Understanding developmental psychopathology in Type 1 diabetes through attachment, mentalisation and diabetes distress

This article examines the combined roles of attachment mentalisation and diabetes distress in the psychological development of young people with Type 1 diabetes (T1D). We use these ideas to unify the evidence for psychological variables affecting young people and their families and suggest how diabetes distress and mentalisation might be part of the pathways for development of psychiatric diagnoses.Attachment theory's central hypothesis is that a secure relationship with a care-giver in the early life of a child is essential to normal emotional and relational development, whilst diabetes distress is a well recognised phenomena of burden experienced by both child and parent in relation to the condition.We extend the ideas of attachment, into the psychological adaptation processes for young people at the time of diagnosis of T1D with emphasis on the function of the parent/caregiver in mentalising the experience of the child. We also connect our current understanding of diabetes distress to the associated increased risk for disorders of eating and personality in T1D.Using principles learnt in other areas of psychotherapeutic practice we end by suggesting interventions that could impact mental health and diabetes outcomes using the mentalisation model.

Self-other distinction and borderline personality disorder features: Evidence for egocentric and altercentric bias in a self-other facial morphing task

Self-other distinction (SOD) refers to the ability to distinguish one's own body, actions, and mental representations from those of others. Problems with SOD are considered to be a key feature of borderline personality disorder (BPD). However, empirical studies on SOD in BPD are scarce. Here, we present a study providing preliminary support for the usefulness and validity of a self-other facial morphing task to capture the capacity for SOD in a sample of nonclinical participants high (n = 30) and low (n = 32) in BPD features. Participants had to watch a video sequence in which their own face was gradually morphed into the face of an unfamiliar other (self-to-other) or vice versa (other-to-self), requiring them to indicate at which point they judged the morph to look more like the target face than the starting face. Consistent with predictions, results showed that participants in the high-BPD group judged the morph to look like themselves for longer in the self-to-other direction (suggestive of egocentric bias), but only with a relatively more attractive target face. In the other-to-self direction, the high-BPD group had more difficulty recognizing their own face (i.e., an altercentric bias), but this time only with the relatively less attractive face. Further research is needed to replicate these findings in clinical samples, but overall they suggest that the current task might be suited to investigate SOD problems in BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Integrating and differentiating personality and psychopathology: A psychodynamic perspective

Several strands of research converge to suggest that personality and psychopathology can be integrated in the form of a hierarchical model of individual differences. The notion that personality and psychopathology are intrinsically linked has a long tradition within psychodynamic approaches. In this article, we first summarize empirical evidence supporting two related key assumptions of psychodynamic approaches to personality and psychology: that a developmental, person-centered approach is needed to complement a static, disorder-centered approach in the conceptualization and treatment of psychopathology; and that personality and psychopathology are best conceptualized as dynamic attempts at adaptation. Research in each of these areas supports the notion that personality and psychopathology are difficult to separate and may be moderated by severity (i.e., general psychopathology) such that increasing levels of severity result in increased intrinsic coupling between the two. We then discuss these findings in the context of a newly emerging social-communicative approach to human development that suggests that personality and psychopathology are better conceptualized in terms of a disorder of social communication, and that the purported rigidity and stability typically attributed to them are largely explained by the stability of the environmental mechanisms that underpin them, rather than by stable intrapersonal traits. The implications of these new views for the future of the science of personality and psychopathology, and for treatment strategies, are discussed.

Imagery of negative interpersonal experiences influence the neural mechanisms of social interaction

Negative interpersonal experiences are a key contributor to psychiatric disorders. While previous research has shown that negative interpersonal experiences influence social cognition, less is known about the effects on participation in social interactions and the underlying neurobiology. To address this, we developed a new naturalistic version of a gaze-contingent paradigm using real video sequences of gaze behaviour that respond to the participants' gaze in real-time in order to create a believable and continuous interactive social situation. Additionally, participants listened to two autobiographical audio-scripts that guided them to imagine a recent stressful and a relaxing situation and performed the gaze-based social interaction task before and after the presentation of either the stressful or the relaxing audio-script. Our results demonstrate that the social interaction task robustly recruits brain areas with known involvement in social cognition, namely the medial prefrontal cortex, bilateral temporoparietal junction, superior temporal sulcus as well as the precuneus. Imagery of negative interpersonal experiences compared to relaxing imagery led to a prolonged change in affective state and to increased brain responses during the subsequent social interaction paradigm in the temporoparietal junction, medial prefrontal cortex, anterior cingulate cortex, precuneus and inferior frontal gyrus. Taken together this study presents a new naturalistic social interaction paradigm suitable to study the neural mechanisms of social interaction and the results demonstrate that the imagery of negative interpersonal experiences affects social interaction on neural levels.

Metaphors in Mentalization-Based Treatment: Reintroducing the Language of Change in “Plain Old Therapy”

Metaphors, a central conduit of change in psychotherapy, have not been taken adequately into account in Mentalization-Based Treatment (MBT). Despite successfully utilized by other evidence-based treatments for borderline personality disorder (BPD), MBT considers metaphors confusing for patients with low mentalizing abilities. For metaphors and teaching stories to stimulate growth within the window of tolerance, interventions should be responsively tailored (e.g., explained). Metaphors might be a route to making spoken matter more apprehensible, and bridge emotions with cognitive content. They hold the potential for challenging without being too confronting, and to translate knowledge between different range of understanding. This theoretical article presents why the use of metaphors in MBT—in the hands of a responsive therapists—may prove a powerful tool to open social trust, despite being considered a “high risk” intervention. The timeless lens of the metaphor may help us connect with archetypical versions of our own narratives, hence understanding our subjectivity in a larger perspective. By reaching towards concepts beyond our normal reasoning, typically denoted perennial philosophy or wisdom, they may substitute and/or supplement mentors in a memorable way.

