Self-reported patterns of impairments in mentalization, attachment, and psychopathology among clinically referred adolescents with and without borderline personality pathology

Adolescent mentalizing and childhood emotional abuse: implications for depression, anxiety, and borderline personality disorder features

Background

There is preliminary evidence that childhood emotional abuse (CEA) is a risk factor for adolescent mentalizing difficulties (Uncertainty/Confusion about mental states) and borderline personality features and that Uncertainty/Confusion about mental states mediate the relationship between CEA and adolescent borderline personality features, but these findings need replication. Furthermore, no previous studies have examined the relationship between adolescent mentalizing deficits, anxiety, and depression in the context of CEA.

Objectives

This study examined the associations between CEA, adolescent borderline personality features, depression and anxiety symptoms and tested a pathway model where Uncertainty/Confusion about mental states mediates the relationships between CEA and adolescent borderline personality features, depression and anxiety symptoms.

Method

A clinical sample of 94 adolescents completed the Reflective Function Questionnaire for Youth (RFQY) to assess mentalizing, the Childhood Experiences of Care and Abuse Questionnaire (CECA-Q), the Borderline Personality Disorders Features Scale (BPFS-C), and the Beck Youth Inventories for Depression (BDI-Y) and Anxiety (BAI-Y).

Results

Uncertainty/Confusion about mental states partially mediated the relationship between CEA and borderline traits as well as anxiety. In addition, there was an indirect effect where CEA predicted Uncertainty/Confusion about mental states, which then predicted depression.

Discussion

The findings are consistent with the mentalizing model of psychopathology and provide new evidence that Uncertainty/Confusion about mental states might be a critical mentalizing deficit that characterizes the associations between CEA and adolescent BPD features and depression and anxiety symptoms. Uncertainty/Confusion may be a transdiagnostic risk factor for adolescent psychological distress and dysfunction. We discuss the clinical implications.

Perceived social support as related to social wellbeing in patients with Emotionally Unstable Personality Disorder (EUPD)

Background

People diagnosed with EUPD also known as borderline personality disorder (BPD) experience different challenges in their lives. These challenges include compulsive behavior, irritability, depression, sadness, guilt, shame, loneliness, grandiosity, and feeling of worthlessness. It is noteworthy that such challenges trigger among them a self-destructive behaviour, in addition to social isolation, and impaired social relationships. It is also found to significantly impact their physical, mental, and social wellbeing. This study is a humble attempt to examine the role of perceived social support in improving the social wellbeing of BPD outpatients. Through the purposive sampling technique, 100 BPD outpatients were selected for the study. The mean age of the participant was 25 years.

Results

It was found that perceived social support (family, friends, and significant others) plays a vital role in the wellbeing of these participants. The correlation between the two is positive as well as statistically significant. This means higher the support these patients experience from their relatives, the better is their social wellbeing.

Conclusions

This study has practical implications for counselors, clinical psychologists, and psychiatrists working in the field.

Mentalizing in Adolescents With and Without Prominent Borderline Features: Validation of the Reflective Functioning Questionnaire for Youths (RFQY) and an Investigation of the Factor Structure of Hypo- and Hypermentalizing

The Reflective Functioning Questionnaire for Youths (RFQY) is a self-report measure of reflective functioning (RF) also referred to as mentalizing. Lower levels of RF are characteristic of a wide range of mental disorders and are especially relevant in the assessment of personality pathology. The goal of the current study is to examine the psychometric properties of a Danish translation of the RFQY and to corroborate previous research on the measure's ability to differentiate between adolescents with and without borderline personality disorder (BPD) features. 889 adolescents were administered the RFQY and divided into three subsamples: a community sample (n = 644), a clinical non-personality disorder sample (n = 64), and a BPD sample (n = 181). Construct validity was examined through bivariate correlations between RFQY and a dimensional assessment of borderline personality features. Analysis of variance (ANOVA) supported the utility of the RFQY to discriminate between adolescents with and without BPD features. Moreover, a two-factor structure based on previous research of the adult version of the RFQ was examined. A series of exploratory and confirmatory factor analyses yielded a two-factor structure corroborating previous research. Implications for prevention, assessment, and treatment are discussed along with methodological limitations and suggestions for future research.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

The Italian version of the Reflective Functioning Questionnaire: Validity within a sample of adolescents and associations with psychological problems and alexithymia

Objectives

This study aims to test the psychometric proprieties of the Reflective Functioning Questionnaire (RFQ) applied to younger (13–16 years) and older (17–20 years) Italian adolescents examining (1) the factorial structure of RFQ; (2) its invariance across age and sex; (3) correlations between RFQ subscale scores, as well as the associations of the RFQ with (4) psychological problems and alexithymia dimensions.

