What we have changed our minds about: Part 2. Borderline personality disorder, epistemic trust and the developmental significance of social communication

An exploration of the relationship between ineffective modes of mentalization and difficulties related to borderline personality disorder: A network approach

BACKGROUND

The mentalization-based perspective of Borderline Personality Disorder (BPD) underscores fluctuating interpersonal functionality, believed to arise from suboptimal mentalization modes, including hyper- and hypomentalizing. The connection between ineffective mentalizing and specific BPD challenges remains ambiguous. Network theory offers a unique means to investigate the hypothesis that distinct yet interconnected mental challenges ('symptoms') construct 'disorders' through their continuous mutual interactions. This study aimed to probe the pairwise interrelations between ineffective mentalizing and BPD challenges and to distinguish these relations between individuals with (clinical group) and without (community group) a BPD diagnosis using a network analysis approach.

METHODS

Through a cross-sectional secondary data analysis, a moderated Mixed Graphical Model was employed on data from 575 individuals (350 clinical, 225 community). The study evaluated associations between ineffective mentalization modes (hypermentalization, hypomentalization, and no mentalization) gauged by the MASC and self-reported BPD-associated challenges, using BPD diagnosis as the moderating variable.

RESULTS

The analysis confirmed the presence of significant links between ineffective mentalizing and specific interpersonal BPD challenges, which were moderated by BPD diagnosis. It implied that hypermentalization and hypomentalization might simultaneously shape BPD-associated challenges.

CONCLUSIONS

The results offer fresh insights into the interplay between hypermentalization, hypomentalization, and BPD-related difficulties.

Somatic symptom disorder and the role of epistemic trust, personality functioning and child abuse: Results from a population-based representative German sample

BACKGROUND

A growing body of evidence explored symptom burden of somatic symptom disorder (SSD) and its complex etiology involving psychosocial aspects. Child abuse has been linked to numerous psychopathologies including somatic symptoms as well as impaired personality functioning and disruptions in epistemic trust. This work aims to investigate personality functioning and epistemic trust in the association between child abuse and somatic symptom burden.

METHODS

We conducted structural equation modelling (SEM) using representative data of the German population (N = 2436). Personality functioning (OPD-SQS) was applied as a mediator between retrospectively recalled child abuse (ICAST-R) and somatic symptom burden (SSS-8, SSD-12, 6 month time criterion), while epistemic trust was added as a predictor of personality functioning.

RESULTS

6.8 % (n = 166) of participants self-reported SSD. Prevalence of child abuse (53.6 % vs. 31.7 %; χ2 = 33.44, p < .001) was significantly higher among those with SSD. Child abuse was significantly associated with somatic symptom burden (criterion A: β = 0.23, 95 %-CI: 0.19-0.27, p < .001; criterion B (β = 0.24, 95 %-CI: 0.20-0.28, p < .001) and explained 6 % and 5 % of its variance respectively. Adding personality functioning as a mediator increased the explained variance to 28 % for both somatic symptom burden criterion A and B. Including epistemic trust further increased the explained variance of personality functioning (from 15 to 36 %).

LIMITATIONS

All assessments and results are based on self-report and cross-sectional data.

CONCLUSIONS

Impairments in personality functioning and disruptions in epistemic trust might play an important role in experiencing symptoms of SSD. Both domains thus present new avenues for treatment improvement and further research in patients with SSD.

The role of epistemic trust and epistemic disruption in vaccine hesitancy, conspiracy thinking and the capacity to identify fake news

Epistemic trust - defined as readiness to regard knowledge, communicated by another agent, as significant, relevant to the self, and generalizable to other contexts-has recently been applied to the field of developmental psychopathology as a potential risk factor for psychopathology. The work described here sought to investigate how the vulnerability engendered by disruptions in epistemic trust may not only impact psychological resilience and interpersonal processes but also aspects of more general social functioning. We undertook two studies to examine the role of epistemic trust in determining capacity to recognise fake/real news, and susceptibility to conspiracy thinking-both in general and in relation to COVID-19. Measuring three different epistemic dispositions-trusting, mistrusting and credulous-in two studies (study 1, n = 705; study 2 n = 502), we found that Credulity was associated with inability to discriminate between fake/real news. We also found that both Mistrust and Credulity mediated the relationship between exposure to childhood adversity and difficulty in distinguishing between fake/real news, although the effect sizes were small. Finally, Mistrust and Credulity were associated with general and COVID-19 related conspiracy beliefs and vaccine hesitancy. We discuss the implications of these findings for our understanding of fake news and conspiracy thinking.

Mentalizing, Epistemic Trust, and the Active Ingredients of Psychotherapy

This article explores the implications of epistemic trust within the mentalizing model of psychopathology and psychotherapy, emphasizing the role of the restoration of epistemic trust in therapeutic settings. At the core of this exploration is the developmental theory of mentalizing, which posits that an individual's ability to understand mental states-both their own and others'-is cultivated through early caregiver interactions. The article expands on this concept by reviewing and integrating evolutionary theories suggesting that humans have evolved a unique sensitivity to teaching and learning through ostensive cues, enhancing our capacity for cultural transmission and cooperation. However, adversities such as trauma or neglect can disrupt this developmental trajectory, leading to epistemic disruption, where individuals struggle to engage with or learn from social experiences effectively. This disruption can manifest in psychological disorders, where mentalizing failures are associated with difficulties in social functioning and in maintaining relationships. The article proposes that psychotherapeutic approaches can effectively address these disruptions, and it outlines three key aspects of communication that unfold in psychotherapeutic interventions. It discusses how the effectiveness of these interventions may hinge on the reestablishment of epistemic trust, enabling patients to reengage with their social environments constructively and adaptively.

Recognizing Social Injustice and Epistemic Mistrust in Helping Adolescents with Multiple Needs: The AMBIT (Adaptive Mentalization-Based Integrative Treatment) Approach

Epistemic trust-trust in the relevance and utility of social learning-is central to helping processes between clients and workers in helping services. Yet, due to their experiences, clients may adaptively develop predispositions toward stances of epistemic mistrust or epistemic credulity. From an AMBIT (adaptive mentalization-based integrative treatment) perspective, this article argues that epistemic mistrust and credulity are both caused by social injustice and generate further social injustice. Helping services commonly respond in ways that fail to acknowledge this social injustice and, perversely, deliver further injustice still. Our primary focus is how these issues relate to work with clients, but we argue that they are present in work within AMBIT's other foci, too: in teams, multiagency networks, and learning. We conclude that workers and helping services have a moral duty to recognize and attend to the multiple social injustices associated with epistemic mistrust and credulity.

