salut, Universitat Autònoma de Barcelona (Edifici B), 08193 Cerdanyola del Vallés, Barcelona, Catalonia, Spain © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 Y. L. MERTENS ET AL. 方法:评估了89名非临床明确的青壮年的童年期情感虐待, 解离, 依恋风格和偏执特质。考 查了平行和链式中介模型。 结果:童年期情感虐待与基于访谈和自我报告的偏执特质的相关由解离和先占型依恋显著 中介。恐惧型依恋是自我报告偏执特质模型的显著中介。未发现链式中介效应的证据。 结论:本研究结果支持解离和依恋不安全感作为童年期情感虐待与偏执特质之间联系的机 制基础。需要进行纵向研究, 以了解不安全依恋是否会导致解离与偏执特质一起。 Traumatic stress in childhood provides a risk factor for interpersonal threat and hypersensitivity towards rejec­ both the occurrence and persistence of psychotic experi­ tion (Lorenzini & Fonagy, 2013; Mikulincer & Shaver, ences in adolescence and adulthood (Van Os, Kenis, & 2008, 2019). Fearful attachment is characterized by Rutten, 2010; Van Os & Reininghaus, 2016). Extensive a combination of both hyperactivating (approach) and research has found increased developmental risk for psy­ deactivating (avoid) strategies. Due to the inconsistent chosis when childhood adversity is reported, even when attachment strategies employed, fearful attachment has controlling for family history of mental illness or sub­ been suggested as a proxy adult measure of disorganized stance abuse (Read, Van Os, Morrison, & Ross, 2005; attachment in childhood (e.g. Simpson & Rholes, 2002). Varese et al., 2012). In addition, findings indicate a dose- Fearful attachment is the most prevalent style in clinical response relationship that holds across the psychosis psychosis (Carr, Hardy, & Fornells-Ambrojo, 2018) and spectrum from subclinical schizotypy (Velikonja, Fisher, has been proposed as a precursor to psychotic phenom­ Mason, & Johnson, 2015) to schizophrenia (Matheson, ena among individuals exposed to maltreatment Shepherd, Pinchbeck, Laurens, & Carr, 2013). For exam­ (Sheinbaum, Kwapil, & Barrantes-Vidal, 2014). ple, a prospective study revealed exponential increases of Research has identified specific associations between psychotic symptoms aligned with mild, moderate, and insecure attachment styles and schizophrenia-spectrum severe childhood abuse (Janssen et al., 2004). Altogether, traits. Preoccupied attachment was associated with posi­ the findings highlight the necessity for careful and sever­ tive schizotypy, characterized by unusual perceptual ity-based trauma assessment in psychosis risk research. experiences, odd beliefs, and negative affect. Dismissing Trauma can predispose people to risk for a wide attachment was associated with negative schizotypy, variety of psychopathology and not every person which includes affective flattening, avolition, and asoci­ experiencing abuse or neglect in childhood develops ality. Fearful attachment was associated with both posi­ psychotic psychopathology. Various researchers have tive and negative schizotypy (Sheinbaum, Bedoya, Ros- suggested different psychobiological mechanisms that Morente, Kwapil, & Barrantes-Vidal, 2013) and mediated help explain when and how childhood adversity the link of physical/emotional childhood trauma with increases the risk of reality distortion (Bentall et al., positive and negative schizotypy, paranoid beliefs, and 2014; Debbané et al., 2016; Read et al., 2005). In psychotic-like experiences (Sheinbaum et al., 2014). particular, two explanatory pathways shed light on Overall, there is robust evidence for associations between the risk for psychotic phenomena following child­ insecure (anxious) attachment and paranoia even when hood adversity exposure: Attachment insecurity and controlling for potential confounders such as self-esteem dissociation (Berry, Bucci, & Varese, 2019). or illness severity (Lavin, Bucci, Varese, & Berry, 2020; Murphy, Goodall, & Woodrow, 2020). Studies focused on specific adversity subtypes in non­ 1.1. Pathway 1: attachment insecurity clinical samples have also supported attachment insecur­ Attachment insecurity is an umbrella term that reflects ity as an explanatory mechanism, particularly in relation disruptions in the ways individuals relate to significant to emotional abuse. In an interview study, angry- others and is generally conceptualized in terms of indivi­ dismissive and/or preoccupied/enmeshed attachment dual differences in attachment anxiety and avoidance were mediators of associations of two forms of poor (Mikulincer & Shaver, 2019). Along the dimensions of childhood care, namely parental antipathy (which over­ self and others, four attachment styles have been identi­ laps with emotional abuse) and role reversal, with sub­ fied in adulthood (Bartholomew & Horowitz, 1991): clinical psychosis-spectrum phenomenology, including secure (positive self/positive other), dismissing (positive paranoid traits (Sheinbaum et al., 2015). Another study self/negative other), preoccupied (negative self/positive focusing on the link between emotional abuse and schi­ other), and fearful (negative self/negative other). zotypy found significant mediation via attachment anxi­ Dismissing attachment is characterized by deactivating ety and avoidance (Goodall, Rush, Grünwald, Darling, & affect-regulation strategies to avoid interpersonal engage­ Tiliopoulos, 2015). However, an important limitation of ment including reduced emotional reactivity and expres­ this study is that it tested schizotypy as a unidimensional siveness (Mikulincer & Shaver, 2008). Preoccupied construct despite evidence indicating that positive and attachment is characterized by hyperactivating affect- negative schizotypy are two interrelated, but distinct regulation strategies including hypervigilance to dimensions (Barrantes-Vidal et al., 2013; Kwapil & EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 3 Barrantes-Vidal, 2015) differentially associated with inse­ auditory verbal hallucinations. Nonetheless, the scar­ cure attachment patterns (Sheinbaum et al., 2013). city of research on other psychotic symptoms such as paranoid traits precludes fully answering the extent to which psychosis is indeed ‘traumatic in origin and 1.2. Pathway 2: dissociation dissociative in kind’ (Moskowitz, Read, Farrelly, There is growing emphasis on the role of dissociative Rudegeair, & Williams, 2009, p. 521). experiences in the aetiology of psychosis (Moskowitz, Dorahy, & Schäfer, 2019). Dissociation is a multi- 1.3. The two-pathway model faceted phenomenon broadly defined as a disruption of ‘normal integration of consciousness, memory, identity, In alignment with the differential mediation patterns emotion, perception, body representation, motor control, found for attachment insecurity and dissociation, and behavior’ (American Psychiatric Association, 2013, Bentall and colleagues (Bentall et al., 2014) offered p. 291). Dissociative experiences appear in nonclinical an explanatory model in which specific psychotic populations (Kate, Hopwood, & Jamieson, 2020) and experiences correspond with specific psychological a wide range of psychiatric disorders (Lyssenko et al., underpinnings and childhood exposures. The authors 2018). Symptoms include absorption (i.e. daydreaming), postulated two distinct pathways. First, early relation­ amnesia, and feeling detached from the self, (i.e. deperso­ ship disruptions, such as childhood neglect, foster nalization, often accompanied by disembodiment, insecure attachment styles leading to paranoia. decreased sense of agency, and emotional numbing) Secondly, severe forms of trauma, e.g. childhood sex­ and one’s surroundings (i.e. derealization, in which peo­ ual abuse, foster dissociative symptoms that increase ple, objects, or the external environment can appear the risk for auditory hallucinations. unreal) (Carlson & Putnam, 1993; Holmes et al., 2005). To provide empirical evidence for this model, Pearce At the most severe end of the spectrum, dissociative et al. (2017) tested dissociation and fearful attachment as patients can report identity confusion (e.g. presence of parallel mediators between childhood trauma and para­ distinct dissociative self-states), likely related to chronic noia and hearing voices, respectively. Dissociation and childhood abuse (Nijenhuis, Van Der Hart, & Steele, fearful attachment were significantly correlated with 2010). moderate association strength in their sample. In keeping In light of the commonality of reality disturbances with former findings (Pilton et al., 2015; Sheinbaum et al., and feelings of detachment shared by the symptom 2014), they found that dissociation mediated the associa­ patterns of psychosis and dissociation, it is not sur­ tion of childhood trauma with hearing voices and that prising that dissociation is – while distinguishable – fearful attachment mediated the association of childhood strongly associated with schizophrenia-spectrum dis­ trauma with paranoia. To the authors’ surprise, dissocia­ orders (for a review, see Renard et al., 2017). The tion also mediated the link between childhood trauma available data also suggest that dissociation in schizo­ and paranoia, while accounting for the variance phrenia-spectrum disorders is more strongly related explained by fearful attachment. This finding suggests to childhood trauma compared to adult trauma that the role of dissociation as a mechanism is not (Rafiq, Campodonico, & Varese, 2018; Renard et al., restricted to hallucinatory symptoms, but might also be 2017). In particular, clinical research found robust relevant in the aetiology of paranoia (Pearce et al., 2017). associations between childhood emotional abuse and One limitation of this study is the sole use of online self- dissociation in both psychotic (Braehler et al., 2013; report measures. Furthermore, the assessment of child­ Schäfer et al., 2006) and general psychiatric popula­ hood trauma was based on only nine items of the Brief tions (Mueller-Pfeiffer et al., 2013). Betrayal Trauma Survey, which does not allow to distin­ So far, most psychosis research has focused on disso­ guish between specific childhood trauma types. This is ciation in the context of auditory verbal hallucinations. relevant because increased attention to specificity has There is growing evidence that dissociative experiences been considered an important step towards elucidating are a relevant mechanism in hearing voices (Pilton, underlying mechanisms (e.g. Bentall & Fernyhough, Varese, Berry, & Bucci, 2015) and mediate the link 2008). between childhood trauma and hallucination proneness The conceptualization of attachment insecurity and in clinical (Perona-Garcelán et al., 2012) and nonclinical dissociation as distinct mediators that do not causally populations (Cole, Newman-Taylor, & Kennedy, 2016). influence each other may not adequately reflect the reality By contrast, its impact on paranoid traits has been less of the complex aetiological patterns. For example, it has well-established. The two latter mediation studies showed been proposed that trauma, attachment disorganization, inconsistent results in which significant mediation via and dissociation are ‘inextricably intertwined, like three dissociation was only found for subclinical delusional threads woven into a single strand’ (Liotti, 2004, p. 14) ideation (Cole et al., 2016; Perona-Garcelán et al., 2012). and that disorganized attachment might precede