Methods

A cross‐sectional study was conducted with 593 adolescents between the ages of 13 and 20 years old recruited from the community within Italy. These participants completed the RFQ, Symptom Checklist‑90, and Toronto Alexithymia Scale.

Results

The two‐factor structure of the RFQ was confirmed. However, higher internal consistency of RFQ was obtained by removing two items that seemed problematic within this sample. Using a six‐item version of RFQ, the two‐factor structure was invariant across adolescent age and sex. Significant correlations among RFQ subscale scores, and between RFQ subscales with both psychological problems and alexithymia dimensions were found.

Conclusions

Preliminary results reveal a short version of RFQ (six‐item) is a suitable measure to assess mentalizing in adolescents in the Italian context.

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.

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.

Exploring mentalization, trust, communication quality, and alienation in adolescents

INTRODUCTION

A growing body of evidence has demonstrated the importance of mentalization for adolescents' psychosocial functioning; however, further research is needed to understand links between mentalization and other socio-cognitive factors. The aim of this quantitative, cross-sectional study was to investigate the relationship between a teen's capacity to mentalize and three attachment-related factors: parent-teen trust, parent-teen communication, and parent-teen alienation.

METHODS

In an online survey, 82 (mainly) Australian adolescents (57 female; 23 male; 2 non-binary; mean age 17.09 years) completed: i) The Children's Eyes Test, which measured mentalization; and ii) The Inventory of Parent and Peer Attachment-45, which measured trust, communication quality, and alienation.

RESULTS

In teens' relationships with both mothers and fathers, trust and communication quality were significantly positively correlated (p = .001) when controlling for age and gender. Both were significantly negatively correlated with alienation (p = .001) with control variables included. Capacity to mentalize did not correlate with trust, communication quality, or alienation in relationships with either mothers or fathers (p ≤ .05).

CONCLUSIONS

Possible reasons are proposed for why no relationship was found between mentalization and trust, communication quality, or alienation. Implications for future research are discussed.

Microstates-based resting frontal alpha asymmetry approach for understanding affect and approach/withdrawal behavior

The role of resting frontal alpha-asymmetry in explaining neural-mechanisms of affect and approach/withdrawal behavior is still debatable. The present study explores the ability of the quasi-stable resting EEG asymmetry information and the associated neurovascular synchronization/desynchronization in bringing more insight into the understanding of neural-mechanisms of affect and approach/withdrawal behavior. For this purpose, a novel frontal alpha-asymmetry based on microstates, that assess quasi-stable EEG scalp topography information, is proposed and compared against standard frontal-asymmetry. Both proposed and standard frontal alpha-asymmetries were estimated from thirty-nine healthy volunteers resting-EEG simultaneously acquired with resting-fMRI. Further, neurovascular mechanisms of these asymmetry measures were estimated through EEG-informed fMRI. Subsequently, the Hemodynamic Lateralization Index (HLI) of the neural-underpinnings of both asymmetry measures was assessed. Finally, the robust correlation of both asymmetry-measures and their HLI’s with PANAS, BIS/BAS was carried out. The standard resting frontal-asymmetry and its HLI yielded no significant correlation with any psychological-measures. However, the microstate resting frontal-asymmetry correlated significantly with negative affect and its neural underpinning’s HLI significantly correlated with Positive/Negative affect and BIS/BAS measures. Finally, alpha-BOLD desynchronization was observed in neural-underpinning whose HLI correlated significantly with negative affect and BIS. Hence, the proposed resting microstate-frontal asymmetry better assesses the neural-mechanisms of affect, approach/withdrawal behavior.

Psychometric validation of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) in a Danish clinical sample

BACKGROUND

The Childhood Trauma Questionnaire - Short Form (CTQ-SF) is a widely utilized self-report instrument in the assessment and characterization of childhood trauma. Yet, research on the instrument's psychometric properties in clinical samples is sparse, and the Danish version of the CTQ-SF has not been previously evaluated in clinical samples.

OBJECTIVES

To examine the structural validity, internal consistency reliability, and multi-method convergent validity of the CTQ-SF in a heterogenous clinical sample from Denmark.

PARTICIPANTS AND SETTING

The study was based on data from four Danish clinical samples (N = 393): 1) Outpatients diagnosed with personality disorders, 2) Patients commencing psychiatric treatment for non-affective first-episode psychosis, 3) Patients diagnosed with first-episode or prolonged depression recruited from general practitioners and an outpatient mood disorder clinic, and 4) detained delinquent boys.

METHODS

Confirmatory factor analysis was used to explore structural validity. Also, we calculated internal consistency and multi-method convergent validity with interview-based ratings of adverse parenting.