More than Meets the "I": A Panoramic View of Epistemic Trust in Psychotherapy

INTRODUCTION

Epistemic trust (ET), the authenticity and personal relevance we assign to interpersonally transmitted knowledge, is considered an essential component of any effective therapy. Despite its clinical significance, comprehensive empirical support is still lacking regarding whether ET is an inherent characteristic of the patient or acts as a catalyst for therapeutic change. Consequently, unlike other critical components, a clear distinction between its aspects - the patient's attributes, the therapist's contribution, and their unique therapeutic relationship - remains elusive, leaving our understanding incomplete. The current study examines the constituents of ET in therapy and its related effects through three distinct lenses: a blended snapshot lens, a prognostic lens, and a lens focusing on state-like changes. The constituents of ET were measured as follows: patient attributes were measured using attachment orientation and interpersonal functioning scales; therapist contribution was evaluated through scales assessing the therapist's use of techniques; and the patient-therapist therapeutic relationship was gauged using the working alliance scale.

METHODS

We collected and analyzed data from 116 patients who participated in manualized psychodynamic psychotherapy sessions to investigate the trait-like and state-like components of ET.

RESULTS

The results offer a comprehensive panoramic view with small to medium, but meaningful, correlations between ET and patients' attributes (ranging from 0.18 to -0.26); therapists' contributions (ranging between 0.15 and 0.28); and the patient-therapist therapeutic relationship (ranging between 0.17 and 0.23).

CONCLUSION

While some findings were consistent with our expectations, others were contrary, highlighting the necessity of considering the variations between and within patients as they have distinct theoretical, clinical, and empirical implications. Employing these three distinct lenses helps therapists gain a better understanding of the clinical picture reflected by the patient over different treatment periods. This broad perspective is of prognostic importance and encourages clinicians to adjust the treatment focus to meet the evolving needs of their patients.

Borderline personality disorder and post-traumatic stress disorder in adolescents: protocol for a comparative study of borderline personality disorder with and without comorbid post-traumatic stress disorder (BORDERSTRESS-ADO)

BACKGROUND

Borderline Personality Disorder (BPD) is a prevalent and debilitating psychiatric condition often accompanied by Post-Traumatic Stress Disorder (PTSD), with a substantial prevalence of trauma history among affected individuals. The clinical, cognitive, and cerebral parallels shared with PTSD suggest a trauma-related etiology for BPD. Studies consistently demonstrate a reduction in hippocampal volume in individuals with BPD, echoing findings in PTSD. However, the interpretation of this shared neurobiological profile remains contentious, with ongoing debates regarding the independence of these pathologies or the potential exacerbation of diminished hippocampal volume in BPD due to concurrent PTSD. Differential impacts on hippocampal subfields across both disorders may further complicate interpretation, suggesting the volume of hippocampal subfields as a potential discriminant biomarker. This study aims to characterize the multidimensional specific and shared profiles of BPD and PTSD-related alterations, with a particular emphasis on hippocampal subfields during adolescence, a crucial period in BPD development.

METHODS

This study focuses on female adolescents, who are more prevalent in the BPD population. Participants are categorized into three groups: BPD, BPD with comorbid PTSD, and a control group of matched healthy individuals. Data collection encompasses clinical, cognitive, and neuroimaging domains commonly affected in both disorders, utilizing various imaging markers (including gray matter macrostructure, white matter microstructural integrity, and regional functional connectivity).

DISCUSSION

This study examines adolescent BPD with and without comorbid PTSD on clinical, neuroimaging, and cognitive levels. It is the first to use a comprehensive multi-modal approach within the same sample. Additionally, it uniquely explores hippocampal subfield volume differences in adolescents. Analysis of the relationship between the investigated domains and the effects of PTSD comorbidity will elucidate specific and shared alteration profiles in both disorders.

TRIAL REGISTRATION

IDRCB number 2019-A00366-51 / clinicaltrials.gov ID: NCT0485274. Registered on 21/04/2021.

Trust under development: The Italian validation of the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ) for adolescents

INTRODUCTION

In recent years, the concept of epistemic trust has emerged as a critical factor in understanding psychopathology, particularly within the context of personality disorders. A self-report instrument, the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ), has demonstrated its validity among English and Italian adult populations. However, extending its applicability to adolescents is essential for comprehending the role of epistemic trust in the development of mental disorders. The aim of this study was to validate the ETMCQ within the Italian adolescent demographic.

METHODS

Data were gathered from a wide selection of middle and high schools across Italy. The data collection started on 01/03/2022 and ended on 30/06/2022. Besides the ETMCQ (Study 1 = 662 participants, 12-18 years old, M = 15.56, SD = 2.20; 324 females, 338 males), we also administered other self-report instruments measuring mentalization, emotional dysregulation, general levels of psychopathology, and interpersonal trust in a smaller groups (Study 2 = 417 participants, aged from 12-19 years old, M = 15.64; SD = 2.08; 249 females, 168 males).

RESULTS

Our findings provide empirical validation for the theoretical framework concerning the role of epistemic trust in psychological functioning and substantiate the validity of ETMCQ as a measure to assess it among teenagers.

CONCLUSIONS

The ETMCQ is a valid and promising instrument for adolescent populations; its ease and brevity of administration could make it a valuable tool both in clinical and research contexts, shedding light on the role of epistemic trust in mental health.

Childhood adversity and adolescent acting-out behaviors: the mediating role of mentalizing difficulties and epistemic vigilance

Childhood adversity is a well-established risk factor for adolescent acting-out behaviors such as self-harm, bingeing, substance abuse, and aggressive behavior. From a mentalizing perspective, acting-out behaviors are understood as resulting from a combination of impairments in mentalizing and epistemic vigilance that are a consequence of childhood adversity. Yet, few studies have investigated these assumptions. The current study investigated the potential mediating role of mentalizing impairments and epistemic vigilance in the relationship between childhood adversity and acting-out behaviors in adolescents, oversampled for risk status for psychopathology (N = 451, mean age = 15.40 years). Structural equation modeling showed a strong, direct relationship between childhood adversity and acting-out behaviors, confirming the importance of traumatic childhood experiences for adolescent acting-out behaviors. This relationship was partially mediated by both mentalizing difficulties and epistemic vigilance, explaining about 40% of the total variance. These results support the importance of focusing on strengthening mentalizing abilities and lowering epistemic hypervigilance in psychotherapeutic work with adolescents who have experienced childhood trauma.

How do we know whether treatment has failed? Paradoxical outcomes in counseling with young people

Background

In both routine practice contexts and research studies, evidence from standardized self-report symptom measures, administered pre- and post-treatment, is predominantly used to determine whether psychotherapy has been successful. Understanding the nature of unsuccessful psychotherapy requires an ability to evaluate the credibility of outcome data generated by such techniques. An important body of research has identified discrepancies between outcomes assessed through symptom measures and those obtained from other sources. However, not enough is known about the extent to which such paradoxical outcomes exist.

Objective

This study analyzes the relationship between outcomes, as assessed by a standardized self-report measure, and as assessed by ratings of young people's descriptions of change at post-counseling interviews.