disso­ In sum, there is substantial evidence for an asso­ ciation in the development of psychotic experiences ciation between childhood trauma, dissociation, and (Berry & Bucci, 2016). To our knowledge, previous 4 Y. L. MERTENS ET AL. studies have not examined attachment insecurity as Autònoma de Barcelona recruited via the university a mediator between childhood trauma and dissociative participation system, who participated in an ongoing experiences within the traumagenic model of paranoia. longitudinal research investigating vulnerability and However, it is relevant to note that longitudinal research protective factors for psychotic experiences. As with at-risk low-income families showed that disorga­ described in Barrantes-Vidal et al. (2013), 589 unse­ nized attachment, as coded from young adult-parent lected participants were recruited in the first phase interactions (e.g. out-of-context conflict behaviour), (T1) of the study, of which 547 (mean (M) age = 20.6, mediated the relationship between childhood abuse and SD = 4.1; 86% female) provided usable screening data. dissociation (Byun, Brumariu, & Lyons-Ruth, 2016). Three follow-up assessments were conducted (T2, T3, Furthermore, a recent study with psychiatric patients T4). The T2 reassessment took place 1.7 years found that attachment anxiety, and not avoidance, fully (SD = 0.2 years, range 1.4 to 2.2 years) after the baseline mediated the effect of emotional abuse on dissociation assessment. At T2, a selected subsample of 214 partici­ (Kong, Kang, Oh, & Kim, 2018). On the basis of these pants (M = 21.4 years, SD = 2.4; 78% female) completed findings, it is conceivable that early exposure to emotional an extensive laboratory, interview, and experimental abuse (i.e. threatening, insulting, or showing hostility protocol; 123 participants had standard scores above towards the child) increases the risk for dissociative 1.0 and 91 participants below 1.0 on schizotypy dimen­ experiences through its internalization into a sensitized sions. At T3, a further selected subsample of 104 parti­ stress system and insecure attachment strategies. cipants (M = 23.1, SD = 2.6; 62.1% female) completed the reassessment. At T4, the current 89 participants (M = 24.8 years, SD = 2.7; 61.8% female) were assessed, 1.4. Study aims of which 66 had elevated schizotypy scores and 23 had The current study’s aims were twofold: First, to examine standard scores below 1.0. Participants with high schi­ whether dissociation and attachment insecurity act as zotypy scores were oversampled to ensure enough var­ parallel mediators between childhood maltreatment and iance given the nonclinical nature of the sample; yet, the self-reported and interview-assessed paranoid traits in overall sample contained a wide distribution of scores. a nonclinical cohort of young adults. In keeping with The mean interval between T2 and T4 was 2.7 years prior work (Goodall et al., 2015; Sheinbaum et al., (SD = 0.2, range 2.3 to 3.4 years) and between T1 and T4 2015), this study focused specifically on emotional 4.4 years (SD = 0.3 years, range 4.0 to 5.2 years). The abuse. Emotional abuse is an often overlooked but highly current sample was predominantly Western European prevalent and detrimental form of abuse (Spinazzola (94.4% Spanish). At T4, the majority was in et al., 2014; Stoltenborgh, Bakermans-Kranenburg, a relationship (58.4%) or married (5.6%) and 36.0% of Alink, & Van Ijzendoorn, 2012) and may be of particular the sample was single. relevance to psychosis vulnerability in samples in which sexual and physical abuse are less prevalent (Goodall 2.2. Procedure et al., 2015). Furthermore, emotional abuse shows robust associations with dissociation (Braehler et al., 2013; Participants completed self-report measures at T1 and Mueller-Pfeiffer et al., 2013; Rafiq et al., 2018; Schäfer later undertook an extensive interview and questionnaire et al., 2006) and insecure attachment (Oshri, Sutton, battery at each subsequent data wave. Childhood trauma Clay-Warner, & Miller, 2015; Riggs, 2010). The second was assessed at T2, the other measures of attachment aim was to explore a serial mediation model testing style, dissociation, and paranoid traits were assessed at whether insecure attachment precedes dissociative T4. The interviews were conducted by trained psycholo­ experiences in the pathway to paranoid traits. Three gists and advanced graduate students in clinical psychol­ hypotheses were tested. It was predicted that insecure ogy. The interviewers were unaware of participants’ attachment styles would significantly mediate the asso­ screening instruments’ scores and ratings were frequently ciation between emotional abuse and paranoid traits. discussed throughout the data collection period via con­ Furthermore, dissociation was hypothesized to signifi­ sensus meetings. All participants were over 18 years of cantly mediate the association between emotional abuse age at the initiation of the study and provided informed and paranoid traits. Ultimately, insecure attachment consent to participate at every stage of the study. The styles were expected to precede dissociation in a serial study was approved by the Ethics Committee of the mediation model of paranoid traits. Universitat Autònoma de Barcelona (Spain). 