RESULTS

Confirmatory factor analyses indicated that the five-factor structure described in CTQ-SF manual with three error correlated items best fitted the data, as compared to various other models. Coefficients of congruence also supported factorial similarity across countries (i.e. US substance abuser and a mixed Brazilian sample). Internal consistency reliability was acceptable and comparable to estimates previously published. Multi-method convergent validity associations further corroborated the validity of the CTQ-SF.

CONCLUSION

These findings provide support for the reliability and validity of the Danish version of the CTQ-SF in clinical samples.

Mentalization mediates the relationship between borderline personality features and internalizing and externalizing psychopathology in adolescents

Background:

Findings show that deficiencies in the ability to understand mental states are related to many forms of psychopathology. Mentalizing dysfunctions are suggested to be the core pathology underlying borderline personality disorder (BPD). Moreover, research suggests that BPD predicts psychopathology in general and findings display that diminished mentalization is related to a range of psychiatric disorders. As yet, no study has investigated the potential link between borderline personality features, mentalization and internalizing and externalizing psychopathology, and whether internalizing and externalizing psychopathology in BPD might be driven by impaired mentalization.

Objective:

In a cross-sectional study, 109 patients referred to a child and adolescent psychiatric clinic were assessed with a battery of self-report instruments to asses borderline personality features, mentalization, and internalizing and externalizing psychopathology.

Method:

Simple mediation model was used to examine whether mentalizing abilities mediated the relationship between borderline features and psychopathology in regard to externalizing and internalizing psychopathology in adolescents.

Results:

The results indicated that mentalization mediated the relationship between borderline personality features and both externalizing and internalizing psychopathology in adolescents, indicating that mentalization underlie externalizing and internalizing psychopathology in adolescents with borderline personality features.

Conclusion:

The current study is the first empirical study to evaluate mentalization as a mediating factor between adolescents who met full or sub-threshold criteria for BPD and psychopathology. Clinical implications are discussed.

Attachment and reflective functioning in children with somatic symptom disorders and disruptive behavior disorders

Our goal in conducting this study was to examine whether children with somatic symptom disorders (SSD) and disruptive behavior disorders (DBD) have higher rates of insecure or disorganized attachment and difficulties in mentalizing (operationalized as reflective functioning) as compared to a control group. Participants were 131 children (8-15 years) spanning two groups-a clinical group (n = 85), comprised of children fitting the criteria of our target diagnostic classifications (SSD: N = 45; DBD: N = 40), as well as a comparison group of healthy control children (n = 46). Children completed the Child Attachment Interview, which was later coded by reliable raters for attachment security and reflective functioning (RF). Consistent with our predictions, children in the clinical group had significantly lower RF and were significantly more likely to have insecure (over 80%) and disorganized attachment (over 40%) than children in the comparison group. In addition, RF was significantly lower in children with DBD than children with SSD. Furthermore, in the SSD group, children's RF regarding self was significantly lower than RF regarding others. Finally, consistent with prior studies, RF and attachment were associated. The findings indicate that school-aged children with SSD and DBD have higher rates of insecure and disorganized attachment. Consistent with theory, RF and attachment were loosely coupled, but RF alone differentiated among the diagnostic subgroups. Implications for treatment and prevention are discussed.

A Temperament-Attachment-Mentalization-Based (TAM) Theory of Personality and Its Disorders

Theories of personality and its disorders need, from time to time, to be revised and updated according to new empirical and conceptual developments. Such development has taken place in the realms of affective neuroscience, evolution, and social cognition. In this article, we outline a new personality theory, which claims that phenomena we usually ascribe to the concept personality are best understood by postulating a web consisting of three major constituents: temperament (mainly primary emotions), attachment, and self-consciousness (mentalizing). We describe these constituents, their neurobiological underpinnings, the subjective experiences they evoke, and their behavioral implications. We discuss the relevance of the espoused theory in the field of personality disorders with references to borderline, narcissistic, and avoidant personality disorders as well as the DSM-5 alternative model. Implications for social psychology, psychotherapy, and common sense self-understanding are outlined. The theory aims to bridge previous contradictions between natural sciences and hermeneutics by its propositions of the evolution of self-consciousness.

Early Detection and Outcome in Borderline Personality Disorder

Borderline personality disorder (BPD) is a severe and heterogeneous mental disorder that is known to have the onset in young age, often in adolescence. For this reason, it is of fundamental importance to identify clinical conditions of childhood and adolescence that present a high risk to evolve in BPD. Investigations indicate that early borderline pathology (before 19 years) predict long-term deficits in functioning, and a higher percentage of these patients continue to present some BPD symptoms up to 20 years. There is a general accordance among investigators that good competence in both childhood and early adulthood is the main predictive factor of excellent recovery in BPD patients. Some authors suggest that specific childhood personality traits can to be considered precursors of adult BPD, as well as some clinical conditions: disruptive behaviours, disturbance in attention and emotional regulation, conduct disorders, substance use disorders, and attention-deficit-hyperactivity disorder. Unfortunately, diagnosis and treatment of BPD is usually delayed, also because some clinicians are reluctant to diagnose BPD in younger individuals. Instead, the early identification of BPD symptoms have important clinical implications in terms of precocious intervention programs, and guarantees that young people with personality disorders obtain appropriate treatments. This review is aimed to collect the current evidences on early risk and protective factors in young people that may predict BPD onset, course, and outcome.