Methods

Participants were 50 young people (13-16 years old) who had taken part in a trial of up to 10 weeks of school-based humanistic counseling. Our primary standardized measure was the Young Person's CORE (YP-CORE). To assess young people's experiences of counseling change, three independent raters scrutinized transcripts of post-counseling interviews, and scored levels of helpfulness on a 1 (Not at all helpful) to 10 (Extremely helpful) scale. Inter-rater reliabilities were 0.94 (Cronbach's Alpha) and 0.96 (McDonald's Omega). Sensitivity analyses were conducted to explore relationships between helpfulness ratings and other outcome measures, i.e., satisfaction with counseling (ESQ) and the Goal-Based-Outcome Tool (GBO), and process measures, i.e., the Working Alliance Inventory (WAI-S) and the Barret Lennard Relationship Inventory (BLRI).

Results

Multilevel analysis indicated that helpfulness ratings were not significantly associated with changes in YP-CORE scores. Analyzed categorically, 38% of those showing reliable improvement on the standardized measure were below the median for self-described helpfulness, and 47% of those not showing reliable change were at or above the median for self-described helpfulness. Sensitivity analyses demonstrated closer correlations between helpfulness ratings and other outcome measures (ESQ and GBO), and between helpfulness ratings and process measures (WAI-S and BLRI).

Discussion

Our results raise questions about reliance on symptom change outcome measures for defining treatment success and failure, given their disparity with clients' own descriptions of the helpfulness of therapy. Implications for practice and research are discussed.

Utilization of Mental Health Provision, Epistemic Stance and Comorbid Psychopathology of Individuals with Complex Post-Traumatic Stress Disorders (CPTSD)-Results from a Representative German Observational Study

Background: Complex post-traumatic stress disorder (CPTSD) is a severely debilitating recently added symptom cluster in the International Classification of Diseases (ICD-11). So far, only limited information on mental health treatment-uptake and -satisfaction of individuals with CPTSD is available. The aim of this study is to investigate these aspects in a representative sample of the German general population. Methods: Participants completed the International Trauma Questionnaire (ITQ) to identify participants with CPTSD, as well as questionnaires on mental health treatment uptake and satisfaction, adverse childhood experiences, anxiety, depression, working ability, personality functioning, and epistemic trust. Results: Of the included n = 1918 participants, n = 29 (1.5%) fulfilled the criteria for CPTSD. Participants with CPTSD had received mental health treatment significantly more often than participants with PTSD or depression (65.5% vs. 58.8% vs. 31.6%; p = 0.031) but reported significantly less symptom improvement (52.9% vs. 78.0% vs. 80.0%; p = 0.008). Lower levels of epistemic trust were associated with higher CPTSD symptoms (p < 0.001). Conclusions: Our study shows that while the vast majority of individuals with CPTSD had received mental health treatment, subjective symptom improvement rates are not satisfactory. CPTSD was associated with a broad number of comorbidities and impairments in functioning. Lower levels of epistemic trust may partially explain worse treatment outcomes.

Clinical Evidence, Triangulation of Perspectives and Contextualization. Part 1: The Beginning of Carla's Treatment

We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the three-level model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable, and replicable.

The development of the Epistemic Trust Rating System (ETRS)

OBJECTIVE

The present study introduces and validates the Epistemic Trust Rating System (ETRS), an observer-based measure designed to assess epistemic trust (ET) within psychotherapy. ET in psychotherapy has gained much theoretical attention as a critical component in the therapeutic context, given its inherent link to social communication. However, its empirical validation remains pending, largely due to the absence of a refined instrument to gauge ET levels within the therapy environment. Therefore, this study aimed to translate ET's theoretical construct into tangible markers within the therapeutic context.

METHOD

One hundred eighteen patients enrolled in a randomized controlled trial received psychodynamic psychotherapy for depression. Incorporating top-down theoretical considerations with bottom-up empirical observations yielded an overall ETRS score accompanied by three distinct sub-scales, each assessing a singular ET element: one gauges the patient's propensity to share; another measures the degree to which "we-mode" moments are achieved within the session; and the third evaluates the patient's receptiveness to learning.

RESULTS

The findings demonstrate the psychometric robustness of the ETRS, with good internal consistency, interrater reliability (ICC(1,8) = .86-.90), and convergent (r = .23-.29) and discriminant validity (r = -.10).

CONCLUSION

The current study highlights the ETRS as a promising tool bridging theory and empirical exploration, enhancing our understanding of epistemic trust in psychotherapy.

Etiopathogenesis in the Development of Borderline Personality Characteristics in Children and Adolescents

The validity and clinical significance of the characteristics of borderline personality disorder (BPD) in adolescents are increasingly being recognized. The persistence of BPD characteristics in adolescence is high and is associated with negative interpersonal, academic, professional, and financial outcomes. In the literature, BPD characteristics observed in children and adolescents are explained with psychodynamic theories, developmental models, and evolutionary approaches. Emotional dysregulation, interpersonal dysfunction, impulsivity, and self-harming behavior, negative life events, temperament characteristics, neuropsychological dysfunctions, neuroanatomical, genetic, hormonal, and immunological factors may play a role in BPD etiopathogenesis. This review aims to address different approaches and relevant factors for the development of BPD. The articles published between 1968-2021 in the PubMed database were reviewed, and prominent studies were selected for evaluation. The importance of invalidating environment, epistemic freezing and hypermentalization, complex or attachment trauma is emphasized in psychodynamic and developmental literature. In the evolutionary approach, on the other hand, romantic relationships and the onset of reproduction are emphasized as the reason for the emergence of symptoms during adolescence, and it is argued that BPD is related to the rapid life history strategy. It is stated that a decrease in volume in the orbitofrontal cortex and anterior cingulate cortex, which are involved in top-down emotional processing, and an increase in the activity of thalamus and hippocampus regions, which are involved in bottom-up emotional processing are observed in adolescents with BPD characteristics when compared to healthy controls. It is thought that the increase in activation in the superior temporal gyrus and precuneus observed in adolescents with BPD features is a neural indicator of hypermentalization, and the increase in activation in the insula is a neural indicator of social pain. It has been reported that the decrease in resting heart rate and the increase in heart rate variability observed in adolescents with BPD symptoms are associated with the activation of the parasympathetic system. BPD in adolescents is a disorder that challenges clinicians in terms of diagnosis, differential diagnosis, and treatment. It is crucial to evaluate the factors related to etiopathogenesis in BPD in a multifaceted and detailed manner. Keywords: Borderline Personality Disorder, Difficulty in Emotion Regulation, Mentalization, Trauma, Self-harming Behavior, Temperamental Characteristics.

To trust or not to trust in the thrall of the COVID-19 pandemic: Conspiracy endorsement and the role of adverse childhood experiences, epistemic trust, and personality functioning

RATIONALE

Conspiracy endorsement is a public health challenge for the successful containment of the COVID-19 pandemic. While usually considered a societal phenomenon, little is known about the equally important developmental backdrops and personality characteristics like mistrust that render an individual prone to conspiracy endorsement. There is a growing body of evidence implying a detrimental role of adverse childhood experiences (ACEs) - a highly prevalent developmental burden - in the development of epistemic trust and personality functioning. This study aimed to investigate the association between ACEs and conspiracy endorsement in the general population, specifically questioning a mediating role of epistemic trust and personality functioning.