2.3. Time 2 measures 2. Methods 2.3.1. Childhood trauma 2.1. Participants Interpersonal abuse and neglect experiences in child­ The participants (N = 89) were drawn from a sample of hood were assessed via the structured Interview for undergraduate students from the Universitat Traumatic Events in Childhood (ITEC; Lobbestael, EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 5 Arntz, Harkema-Schouten, & Bernstein, 2009). of all items by 28. The questionnaire has excellent Participants answered a set of standardized questions internal consistency (Carlson & Putnam, 1993). concerning five types of childhood maltreatment including sexual abuse, physical abuse, emotional 2.4.3. Paranoid traits abuse, emotional neglect, and physical neglect. Based on research supporting dimensional models of para­ Severity scores of the ITEC are calculated based on noia (e.g. Bell & O’Driscoll, 2018; Costello, 1994; Freeman, a formula that includes parameters such as the age of 2006; Van Os & Verdoux, 2003), paranoia was conceptua­ onset, proximity to the perpetrator, and duration lized and measured as a continuum in which nonclinical (Lobbestael, Arntz, & Bernstein, 2010). In a mixed expressions (e.g. trait suspiciousness) are less severe but sample of nonclinical and clinical adults (N = 217), have continuity with clinical expressions (e.g. symptoms of the emotional abuse subscale showed high internal paranoid personality disorder and paranoia). Two mea­ consistency and satisfactory convergent validity sures were used. The self-reported paranoid trait of suspi­ (Lobbestael et al., 2009). ciousness was assessed with the 8-item Suspiciousness subscale of the Schizotypal Personality Questionnaire (SPQ), which has high internal consistency (Raine, 1991). 2.4. Time 4 Measures Interview-based paranoid traits and symptoms were 2.4.1. Attachment Style assessed with the Structured Clinical Interview for DSM- The Relationship Questionnaire (RQ; Bartholomew & IV Axis II Disorders (SCID-II; Gibbon, Spitzer, Williams, Horowitz, 1991) is a validated self-report measure to Benjamin, & First, 1997), which has demonstrated excel­ assess secure, dismissing, preoccupied, and fearful lent inter-rater reliability for paranoid personality disorder attachment styles. Participants rated (continuous) traits in clinical and non-clinical populations (Lobbestael, how much they agree with four statements reflecting Leurgans, & Arntz, 2011). The sum of the SCID-II para­ each attachment style on a Likert scale from 1 noid trait ratings produced a continuous score for each (‘totally disagree’) to 7 (‘totally agree’). They also participant. indicated which attachment style describes them best (categorical). As recommended by the authors, only the continuous scores were used for analysis. 2.5. Data analysis The RQ has adequate test-retest reliability (Scharfe The data were analysed with the IBM Statistical & Bartholomew, 1994) and has been frequently used Package for Social Sciences (SPSS, Version 22, IBM, in clinical and nonclinical populations (e.g. Pearce Armonk, NY). Descriptive and correlational analyses et al., 2017; Sheinbaum et al., 2014). including all variables were conducted. In order to test our hypotheses, a three-step approach 2.4.2. Dissociation was implemented using the PROCESS macro for SPSS The Dissociative Experiences Scale (DES-II; Carlson (Hayes, 2013): First, the three insecure attachment styles & Putnam, 1993) is a validated self-report screening (dismissing, preoccupied, and fearful attachment) were measure containing 28 items. Participants rate on entered as parallel mediators of the effect of emotional a percentage scale from 0% (=never) to 100% abuse on paranoid traits. Second, the significant attach­ (=always) how often they experience dissociative ment styles obtained in the previous step were tested symptoms along the dimensions of amnesia, deper­ individually as parallel mediators with dissociation in sonalization/derealization, and absorption. The total separate models for self-reported and interview-based dissociation scores were obtained by dividing the sum paranoid traits. These analyses comprised four parallel Table 1. Descriptive statistics (N = 89). n (%) Mean SD Min. Max. Skewness Kurtosis Childhood trauma (ITEC) 77 (86.5) 8.94 10.63 0.00 68.79 3.15 13.66 Sexual abuse 6 (6.7) 0.25 1.19 0.00 9.52 6.28 44.39 Physical abuse 20 (22.5) 1.24 3.51 0.00 25.46 4.66 26.92 Emotional abuse 67 (75.3) 4.45 4.44 0.00 22.58 1.88 5.18 Emotional neglect 23 (25.8) 1.36 2.66 0.00 12.40 2.18 4.64 Physical neglect 30 (33.7) 1.63 2.81 0.00 16.32 2.34 7.64 Dissociation (DES-II) 6.17 4.87 0.00 23.57 1.03 0.97 Attachment style (RQ) Secure 4.64 1.55 1.00 7.00 − 0.62 − 0.36 Dismissive 3.22 1.51 1.00 7.00 0.53 − 0.74 Preoccupied 2.44 1.43 1.00 7.00 0.88 0.09 Fearful 2.76 1.80 1.00 7.00 0.70 − 0.78 Self-reported paranoid traits (SPQ) 1.25 1.53 0.00 7.00 1.69 3.03 Interview-based paranoid traits (SCID-II) 1.65 2.30 0.00 12.00 1.99 4.58 RQ = Relationship Questionnaire; ITEC = Interview for Traumatic Experiences in Childhood; DES-II = Dissociative Experiences Scale; SPQ = Schizotypy Personality Questionnaire; SCID-II = Structured Clinical Interview for DSM-IV Axis II; SD = Standard Deviation. 