An investigation of the mentalization-based model of borderline pathology in adolescents

OBJECTIVE

According to mentalization-based theory, transgenerational transmission of mentalization from caregiver to offspring is implicated in the pathogenesis of borderline personality disorder (BPD). Recent research has demonstrated an association between hypermentalizing (excessive, inaccurate mental state reasoning) and BPD, indicating the particular relevance of this form of mentalizing dysfunction to the transgenerational mentalization-based model. As yet, no study has empirically assessed a transgenerational mentalization-based model of BPD. The current study sought firstly to test the mentalization-based model, and additionally, to determine the form of mentalizing dysfunction in caregivers (e.g., hypo- or hypermentalizing) most relevant to a hypermentalizing model of BPD.

METHOD

Participants were a mixed sample of adolescents with BPD and a sample of non-clinical adolescents, and their respective primary caregivers (n = 102; 51 dyads). Using an ecologically valid measure of mentalization, mediational analyses were conducted to examine the relationships between caregiver mentalizing, adolescent mentalizing, and adolescent borderline features.

RESULTS

Findings demonstrated that adolescent mentalization mediated the effect of caregiver mentalization on adolescent borderline personality pathology. Furthermore, results indicated that hypomentalizing in caregivers was related to adolescent borderline personality pathology via an effect on adolescent hypermentalizing.

CONCLUSIONS

Results provide empirical support for the mentalization-based model of BPD, and suggest the indirect influence of caregiver mentalization on adolescent borderline psychopathology. Results further indicate the relevance of caregiver hypomentalizing to a hypermentalizing model of BPD.

Models of borderline personality disorder: recent advances and new perspectives

PURPOSE OF REVIEW

The purpose of this article is to review the most relevant conceptual models of borderline personality disorder (BPD), with a focus on recent developments in this area.

RECENT FINDINGS

Several conceptual models have been proposed with the aim of better understanding BPD: the borderline personality organization, emotion dysregulation, reflective (mentalization) dysfunction, interpersonal hypersensitivity and hyperbolic temperament models. These models have all been supported to some extent and their common components include disorganized attachment and traumatic early experiences, emotion dysregulation, interpersonal sensitivity and difficulties with social cognition. An attempt to integrate some components of the conceptual models of BPD has resulted in an emerging new perspective, the interpersonal dysphoria model, which emphasizes dysphoria as an overarching phenomenon that connects the dispositional and situational aspects of BPD.

SUMMARY

Various conceptual models have expanded our understanding of BPD, but it appears that further development entails theoretical integration. More research is needed to better understand interactions between various components of BPD, including the situational factors that activate symptoms of BPD. This will help develop therapeutic approaches that are more tailored to the heterogeneous psychopathology of BPD.

The mediating role of mentalizing capacity between parents and peer attachment and adolescent borderline personality disorder

BACKGROUND

Insecure attachment is a precursor and correlate of borderline personality disorder. According to the mentalization-based theory of borderline personality disorder, the presence of insecure attachment derails the development of the capacity to mentalize, potentially resulting in borderline pathology. While one prior study found support for this notion in adolescents, it neglected a focus on peer attachment. Separation from primary caregivers and formation of stronger bonds to peers are key developmental achievements during adolescence and peer attachment warrants attention as a separate concept.

FINDINGS

In a cross-sectional study, female outpatients (M_age 15.78=, SD = 1.04) who fulfilled DSM-5 criteria for BPD (N = 106) or met at least 4 BPD criteria (N = 4) completed self-reports on attachment to parents and peers, mentalizing capacity (reflective function) and borderline personality features. Our findings suggest that in a simple mediational model, mentalizing capacity mediated the relation between attachment to peers and borderline features. In the case of attachment to parents, the mediational model was not significant.

CONCLUSIONS

The current study is the first to evaluate this mediational model with parent and peer attachment as separate concepts and the first to do so in a sample of adolescents who meet full or sub-threshold criteria for borderline personality disorder. Findings incrementally support that mentalizing capacity and attachment insecurity, also in relation to peers, are important concepts in theoretical approaches to the development of borderline personality disorder in adolescence. Clinical implications are discussed.