METHODS

Based on cross-sectional data from a representative German survey collected during the COVID-19 pandemic (N = 2501), we conducted structural equation modelling (SEM) where personality functioning (OPD-SQS) and epistemic trust (ETMCQ) were included as mediators of the association between ACEs and conspiracy endorsement. Bootstrapped confidence intervals (5000 samples, 95%-CI) are presented for all paths.

RESULTS

ACEs were significantly associated with conspiracy endorsement (β = 0.25, p < 0.001) and explained 6% of its variance. Adding epistemic trust and personality functioning as mediators increased the explained variance of conspiracy endorsement to 19% while the direct association between ACEs and conspiracy endorsement was diminished (β = 0.12, p < 0.001), indicating an indirect effect of personality functioning and epistemic trust in the association between ACEs and conspiracy endorsement. Fit indices confirmed good model fit.

CONCLUSIONS

Establishing an association between ACEs and conspiracy endorsement further increases the evidence for early childhood adversities' far-reaching and detrimental effects. By including epistemic trust and personality functioning, these findings contribute to a deeper understanding of the underlying mechanisms in the way that ACEs may be associated with conspiracy endorsement.

"Trust me, do not trust anyone": how epistemic mistrust and credulity are associated with conspiracy mentality

Previous research shows that the propensity to endorse conspiracy theories is associated with disrupted forms of epistemic trust, i.e., the appropriate openness towards interpersonally communicated information. There are associations, first, with an increased mistrust in several actors and institutions responsible for the communication of information in society, and second, with a pronounced credulity in unreliable sources and implausible phenomena (e.g., superstition, astrology). This study aims to investigate whether these phenomena are associated with specific personality-related disruptions of epistemic trust. Based on selfreported data of 417 individuals (mean = 33.28; standard deviation = 11.11) from a UK population sampled online, the potential relationships between disruptions in epistemic trust and the endorsement of a conspiracy mentality are explored. The epistemic stances characterized by mistrust and credulity (independent variables) are measured with the epistemic trust, mistrust, and credulity questionnaire (ETMCQ), and conspiracy mentality (dependent variable) is measured with the conspiracy mentality questionnaire. In a multiple linear regression model, mistrust is associated with the endorsement of a conspiracy mentality, even when accounting for other contributing factors (e.g., individual narcissism, attachment avoidance and anxiety, authoritarianism, loneliness). In a bootstrapped mediation model controlling for other relevant predictors, the association between credulity and conspiracy mentality is fully mediated by mistrust. In future research, the impact of disrupted epistemic trust on conspiracy beliefs should be investigated in terms of the specific epistemic stances of mistrust and credulity. In this respect, the ETMCQ represents a highly promising instrument to assess individual differences in factors underpinning aspects of conspiracy endorsement.

Epistemic Trust Is a Critical Success Factor in Psychosomatic Rehabilitation-Results from a Naturalistic Multi-Center Observational Study

Knowledge about critical success factors underpinning beneficial treatment outcomes in psychosomatic inpatient rehabilitation is scarce. The aim of this study was to evaluate the influence of patients' epistemic stance in relation to the improvement of psychological distress during rehabilitation. In this naturalistic longitudinal observational study, n = 771 patients completed routine assessments for psychological distress (BSI-18), health-related quality of life (HRQOL; WHODAS), and epistemic trust (ETMCQ) before (T1) and after (T2) psychosomatic rehabilitation. Patients were grouped as best, average, and worst responders based on their mean BSI-18 changes during treatment, and their mean change in epistemic trust, mistrust, and credulity was compared using repeated measures analyses of variance (rANOVAs). No associations of performance with sex (p = 0.09), age (p = 0.11), or relationship status (p = 0.58) were found. Best responders reported significantly improved epistemic trust (p = 0.001) and reduced epistemic mistrust (p < 0.001), whereas worst responders reported a significant increase in epistemic mistrust (p < 0.001) and credulity (p < 0.001). Average responders did not change for either epistemic trust (p = 0.11), mistrust (p > 0.99), or credulity (p = 0.96). Our results underscore the role of the epistemic stance in psychosomatic and psychotherapeutic treatments. These results help to better understand what might determine psychosomatic rehabilitation outcomes and indicate the role of epistemic trust as a critical success factor.

Epistemic trust: a comprehensive review of empirical insights and implications for developmental psychopathology

Originally rooted in philosophy and sociology, the concept of epistemic trust has recently transitioned to developmental psychopathology, illuminating social-cognitive processes in psychopathology. This narrative review synthesizes empirical evidence on epistemic trust to inform future research. A literature search highlighted 3 areas: i) the development of selective trust in children; ii) epistemic trust in non-clinical adults; iii) its link to mental health. Young children demonstrate selective learning from reliable sources using epistemic cues. Empirical studies beyond childhood were greatly facilitated in the last 2 years with the introduction of the Epistemic Trust, Mistrust and Credulity Questionnaire, a self-report scale measuring epistemic stance. Cross-sectional studies pinpointed dysfunctional epistemic strategies as factors in mental health vulnerability, and some qualitative work offered initial evidence linking restored epistemic trust to effective psychotherapy. For future research, we propose focusing on 3 primary areas. First, empirical investigations in adolescent samples are needed, as adolescence seems to be a pivotal phase in the development of epistemic trust. Second, more experimental research is required to assess dysfunctional and functional epistemic stances and how they relate to vulnerability to mental health disorders. Finally, intervention studies should explore the dynamics of epistemic stances within and between therapy sessions and their impact on therapeutic outcomes.

Different epistemic stances for different traumatic experiences: implications for mentalization

Traumatic experiences may impair reflective functioning (RF), making it difficult for individuals to understand their own and others' mental states. Epistemic trust (ET), which enables evaluating social information as reliable and relevant, may vary in association with RF. In this study, we explored the implications of different ET stances (i.e., trust, mistrust, and credulity) in the relation between different childhood traumatic experiences (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) and different types of RF impairments (uncertainty and certainty about mental states). A non-clinical community sample of 496 cisgender emerging adults (mage = 24.91, standard deviation = 2.66, 71.85% assigned female at birth, 63.63% heterosexual) reported on their childhood traumatic experiences, ET, and RF. We used structural equation models to examine direct and indirect associations. The results showed significant indirect effects between emotional abuse and uncertainty about mental states through credibility. We also observed significant indirect effects between emotional abuse and certainty about mental states through mistrust and credibility. The findings suggest that a lack of discrimination when evaluating knowledge from others (i.e., credulity) might promote increased uncertainty in RF when emerging adults have experienced emotional abuse in their childhood. Conversely, a tendency to view all information sources as unreliable or ill-intentioned (i.e., mistrust) may foster greater certainty in RF as a protective mechanism against an unreliable and potentially harmful world when combined with childhood emotional abuse. The implications for clinical practice and intervention are discussed.