6 Y. L. MERTENS ET AL. mediation analyses (PROCESS Model 4) testing dissocia­ lower compared to prior research conducted in tion and attachment styles as two explanatory pathways a similar cohort (Fonseca-Pedrero et al., 2014). Mean between emotional abuse and both measures of paranoid interview-based paranoid traits were comparable to pre­ traits, respectively. In comparison to multiple single med­ vious nonclinical research (Chun, Barrantes-Vidal, iator analyses, parallel mediation as introduced by Hayes Sheinbaum, & Kwapil, 2017). (2013) accounts for the variance explained by the other mediator and thus offers a more precise estimate of the specific indirect effects. The utility of exploring unique 3.1. Correlational analysis mechanistic pathways with the use of parallel mediation Correlation analysis (Table 2) indicated positive sig­ in psychosis research has been repeatedly demonstrated nificant correlations of emotional abuse with preoc­ (Pearce et al., 2017; Sheinbaum et al., 2014). cupied and fearful attachment, dissociation, and Third, an alternative model using serial indirect effects paranoid traits (self-reported and interview-based). (PROCESS Model 6) was explored. In contrast to parallel Dissociation showed significant positive associations mediation, serial multiple mediator models presume an with both self-reported and interview-based paranoid a priori causal relationship between the mediators. By traits. Dissociation also correlated negatively with entering insecure attachment styles as preceding media­ secure attachment, and positively with preoccupied tors to dissociation, it was possible to examine whether and fearful attachment, but not with the dismissing insecure attachment explained the effect of emotional style. Fearful and preoccupied attachment showed abuse on dissociation (Hayes & Rockwood, 2017) and positive correlations with paranoid traits while secure dissociation explained the effect of attachment on para­ attachment was negatively associated with all other noia. Statistical significance of the indirect effects was measures. Following Cohen (1992), correlations evaluated with the use of 95% bootstrapped bias- between dissociation and self-reported paranoid corrected confidence intervals (CI) with 10,000 draws. traits, emotional abuse and self-reported paranoid traits, preoccupied attachment and interview-based paranoid traits, as well as between both measures of 3. Results paranoid traits, were of a large magnitude. The asso­ Independent t-tests showed there were no significant sex ciations of fearful attachment with both paranoid differences on any of the investigated variables, emotional trait measures, as well as between emotional abuse, abuse t(87) = 0.30, p = .78; dissociation: t(87) = −0.91, dissociation, and interview-based paranoid traits, p = .36; self-reported paranoid traits: t(87) = 0.37, p = .71; were of a medium magnitude. Most other correla­ interview-based paranoid traits: t(87) = 1.51; p = .13; tions were of a small effect size. secure attachment: t(87) = 1.16, p = 1.34; dismissive attachment: t(87) = 1.07, p = .29; preoccupied attachment: 3.2. Mediation analyses t(87) = 0.77, p = .44; fearful attachment: t(87) = −0.72, p = .47. For the sake of completeness, all forms of child­ As recommended by Hayes (2013), parameter estima­ hood maltreatment were examined in the descriptive tion and interpretation are based on the unstandar­ analysis (see Table 1). Out of all participants, 86.5% dized (raw) coefficients. After entering all three (n = 77) indicated the experience of some form of child­ insecure attachment styles as parallel mediators in hood maltreatment. On average, participants reported the models for interview-assessed and self-reported experiencing dissociation 6.17% (SD = 4.87) of the time, paranoid traits, preoccupied and fearful attachment which is slightly above the cut-off (5.4) for the general significantly mediated the effect of emotional abuse population (Carlson & Putnam, 1993). Secure attach­ on both paranoid trait measures. The parameter esti­ ment had the highest mean average of all attachment mates of the indirect effects in the model for self- styles, followed by dismissing, fearful, and preoccupied reported paranoid traits were: b = 0.018; 95% CI attachment. Self-reported paranoid traits were slightly [0.002; 0.047]) for preoccupied, and b = 0.020; 95% Table 2. Correlational matrix. 1. 2. 3. 4. 5. 6. 7. 8. 1. Emotional abuse 2. Secure attachment −.18 3. Dismissive attachment .08 −.27* 4. Preoccupied attachment .24* −.29** −.02 5. Fearful attachment .26* −.47** .33** .09 6. Dissociation .31** −.23* .17 .21* .24* 7. Self-reported paranoid traits .50** −.26* .24* .33** .39** .53** 8. Interview-based paranoid traits .49** −.30** .15 .50** .33** .44** .59** Correlations of medium effect size are marked bold. Correlations of large effect size are marked bold and are italized. *Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the 0.01 level (2-tailed). EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 7 CI [0.001; 0.052]) for fearful attachment. The para­ reported and interview-based paranoid traits. Figure 1 meter estimates of the indirect effect in the model for displays the parallel mediation model estimating the interview-based paranoid traits were: b = 0.050; 95% indirect effect of emotional abuse on interview-based CI [0.011; 0.103]) for preoccupied and b = 0.025; 95% paranoid traits via preoccupied attachment and dissocia­ CI [0.001; 0.073]) for fearful attachment. The dis­ tion. All regression pathways were significant, indicating missing style was not a significant mediator of the that emotional abuse predicts dissociation (a1: b = 0.343, association of emotional abuse with self-reported 95% CI [0.121; 0.565], p = .03) and preoccupied attach­ (indirect effect: b = 0.004; 95% CI [−0.006; 0.048]) ment (a2: b = 0.077, 95% CI [0.010; 0.143], p = .03), which or interview-based paranoid traits (indirect effect: in turn predicted interview-based paranoid traits. When b = 0.003; 95% CI [−0.006; 0.041]). Thus, only pre­ entered as a parallel mediator alongside dissociation, occupied and fearful attachment were tested as par­ results indicated that fearful attachment was allel