and paranoia were mediated (partially in the case of at-

tachment anxiety, fully in the case of attachment avoid-

ance) by negative self-esteem. These ﬁ ndings are

consistent with evidence that negative self-esteem

plays an important role in paranoid beliefs (Freeman

& Garety, 2003 ; Freeman et al. 2005 ; Pickering et al.

2008 ; Bentall, 2009 ), and suggest that these beliefs are

associated with schematic representations, not only of

others as untrustworthy, but of the self as unlovable.

It is not clear from these data how these schemas

unfold developmentally although, as noted above,

we have hypothesized that they are promoted by

attachment-disrupting events in childhood such as

being raised in an institution or being neglected.

There are some important limitations to this study

that we would like to acknowledge. First, the present

analysis used cross-sectional data and direction of

causality cannot be tested using the statistical models

we have employed. Complete backward causation

seems unlikely, however, as previous research suggests

that indices of many of the mechanisms we have inves-

tigated predate the onset of psychosis. As already

noted, in our previous research we have shown that

attachment-disrupting events in childhood predict

paranoid symptoms but not hallucinations in adult-

hood (Bentall et al. 2012 ; Sitko et al. 2014 ). Other

researchers have reported associations between other

childhood markers of disrupted attachment, for exam-

ple being unwanted at childbirth (Myhrman et al. 1996 )

or early separation from parents (Morgan et al. 2007 )

and future psychosis, although speci ﬁ city for paranoia

was not tested in these studies. Longitudinal research

has also shown that low self-esteem is predictive of in-

cident psychotic symptoms in a general population

sample (Krabbendam et al. 2002 ), although speci ﬁ city

for paranoia was again not tested. However, we cannot

completely exclude the possibility of some backward

causation, as a diagnosis of schizophrenia may give

rise to negative self-esteem (perhaps linked to social

and self-stigma) and this may in turn affect the way

that individuals think about their attachments to

others. Future studies might attempt more robust

tests of causality, for example by conducting appropri-

ately sophisticated analyses on longitudinal datasets,

and also by exploiting ‘ natural experiments ’ such as

prospective studies of children who have been reared

in adverse circumstances.

A further limitation is that our measure of hallucina-

tions, the PANSS, measured only current hallucinatory

experiences and it is possible that some association

with hallucinations might have been found over a

longer time period. However, as noted above, when

speci ﬁ city has been tested, attachment-disrupting

events in childhood have not been associated with hal-

lucinations in adults and, moreover, Pickering et al.

( 2008 ) did not ﬁ nd an association between insecure

attachment and a trait measure of hallucination-

proneness in a large non-clinical sample, although an

association with paranoia was found. The variance in

the PANSS scores was low in the control group,

which must be considered when looking at the regres-

sions found with this sample. However, signi ﬁ cant

results were obtained when using the PaDS. This

needs consideration for future research. A ﬁ nal limi-

tation that needs to be addressed by further research

is the use of the four-item RQ to derive attachment

dimensions. The measure, although routinely used by

researchers to assess attachment styles, may be insuf ﬁ -

cient to address the complexities and progression of at-

tachment in adulthood. In future research it may be

appropriate to use other measures of insecure attach-

ment. In particular, we note that the RQ measure of

fearful attachment does not re ﬂ ect the concept of disor-

ganized attachment as assessed by interview measures

such as the Adult Attachment Interview.

The likely role of attachment processes in paranoid

delusions has important clinical implications. If this

study is supported by future research, consideration

might be given to how to protect young people who

are exposed to attachment-threating experiences, for

example children raised in children ’ s homes. It may

also be bene ﬁ cial to adapt cognitive – behavioural

therapy to address attachment-related cognitions

speci ﬁ cally, especially when working with paranoid

patients. It seems important for clinicians to be aware

of their own attachment styles and how their interper-

sonal interactions are affected by them, as evidence

from the broader literature suggests that early ratings

of the therapeutic alliance are higher when therapist

and client do not share the same insecure styles (see

Marmarosh et al. 2014 ). Owen et al .( 2013 ) hav e discussed

the need for clinicians to vary their therapeutic

approaches based on their patients ’ attachment styles

and future research might address whether this leads

to more personalized interventions of increased effec-

tiveness. For these reasons, there may be important clini-

cal advantages to be gained from assessing attachment

styles within the therapeutic setting and considering tar-

geted psychological interventions based on patients ’

internal working models of themselves and of others.

Acknowledgements

We would like to acknowledge the help of Professor

Tony Morrison, Dr Rosie Beck, Ms Suzanne

Heffernine and Dr Heather Laws, who kindly pro-

vided us with data from their National Institute for

Health Research-funded programme of research on

subjective judgements of perceived recovery from

psychosis.