Beyond Mentalizing: Epistemic Trust and the Transmission of Culture

We explore the interpersonal origins of human culture, arguing that culture emerges as a necessary consequence of our helplessness in infancy, which in turn requires a greater degree of collaboration and social organization than is necessary for other mammals. We propose a model of cultural transmission that depends on a dyadic interpersonal process whose vicissitudes can have a lifelong impact. We explore the role played by imagining subjectively experienced psychological states and processes in others, which we have defined as mentalizing, in the process of cultural transmission, and propose that mentalizing is key to the establishment of epistemic trust-that is to say, an experience of trust that enables the individual to absorb and use the knowledge they are being offered. We suggest that psychoanalysis can be viewed as a paradigmatic example of a process of transferring knowledge from one human being (the teacher, the caregiver, the analyst) to another (the learner, the young person, the patient) and argue that the mechanisms of psychic change in analysis cannot be fully understood without appreciating this aspect of the biological/evolutionary origins of our essential humanity. Finally, we discuss the clinical implications of the model we are proposing for the psychoanalytic process.

Associations of mentalization and epistemic trust with internalizing and externalizing problems in adolescence: A gender-sensitive structural equation modeling approach

INTRODUCTION

Mentalization, operationalized as reflective functioning (RF), allows individuals to interpret actions as caused by intentional mental states. Previous research highlighted the gender-specific associations between adolescents' internalizing and externalizing difficulties and mentalizing impairments. In addition, research suggested that mentalizing facilitates the creation of epistemic trust (ET) to evaluate social information as accurate, reliable, and relevant. However, few investigations explored the concurrent associations between RF, ET, and adolescent psychopathology.

METHODS

A sample of 447 Italian cisgender adolescents (57% assigned females at birth; age range 12-19 years old; Mage  = 15.54, SD = 1.98) self-reported RF (RFQY-5), ET towards mother, father, and peers (IPPA) and mental health problems (YSR-112). Gender-specific structural equation modeling explored the associations between RF, ET, and internalizing/externalizing problems.

RESULTS

Results suggested an excellent fit for the theoretical model and revealed gender-related associations. In females, findings suggest that ET mediates the association between RF and psychopathology, with indirect associations from RF through ET to lower internalizing and externalizing problems. However, in males, RF and ET display independent associations with psychopathology.

CONCLUSION

Overall, findings suggest that ET might be a transdiagnostic factor playing different roles associated with adolescent psychopathology. Indeed, links between RF and ET might help to explore gender differences in mental health problems in this developmental phase.

The development and psychometric evaluation of the Questionnaire Epistemic Trust (QET): A self-report assessment of epistemic trust

Epistemic trust (ET) refers to the predisposition to trust information as authentic, trustworthy and relevant to the self. Epistemic distrust - resulting from early adversity - may interfere with openness to social learning within the therapeutic encounter, reducing the ability to benefit from treatment. The self-report Questionnaire Epistemic Trust (QET) is a newly developed instrument that aims to assess ET. This study presents the first results on the psychometric properties of the QET in both a community and a clinical sample. Our findings indicate that the QET is composed of four meaningful subscales with good to excellent internal consistency. The QET shows relevant associations with related constructs like personality functioning, symptom distress and quality of life. QET scores clearly distinguish between a clinical and community sample and are associated with the quality of the therapeutic alliance. The QET provides a promising, brief and user-friendly instrument that could be used for a range of clinical and research purposes. Future studies with larger samples are needed to strengthen construct validity and to investigate the value of the QET to predict differential treatment responses or to study mechanisms of change.

A Model of Trust Processes in Borderline Personality Disorder: A Systematic Review

PURPOSE OF REVIEW

Unstable relationships are a core feature of borderline personality disorder (BPD). Impairments in trust processes (i.e., appraisal and learning regarding others' trustworthiness) can subserve interpersonal problems associated with BPD, but the determinants, mechanisms, consequences, and variations in trust impairments among individuals with BPD remain poorly characterized. Thus, a better understanding of such impairments could help target interventions that address the interpersonal problems of individuals with BPD beyond emotion dysregulation, impulsivity, and aggression.

RECENT FINDINGS

We conducted a pre-registered systematic review of empirical studies on trust processes and BPD features (k = 29). Results are organized around a heuristic model of trust processes in BPD comprising the following stages: developmental factors, prior beliefs and dispositions, situation perception, emotional states, trust appraisal, behavioral manifestations, and trust learning. Based on the synthesis of the findings, we recommended directions for future research and clinical assessment and intervention, such as managing trust during the early stages of therapy and considering improvements in trust processes as a central mechanism of change in treating individuals with BPD.

Predictors of psychotherapy dropout in patients with borderline personality disorder: A systematic review

INTRODUCTION

Borderline personality disorder (BPD) is a highly debilitating psychiatric condition. Despite the expansion of new BPD specific forms of psychotherapy in the last few decades, high dropout rates have been reported in these treatments. Treatment discontinuation is associated with poor patient outcomes, inefficient resource utilization and the demoralization of healthcare providers.

METHODS

In order to identify predictors of psychotherapy dropout among patients with BPD, a systematic search of Medline, the Cochrane Library, PsycInfo and PsycArticles was conducted. Studies included were randomized-controlled trials in which patients diagnosed with BPD were exposed to a therapeutic intervention consisted of an evidence-based psychotherapy. The quality of evidence in the studies was assessed through the use of revised Cochrane risk of bias tool.

RESULTS

Six articles, incorporating four types of psychotherapy programmes, were included. Overall, the studies present low risk of attrition and reporting bias and unclear risk of selection, performance and detection bias. Patients with weaker therapeutic alliance scores and higher hostility presented with higher dropout rates. In contrast, better mindfulness skills and greater performance in specific neuropsychological domains, such as memory and executive control, were identified as predictive of lower risk of dropout. Sociodemographic variables and treatment history did not influence treatment retention.

CONCLUSIONS

Factors that influence discontinuation should be taken into consideration in future treatment programmes, in an effort to optimize retention. Qualitative assessments of patients' reasons for dropping out may also help guide adjustments.

Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

OBJECTIVE

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

METHOD

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

RESULTS

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k2=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

CONCLUSIONS

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

Measuring mentalizing in youth: further validation of the reflective functioning questionnaire for youth (RFQY-13)

Objective

This study investigated the psychometric properties, including the factor structure, validity, and reliability of the 13-item Reflective Function Questionnaire for Youth (RFQY-13), using a new scoring system.

Method

A community sample of 414 adolescents and a clinical sample of 83 adolescents (aged 12-21) completed the RFQY, the Borderline Personality Features Scale for Children (BPFS-C), the Beck Youth Inventories (BYI), the Child Behavior Checklist-Youth Self Report (CBCL-YSR) and the Movie for the Assessment of Social Cognition (MASC).

Results

Using the new scoring system, our results demonstrated configural and metric invariance, as well as adequate reliability and validity across both samples for the two-factor structure of the RFQY. The Uncertainty subscale also showed strong associations with psychopathology.

