Background: The relationship between attachment and paranoia is now well established. There is good theoretical reason and evidence to indicate that attachment style affects cognitive, affective, and behavioural processes which, in turn, contribute to the maintenance of paranoia, but this research has not been integrated. We critically and systematically review research that examines relevant cognitive, affective, and behavioural processes, which may explain how attachment insecurity leads to paranoia and constitute key targets in psychotherapeutic interventions for people with psychosis. Method: We conducted three systematic searches across six databases (PsycINFO, CINAHL, Medline, Web of Science, Embase, and Google Scholar), from inception to September 2021, to investigate key cognitive, affective, and behavioural processes in the attachment–paranoia association. Results: We identified a total of 1930 papers and critically reviewed 16. The literature suggests that negative self‐ and other‐beliefs, inability to defuse from unhelpful cognitions, and use of maladaptive emotion regulation strategies mediate the association between attachment insecurity and paranoia in people with psychosis/psychotic experience. Attachment‐secure people with psychosis are more likely to seek help and engage with services than attachment‐insecure people. Conclusions: Attachment styles impact help‐seeking behaviours in people with psychosis and are likely to influence paranoia via self‐ and other‐beliefs, cognition fusion, and emotion regulation – these candidate mechanisms may be targeted in psychological therapy to improve clinical outcomes for people with psychosis, characterized by paranoia. Practitioner points: Insecure attachment is likely to lead to paranoia via negative beliefs about self and others, cognitive fusion, and use of maladaptive emotion regulation strategies. These mechanisms can be targeted in psychotherapeutic interventions for psychosis, such as cognitive behaviour therapy, to improve clinical and recovery outcomes. People with psychosis who are attachment‐secure are more likely to seek help and engage with services than those who are attachment‐insecure (particularly avoidant). Attachment style can be assessed to predict service engagement and help‐seeking behaviours in people with psychosis. Attachment styles are important predictors of key cognitive, affective, and behavioural processes in people with psychosis. These processes can be assessed and incorporated into individualised formulations, and then targeted in therapy to effect psychotherapeutic change.

Objectives: Paranoia describes unfounded and distressing interpersonal threat beliefs. Secure attachment imagery has been shown to attenuate paranoia and anxiety in non‐clinical and clinical groups, but little is known about the differential effects of anxious and avoidant imagery or mechanisms of change. In this study, we tested the impact of secure, anxious, and avoidant attachment imagery on paranoia, anxiety, and help‐seeking intentions. We also examined hypothesized mechanisms of change, specifically whether cognitive fusion and negative self‐ and other‐beliefs mediate these relationships. Design: This study utilized an experimental, cross‐sectional design. Methods: A large ( N = 303), international general population sample with high levels of non‐clinical paranoia completed a series of measures before and after engaging in secure, anxious, or avoidant imagery. Results: Relative to anxious and avoidant attachment imagery, secure attachment imagery reduced paranoia and anxiety and increased help‐seeking intentions. Cognitive fusion and negative self‐ and other‐beliefs mediated the impact of attachment imagery on paranoia and anxiety, but not help‐seeking. Conclusions: In line with attachment and cognitive theory, secure attachment imagery is effective in reducing paranoia and anxiety and works by reducing cognitive fusion and negative self‐ and other‐beliefs. These novel findings suggest that the secure imagery task could be incorporated into cognitive and behavioural therapies to reduce distressing interpersonal threat beliefs and associated negative affect, and increase help‐seeking intentions. Practitioner points: When working with people experiencing paranoia, secure attachment imagery may be effective in reducing state paranoia and anxiety and improving help‐seeking intentions. Attachment imagery works by influencing beliefs about self and others, and the degree to which people are fused with their beliefs. In clinical practice, the rationale for the imagery task fits well with psychological models of paranoia and the secure imagery task can be introduced as a way to cope when struggling with distressing beliefs about self and others, and feeling overwhelmed by these fears.

