The role of trauma, attachment, and voice-hearer's appraisals: a latent profile analysis in the AVATAR2 trial.

Background: There is evidence that attachment, trauma, and voice appraisals individually impact voice hearing in psychosis, but their intersectional relationship has not been examined. The aim of this study was to identify subgroups of individuals from the intersectional relationship between these factors and examine differences between subgroups on clinical outcomes.

Methods: A latent profile analysis was conducted on baseline data from the AVATAR2 trial (n = 345), to identify statistically distinct subgroups of individuals with psychosis who hear distressing voices based on co-occurring patterns of trauma, fearful attachment, and voice appraisals. The association between profile membership and demographic characteristics, voice severity, posttraumatic stress disorder symptoms, emotional distress, and difficulties with motivation and pleasure was then examined. Experts by experience were consulted throughout the process.

Results: Four profiles were identified: 'adverse voices and relational trauma', 'low malevolent and omnipotent voices', 'adverse voices yet low relational trauma', and 'high benevolent voices'. Negative voice appraisals occurred in the presence of high and low trauma and attachment adversities. The first profile was associated with being female and/or other non-male genders and had worse voice severity and emotional distress. High adversities and worse emotional distress occurred in the presence of voice benevolence and engagement. Black and South Asian ethnicities were not associated with specific profiles.

Conclusions: The identified profiles had negative and positive voice appraisals associated with higher and lower occurrence of adversities, and different clinical outcomes. These profiles could inform detailed case formulations that could tailor interventions for voice hearers.