The Development of Market-Driven Identities in Young People: A Socio-Ecological Evolutionary Approach

With the transition toward densely populated and urbanized market-based cultures over the past 200 years, young people's development has been conditioned by the ascendancy of highly competitive skills-based labor markets that demand new forms of embodied capital (e.g., education) for young people to succeed. Life-history analysis reveals parental shifts toward greater investment in fewer children so parents can invest more in their children's embodied capital for them to compete successfully. Concomitantly, the evolution of market-based capitalism has been associated with the rise of extrinsic values such as individualism, materialism and status-seeking, which have intensified over the last 40-50 years in consumer economies. The dominance of extrinsic values is consequential: when young people show disproportionate extrinsic relative to intrinsic values there is increased risk for mental health problems and poorer well-being. This paper hypothesizes that, concomitant with the macro-cultural promotion of extrinsic values, young people in advanced capitalism (AC) are obliged to develop an identity that is market-driven and embedded in self-narratives of success, status, and enhanced self-image. The prominence of extrinsic values in AC are synergistic with neuro-maturational and stage-salient developments of adolescence and embodied in prominent market-driven criterion such as physical attractiveness, displays of wealth and material success, and high (educational and extra-curricular) achievements. Cultural transmission of market-driven criterion is facilitated by evolutionary tendencies in young people to learn from older, successful and prestigious individuals (prestige bias) and to copy their peers. The paper concludes with an integrated socio-ecological evolutionary account of market-driven identities in young people, while highlighting methodological challenges that arise when attempting to bridge macro-cultural and individual development.

General mentalizing, emotional theory of mind and interpersonal mistrust in anorexia nervosa: The validation of the Hebrew version of the Cambridge mindreading face-task

OBJECTIVE

This study had two goals. The first was to validate and examine the potential of the Hebrew version of the Cambridge Mindreading face task (CAM^Heb )-an ecological measure of emotional theory of mind (eToM)-to assess eToM in individuals with anorexia nervosa (AN). The second goal was to examine whether interpersonal mistrust would mediate the relation between mentalizing and eToM and the severity of AN.

METHOD

The validity of the CAM^Heb was examined using well-established measures of mentalizing ability and eToM in 45 young female patients with AN and 53 control participants. Next, the mediation model was assessed using a subsample of 33 AN patients and 34 controls, in which interpersonal mistrust was additionally assessed.

RESULTS

The CAM^Heb correlated with the measures of mentalizing ability and eToM. The CAM^Heb , along with the measure of general mentalizing, significantly differentiated between the AN and control groups. The associations of general mentalizing and CAM^Heb with eating disorder (ED) symptoms were mediated by interpersonal mistrust.

CONCLUSION

The CAM^Heb is a valid measure of deficient eToM in AN. In therapy, an increase in mentalizing ability and accurate eToM may enhance interpersonal trust, which may further contribute to attenuation of AN symptoms.

Mindfulness-based stress reduction adapted to pregnant women with psychosocial vulnerabilities-a protocol for a randomized feasibility study in a Danish hospital-based outpatient setting

Background

This protocol is for a feasibility study of a mindfulness-based stress reduction (MBSR) program adapted for pregnant women with psychosocial vulnerabilities. The rationale for the study is the need for a wider array of evidence-based options to address prenatal mental health care needs in pregnant women. MBSR is a promising mental health intervention but has not yet been adapted for pregnant women with the aim of addressing prenatal mental health. The purpose is thus to evaluate the feasibility, acceptability, and clinical outcomes of an adapted MBSR program, prenatal MBSR, compared to usual care to inform a randomized controlled trial.

Methods/design

Pregnant women (n = 60) referred to an outpatient clinic at Copenhagen University Hospital, Amager and Hvidovre, Denmark, will be recruited for the study. The design is a single-center feasibility trial, with prenatal MBSR, as an add-on to usual care. The primary outcome is to assess the feasibility of a full-scale randomized controlled trial. The secondary feasibility outcome includes possible effects of the adapted MBSR program estimated by self-report questionnaires measuring stress, anxiety, depression, well-being, decentering, reflective functioning, mindfulness, and compassion. Participants will be randomized in a 1:1 ratio to prenatal MBSR or usual care.

Discussion

The study is part of the Good Start to Family Life study anchored at Copenhagen University Hospital, Amager and Hvidovre, Denmark. Teaching the skills of mindfulness meditation to a psychosocially vulnerable group of pregnant women could prove a viable and non-pharmacological approach to reduce stress, improve mental health, and provide support in the transition to parenthood. The outcomes of the feasibility study will inform the design of a fully powered randomized controlled trial.

Trial registration

ClinicalTrials.gov, NCT04571190. Registered on September 30, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00860-w.

Construct Validity of the Mentalization Scale (MentS) Within a Mixed Psychiatric Sample

Introduction: The concept of mentalizing is nowadays widely used in research as well as in clinical practice. Despite its popularity, the development of an economic assessment is still challenging. The Mentalization Scale appears to be a promising measurement with good psychometric properties but lacking convergent validity with the Reflective Functioning Scale. Objective: This study aims to test the construct validity of the Mentalization Scale through correlations with the gold standard, the Reflective Functioning Scale, within a clinical sample. Furthermore, it was of interest to replicate its internal consistency. Methods: Twenty-six inpatients of an acute psychiatric ward in Vienna were given the Mentalization Scale (MentS). They were interviewed with the Brief Reflective Function Interview, which was coded with the Reflective Functioning Scale. Correlations and internal consistency were calculated. Results: Concerning the primary aim of this study, the validity was satisfactory for the MentS whole-scale mentalizing as well as for the subscales self- and other-oriented mentalizing. Internal consistency was lower to the findings of the developer and close to the 0.70 threshold. Conclusion: Our findings could foster the psychometric properties of the MentS. Furthermore, the MentS seems to be a promising measurement tool for detecting different dimensions of reflective functioning. Limitations and further research are discussed.