mediators alongside dissociation. a significant mediator between emotional abuse and self- reported paranoid traits (b = 0.019; 95% CI [0.003; 0.050]), but not interview-based paranoid traits 3.2.1. Attachment insecurity and dissociation as (b = 0.024; 95% CI [0.000; 0.075]). parallel mediators The results of the parallel mediation analyses can be found in Table 3 for preoccupied attachment and Table 3.2.2. Serial multiple mediation 4 for fearful attachment. Overall, the total, direct, and The results of the serial multiple mediator models can total indirect effects of each model were all significant be found in Table 5 for preoccupied and Table 6 for according to the bias-corrected bootstrapped 95% CI. fearful attachment. All four models revealed significant Dissociation was a significant mediator in the models total, direct, and overall indirect effects. However, none for both self-reported and interview-assessed paranoid of the models resulted in a significant serial mediation traits. Also, preoccupied attachment significantly effect. Neither fearful (b = 0.006; 95% CI [0.000; 0.024]) mediated the relation of emotional abuse with both self- nor preoccupied attachment (b = 0.050; 95% CI Table 3. Preoccupied attachment and dissociation as parallel mediators of the effect of emotional abuse on paranoid traits. 95% Bias-corrected Confidence Interval (CI) Raw parameter estimate Standard error Lower Upper Self-reported paranoid traits Total effect 0.171* 0.044 0.083 0.259 Direct effect 0.115* 0.039 0.038 0.192 Total indirect effect 0.056* 0.023 0.019 0.112 Indirect effect via dissociation 0.042* 0.020 0.010 0.091 Indirect effect via preoccupied attachment 0.014* 0.009 0.001 0.038 Interview-based paranoid traits Total effect 0.252* 0.076 0.101 0.403 Direct effect 0.164* 0.059 0.047 0.281 Total indirect effect 0.088* 0.038 0.027 0.179 Indirect effect via dissociation 0.043* 0.030 0.004 0.128 Indirect effect via preoccupied attachment 0.046* 0.021 0.011 0.098 Results are based on 10,000 bias-corrected bootstrap samples. *95% CI does not include zero. Table 4. Fearful attachment and dissociation as parallel mediators of the effect of emotional abuse on paranoid traits. 95% Bias-corrected Confidence Interval (CI) Raw parameter estimate Standard error Lower Upper Self-reported paranoid traits Total effect 0.171* 0.044 0.082 0.259 Direct effect 0.111* 0.037 0.038 0.184 Total indirect effect 0.060* 0.026 0.017 0.122 Indirect effect via dissociation 0.041* 0.020 0.011 0.093 Indirect effect via fearful attachment 0.019* 0.011 0.003 0.050 Interview-based paranoid traits Total effect 0.252* 0.076 0.102 0.403 Direct effect 0.182* 0.066 0.050 0.314 Total indirect effect 0.070* 0.043 0.010 0.189 Indirect effect via dissociation 0.047* 0.032 0.004 0.136 Indirect effect via fearful attachment 0.024 0.018 0.000 0.075 Results are based on 10,000 bias-corrected bootstrap samples. *95% CI does not include zero. 8 Y. L. MERTENS ET AL. M1 = Dissociation a1 = 0.343* (0.112) b1 = 0.125* (0.040) X= c’ = 0.164** (0.044) Y= Emotional Interview-based abuse Paranoid Traits a2 = 0.077* (0.034) b2 = 0.594** (0.134) M2 = Preoccupied Attachment Figure 1. Parallel mediation model. Note. X = independent variable; M1 = first mediator; M2 = second mediator; Y = dependent variable. Standard errors are reported in parenthesis.*p < .05; **p < .01. Table 5. Preoccupied attachment and dissociation as serial mediators of the effect of emotional abuse on paranoid traits. 95% Bias-corrected Confidence Interval (CI) Raw parameter estimate Standard error Lower Upper Self-reported paranoid traits Total effect 0.171* 0.044 0.083 0.259 Direct effect 0.115* 0.039 0.038 0.192 Total indirect effect 0.056* 0.023 0.019 0.114 Indirect effect via dissociation 0.038* 0.019 0.007 0.089 Indirect effect via preoccupied attachment 0.014* 0.009 0.001 0.038 Serial indirect effect 0.005 0.004 − 0.001 0.018 (EA → PREO → DIS → Self-reported Paranoid Traits) Interview-based paranoid traits Total effect 0.252* 0.076 0.101 0.403 Direct effect 0.164* 0.059 0.047 0.281 Total indirect effect 0.088* 0.038 0.026 0.180 Indirect effect via dissociation 0.038* 0.028 0.002 0.120 Indirect effect via preoccupied attachment 0.046* 0.021 0.010 0.096 Serial indirect effect 0.005 0.005 − 0.001 0.022 (EA → PREO → DIS → Interview-based Paranoid Traits) Results are based on 10,000 bias-corrected bootstrap samples (EA = Emotional Abuse; PREO = Preoccupied Attachment; DIS = Dissociation). *95% CI does not include zero. [−0.001; 0.018]) significantly predicted dissociation in were obtained for interview-based paranoid traits (fear­ the serial mediation model for self-reported paranoid ful: b = 0.007; 95% CI [0.000; 0.037]; preoccupied: traits (see example in Figure 2). Comparable results b = 0.005; 95% CI [−0.001; 0.023]). Table 6. Fearful attachment and dissociation as serial mediators of the effect of emotional abuse on paranoid traits. 