A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder

Goals and outcomes of chaplaincy in varying outpatient, primary, and community care contexts

Several studies have examined the goals and outcomes of chaplaincy within institutional settings. Our study contributes to the literature by examining whether chaplaincy goals and outcomes are specific to different outpatient, primary, and community care contexts. We conducted a round of 9 and one of 8 focus groups, with clients, chaplains, and other professionals from five contexts: the Dutch earthquake zone, general healthcare, pediatric palliative care, care for the unhoused, and veteran care. Using an explorative, descriptive and quantitative design, 77 goals and 59 outcomes are compared and categorized in a four-quadrant framework. Our findings show few differences between goals and outcomes of different contexts. However, the goals of care for the unhoused and veterans focus more on the inner experience of the relationship with the chaplain. Non-context-specific goals and outcomes might be related to how chaplaincy is approached, and the context-specific ones to existential concerns in the care contexts.

Impathy and Emotion Recognition: How Attachment Shapes Self- and Other-Focused Emotion Processing

Background/Objectives: Early attachment experiences and psychopathology both shape individuals' emotion processing. However, the specific influence of adult attachment representations on self- (intrapersonal) and other-focused (interpersonal) emotion processing remains unclear, particularly in the context of personality disorders. This study examined how attachment representations (organized vs. unresolved) modulate intrapersonal emotion perception ("impathy") and interpersonal emotion recognition while accounting for personality pathology. Methods: Thirty-three adults (twenty-four patients with a personality disorder and nine healthy controls) were assessed for attachment representation using the Adult Attachment Projective Picture System (AAP). Emotion processing was measured via the Impathy Inventory and a facial emotion recognition task (READ-64). Group differences (organized vs. unresolved attachment; patients vs. controls) and correlations with the severity of unresolved attachment status were analyzed. Results: Patients with organized attachment representations did not differ from healthy controls in emotion recognition but showed significantly reduced impathy (M difference = -21.72, SE = 6.20, p = 0.002, 95% CI [-34.42, -9.01], d = -1.57). In contrast, patients with unresolved attachment exhibited impairments in both intrapersonal (M difference = -32.99, SE = 6.20, p < 0.001, 95% CI [-45.69, -20.29], d = -2.39) and interpersonal (M difference = -12.37, SE = 4.36, p = 0.008, 95% CI [-21.28, -3.46], d = -1.23) emotion processing compared to healthy controls. Furthermore, the severity of unresolved attachment status correlated with greater impairment in recognizing anger (r = -0.74, p = 0.004). Conclusions: An organized attachment representation may act as a protective factor, preserving interpersonal emotion recognition even in the presence of psychopathology. Conversely, an unresolved attachment constitutes an additional risk factor that exacerbates emotion processing impairments in the context of personality pathology. Attachment representation thus emerges as an active modulator of core emotion processes, with important implications for theory and targeted interventions in personality disorders.

"If I could read your mind…": parental mentalizing in mothers with borderline personality disorder

BACKGROUND

Individuals with a borderline personality disorder (BPD) show impairments in their ability to mentalize. Particularly in the parent-child relationship, mentalizing is an important foundation for sensitive parenting and the quality of interactive behavior. Previous studies of parental mentalizing in mothers with BPD are scarce and have focused primarily on one aspect of the multidimensional construct. In addition, there is currently no research comparing different mental disorders on different aspects of parental mentalizing, leaving disorder-specific differences unclear. Aim of this study is to examine disorder-specific differences in reflective functioning and mind-mindedness, two facets of parental mentalizing.

METHODS

We compared mothers with BPD (n = 156) with a clinical control group of mothers with depressive or anxiety disorders (n = 65) and with healthy mothers (n = 91) using non-parametric inference for multivariate data. Mothers completed the Parental Reflective Functioning Questionnaire (PRFQ) and participated in a five-minute speech sample (FMSS) in which they reflected on their child and their relationship with their child. Verbal transcripts of the FMSS were rated using an adapted manual for coding mind-mindedness with the FMSS that incorporates the assessment of additional characteristics of mind-related speech.