Enhancing the capacity for optimal social and personality function through the mediational intervention for sensitizing caregivers: A case illustration

OBJECTIVE

Based on the well-known principle that the ability to meaningfully relate to others starts in the context of early attachment relationships, the current case illustration uses a recent extension of mentalization-based theory and practice to demonstrate how caregivers can enhance the capacity for optimal social and personality function through the mediational intervention for sensitizing caregivers (MISC).

METHODS

Case material is presented to demonstrate the implementation of the MISC affective and cognitive components with a mother of an adopted 10-year-old girl who shows signs of affect avoidance, social isolation within and outside the family, and maladaptive personality development.

RESULTS

The case illustration shows how video feedback sessions facilitate the gradual use of affective and cognitive components in the daily interactions between mother and daughter, thereby scaffolding optimal social and personality development.

CONCLUSIONS

Affective and cognitive components of the Mediational Intervention for Sensitizing Caregiving can be effectively integrated to enhance mentalizing capacity in caregiver-child interactions.

Decentering as a core component in the psychological treatment and prevention of youth anxiety and depression: a narrative review and insight report

Decentering is a ubiquitous therapeutic concept featuring in multiple schools of psychological intervention and science. It describes an ability to notice to day-to-day psychological stressors (negative thoughts, feelings, and memories) from an objective self-perspective and without perseverating on the themes they represent. Thus, decentering dampens the impact and distress associated with psychological stressors that can otherwise increase mental ill health in vulnerable individuals. Importantly, the strengthening of decentering-related abilities has been flagged as a core component of psychological interventions that treat and prevent anxiety and depression. We provide an in-depth review evidence of the salutary effects of decentering with a special focus on youth mental health. This is because adolescence is a critical window for the development of psychopathology but is often under-represented in this research line. A narrative synthesis is presented that integrates and summarizes findings on a range of decentering-related abilities. Section 1 reviews extant conceptualizations of decentering and data-driven approaches to characterize its characteristic. A novel definition is then offered to guide future empirical research. Section 2 overviews laboratory-based research into the development of decentering as well as its relationship with anxiety and depression. Section 3 examines the role decentering-related skills play in psychological interventions for anxiety and depression. Critically, we review evidence that treatment-related increases in decentering predict latter reductions in anxiety and depression severity. Each section highlights important areas for future research. The report concludes by addressing the vital questions of whether, how, why and when decentering alleviates youth anxiety and depression.

Mentalizing mediates the association between emotional abuse in childhood and potential for aggression in non-clinical adults

BACKGROUND

Emotional abuse in childhood has been linked to a higher expression of aggressive behavior in adulthood. The identification of protective factors that mitigate this association is needed. Mentalizing-the capacity to understand behavior in terms of intentional mental states-appears to be a promising candidate factor that possibly modifies maladaptive consequences of early emotional abuse.

OBJECTIVE

This study investigated associations between the history of emotional abuse, aggressive behavior in adulthood and mentalizing capacities in a non-clinical sample of adults.

METHODS

214 healthy adults completed questionnaires measuring retrospectively rated experiences of emotional abuse in childhood, mentalizing capacities and aggressive behavior in a cross-sectional design.

RESULTS

Results indicated associations between emotional abuse in childhood, uncertainty about mental states, and aggressive behavior in adulthood. Moreover, certainty about mental states counteracted the negative effect of emotional abuse and partially mediated the associations between emotional abuse and aggressive behavior in adulthood.

CONCLUSION

This study extends current research and sheds further light on the relationship between emotional abuse in childhood, the health-promoting capacity of mentalizing, and aggressive behavior in non-clinical adults.

Probing commitment in individuals with borderline personality disorder

Interpersonal problems are a core symptom of borderline personality disorder (BPD). In particular, patients with BPD exhibit a heightened sensitivity to cues of acceptance or rejection in their relationships. The current study investigated the psychological processes underpinning this heightened responsiveness. In a between-subjects design, we implemented a reactivity induction designed to trigger either acceptance or rejection of a partner in two separate groups, and measured the effects which this manipulation had upon 49 patients with BPD, as well as 52 control participants. The experimental paradigm required participants to repeatedly choose whether to coordinate with their partner on a decision-making task. When both players coordinate on the same option, both are rewarded. The experiment probed participants' commitment to their partners: participants were sometimes presented with tempting opportunities to unilaterally defect from the coordination. The results show that participants in the BPD group were less committed than participants in the control group when exposed to the rejection manipulation.

The role of impairments in self-other distinction in borderline personality disorder: A narrative review of recent evidence

Impairments in maintaining a differentiated sense of "self" and "other" are thought to be a central feature of borderline personality disorder (BPD). However, studies directly focusing on self-other distinction (SOD) in BPD are scarce, and these findings have not yet been integrated with novel insights into the neural mechanism involved in SOD. Here, we present a narrative review of recent behavioral and neuroimaging findings focusing on impairments in SOD in BPD. Behavioral findings of SOD at the embodied level provide preliminary evidence for impairments in multisensory integration in BPD. Furthermore, both behavioral and neuroscientific data converge to suggest that SOD impairments in BPD reflect an inability to shift between self and other representations according to task demands. Research also suggests that disruptions in infant-caregiver synchrony may play a role in the development of these impairments. Based on these findings, we present a new, integrative model linking impairments in SOD to reduced neural and behavioral synchrony in BPD. The implications of these findings for future research and clinical interventions are outlined.