Discussion

The findings show that the RFQY-13, when used with the new coding system, has good psychometric properties and is a reliable measure of mentalizing for adolescents and young adults. We discuss clinical implications, limitations and future directions.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Becoming Trustworthy in Treating Patients With Borderline Personality Disorder

No one doubts the importance of trust in psychotherapy, but few therapists think about the complexities of trusting relationships, and the trustworthiness that would justify trusting remains far from view. Fortunately, inasmuch as trusting and trustworthiness are inherently ethical concepts, contemporary philosophers have given trust the consideration it warrants. Integrating science and philosophy, the author reviews the broad scope and multifaceted nature of trust and trustworthiness, the social-cognitive development of trust, and the development of distrust in the context of borderline personality disorder. Without questioning therapists' character, the author makes the case for shifting the emphasis from the patient's distrust to the therapist's challenge to become trustworthy in the course of each treatment relationship and, more broadly, over the course of a professional career.

Contending With Polarization in the Expanding Scope of Psychotherapy

The author queried 32 colleagues about their sense of polarization in the field of psychotherapy, using as an example the contrast between generalists (like himself) and specialists. This query was inspired by the proliferation of brands of psychotherapy coupled with the dominance of cognitive-behavioral therapies. His key conclusions: (a) tensions in the field are associated with a multitude of polarities and individual differences; (b) it is folly to reduce polarization to any single polarity; and (c) given the field's huge diversity, we are all specialists. While the author advocates greater integration of theories and methods, he also argues for expansion by including ethical thought into the scientific zeitgeist. He proposes skill in being human as a broad aspiration for therapists and patients.

Epistemic trust and unchanging personal narratives

Focusing on imagination and the social context in the generation of conviction narratives, we propose that these elements are dynamically related to one another, and crucially that it is the nature of this relationship that determines individuals' level of epistemic openness and capacity to respond adaptively to update their narratives in a way that increases the possibility of more successful decision-making.

Adolescence in lockdown: The protective role of mentalizing and epistemic trust

OBJECTIVE

Mentalizing is the ability to interpret one's own and others' behavior as driven by intentional mental states. Epistemic trust (openness to interpersonally transmitted information) has been associated with mentalizing. Balanced mentalizing abilities allow people to cope with external and internal stressors. Studies show that social isolation imposed by the COVID-19 pandemic was highly stressful for most people, especially for adolescents. Here we examine whether mentalizing and epistemic trust were protective factors in relation to emotional distress during the lockdown.

METHOD

A total of 131 nonclinical adolescents, aged between 12 and 18 years, were evaluated during the lockdown using the Reflective Functioning Questionnaire for Youth, Inventory of Parent and Peer Attachment, Perceived Stress Scale, and Difficulties in Emotion Regulation Scale.

RESULTS

Results from network analysis showed that epistemic trust and mentalizing were negatively associated with perceived stress and emotion dysregulation. Epistemic trust in fathers was associated with level of perceived stress, and epistemic trust in mothers with emotion dysregulation.

CONCLUSION

These findings suggest that epistemic trust and the capacity to mentalize were low in adolescents during lockdown, and this was associated with high levels of stress. However, robust levels of epistemic trust and mentalizing may have acted as protective factors that buffered individuals from the risk of emotional dysregulation during the lockdown.

Mentalizing the therapist - Therapist experiences with short-term mentalization-based therapy for borderline personality disorder: A qualitative study

Background

Mentalization-Based Therapy (MBT) was originally developed as a structured psychotherapy approach developed to treat borderline personality disorder (BPD) lasting up to 18 months in outpatient settings. However, a short-term (5 months) MBT program has recently been developed. No studies have investigated how MBT therapists experience the shift towards conducting short-term MBT for BPD.

Objective

The objective of this study was to explore therapist experiences with conducting short-term MBT for outpatients with BPD in the Danish mental health services.

Methods

Semi-structured qualitative interviews were conducted with seven therapists about their experiences with short-term MBT after a one-year pilot phase. The interviews were verbatim transcribed and analyzed using thematic analysis.

Results

The following four major themes from the therapists' experiences with short-term MBT were found in the qualitative analysis: (1) The longer the better, (2) Change processes can be intellectual or experiential, (3) Short-term therapy is hard work, and (4) Termination is more challenging in short-term MBT.

Conclusion

Most therapists were overall reluctant towards changing from long-term to short-term MBT. These therapist experiences could inform implementation of short-term MBT in mental health settings in the future.

Attachment, Mentalizing and Trauma: Then (1992) and Now (2022)

This article reviews the current status of research on the relationship between attachment and trauma in developmental psychopathology. Beginning with a review of the major issues and the state-of-the-art in relation to current thinking in the field of attachment about the impact of trauma and the inter-generational transmission of trauma, the review then considers recent neurobiological work on mentalizing and trauma and suggests areas of new development and implications for clinical practice.

Measuring Impairments of Mentalization with the 15-Item Mentalization Questionnaire (MZQ) and Introducing the MZQ-6 Short Scale: Reliability, Validity and Norm Values Based on a Representative Sample of the German Population

Deficits in mentalization are indicated by impaired emotional awareness and self-reflectiveness, and are associated with various mental disorders. However, there is a lack of validated research instruments. In this study, the psychometric properties of the Mentalization Questionnaire (MZQ) were evaluated in a representative German population sample with n = 2487 participants. Analyses included evaluation of the MZQs acceptance, reliability, and validity. Factorial validity was established with exploratory (EFA) and confirmatory factor analyses (CFA) after the dataset was randomly split. Dimensionality was evaluated with a bi-factor model. For convergent validity, correlations with the OPD SQS, PHQ-4, and POMS were calculated. While acceptance was good, internal consistencies (ω = 0.65-0.79) and factor structure of the original four subscales were not acceptable (TLI = 0.87, CFI = 0.91, RMSEA = 0.071). EFA indicated a 3-factor solution, which was not confirmed by CFA (TLI = 0.89, CFI = 0.91, RMSEA = 0.073). Correlations between subscales and bi-factor analyses indicated an underlying general factor (TLI = 0.94, CFI = 0.96, RMSEA = 0.053). A shortened 6-item version was comparable to the original scale. Age and sex-specific representative norm-values are presented. The MZQ is a feasible, reliable and valid self-report instrument to measure representations of inner mental states. However, when applied to non-clinical samples, the total score of the MZQ should be used.

The in-session discourse of unresolved/disorganized psychotherapy patients: An exploratory study of an attachment classification

The Unresolved/disorganized (U/d) attachment classification has generated considerable interest among clinicians. This is in part based on its empirical associations with adult mental health, parenting practices, and treatment outcomes. Despite decades of theorizing, however, we have little empirical information regarding how patients with a U/d classification assigned by accredited coders actually behave or speak in psychotherapy sessions. Here, we take a step towards bridging this gap by reporting our observations of the psychotherapy session transcripts of 40 outpatients who were independently classified as U/d on the Adult Attachment Interview (AAI), the gold standard measure of adult attachment research. These patients were extracted from a larger sample of 181 and compared to others without a U/d classification. In this paper, we discuss two different discourse styles associated with a U/d classification. Some U/d patients did not seem to sufficiently elicit the therapist's endorsement of what they said. For example, they did not justify their claims with examples or explanations, or did not consider others' intentions or experiences. Other U/d patients were credible, but left the listener uncertain as to the underlying point of their discourse, for example, by glaringly omitting the consequences of their experiences, or interrupting their narratives mid-way. In the discussion, we place these observations in the context of recent thinking on attachment and epistemic trust, and discuss how this study may form the basis for future quantitative studies of psychotherapy.