RESULTS

Mothers with BPD showed the highest impairments in parental mentalizing compared to both other groups, as evident in both operationalizations: They made more maladaptive attributions (PRFQ pre-mentalizing) than the other two groups and reported lower interest and curiosity and certainty in mental states than healthy mothers. In addition, mothers with BPD used more mental attributes with negative valence when asked to describe their child and the relationship compared to both other groups and more self-related mental attributes compared to healthy mothers. Additionally, Pearson correlational analyses revealed that only the use of mental attributes with negative valence was associated with all three subscales of the PRFQ in the anticipated directions. This supports the idea that the two operationalizations target different facets of parental mentalization.

CONCLUSIONS

Our findings revealed impaired parental mentalization in several domains for mothers with BPD. Disorder-specific differences were observed in the amount of maladaptive attributions and in the negativity of mental state references. These aspects should be considered in diagnostic and therapeutic processes when working with mothers with BPD. As a limitation, it should be noted that the group comparisons did not control for sociodemographic variables, which may have contributed to some of the observed group differences.

Towards the understanding of the core of general personality disorder factor: g-PD and its relation to hostile attributions

There is a general consensus that personality disorders (PDs) share a general factor (g-PD) overlapping with the general factor of psychopathology (p-factor). The general psychopathology factor is related to many social dysfunctions, but its nature still remains to some extent ambiguous. We posit that hostile attributions may be explanatory for the factor common for all PDs, i.e., interpersonal problems and difficulty in building long-lasting and satisfying relationships of all kinds. Thus, the main objective of the current project was to expand the existing knowledge about underlying factors of g-PD with regard to hostile attributions. We performed a cross-sectional study on a representative, community sample of Poles (N = 1031). Our hypotheses were primarily confirmed as hostile attributions predicted p-factor. However, the relation was positive only for hostile attributions related to ambiguous situations involving relational harm and physical harm done by female authorities and negative in case of hostile attributions in situations involving physical harm done by peers. Additionally, paranoia-like thoughts strongly related to hostile attributions and independently predicted g-PD. The results contribute to the current discussion on the nature of the g-PD, confirm that hostile attributions and paranoia are a crucial aspect of personality pathology, and indicate the importance of working on these cognitions in the course of therapeutic work.

The freedom to mentalize: The influence of socio-demographic indicators of empowerment on parental reflective functioning

Parental reflective functioning (PRF), a critical construct in the field of infant mental health, has been under investigated in non-WEIRD countries, where the majority of the world's infants are born. Studies from WEIRD contexts have demonstrated a relationship between socio-demographic and parental reflective functioning scores. This study used a mixed-methods concurrent exploratory research design to investigate relationships between socio-demographic factors and parental reflective functioning in a cohort of Black mothers living in Alexandra Township, South Africa. The study found relationships between parental reflective functioning and both abuse disclosure and father involvement in unexpected directions. Qualitative analysis of interview transcripts and intervention case notes highlighted the potential role of empowerment in the participants PRF scores. The findings highlight the central importance of considering the influence of power dynamics and social positioning when measuring parental reflective functioning for both research and clinical purposes.

Mentalization-based interventions in schools for enhancing socio-emotional competencies and positive behaviour: a systematic review

Mentalization-based interventions (MBIs) have been increasingly applied in school settings to support the social-emotional development and mental health of children and adolescents. This systematic review aimed to synthesize the evidence on the effectiveness of MBIs implemented in educational contexts for students aged 6-18 years. A comprehensive search was conducted in PsychInfo, MEDLINE, EMBASE, Web of Science, and ERIC databases from inception to October 2023. The search strategy combined terms related to mentalization, school-based interventions, and the target age group. The review protocol was registered with PROSPERO (CRD42022302757). Inclusion criteria included peer-reviewed publications in English, studies published between 1980 and 2023, interventions based on mentalization principles, and a primary focus on children aged 6 to 18 years. Exclusion criteria involved non-mentalization based interventions and research outside the 6-18 age range. The risk of bias was assessed using the Quality Assessment Tools from the National Institutes of Health (NIH). Data were synthesized narratively due to the heterogeneity of study designs and outcomes. Of the 5,250 articles screened, 21 studies met the inclusion criteria, comprising over 7,500 participants. The reviewed interventions targeted various aspects of mentalizing, such as emotion-understanding, empathy, perspective-taking, and Theory of Mind. Significant improvements were found in social-cognitive abilities, emotion regulation, and mental health outcomes, including reductions in disruptive behaviours. Interventions that combined mentalizing training for both students and teachers showed promising results. However, the long-term sustainability of these benefits remains unclear. Limitations of the reviewed studies include the lack of control groups, small sample sizes, and variations in outcome measures. The findings highlight the potential of MBIs as a promising approach to fostering socio-emotional competence, positive behaviour, and well-being in school-aged children. Future research should aim to establish the active components and optimal delivery of these interventions through well-designed randomized controlled trials with larger, more diverse samples and extended follow-up periods. The integration of MBIs within educational systems holds promise for promoting resilience and positive mental health outcomes in young people. Embedding MBIs within school curriculums and evaluating cost-effectiveness are important next steps to guide widespread implementation.