Depression in Belgian first-year university students: A longitudinal study of self-definition, interpersonal relatedness, mentalizing, and integration

Despite evidence of increasing prevalence of depression in university students, few studies investigated how depression evolves over the first months at university. We investigate severity of depression among first-year university students during their first semester at university, and whether it was associated with impairments in personality, mentalizing (or reflective functioning), and social and academic integration. Participants in this two-wave prospective study were 377 Belgian first-year students in 2018 and 2019. Results showed that maladaptive interpersonal relatedness and self-definition at the start of the first semester (T1) were prospectively associated with increases in the prevalence and severity of depression at the end of the semester (T2). Uncertainty, but not certainty, with regard to mentalizing was positively associated with severity of depression at T2 and mediated the association between personality dimensions and severity of depression. The implications of these findings for depression prevention and intervention strategies in first-year university students are discussed.

Development and validation of a self-report measure of epistemic trust

Epistemic trust (ET) refers to trust in communicated knowledge. This paper describes the development and validation of a new self-report questionnaire, the Epistemic Trust, Mistrust and Credulity Questionnaire (ETMCQ). We report on two studies (Study 1, n = 500; Study 2, n = 705) examining the psychometric properties of the ETMCQ and the relationship between EMTCQ scores (i.e., an individual’s epistemic stance) and exposure to adverse childhood experiences, mental health symptoms, attachment, mentalizing and general self-efficacy. The factor structure of the ETMCQ was examined using Exploratory and Confirmatory Factor Analyses, and its reliability and test-retest reliability were tested. Both studies yielded three correlated yet distinct factors–Trust, Mistrust and Credulity–and confirmed the reliability and validity of the ETMCQ. Preregistered hypotheses were confirmed and replicated across both studies. Main findings suggest intriguing links between the ETMCQ and developmental psychopathology constructs and are consistent with thinking on the role of epistemic stance in undermining adaptation and increasing the developmental risk of mental health problems. Mistrust and Credulity scores were associated with childhood adversity and higher scores on the global psychopathology severity index and both factors partially mediated the link between early adversity and mental health symptoms. Mistrust and Credulity were positively associated with difficulties in understanding mental states and insecure attachment styles. Post-hoc analysis identified that different attachment styles were associated with differences in epistemic stance. In addition, Trust was not associated with reduced levels of mental health symptoms and did not moderate the impact of childhood adversity–findings are congruent with the suggestion that the reduction of mistrust and credulity may be crucial common factors in promoting resilience and the effectiveness of psychotherapeutic interventions. This investigation and the ETMCQ provide an empirical measure of what until now has been largely a theoretical concept and open new avenues for future research.

Development of a New Measure for Assessing Mentalizing: The Multidimensional Mentalizing Questionnaire (MMQ)

This research consists of two studies which aimed to: (1) evaluate the psychometric properties of a new self-report measure for the assessment of mentalizing, the Multidimensional Mentalizing Questionnaire (MMQ); and (2) investigate the ability of the instrument to discriminate between community and clinical populations. A sample of 349 participants (19% male, 81% female; M_age = 38.6, SD = 15.3) filled in the MMQ and other self-report measures, in order to assess the factor structure, reliability and some aspects of construct validity of the measure. Then, a clinical sample (N = 46; 52% male and 48% female; M_age = 33.33, SD = 12.257) and a community one (N = 50; 42% male and 58% female; M_age = 38.86, SD = 16.008) filled in the MMQ, to assess its clinical sensitivity. The factorial analysis identified six principal dimensions of the measure: reflexivity, ego-strength, relational attunement, relational discomfort, distrust, and emotional dyscontrol. The MMQ showed satisfactory psychometric properties and a theoretically relevant factor structure. Furthermore, significantly greater impairment in mentalizing was found in the clinical sample in respect of the community one. The findings are discussed in terms of clinical implications, emphasizing the usefulness of the MMQ in both research and clinical practice.

Awakening to recognize the detrimental effects of social avoidance and the possibility of healing through reconnection

BACKGROUND

Loneliness and social avoidance are widespread and serious mental health problems. People experiencing loneliness or social avoidance have difficulties maintaining ordinary life activities and often experience profound suffering. How do we as clinicians deal with or help people out of loneliness and social avoidance?

AIMS

In this paper, we introduce the issue on loneliness and social avoidance. We do so by first defining loneliness and social avoidance and outlining the impact on mental health issues of these phenomena. Next, we introduce the six papers central to the special issue along with some thoughts on how to understand therapy and treatment of social avoidance.

DISCUSSION

We discuss new directions and how to move beyond more conventional therapeutic approaches to these problems.

Culture and psychopathology: An attempt at reconsidering the role of social learning

This paper proposes a model for developmental psychopathology that is informed by recent research suggestive of a single model of mental health disorder (the p factor) and seeks to integrate the role of the wider social and cultural environment into our model, which has previously been more narrowly focused on the role of the immediate caregiving context. Informed by recently emerging thinking on the social and culturally driven nature of human cognitive development, the ways in which humans are primed to learn and communicate culture, and a mentalizing perspective on the highly intersubjective nature of our capacity for affect regulation and social functioning, we set out a cultural-developmental approach to psychopathology.

Various mentalizing concepts in mothers with postpartum depression, comorbid anxiety, and personality disorders

BACKGROUND

Mentalization is defined as the human capacity to reflect upon one's own or others' behaviors in terms of underlying mental states and intentions. Several concepts of mentalizing exist, which differ in content, assessment, and clinical prediction.

AIMS

The present study examines the relationship between the three main concepts of mentalizing, namely, reflective functioning (RF), parental reflective functioning (PRF), and Mind-Mindedness (MM), in mothers with postpartum depression. It was hypothesized that mentalizing concepts differ in their convergent and divergent variance, as well as their clinical validity regarding comorbid anxiety and personality disorders (PDs).

METHOD

Fifty clinically referred mothers with postpartum depression and infants aged 3-10 months were examined by means of the Reflective Functioning Scale, Parental Reflective Functioning Questionnaire, and Mind-Mindedness Coding-System.

