Attachment, Neurobiology, and Mentalizing along the Psychosis Continuum

Abstract

In this review article, we outline the evidence linking attachment adversity to psychosis, from the premorbid stages of the disorder to its clinical forms. To better understand the neurobiological mechanisms through which insecure attachment may contribute to psychosis, we identify at least five neurobiological pathways linking attachment to risk for developing psychosis. Besides its well documented influence on the hypothalamic-pituary-adrenal (HPA) axis, insecure attachment may also contribute to neurodevelopmental risk through the dopaminergic and oxytonergic systems, as well as bear influence on neuroinflammation and oxidative stress responses. We further consider the neuroscientific and behavioral studies that underpin mentalization as a suite of processes potentially moderating the risk to transition to psychotic disorders. In particular, mentalization may help the individual compensate for endophenotypical impairments in the integration of sensory and metacognitive information. We propose a model where embodied mentalization would lie at the core of a protective, resilience response mitigating the adverse and potentially pathological influence of the neurodevelopmental cascade of risk for psychosis.

Keywords: HPA; UHR; mentalizing; schizophrenia; schizotypy; self; theory of mind.

Figure 1

The clinical developmental course of psychotic disorders, across the first two phases indicating increased vulnerability, and the last two phases charting the onset and development of the disorder. FEP, First-Episode Psychosis; ND, Neurodevelopment; Env, Environmental.

Figure 2

Illustration of the five neurobiological pathways (red arrows) through which attachment adversity (both during childhood and adolescence) may augment risk for psychosis. Dotted arrows represent potential interactions between pathways.

Figure 3

Illustration adapting Figure 2 to account for the interaction between sensory and beliefs priors influencing each other’s precision (certainty); at different levels of analysis, this relationship is foundational to embodied mentalizing, and may differentially sustain early trait vulnerability, and later state manifestations of psychosis.