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.

Improvement of alexithymia in patients treated in mental health services for personality disorders: a longitudinal, observational study

Background

The majority of mental health services include patients with personality disorder (PD) and comorbid conditions. Alexithymia, a psychological construct referring to difficulties in identifying and describing internal mental states, may represent a challenge to the psychotherapeutic treatment of patients with PD. This study aimed to investigate the prevalence of alexithymia among patients in specialized PD mental health services, differences according to PD severity and PD type, and the longitudinal course of alexithymia during treatment.

Methods

The study included 1,019 patients treated in specialized PD treatment units, with 70% of them with personality difficulties above the PD diagnostic threshold [borderline PD, 31%; avoidant PD, 39%; PD not otherwise specified (PD-NOS), 15%; other PDs, 15%; and more than one PD, 24%]. Alexithymia was measured repeatedly throughout treatment using the Toronto Alexithymia Scale (TAS-20) self-report questionnaire. Supplementary outcomes included global psychosocial function and health-related life quality. Linear mixed models were applied for data analysis.

Results

Alexithymia was highly prevalent in the sample: 53% of subjects reported high levels and 20% moderate levels. The TAS-20 subscale Difficulty Identifying Feelings was more strongly associated with borderline PD, while the subscale Difficulty Describing Feelings was more closely linked to avoidant PD. For all TAS subscales, poorer abilities were associated with more severe PD, higher levels of anxiety and depression, and poorer psychosocial functioning and life quality. Both alexithymia and measures of psychological functioning improved significantly during treatment with moderate effect sizes regardless of initial PD status. In total, 19% of the patients reported full remission of alexithymia.

Conclusion

Alexithymia is a common problem among patients with PDs and is associated with mental health difficulties and psychosocial dysfunction, with rates varying across PD type and severity. The study demonstrates moderate improvement of alexithymia during treatment in specialized PD mental health services. Further research should evaluate the effectiveness of different treatments and interventions in reducing alexithymia among PD patients.

Mentalizing Oneself and Others in Anorexia Nervosa: From Subjective Evaluation to Performance

OBJECTIVE

The present study examined impairment in two main dimensions of mentalizing (self-other and emotional-cognitive) in patients with anorexia nervosa (AN) by combining self-reported measures with performance-based tasks.

METHOD

Forty-five patients with AN recruited from an eating disorder unit and 45 healthy controls (HCs) recruited from the general population completed the Mentalization Scale and the Movie for Assessment of Social Cognition.

RESULTS

The results revealed that in self-reported evaluations of their mentalization process, patients with AN hypo-mentalized about themselves and others' mental states. However, they used more hyper-mentalizing than HCs when mentalizing others' emotional and cognitive mental states in performance-based tasks. Finally, the severity of eating symptoms in patients with AN was associated with higher levels of perceived hypo-mentalizing about their own mental states and lower levels of perceived hypo-mentalizing of others' mental states. No associations were found between the severity of eating symptoms and mentalizing performance.

CONCLUSIONS

This study emphasizes the importance of mentalizing impairment in patients with AN, which should be considered via a multidimensional approach that considers both emotional and cognitive dimensions and the ability to assess patients' competences.

Emotional arousal and reflective functioning among parents participating in attachment-based family therapy for LGBTQ+ young adults and their nonaccepting parents

OBJECTIVE

Parents' rejection of their LGBTQ + young adults can have a negative impact on their young adult's psychological welfare, and on the young adult-parent relationship. Parents' ability to reflect on their child's pain and unmet needs is thought to evoke empathy and compassion, and reduce rejection. Empirical and clinical evidence suggest that parents' level of reflective functioning (RF) is impacted by their level of emotional arousal (EA). This study examined the association between parents' EA and RF within the context of attachment-based family therapy for nonaccepting parents and their LGBTQ+ young adults.