RESULTS

No significant associations were found between RF and PRF, or between PRF and MM; higher RF was associated with more MM-nonattuned mind-related comments. Increased depression and anxiety were linked to lower PRF in terms of higher PRF-prementalizing. Lower RF, but not PRF, was associated with comorbid PDs. Specifically, obsessive-compulsive PD was associated to considerably fewer MM-nonattuned mind-related comments.

CONCLUSION

Distinct concepts of mentalizing represent divergent competencies, differentially linked to maternal postpartum psychopathology.

Mothers' parental mentalization, attachment dimensions and mother-infant relational patterns

We examined the links between mothers' prenatal attachment dimensions, parental mentalization and mother-infant relational patterns. The sample consisted of 68 mother-infant dyads. During pregnancy, mothers reported on attachment-related anxiety and avoidance. When the infants were three months old, the mothers' parental reflective functioning (PRF) was assessed via the PDI-R2-S interview. Mothers-infant free play interactions were coded for maternal sensitivity and dyadic reciprocity and mothers' utterances were coded for appropriate and non-attuned mind-mindedness (MM). Prenatal attachment anxiety was associated with less appropriate MM. Appropriate MM was associated with maternal sensitivity and mother-infant dyadic reciprocity. The models predicting maternal sensitivity and dyadic reciprocity from dimensions of the mothers' prenatal anxiety/avoidance attachment, mediated by their PRF, appropriate and non-attuned MM, were significant. Univariate analyses revealed a significant direct link only between appropriate MM and mother-infant dyadic reciprocity. We discuss these results as well as the differences between the PRF and MM constructs.

Reflective Functioning in Patients with Irritable Bowel Syndrome, Non-Affective Psychosis and Affective Disorders-Differences and Similarities

Irritable bowel syndrome (IBS), as part of the functional somatic syndromes, is frequent in the general population. Medical care and morbidity costs are high, and so is the psychological and somatic strain. The etiopathogenesis of IBS is still poorly understood; it is assumed to be multifactorial and to include biopsychosocial factors. Links between the intestine, psyche, nervous system (e.g., via the hypothalamic-pituitary-adrenal axis (HPA-Axis/neurotransmitters) and with the microbiome, the immune system have lately been investigated. Factors such as personality traits, mentalization, and early attachment strategies (deactivating and hyperactivating) have been suggested to influence IBS with relevance for treatment regimens. At this time, data on reflective functioning (RF) is lacking. Within a cross-sectional, we examined the mentalizing capacity of a clinical sample (n = 90) consisting of patients with IBS (n = 30), affective disorders (AD; n = 28), and non-affective psychosis (NAP; n = 32). The reflective functioning scale was used based on the brief reflective function interview (BRFI). The results revealed severe impairment in patients with IBS concerning their mentalizing ability, which was comparable to patients with affective disorders. Patients with non-affective-psychosis showed the lowest mentalizing ability. Thus, psychotherapeutic treatment with a focus on mentalization could be a promising approach.

The relationship between global distress, mentalizing and well-being in a German teacher sample

Many studies have linked global distress including higher psychological symptom severity and high levels of stress with low levels of well-being among teachers, indicating a need to identify and empirically evaluate protective factors. Mentalizing—the capacity to understand behavior in terms of intentional mental states—may be a candidate protective factor to mediate this association, enhancing well-being in the face of high levels of global distress. The present study examines whether the capacity to mentalize can buffer subjectively experienced stress and psychological symptom severity in a sample of teachers. 215 teachers completed questionnaires measuring self-rated experiences of stress, psychological symptoms, mentalizing capacities and well-being in a cross-sectional design. Structural equation modeling was used to test mediation effects. Our findings show that mentalizing was positively associated with well-being. In addition, mentalizing counteracted the negative influence of stress and psychological symptom severity. However, a structural equation model assessing the mediating effect of global distress on well-being via mentalizing was not significant. Therefore, the data indicate that teachers’ capacity to mentalize, regardless of psychological symptom load and subjective experience of stress, has a positive impact on their well-being. The study highlights the protective function of mentalizing and forms a framework for psychological interventions to increase teachers’ well-being.

Self and Other Mentalizing Polarities and Dimensions of Mental Health: Association With Types of Symptoms, Functioning and Well-Being

Research suggests that the ability to understand one's own and others' minds, or mentalizing, is a key factor for mental health. Most studies have focused the attention on the association between global measures of mentalizing and specific disorders. In contrast, very few studies have analyzed the association between specific mentalizing polarities and global measures of mental health. This study aimed to evaluate whether self and other polarities of mentalizing are associated with a multidimensional notion of mental health, which considers symptoms, functioning, and well-being. Additionally, the level or depth of mentalizing within each polarity was also analyzed. A sample of 214 adolescents (12-18 years old, M = 14.7, and SD = 1.7; 53.3% female) was evaluated on measures of self- (Trait Meta-Mood Scale or TMMS-24) and other- mentalizing (Adolescent Mentalizing Interview or AMI), multi-informed measures of psychopathology and functioning based on Achenbach's system, and measures of psychological well-being (self-esteem, happiness, and motivation to life goals). Results revealed no association between mentalizing polarities and higher-order symptom factors (internalizing, externalizing, and global symptoms or "p" factor). Self-mentalizing was associated with self-esteem (B = 0.076, p < 0.0005) and motivation to life goals (B = 0.209, p = 0.002), and other-mentalizing was associated to general, social and role functioning (B = 0.475, p < 0.0005; B = 0.380, p = 0.005; and B = 0.364, p = 0.004). This association between aspects of self-other mentalizing and self-other function has important implications for treatment and prevention. Deeper mentalizing within each polarity (i.e., comprehension beyond simple attention to one's own mental states, and mentalizing referred to attachment figures vs. mentalizing referred to the characters of a story) revealed stronger associations with functioning and well-being. Because mentalizing polarities are associated with functioning and well-being but not with symptoms, a new hypothesis is developed: mentalizing does not contribute to resiliency by preventing symptoms, but by helping to deal with them, thus improving functioning and well-being independently of psychopathology. These findings support that promoting mentalizing across development may improve mental health, even in non-clinical population.