95% Bias-corrected Confidence Interval (CI) Raw parameter estimate Standard error Lower Upper Self-reported paranoid traits Total effect 0.171* 0.044 0.083 0.259 Direct effect 0.111* 0.037 0.038 0.184 Total indirect effect 0.060* 0.027 0.015 0.049 Indirect effect via dissociation 0.035* 0.019 0.007 0.086 Indirect effect via fearful attachment 0.019* 0.011 0.002 0.049 Serial indirect effect 0.006 0.005 0.000 0.023 (EA → FEAR → DIS → Self-reported Paranoid Traits) Interview-based paranoid traits Total effect 0.252* 0.076 0.101 0.403 Direct effect 0.182* 0.066 0.050 0.314 Total indirect effect 0.070* 0.043 0.012 0.118 Indirect effect via dissociation 0.040* 0.028 0.004 0.121 Indirect effect via fearful attachment 0.024 0.018 0.000 0.077 Serial indirect effect 0.007 0.007 0.000 0.036 (EA → FEAR → DIS → Interview-based Paranoid Traits) Results are based on 10,000 bias-corrected bootstrap samples (EA = Emotional Abuse; FEAR = Fearful Attachment; DIS = Dissociation). *95% CI does not include zero. EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 9 M1 = d21= 0.458ns (0.284) M2 = Fearful Attachment Dissociation a1 = 0.106* (0.042) a2 = 0.295* (0.115) b2 = 0.178* (0.073) b1 = 0.120** (0.027) X= c’ = 0.111** (0.030) Y= Emotional Self-reported Abuse Paranoid Traits Figure 2. Serial multiple mediator model. Note. X = independent variable; M1 = first mediator; M2 = second mediator; Y = dependent variable. Standard errors are reported in parenthesis.*p < .05; **p < .01. 4. Discussion the aetiology of persecutory delusions (Kesting & Lincoln, 2013). It appears that even subtle paranoid The present study aimed to extend previous findings traits are related to the hyperactivation of attachment suggesting dissociation and attachment insecurity needs and the core belief that one is insufficient and serve as traumagenic pathways from childhood unwanted (Lorenzini & Fonagy, 2013; Sheinbaum adversity to paranoid traits in adulthood. In order et al., 2015). to overcome previous methodological shortcomings, The empirical findings correspond with theories that interview-based measures for childhood trauma and experiences of (interpersonal) childhood adversity can paranoid traits were used. Additionally, an alternative result in a sensitized stress system (Rutten et al., 2013). model testing a serial mediation relationship between As a common feature in the model of latent vulnerability, attachment and dissociation was explored. Overall, the heightened stress reactivity in trauma-exposed indi­ results support dissociation as an explanatory link viduals increases susceptibility to daily life and interper­ between emotional abuse and paranoid traits. When sonal stressors (McCrory, Gerin, & Viding, 2017). comparing all insecure attachment styles, only styles Specifically, insecure attachment styles containing the high in attachment anxiety (preoccupied and fearful) hyperactivation of attachment needs (fearful and preoc­ were significant mediators. When examined simulta­ cupied attachment) appear to aggravate vigilance towards neously with dissociation, preoccupied attachment, threat cues (Mikulincer & Shaver, 2019). As a conse­ not fearful attachment, was the most robust mediator. quence, these trajectories may amplify the risk for psy­ Meanwhile, the current findings did not support the chotic experiences, including paranoid traits (Sheinbaum hypothesis that insecure attachment and dissociation et al., 2015, 2014). are linked in serial in the pathway to nonclinical The second main finding of this study was that dis­ paranoid traits. sociation significantly mediated the effect of emotional At first glance, the pathway from emotional abuse abuse on both paranoid trait measures even when to paranoid traits via preoccupied attachment may accounting for insecure attachment styles. Combined appear odd considering that preoccupied people with the clinical evidence of Pearce and colleagues tend to have negative self-schema, but positive views (Pearce et al., 2017), the results support the notion of an of others (Bartholomew & Horowitz, 1991). However, explanatory pathway from childhood trauma to paranoid an association between preoccupied attachment and traits via dissociation in the extended psychosis pheno­ paranoid traits has been reported in nonclinical type (Van Os & Reininghaus, 2016). But how exactly (Ciocca et al., 2017; Sheinbaum et al., 2015) and could dissociative experiences contribute to the develop­ clinical cohorts (Ponizovsky, Vitenberg, Baumgarten- ment of paranoia? One possibility relates to the strong Katz, & Grinshpoon, 2013). A relevant model for resemblance of nonclinical dissociation and basic symp­ understanding this finding is that of Trower and toms in the prodromal phase of psychosis. Basic symp­ Chadwick (1995) that posits the existence of two toms contain perceptual anomalies triggered by everyday types of paranoia. The first type is ‘poor me’ para­ situations, for instance ‘decreased emotional and gestalt noia, in which the perceived hostility is undeserved. connection with the environment’ (Schultze-Lutter, In contrast, individuals with the second type, called 2009, p. 7). Furthermore, both dissociative and basic ‘bad me’ paranoia, blame themselves for the persecu­ symptoms fall within the boundaries of positive schizo­ tion. Congruent with the ‘bad me’ paranoia type, typy. The main difference between these anomalous there is substantial research emphasizing the crucial experiences and full-blown psychosis is that the indivi­ role of low self-esteem and negative self-schemas in dual immediately recognizes them as subjective sensory 10 Y. L. MERTENS ET AL. disturbances, instead of externally attributing them to support such a serial mediation model. Meanwhile, someone or something else taking control over mind prior research found that fearful attachment uniquely and body. According to Sass and Parnas (2003), these predicted dissociation in undergraduate females subtle forms of reality disturbance reflect the psychosis (Sandberg, 2010) and that insecure attachment mediated prodrome defined by a ‘loss of inhabiting one’s own the association of abuse with dissociation in clinical and actions, thoughts, feelings, impulses, bodily sensations, at-risk cohorts (Byun et al., 