METHODS

43 therapy sessions drawn from six different cases were coded for parental RF and EA, based on 30-second segments. This generated a total of 343 observations for analyses.

RESULTS

Hierarchal linear modeling revealed that parents' level of RF was a function of their concomitant EA, with moderate levels of arousal predicting the highest RF levels.

CONCLUSION

Moderate EA may facilitate optimal parental reflective functioning. With nonaccepting parents, who typically present for treatment with high levels of maladaptive fear and shame, therapists would do well to assess their level of arousal and, when indicated, employ downregulating interventions before inviting them to reflect on their young adult's experience and needs.

A qualitative evaluation of the reflective fostering programme - examining foster and kinship carers' experiences, practical application, and perceived impact

BACKGROUND

Mentalization is the ability to think about and interpret behaviours of both self and others in terms of thoughts and feelings. Caregiver's capacity to mentalize can enhance the quality of parent-child relationships. The UK Reflective Fostering Programme (RFP) has been developed to enhance foster and kinship carers' self-regulation and self-mentalizing.

AIM

To understand carers' experiences, practical application, and perceived impact of the RFP.

METHODS

A qualitative evaluation of the RFP using in depth interviews with twenty-four carers. Interviews were audio-recorded, transcribed verbatim and analysed thematically.

RESULTS

Three key themes were identified: (1) 'Me time' - carer's reflections on the programme and what makes it work, highlights sharing of challenging experiences as important for practising mentalizing. (2) 'Stopping and thinking in the moment' - carer's understanding of programme concepts explores carer's conceptualizations of mentalization, revealing some male carers described challenges regarding sharing personal experiences in a group and the practical application of mentalization. (3) Practical application and perceived impact of the programme suggests successful enactment of learning from the programme, resulting in enhanced capacity to cope with stress, prevention of outbursts and better communication with children in their care.

CONCLUSIONS

Our findings suggest the programme can successfully facilitate carer's use of self-mentalizing, leading to greater self-regulation and capacity to support children in their care. Future research should explore experiences of male and kinship carers to inform tailoring.

Relationship-Specific Attachment and Mentalization as Predictors of Borderline Personality Features and Interpersonal Competence Among Emerging Adults

Developmental psychopathology models, like the mentalization theory, have facilitated the theoretical understanding of trajectories that contribute to the expression and experience of borderline personality (BP) features. Mentalization theory posits that BP vulnerabilities and interpersonal difficulties arise from insecure attachment experiences and deficits in mentalizing ability. This study explored the intersections of attachment vulnerabilities in close relationships, mentalizing domains, and their combined impact on BP features and interpersonal competence in emerging adults. The sample included 742 emerging adults (18-25 years) from colleges across 23 Indian states, who completed an online survey measuring relationship-specific attachment anxiety and avoidance (mother, father, best friend), mentalization (self-related, other-related, motivation to mentalize), BP features, and interpersonal competence. Path analysis was conducted to examine (a) the association between relationship-specific attachment dimensions and BP features/interpersonal competence and (b) mentalization as a mediator. Attachment anxiety and avoidance in specific relationships were found to have direct positive effects on BP features and direct negative effects on interpersonal competence. However, the strength and significance of these effects were not similar across relationships, shedding light on unique contributions of relationship-specific attachment difficulties on BP features and interpersonal competence. Mentalization mediated these associations, with self-related mentalization uniquely affecting BP features and other-related mentalization influencing interpersonal competence. The findings underscore the importance of relationship-specific attachment and mentalization domains in BP vulnerabilities among emerging adults. They provide empirical support for developing targeted mentalization-based interventions to enhance self and interpersonal functioning.

Disruption of Epistemic Trust in Borderline Personality Disorder: A Possible Adaptation to Avoid Making Costly Mistakes

This paper applies error management theory (EMT) (Haselton and Buss 2000) to explore how disruptions in epistemic trust-trust in communicated information-can be understood as adaptive responses to early adversity in individuals with borderline personality disorder (BPD). I propose that epistemic mistrust (EM) and epistemic credulity (EC), characterized by inappropriate trust patterns, arise from the differential costs of trusting unreliable versus mistrusting reliable information. Although these biases may seem maladaptive, they function as evolutionary survival mechanisms in response to harsh environments. Signal detection analysis can provide empirical evidence for these trust biases by assessing how individuals with BPD make trust-related decisions. Clinically, understanding these biases as evolutionary adaptations helps reduce stigma and informs evolutionary-informed interventions to recalibrate trust responses and improve interpersonal relationships. This approach highlights the significance of integrating evolutionary perspectives in treating trust disturbances in BPD.