Family Minds: A randomized controlled trial of a group intervention to improve foster parents' reflective functioning

Family Minds is a brief group psychoeducational parenting intervention designed to increase the reflective functioning (RF) and mentalization skills of foster parents. RF is important for foster parents who have to build relationships with children whose adverse experiences increase their risk for psychosocial challenges. A randomized controlled trial (RCT) for Family Minds was conducted in Texas with 89 foster parents. The main aims of this study were to examine whether the intervention could significantly increase the RF/mentalization skills of the foster parents and decrease their parenting stress. After 6 weeks, compared with the control group, intervention foster parents improved their RF via a lowering of pre-mentalizing and also significantly decreased parenting stress related to parent-child dysfunctional interactions. Other measures of RF and parenting stress showed no significant differences between groups. Foster child behavior was not significantly different between groups, although data at 6 months showed a possible lowering of internalizing symptoms for children of intervention parents. This RCT provides some encouraging evidence that Family Minds may increase RF in foster parents, improve parental sensitivity and their ability to emotionally regulate, decrease parenting stress related to challenging interactions with their foster children, and possibly decrease children's internalizing behavior.

Self-Rated Mentalizing Mediates the Relationship Between Stress and Coping in a Non-Clinical Sample

BACKGROUND

The clinical concept of mentalizing has recently been extended into non-clinical contexts. In particular, the protective function of robust mentalizing as a processing capacity of interpersonal and intrapsychic events has become a focus of consideration. Theoretical approaches hypothesize that mentalizing may allow for an adequate self-awareness in the face of aversive experiences such as stress, leading to a reappraisal of these experiences and therefore enables the use of adaptive coping behaviors.

OBJECTIVE

The study aimed to investigate the association between coping behavior, mentalizing and experiences of stress.

METHOD

534 healthy adults completed the German-language Stress Processing Questionnaire (SVF), the Mentalization Questionnaire (MZQ), and a short scale of the Trierer Inventory of Chronic Stress (TICS) in a cross-sectional research design.

RESULTS

Correlational analyses suggested associations between coping and mentalizing. Furthermore, MZQ scores predicted both positive and negative coping behavior. The relationship between stress and both negative and positive coping was mediated by mentalizing capacity.

CONCLUSION

Findings confirm the hypothesis that mentalizing may represent a coping resource within a resilience framework. An implementation of the concept in preventive mental health interventions is discussed.

The moderating effects of self and other mentalizing on the relationship between distress and disordered eating: A cross-cultural examination

OBJECTIVE

Cross-cultural comparisons that focus on underlying psychological mechanisms in disordered eating (DE) are lacking. With the aim of addressing this gap, we investigated the interplay between mentalizing, distress, and DE in two cultural groups: the ultra-Orthodox and secular Jewish societies in Israel.

METHOD

A combination of performance-based and self-report measures of two mentalizing-related constructs (emotional awareness and alexithymia), along with self-report measures of distress, DE, and values preferences, were employed in a community sample (N = 300) of ultra-Orthodox and secular Jewish women.

RESULTS

Distress predicted DE in both cultural groups, yet there were cultural differences in the moderating role of mentalizing. Both mentalizing measures moderated the distress-DE link in the secular group, but not in the ultra-Orthodox group. Furthermore, there were cultural differences in the moderating effects of self versus other mentalizing.

CONCLUSIONS

The results suggest cultural differences in the underlying psychological mechanism of DE.

Navigating the Social Environment in Adolescence: The Role of Social Brain Development

Successful navigation of the social environment is dependent on a number of social cognitive processes, including mentalizing and resistance to peer influence. These processes continue to develop during adolescence, a time of significant social change, and are underpinned by regions of the social brain that continue to mature structurally and functionally into adulthood. In this review, we describe how mentalizing, peer influence, and emotion regulation capacities develop to aid the navigation of the social environment during adolescence. Heightened susceptibility to peer influence and hypersensitivity to social rejection in adolescence increase the likelihood of both risky and prosocial behavior in the presence of peers. Developmental differences in mentalizing and emotion regulation, and the corticosubcortical circuits that underpin these processes, might put adolescents at risk for developing mental health problems. We suggest how interventions aimed at improving prosocial behavior and emotion regulation abilities hold promise in reducing the risk of poor mental health as adolescents navigate the changes in their social environment.

Predictors of dropout among adolescents with borderline personality disorder attending mentalization-based group treatment

Background: Premature termination from treatment or dropout is prevalent among patients with borderline personality disorder (BPD). To our knowledge, no studies have examined which factors predisposes dropout from therapy among adolescents with BPD. The current study examined sociodemographic, clinical and psychological predictors of dropout among adolescents who attended a one-year treatment program with mentalization-based group treatment (MBT-G).Methods: Participants were 89 female adolescent patients aged 14-18 years who attended MBT-G in a Danish child and adolescent psychiatric service and 56 matched controls who received non-manualized individual sessions (treatment as usual). Forty (45%) dropped out and 49 (55%) completed treatment in MBT-G. Pretreatment predictors included (1) sociodemographic variables such as age, schooling, relationship status and after-school job, (2) clinical measures of self-reported adolescent borderline personality features, depression, self-harm, internalizing and externalizing symptoms, and (3) psychological measures on self-reported reflective functioning (i.e., mentalizing) and attachment to peers and parents.Results: Binary logistic regression analyses revealed that lower reflective functioning was the only significant predictor of dropout in MBT-G. No sociodemographic or clinical variables predicted dropout. No significant predictors of dropout were identified among participants who received treatment as usual.Conclusions: Adolescents with BPD who report low reflective functioning are at increased risk of dropping out of MBT-G treatment but not treatment as usual. These findings highlight that clinicians need to consider level of reflective functioning among adolescents with BPD in MBT or in group therapy and adapt psychotherapy to the needs of the patient in order to reduce dropout.