2016; Kong et al., 2018). With or perceptions’, called diminished self-affection (Sass & respect to the inconsistent results, and considering that Parnas, 2003, p. 431). the current marginally insignificant estimates may be due This corresponds with Morrison, Frame, and Larkin to insufficient statistical power, more research is war­ (2003) who argue that psychosis might be related to post- ranted to elucidate the (potentially reciprocal) relation­ traumatic intrusions following traumatic experiences. In ship of insecure attachment styles and dissociation in consequence, it is suggested that what the world regards psychosis. as ‘being psychotic’ might actually reflect for some Some limitations of this study should be acknowl­ patients a culturally inappropriate interpretation of post- edged. First, it could be argued that the current sample traumatic intrusions. The model states that dissociation size (N = 89) is not sufficiently large in light of multiple and paranoia, e.g. elevated suspiciousness about other’s statistical analyses including different predictors and trustworthiness, could function as (maladaptive) coping dependent variables. However, we limited the study to strategies to avoid further abusive experiences and cope a narrow range of a priori hypotheses, and the current with distressing intrusions. In other words, dissociation results may provide unique information considering the may play an ambivalent role in the face of adversity. On extensive interview-based assessment of childhood the one hand, it serves a protective function in allowing trauma and paranoid traits. Considering the established the maltreated child to maintain physical proximity to the dose-response relationship between childhood adversity caregiver offering food and security while also dissociat­ and psychosis risk, it was crucial that the severity of early ing from the abusive behaviour of the caregiver (Debbané traumatic material was carefully assessed based on para­ et al., 2016). On the other hand, one might speculate that meters such as frequency and duration. Nevertheless, dissociation, potentially fostering a sense of isolation replication studies with larger samples are clearly needed. (Morrison et al., 2003) and diminished self-affection Second, the results appeared to represent relatively small (Sass & Parnas, 2003), also increases feelings of paranoia. effects and should be interpreted with caution. Still, it is Bentall et al. (2014) proposed that dissociation as worth noting that significant effects were detected in a response to severe trauma (e.g. sexual abuse) is primar­ a highly protected sample of nonclinical psychology ily related to hallucinations, whereas paranoia may arise undergraduates. Third, due to the lack of longitudinal from insecure attachment originated in childhood data or experimental manipulation on current sympto­ neglect. Although a certain degree of aetiological specifi­ matology, no statement about causality can be made with city might seem parsimonious (Bentall et al., 2014), our regards to dissociation, attachment styles, and paranoid results together with those of prior studies (Cole et al., traits. For example, theoretical and empirical literature 2016; Pearce et al., 2017) suggest that other types of suggested a causal relationship between insecure attach­ childhood maltreatment might also confer risk for dis­ ment and dissociation, but the reverse may also be the sociative experiences and insecure attachment styles in case. Therefore, future path model analyses should the context of psychosis. Moreover, both factors, not only account for the possibility that dissociative experiences attachment insecurity, seem to facilitate the development (e.g. feelings of detachment) might reinforce insecure of paranoid experiences. Alternatively, Berry and Bucci attachment behaviour. Fourth, the current models do (2016) have introduced a cognitive attachment model of not account for depressive symptoms as a potentially hearing voices, in which emotional abuse internalized as confounding factor despite the fact that prior research disorganized attachment is a precursor of dissociated self- has established meaningful associations of depression states. Combined with source-monitoring deficits, disso­ with dissociation (Sar, Akyüz, Öztürk, & Alioğlu, 2013), ciation is proposed to reinforce the vicious cycle from attachment insecurity (Roberts, Gotlib, & Kassel, 1996), hearing voices to maladaptive appraisals and dysfunc­ and paranoia (Freeman & Garety, 2014). Fifth, the pre­ tional coping of the auditory hallucinations. Arguably, sent sample consisted a of predominantly female and a modified model for paranoia, including interactions Caucasian cohort which might impede generalization of between maladaptive appraisals (e.g. of interpersonal our findings to male populations and other ethnic back­ ambiguity) and coping strategies (e.g. self-to-blame cop­ grounds (Iacovino, Jackson, & Oltmanns, 2014). At last, ing responses) may present similar trauma-attachment a challenging issue in the study of trauma in relation to anxiety-dissociation trajectories. paranoid traits is to what extent some of the traits defin­ It was further speculated that insecure attachment ing paranoid personality might be actually tapping precedes dissociative experiences as a coping response trauma-based mistrust. Although this fact per se would to elevated interpersonal stressors related to insecure not make the causal contribution invalid, it would make it attachment. 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