Transference-focused psychotherapy in an inpatient setting for borderline personality disorders: changes in symptomatology

This prospective, naturalistic, longitudinal study examined changes in borderline-specific symptoms in a six-month, manualbased transference-focused psychotherapy (TFP) inpatient treatment for patients with borderline personality disorder (BPD) in comparison to a waitlist control group. Seventy-four patients with BPD received TFP in a multi-professional inpatient setting, of whom 27 patients represented the waitlist control group. 31 patients completed six months of treatment. Borderline-specific symptoms were measured by means of the Borderline Symptom List (BSL-23) prior to treatment (waitlist control group), at the beginning, after 3 months, and at the end of it. BSL-23 scores decreased significantly from the beginning to the end of the six-month inpatient therapy program with a medium effect size of d=0.54. There was no change in symptoms for the waitlist control group. Our findings suggest that inpatient TFP is effective in terms of the reduction of borderline-specific symptoms. In terms of this, the duration of the treatment seems to be a meaningful factor. Further research will investigate changes in specific psychodynamic aspects as well as in the follow-up measurement.

Associations of Child Amygdala Development With Borderline Personality Symptoms During Adolescence

BACKGROUND

The current understanding of the neural correlates of borderline personality disorder (BPD) is limited, but some evidence suggests that alterations in limbic structures play a role in adult BPD. The developmental course of structural neural differences in BPD is unknown. Whether there is specificity for structural alterations in BPD compared to other psychiatric presentations, such as major depressive disorder (MDD), remains unexplored. In the current study, we examined childhood trajectories of 2 limbic regions that have been implicated in BPD, hippocampal and amygdala volume, as they relate to adolescent BPD symptoms compared to MDD symptoms.

METHODS

Participants (n = 175; 85 [48.6%] female) were from a 17-year longitudinal study of preschool depression. Participants completed up to 5 magnetic resonance imaging scans from late childhood through adolescence. General linear models were used to examine the relationship between gray matter volume intercepts/slopes and BPD symptoms to understand the influence of the developmental trajectory of brain regions on BPD. Separate models were used to examine the relationship between MDD symptoms and volume intercepts to assess diagnostic specificity.

RESULTS

Lower childhood amygdala volume (intercept; age 13 centered) across scans was associated with higher adolescent BPD symptoms (β = -0.25, adjusted p = .015). There was no relationship between the slope of amygdala volume and BPD symptoms. There was no relationship between hippocampal volume and BPD or any relationship between amygdala or hippocampal volume and MDD symptoms during adolescence.

CONCLUSIONS

Our findings add evidence that supports the role of alterations in amygdala structure in BPD development. Decreased amygdala volume as early as age 13 may be an early indicator of the development of BPD during adolescence.

Progress in mentalizing ability among people with psychosis through dialogic literary gatherings

BACKGROUND

People with psychosis often experience a fragmented sense of self, making it difficult to integrate perceptions, memories, thoughts, and emotions related to themselves and others. Enhancing mentalization processes and fostering reflection are crucial for comprehensive recovery. As these processes are naturally developed through meaningful interactions and dialogue, incorporating a dialogic approach into the treatment of psychotic disorders may significantly support recovery.

METHODS

This study examines the impact of Dialogic Literary Gatherings (DLGs) on the ability of mentalizing in individuals with psychosis. A quasi-experimental mixed-methods study was conducted with 23 participants (6 women and 17 men) diagnosed with psychosis. Over five months, participants engaged in 18 DLG sessions. Mentalizing ability was assessed using the Mentalization Scale (MentS), and qualitative data included interviews (n = 2) and focus groups (n = 3), to explore changes in mentalization.

RESULTS

Participants reported an increase in mentalizing towards others and toward him or herself, and in motivation to mentalize. Dialogues during DLGs fostered empathy, awareness of individual differences, and deeper engagement with others' emotions. Besides, sharing feelings in this dialogic environment enabled participants to reflect on past experiences and find purpose in life. Consistently, patients reported that these dialogues provided a platform for expressing emotions, re-evaluating life perspectives, and achieving greater self-awareness.