Future directions in personality pathology

This article suggests two areas of future development in the realm of personality pathology. First, a reconceptualization of personality pathology in the context of research evidence suggestive of a single model for psychopathology. Recent work on the 'p factor', in combination with findings from clinical research, behavior genetics, molecular biology, and neurobiological models are considered in relation to this reconceptualization of personality pathology. Second, a cultural-developmental model for personality pathology is proposed, based on Gergely and Csibra's work on natural pedagogy, Tomasello's work on joint attention and intentionality, and our recent work on epistemic trust and the social-communicative nature of psychopathology.

Emotional Comprehension Is Not Related to Duration of Distress from Daily Life Events

The main aim of this paper is to analyze to what extent insight (i.e., mentalization referring to one’s own mental state) moderates recovering from daily life events. A total of 110 participants (84.5% women; mean age: M = 21.5; SD = 3.2) filled in the Trait Meta-Mood Scale (TMMS-24) and the Eysenck Personality Questionnaire (EPQ-R), and were interviewed about impairment derived from daily life events (everyday life stresses) during the past year. Multivariate regression models were adjusted for neuroticism, sex, and socioeconomic status to analyze whether different degrees of insight moderated the relationship between the intensity and the duration of emotional distress. Results showed that the global measure of insight did not moderate recovering from daily-life distress. Regarding the subdimensions, attention to emotional reactions was related to an increased duration of distress. Results showed that, against our hypothesis, deeper comprehension of emotional reactions, operationalized here as “true insight”, was not associated to faster recovery. Limitations and recommendations for further studies are discussed considering these results.

Personality Functioning and Mentalizing in Patients With Subthreshold or Diagnosed Borderline Personality Disorder: Implications for ICD-11

The 11th revision of the International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11) defines personality disorder according to personality functioning, which relates to self- and interpersonal functioning. The aim of the present study was to assess the relationship between mentalizing and personality functioning in patients with subthreshold or diagnosed borderline personality disorder. A total of 116 eligible participants were included. Mentalizing was assessed using the Mentalization Questionnaire (MZQ), personality functioning (self- and interpersonal functioning) was assessed using the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF), and borderline severity was assessed using the Zanarini Rating Scale (ZAN-BPD). Mediation analysis was employed to test if mentalizing accounted for the relationship between borderline severity and self- and interpersonal functioning. We found a significant relationship between borderline severity and both subscales of the LPFS-BF. Mentalizing fully and significantly mediated the relationship between borderline severity and interpersonal functioning. However, mentalizing only partly mediated the relationship between borderline severity and self-functioning. Controlling for the covariates gender and age did not impact the results. Mentalizing is likely to be involved in the ICD-11 model of personality functioning, especially interpersonal functioning. This could emphasize the relevance of therapy aimed at strengthening mentalizing abilities when treating personality pathology in general and people with borderline personality disorder in particular. However, self-functioning may be more nuanced, as aspects other than mentalizing also influence self-functioning. The study is explorative in nature and has methodological limitations that require caution in the interpretation and generalizability.

Mind reading improvements in mentalization-based therapy training

The psychological strain of many psychiatric disorders arises from difficulties encountered in social interactions. Social withdrawal is often the first symptom of neuropsychiatric disorders. The authors explore the various options for training social cognition skills. Social cognition was assessed using the Movie for the Assessment of Social Cognition (MASC). After completion of mentalization-based therapy (MBT) training, MASC scores improved significantly in health care providers (p = .006, r = .57). Mentalizing (operationalized with reflective functioning [RF]) was assessed in the MBT group (Group A) and compared with RF in a control group (Group B). RF was significantly higher in Group A (RF = 4.35, SD = 1.19) than in Group B (RF = 3.43, SD = 1.70) (p = .0385; Cohen's d = 0.65). MBT might be a promising intervention in social cognition training. Mentalizing skills might be associated with attitude.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity

PURPOSE OF REVIEW

The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders.

RECENT FINDINGS

Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust.

SUMMARY

The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

Achieving successful resolution of alliance ruptures: for whom and when?

Contemporary theories and the empirical literature stress the importance of successful resolution of alliance ruptures for the process and outcome of treatment. Yet, little empirical work has examined what leads to successful resolutions. The aim of the present study was to examine which patients are more likely to achieve successful resolutions of ruptures and under which circumstances.

Sixty-five patients completed measures assessing their trait-like pretreatment characteristics (alliance expectations and general attachment orientation), and state-like changes in treatment (working alliance, therapist serving as an attachment figure, and the implementation of common factor techniques). Successful resolutions were coded using observer behavioral coding at four time points.

State-like changes, but not trait-like characteristics significantly contributed to successful resolution. Stronger working alliance and the therapist as an attachment figure, and the implementation of common factors techniques were found to contribute to successful resolutions.

The current findings emphasize the importance of the process that occurs within treatment, and the therapeutic context in which the resolution process take place for the ability to achieve successful resolutions.

Higher maternal reflective functioning is associated with toddlers' adaptive emotion regulation

Parental reflective functioning (RF), the ability to consider the child's behavior as a function of mental states (cognitions, emotions), is theorized to promote emotion regulation in children via its positive impact on parenting sensitivity. Using a sample of mothers and toddlers (N = 151 dyads; 41% Latinx; 54% girls; M_Age  = 21 months; SD_Age   =  2.5 months), we measured mothers' self-reported RF (high RF = low certainty/high interest-curiosity/low prementalizing), toddlers' distress during a standardized challenging behavioral task (toy removal), and three methods of children's coping with distress. Then, we tested whether RF moderated the association between children's observed distress and coping during the task (mother-directed adaptive coping, task-directed adaptive coping, maladaptive aggression) as an index of emotion regulation. Although RF was not associated with toddlers' distress, indices of RF moderated the associations between distress and coping. As maternal RF increased, the positive association between toddler distress and mother-oriented behavior increased, whereas the association between toddler distress and child aggression decreased. Findings were present only for certainty of mental states, whereas no effects were present for prementalizing or interest/curiosity. We discuss these findings in terms of their contributions to theory regarding parent-child relationships, maternal RF, and child emotion regulation.