Irony detection in patients with borderline personality disorder: an experimental study examining schizotypal traits, response biases and empathy

BACKGROUND

In verbal irony we often convey meanings that oppose the literal words. To look behind these words, we need to integrate perspectives of ourselves, others, and their beliefs about us. Although patients with borderline personality disorder (BPD) experience problems in social cognition and schizotypal symptoms, research on irony comprehension mainly focused on the schizophrenic spectrum. Accounting for possible negative biases in BPD, the current study examined the detection of praising and critical irony in a text messaging interface.

METHODS

The cross-sectional study included 30 patients and 30 matched controls, who completed measures of cognitive and affective empathy (Interpersonal Reactivity Index, IRI), schizotypal (Schizotypal Personality Questionnaire; SPQ), and borderline symptoms (Borderline Symptom List; BSL-23) and the irony detection task. The irony task contained critical and praising remarks embedded in text messages. Asking for literality (ironic vs. literal) and intention ratings (critical to praising) of the stimuli, it allowed to analyze the sensitivity of literality detection as well as implicit and explicit response biases in a signal detection framework.

RESULTS

Borderline symptoms explained lower sensitivity for the detection of literal and ironic statements across groups. Whereas HC showed a negativity bias when implicitly asked about the literalness of the statement, patients with BPD perceived praising utterances as less praising when explicitly asked about their perceived intention. Neither empathy nor schizotypy explained outcomes beyond borderline symptoms.

CONCLUSIONS

This was the first study to show lower detection of verbal irony in patients with BPD. While patients were less biased when asked about the literality of a statement, they perceived praising remarks as less positive on explicit measurements. The results highlight the importance of congruent, transparent communication in promoting epistemic trust in individuals with BPD.

Epistemic trust and personality functioning mediate the association between adverse childhood experiences and posttraumatic stress disorder and complex posttraumatic stress disorder in adulthood

Background

Adverse childhood experiences (ACEs) are associated with posttraumatic and complex posttraumatic stress disorder symptoms in adulthood (PTSD/cPTSD), as well as reduced epistemic trust (trust in the authenticity and personal relevance of interpersonally transmitted information) and impaired personality functioning. The present work aims to investigate the predictive value of epistemic trust-the capacity for social learning-on the mediating effect of personality functioning in the association of ACEs and PTSD/cPTSD.

Methods

We conducted structural equation modeling (SEM) based on representative data of the German population (N = 2,004). Personality functioning (OPD-SQS) was applied as a mediator between ACEs and PTSD/cPTSD (ITQ), while epistemic trust (ETMCQ) was added as predictor for OPD-SQS. TLI, CFI, and RMSEA (95%-CI) determined the models' fit.

Results

N = 477 (23.8%) participants reported at least one ACE and n = 218 (10.9%) reported ≥4 ACEs. Fit indices were good for both PTSD (TLI = 0.96; CFI = 0.99; RMSEA = 0.06; 95%CI: 0.041-0.078) and cPTSD (TLI = 0.96; CFI = 0.99; RMSEA = 0.06; 95%CI: 0.043-0.081). ACEs were significantly associated with cPTSD (β = 0.44, p < 0.001) and PTSD (β = 0.29, p < 0.001), explaining 20 and 8% of its variance. Adding personality functioning as a mediator increased the explained variance of cPTSD and PTSD to 47 and 19% while the direct association between ACEs and cPTSD/PTSD decreased (β = 0.21/β = 0.17), thus, indicating a partial mediation. Including epistemic trust substantially increased the explained variance for personality functioning (41%) compared to ACEs as a single predictor (16%).

Conclusion

We add to previous research emphasizing the association between ACEs and PTSD/cPTSD symptoms. Offering insights on underlying mechanisms, we show that epistemic trust and personality functioning are relevant mediators. Since both are modifiable by psychotherapy, knowledge about the role of these constructs can inform research on psychotherapeutic interventions and prevention.

The moderation effect of secure attachment on the relationship between positive events and wellbeing

Positive events can reduce depression as well as enhance wellbeing. The role of secure attachment style in moderating the relationship between positive events and wellbeing is examined to further understand wellbeing models. Participants (n = 490) included two midlife groups and a student group from the UK. They completed the online Computerized Life Event Assessment Record (CLEAR), a measure of life events, the Vulnerable Attachment Style Questionnaire (VASQ), and the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS). Age was associated with higher rates of wellbeing and secure attachment style. A significant relationship was found between number of positive events and wellbeing, number of people close, and secure attachment score. Hierarchical multiple regression indicated a significant interaction between secure attachment style, number of positive life events, and wellbeing. Simple slopes analysis demonstrated the association between positive life events and wellbeing was significant for secure attachment (B = 1.27, p = .003) but not insecure attachment (B = 0.04, non-significant). This suggests securely attached individuals are better able to take advantage of positive life events than insecurely attached individuals and experience a greater increase in wellbeing.

The interplay of Criterion A of the Alternative Model for Personality Disorders, mentalization and resilience during the COVID-19 pandemic

Background and aims

The COVID-19 pandemic has been accompanied by a worsening of mental health levels in some, while others manage to adapt or recover relatively quickly. Transdiagnostic factors such as personality functioning are thought to be involved in determining mental health outcomes. The present study focused on two constructs of personality functioning, Criterion A of the Alternative Model for Personality Disorders (AMPD, DSM-5) and mentalization, as predictors of depressive symptoms and life satisfaction during the COVID-19 pandemic. A second focus of the study was to examine whether this relationship was mediated by resilience.

Methods

Linear regression analyses were used to examine the relationship between personality functioning measured by Criterion A (AMPD, DSM-5) and mentalizing abilities as predictors, and depression and life satisfaction as mental health outcomes. To assess the hypothesis that this relationship is mediated by resilience a structural equation modeling approach was conducted. Data from N = 316 individuals from the general population were collected.

Results

Linear regression models revealed highly significant associations between Criterion A/mentalization and both outcome measures. Structural equation models showed a significant partial mediation by resilience of these relationships.

Conclusion

Our results support the hypothesis that mentalizing serves as a protective function by promoting resilience to the impact of stress and threats. Criterion A and mentalization performed similarly as predictors of mental health outcomes, providing empirically overlapping operationalizations of personality functioning. This finding emphasizes the importance of personality functioning in positive and negative mental health outcomes. Furthermore, our results are consistent with a mediating role of resilience.

Predicting depression outcomes throughout inpatient treatment using the general and specific personality disorder factors

BACKGROUND

Clinical intuition suggests that personality disorders hinder the treatment of depression, but research findings are mixed. One reason for this might be the way in which current assessment measures conflate general aspects of personality disorders, such as overall severity, with specific aspects, such as stylistic tendencies. The goal of this study was to clarify the unique contributions of the general and specific aspects of personality disorders to depression outcomes.