CONCLUSIONS

This study highlights Dialogic Literary Gatherings as a valuable tool for enhancing the ability to mentalize in clinical populations, offering a complementary approach to traditional psychotherapeutic interventions for individuals with psychosis.

Atypical functional connectome is associated with low reflective functioning in incarcerated adolescents

Introduction

While functional neuroimaging studies have reported on the neural correlates of severe antisocial behaviors, such as delinquency, little is known about whole brain resting state functional connectivity (FC) of incarcerated adolescents (IA). The aim of the present study is to identify potential differences in resting state connectivity between a group of male IA, compared to community adolescents (CA). The second objective is to investigate the relations among FC and psychological factors associated with delinquent behaviors, namely psychopathic traits (callous unemotional traits, interpersonal problems, and impulsivity), socio-cognitive (empathy and reflective functioning RF) impairments and psychological problems (externalizing, internalizing, attention and thought problems).

Methods

31 male IA and 30 male CA participated in 8 minutes resting state functional MRI. Network Based Statistics (NBS) was used to compare FC among 142 brain regions between the two groups. Correlation and regressions analysis were performed to explore the associations between FC and the self-reported psychopathic traits, empathy, RF, and psychological problems.

Results

Compared to the CA, the IA group presented significantly increased resting state FC in a distributed subnetwork including medial prefrontal, posterior and dorsal cingulate, temporal, and occipital regions. Both within the IA group and across the whole sample, increased mean connectivity of the subnetwork correlated with lower RF (RF uncertainty). Across the whole sample, the mean connectivity was associated with higher scores of externalizing problems and impulsivity dimension of psychopathy.

Discussion

While extending the characterization of whole brain resting state FC in IA, our results also provide insights into the neurofunctional mechanisms linking low reflective functioning abilities to externalizing behavior during adolescence.

Influences of maternal reflective functioning on adolescents' psychosocial adjustment: The mediating role of adolescent's reflective functioning

This study examines the relationship between maternal reflective functioning and adolescents' reflective functioning and psychosocial adjustment. In Study 1, The Parental Reflective Functioning Questionnaire for Adolescents (PRFQ-A) and Reflective Functioning Questionnaire for Youth (RFQ-Y), multidimensional scales used to assess reflective functioning in parents and adolescents, respectively, were validated in groups of Korean adolescents and mothers. In the results, the three factors were extracted (non-mentalizing, certainty, interest/curiosity) that were similar to those from the original version of the scale. However, the items comprising the interest/curiosity factor of the Korean validated RFQ-Y differed from the original scale. Both the reliability and validity of the scale were confirmed. Study 2 examined the mediating effects of adolescent reflective function on the relationship between parental reflective functioning and adolescent psychosocial adjustment. The structural equation modeling showed a good fit for all three models (adolescents' uncertainty/confusion, certainty, and interest/curiosity). However, some mediating effects of adolescents' reflective function were not confirmed. In conclusion, the results indicate that maternal reflective function influences the adolescents' psychosocial function through the mediating factor of adolescent reflective function, Unexpectedly, maternal interest/curiosity did not have a significant effect on adolescents' reflective function and psychosocial adjustment. Based on the results, altering Korean mothers' parenting attitudes may have a positive effect on adolescents' psychosocial adjustment. This work highlights that further research is needed to understand parent-child relationships in terms of reflective functioning, taking into account the influence of cultural context.

Early affective empathy, emotion contagion, and empathic concern in borderline personality disorder: A systematic review and meta-analysis

BACKGROUND

Individuals with Borderline Personality Disorder (BPD) are theorized to experience lower cognitive empathy but heightened affective empathy. Despite meta-analyses addressing cognitive empathy, affective empathy remains unexplored. This pre-registered systematic review and meta-analysis investigated affective empathy in individuals with BPD or high BPD traits relative to healthy comparisons, using a multidimensional approach including, early affective empathy, emotion contagion, and empathic concern.

METHODS

Systematic search of SCOPUS, PubMed, Medline COMPLETE, and PsycINFO (June 27, 2022, May 14, 2023, and July 1, 2024) was completed. Included studies compared affective empathy in those with BPD/high BPD traits with healthy comparisons, utilized experimental or self-report designs, and were peer-reviewed or PhD theses. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Among 22 eligible studies identified, results revealed individuals with BPD/high BPD traits showed significantly higher emotion contagion (Npooled = 1797, g = -1.10, 95 % CI [-1.57, -0.62]). No significant differences were found in empathic concern (Npooled = 1545, g = 0.06, 95 % CI [-0.10, 0.22]), or early affective empathy for anger (Npooled = 245, g = 0.28, 95 % CI [-0.0.53, 1.09]) and happiness, (Npooled = 189, g = 0.34, 95 % CI [-0.1.50, 2.18]).