Entrepreneurs' Capacity for Mentalizing: Its Influence on Burnout Syndrome

Burnout is a mental disorder that leads to difficulties for the entrepreneur in controlling his or her personal and professional life. The most common consequences of entrepreneurial burnout include the subject experiencing low motivation, low organizational commitment, loss of energy, demoralization in connection with their work, poor quality of work, feeling of failure, and the perception that his or her company is performing poorly. We used a sample of 157 Spanish entrepreneurs selected at random from the Iberian Balance Sheet Analysis System database. We employed the Spanish version of the Reflective Functioning Questionnaire to measure mentalizing and the Spanish version of the Maslach-Burnout Inventory-General Survey (MBI-GS) to measure burnout. This research showed that entrepreneurial burnout could be avoided in part if the entrepreneur achieved a good capacity for mentalizing. Hypomentalizing contributed to explaining entrepreneurs’ levels of professional efficacy, cynicism, and emotional exhaustion. In contrast, the explanatory power of hypermentalizing was not significant for any of the dimensions of burnout. This study provides new evidence of burnout in entrepreneurs; a professional group with an important economic, politic, and social role has been little studied.

Compassion: From Its Evolution to a Psychotherapy

The concept, benefits and recommendations for the cultivation of compassion have been recognized in the contemplative traditions for thousands of years. In the last 30 years or so, the study of compassion has revealed it to have major physiological and psychological effects influencing well-being, addressing mental health difficulties, and promoting prosocial behavior. This paper outlines an evolution informed biopsychosocial, multicomponent model to caring behavior and its derivative "compassion" that underpins newer approaches to psychotherapy. The paper explores the origins of caring motives and the nature and biopsychosocial functions of caring-attachment behavior. These include providing a secure base (sources of protection, validation, encouragement and guidance) and safe haven (source of soothing and comfort) for offspring along with physiological regulating functions, which are also central for compassion focused therapy. Second, it suggests that it is the way recent human cognitive competencies give rise to different types of "mind awareness" and "knowing intentionality" that transform basic caring motives into potentials for compassion. While we can care for our gardens and treasured objects, the concept of compassion is only used for sentient beings who can "suffer." As psychotherapy addresses mental suffering, cultivating the motives and competencies of compassion to self and others can be a central focus for psychotherapy.

Mentalization Impairment Is Associated with Problematic Alcohol Use in a Sample of Young Adults: A Cross-Sectional Study

Background: Alcohol is one of the most widely used drugs among adolescents and young people, and problematic alcohol use (PAU) is related to significant long-term biological, clinical, and psychosocial sequelae. Although preliminary reports have linked deficits in mentalization to increased vulnerability to addiction, no studies have specifically explored this phenomenon in relation to PAU. Methods: The association between mentalization impairment and PAU severity was investigated in a sample of 271 young adults (183 females, 65.9%; mean age: 23.20 ± 3.55 years; range: 18–34). Self-report measures investigating PAU and mentalization were administered to all participants. Results: Individuals with PAU reported a more frequent use of tobacco and illicit drugs in the last 12 months. PAU severity was negatively associated with mentalization capacity (rho = −0.21; p < 0.001), and also, when possible, confounding variables (i.e., gender, age, occupation, education, tobacco and illegal drugs use) were controlled for (rho = −0.17; p = 0.004). Conclusion: The present data showed that mentalization impairment is significantly associated with PAU among young adults, suggesting that it may have a role in the development and/or maintenance of alcohol use.

[The German Version of the Reflective Functioning Questionnaire (RFQ): A Psychometric Evaluation in the General Population]

The concept of mentalization has attracted broad clinical and scientific interest, particularly because of its high clinical and therapeutic relevance. To make this concept accessible for empirical research, the 8-item Reflective Functioning Questionnaire (RFQ-8) was developed, which comprises 2 subscales tapping into uncertainty about mental states (or hypomentalizing), and certainty about mental states (i. e. hypermentalizing). Although first psychometric examinations have evaluated the RFQ-8 positively, these findings must be interpreted with caution for methodological reasons. The aim of this study was the psychometric evaluation of the German version of the RFQ-8 in a large general population sample (n=2477). Various confirmatory and exploratory factor analyses indicated that the originally introduced 2-factor solution is mis-specified. Instead, the RFQ-8 seems to cover a unidimensional construct. Having excluded 2 items due to their insufficient psychometric qualities, the 6-item measure (RFQ-6) showed high internal consistency (McDonald's ω=0,88) as well as significant rank correlations with depression, anxiety and bodily complaints. Considering the psychometric limitations of the RFQ-8, its use in clinical routine and research should be viewed very critically, particularly with respect to its ability to assess hypermentalizing.

What works for adolescents with borderline personality disorder: towards a developmentally informed understanding and structured treatment model

The efficacy of treatment of borderline personality disorder in adolescents is an underresearched area. Although increasing research in borderline personality disorder in adolescents has emerged over the last decade there is a paucity of knowledge about how treatment is adequately designed for this group of patients. As a consequence, it is currently difficult to provide evidence-based guidelines and firm recommendations for how to design and implement borderline treatment in adolescence. In this selective review we summarize the most important research findings concerning treatment for adolescents with borderline personality disorder, including a recent mentalisation-based group treatment program. We highlight pivotal developmental obstacles for psychotherapy in adolescence and integrate these into a framework for the understanding and designing of effective treatment of borderline in adolescence.