METHODS

Patients admitted to the Menninger Clinic, Houston, between 2012 and 2015 (N = 2352) were followed over a 6-8-week course of multimodal inpatient treatment. Personality disorder symptoms were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition Axis II Personality Screening Questionnaire at admission, and depression severity was assessed using the Patient Health Questionnaire-9 every fortnight. General and specific personality disorder factors estimated with a confirmatory bifactor model were used to predict latent growth curves of depression scores in a structural equation model.

RESULTS

The general factor predicted higher initial depression scores but not different rates of change. By contrast, the specific borderline factor predicted slower rates of decline in depression scores, while the specific antisocial factor predicted a U shaped pattern of change.

CONCLUSIONS

Personality disorder symptoms are best represented by a general factor that reflects overall personality disorder severity, and specific factors that reflect unique personality styles. The general factor predicts overall depression severity while specific factors predict poorer prognosis which may be masked in prior studies that do not separate the two.

Improving treatment outcomes for adolescents with borderline personality disorder through a socioecological approach

BACKGROUND

There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence - a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad.

CASE PRESENTATION

Here, we describe such an approach, and offer a clinical case example with a young 16-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail.

CONCLUSIONS

The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.

Defining the Concept and Clinical Features of Epistemic Trust: A Delphi study

Early identification of "patients at risk" for not completing regular treatment or not benefitting (sufficiently) from treatment might be among the most cost-effective strategies in mental health care. The recently introduced concept of epistemic trust (ET) may have the potential value to predict patients at risk and therefore act as a marker of treatment outcome. We argue that ET may be the final common pathway through which aversive relational experiences in the past result in interpersonal dysfunctioning, which in turn result in dysfunctional therapeutic relationships, rendering it difficult for patients to trust whatever is offered to learn in therapy. Hence, the concept of ET can play an essential role in personalized medicine, allowing for a more tailored treatment assignment to specific patients' characteristics, which may improve treatment outcomes. In this brief report, we define the clinical features of ET by describing its core domains based on consensus of expert opinion on the concept. The response rate was high, and there was a high level of agreement across experts, demonstrating a strong consensus between experts on the definition and clinical features of ET and mistrust and its significance to the understanding of personality disorders.By means of having a clear definition of the clinical features of ET, we hope to make it accessible for assessment.

Cognitive reappraisal training for parents of children with autism spectrum disorder

Parents of children with autism spectrum disorder (ASD) experience higher stress levels than those of typically developing children. The goal of the current study was to examine whether a mentalization-based intervention would enhance parental cognitive reappraisal, an adaptive form of emotion regulation associated with lower levels of stress. Findings from 27 parents who completed a short training indicated an improvement in cognitive reappraisal. In exploratory analyses, two different types of reappraisal were examined. The intervention-related improvement was found mainly with one type of reappraisal, namely reflective reappraisal that consist of cognitive reappraisal with mentalization characteristics. In light of the evidence indicating that high cognitive reappraisal and high reflective functioning are associated with quality caregiving, findings from the current study suggesting that a brief mentalization-based intervention supports ASD parents' cognitive reappraisal with mentalization characteristics are promising and warrant further investigation.

Interpersonal trust in adolescents with psychiatric disorders and borderline pathology

Background:

Adolescents with features of borderline personality disorder (BPD) may experience deficits in interpersonal trust; however, a simultaneous comparison of interpersonal trust among adolescents with BPD, other psychiatric disorders, and no psychiatric conditions (healthy controls) has never been conducted.

Objective:

The aims of this study were to 1) explore differences in interpersonal trust (emotional trust, honesty beliefs, and reliability beliefs) between these three groups, and 2) examine the incremental value of BPD features in association with interpersonal trust over and above internalizing and externalizing.

Method:

Adolescents (N = 445, 67.9% female, M_age = 15.13) recruited from two psychiatric hospitals (psychiatric sample, n = 280) and community organizations (healthy sample, n = 165) completed measures of BPD features, interpersonal trust, and internalizing and externalizing psychopathology. Psychiatric adolescents also completed an interview assessing BPD (n = 83 BPD). ANCOVA and hierarchical linear regression were used for analyses.

Results:

Emotional trust differed significantly across all three groups, with the lowest level of emotional trust in adolescents with BPD. Reliability was also lower in the two psychiatric groups relative to healthy controls. BPD features were significantly, inversely associated with emotional trust and reliability beliefs when controlling for internalizing and externalizing pathology. Post-hoc analyses testing specificity of the three forms of trust found that lower emotional trust predicted BPD diagnosis over and above the other two forms of trust.

Conclusions:

Findings highlight emotional trust as a correlate and important target of intervention for adolescents with BPD, and add to knowledge on interpersonal trust deficits for adolescents with psychiatric disorders more broadly.

The Cognitive, Ecological, and Developmental Origins of Self-Disturbance in Borderline Personality Disorder

Self-disturbance is recognized as a key symptom of Borderline Personality Disorder (BPD). Although it is the source of significant distress and significant costs to society, it is still poorly specified. In addition, current research and models on the etiology of BPD do not provide sufficient evidence or predictions about who is at risk of developing BPD and self-disturbance, and why. The aim of this review is to lay the foundations of a new model inspired by recent developments at the intersection of social cognition, behavioral ecology, and developmental biology. We argue that the sense of agency is an important dimension to consider when characterizing self-disturbances in BPD. Second, we address the poorly characterized relation between self-disturbances and adverse life conditions encountered early in life. We highlight the potential relevance of Life-History Theory-a major framework in evolutionary developmental biology-to make sense of this association. We put forward the idea that the effect of early life adversity on BPD symptomatology depends on the way individuals trade their limited resources between competing biological functions during development.

Understanding chronic feelings of emptiness in borderline personality disorder: a qualitative study

BACKGROUND

Chronic feelings of emptiness are significant in the lives of people with Borderline Personality Disorder (BPD). Feelings of emptiness have been linked to impulsivity, self-harm, suicidal behaviour and impaired psychosocial function. This study aimed to understand the experience of chronic emptiness, the cognitions, emotions and behaviours linked to emptiness, and clarify the differences between chronic emptiness and hopelessness, loneliness and depression.

METHODS

This study interviewed people (n = 15) with BPD and used a template analysis qualitative approach to understand their experiences of chronic feelings of emptiness.

RESULTS

Chronic feelings of emptiness were experienced as a feeling of disconnection from both self and others, and a sense of numbness and nothingness which was frequent and reduced functional capacity. Feelings of purposelessness and unfulfillment were closely associated with emptiness, and most participants experienced emptiness as distressing. Responses to feelings of emptiness varied, with participants largely engaging in either impulsive strategies to tolerate feelings of emptiness or distracting by using adaptive behaviours. Most participants distinguished chronic feelings of emptiness from loneliness, hopelessness, dissociation, and depression.

CONCLUSIONS

Feelings of chronic emptiness are an important and challenging symptom of BPD which require clinical intervention. Strengthening identity, sense of purpose and vocational and relationship functioning may reduce the intensity of emptiness.

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.