Attachment security priming effects therapeutic change in people with depression and anxiety. Preliminary studies indicate that visualising secure attachment memories also reduces paranoia in non-clinical and clinical groups, probably due to a decrease in cognitive fusion. Benefits to clinical populations depend on the sustainability of these effects and the impact on help-seeking behaviours. The combination of paranoia and an insecure-avoidant attachment style is likely to be a particular barrier to help seeking. We used a longitudinal experimental design to test the impact of repeated attachment priming on paranoia, mood and help-seeking intentions and whether cognitive fusion mediates these effects. Seventy-nine people with high levels of non-clinical paranoia, aged 18–50 years (M = 20.53, SD = 4.57), were randomly assigned to a secure or insecure-avoidant priming condition. Participants rehearsed the visualisation prime on four consecutive days and were assessed on standardised measures of paranoia, positive and negative affect, help-seeking intentions and cognitive fusion. A series of mixed-model analyses of variance showed that security priming decreases paranoia, negative affect and cognitive fusion and increases positive affect and help seeking, compared to insecure-avoidant priming. Examining the impact of primed attachment (rather than measured attachment style) allows us to draw conclusions about the causal processes involved; mediation analyses showed indirect effects of the primes on paranoia and negative affect through cognitive fusion. With a growing understanding of (1) the impact of security priming on paranoia, affect and help-seeking behaviours, (2) causal mechanisms and (3) sustainability of effects, security priming may be developed into a viable intervention for clinical populations.

Background: Paranoia, in both clinical and non-clinical groups, is characterised by unfounded interpersonal threat beliefs. Secure attachment imagery attenuates paranoia, but little is known about the mechanisms of change. Cognitive fusion describes the extent to which we can ‘step back’ from compelling beliefs, to observe these as mental events, and is implicated in psychopathology cross-diagnostically. Aims: This study extends previous research demonstrating the impact of attachment imagery on paranoia and anxiety to determine whether cognitive fusion mediates these relationships. Method: We utilised a randomized experimental design and recruited an analogue sample with high levels of non-clinical paranoia to test the impact of imagery and the role of cognitive fusion. Results: Secure attachment imagery resulted in reduced paranoia and anxiety compared to threat/insecure imagery. Cognitive fusion mediated the relationships between imagery and paranoia, and imagery and anxiety. Conclusions: Secure attachment imagery is effective in reducing paranoia and anxiety and operates via cognitive fusion. In clinical practice, these interventions should seek to facilitate the ability to ‘step back’ from compelling threat beliefs, in order to be most beneficial.

Cannabis use can increase severity of symptoms and risk of relapse for people with psychosis. Childhood sexual abuse and high schizotypy increase the risk further. The mechanisms involved remain unclear, and this limits psychological therapies. In three linked studies, we examined the role of two candidate mechanisms – external attribution and cognitive fusion. Study 1 examined these processes in a general population sample and showed that paranoia, psychotic-type experiences, and linked distress were higher in cannabis-users, and mediated by cognitive fusion but not external attribution. Study 2 examined the impact of established risk factors in general population cannabis-users and showed that external attribution and cognitive fusion partially or fully accounted for the effects of childhood sexual abuse and schizotypy on paranoia, psychotic-type experiences and linked distress. Study 3 examined these same processes in a clinical population of people with psychosis and found that external attribution and cognitive fusion partially or fully accounted for the impact of gender, age of first use, sexual abuse and schizotypy. External attribution and cognitive fusion may be key mechanisms in the maintenance of cannabis-related paranoia and account for the impact of established risk factors. We present a cognitive model incorporating these processes to inform clinical practice.

Objective: Financial difficulties are associated with poor mental health. This paper aimed to systematically review the impact of COVID-19 related financial difficulties on mental health in adults. Methods: A systematic search was conducted across Web of Science, Medline, and PsycINFO, from March 2020 to March 2023 to identify studies examining the mental health impact of COVID-19 related financial disruption in adults. We performed two meta-analyses to quantify the effect of income loss due to the pandemic on anxiety and depression. Studies were rated using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Heart, Lung and Blood Institute was used. Results: A total of 2659 papers were identified of which 76 (59 cross-sectional and 17 longitudinal) met inclusion criteria. The results show that COVID-19 related financial disruption (income loss and financial stress) negatively impact mental health across a range of adult populations globally, including the general population, students, and other specific groups. The meta-analyses examined data from 278,854 participants from 15 studies indicated that those who lost income reported greater anxiety levels than those who did not experience income loss. Similarly for 268,128 participants across 16 studies, a meta-analysis showed greater depression symptoms for those experiencing income loss. Conclusion: COVID-related financial constraints, both objective and subjective, are associated with poor mental health outcomes (particularly anxiety and depression) in various populations around the world. The results highlight the need for targeted clinical interventions for those experiencing mental health problems linked to financial problems during global crises.