LIMITATIONS

Few included studies for early affective empathy, methodological shortcomings in the broader literature and study heterogeneity suggest caution when interpreting these effects, emphasizing the need for targeted research.

CONCLUSIONS

While individuals with BPD/high BPD traits are more likely to subjectively experience others' distress through emotion contagion, no differences were found in early affective empathy or ability to direct sympathy and concern towards others.

What do we know about parental embodied mentalizing? A systematic review of the construct, assessment, empirical findings, gaps and further steps

Before the maturation of higher-order cognitive functions, infants primarily communicate via bodily expressions. Their behavior adjustments are also shaped by caregiver reactions, which differ in timing, intensity, and nature. Although mentalizing, or reflective functioning, is thought to influence caregiver interactions, the literature has largely focused on mentalizing as an explicit, cognitive process. Given the inherently embodied nature of early parent-infant exchanges, this emphasis left a clear gap in capturing the implicit facets of parental mentalizing. Addressing this, the concept of "parental embodied mentalizing" (PEM) was developed, which pertains to a caregiver's implicit capacity to discern and respond to an infant's emotional states, thoughts, and intents through bodily movements, gauged via real-time, shared, kinesthetic interplays. This systematic narrative review explores the PEM construct, scrutinizing its theoretical foundations and empirical basis. We aggregate insights from relevant studies, review the current research landscape's strengths and limitations, and pinpoint areas ripe for further investigation.

A computational signature of self-other mergence in Borderline Personality Disorder

A tendency to merge mental representations of self and other is thought to underpin the intense and unstable relationships that feature in Borderline Personality Disorder (BPD). However, clinical theories of BPD do not specify, in computational terms, how the perspectives of self and other might become confused. To address this question, we used a probabilistic false belief task (p-FBT) to examine how individuals with BPD (N = 38) and matched controls from the general population (N = 74) selectively assigned beliefs to self or other. The p-FBT requires participants to track a gradually changing quantity, whilst also predicting another person's belief about that quantity. We found that BPD participants showed less selectivity in belief assignment compared with controls (Cohen's d = 0.64). Behaviourally, participants with BPD tended to predict that others' beliefs resembled their own. Modelling analysis revealed that BPD participants were prone to generalise their own learning signals to others. Furthermore, this generalising tendency correlated with BPD symptomatology across participants, even when controlling for demographic factors and affective psychopathology. Our results support a computational account of self-other mergence, based on a generalisation of learning across agents. Self-other generalisation in learning purports to explain key clinical features of BPD, and suggests a potential transdiagnostic marker of mentalising capability.

Attachment as a predictor of dropout in mentalization-based treatment

OBJECTIVES

Although treatments of patients with borderline personality disorder (BPD) were historically associated with relatively high dropout rates, dropout rates in contemporary evidence-based treatments for BPD are typically substantially lower. However, only a few studies have investigated dropout rates in mentalization-based treatment (MBT), and even fewer have investigated predictors of dropout in this type of treatment. In this study, we investigated dropout rates in two types of MBT (day hospital MBT [MBT-DH] and intensive outpatient MBT [MBT-IOP]) using data from a recent multicenter randomized clinical trial. Given the central importance of attachment considerations in MBT, we also investigated the relationship between dropout in these two treatments and attachment dimensions.

DESIGN

Within a multicenter randomized clinical trial, 114 BPD patients were randomized to MBT-DH (n = 70) or MBT-IOP (n = 44).

METHODS

Dropout in both types of MBT was investigated using descriptive analyses, and its association with attachment anxiety and attachment avoidance, as measured by the Experiences in Close Relationships questionnaire at baseline, was investigated using regression analyses.

RESULTS

Dropout rates were relatively low (10.5% across both types of MBT) and did not significantly differ between groups (11.4% in MBT-DH, 9.1% in MBT-IOP). Attachment avoidance and attachment anxiety did not impact dropout, nor did their interaction or the interaction with the type of MBT.

CONCLUSIONS

Low dropout rates in both types of MBT indicate a high level of engagement of patients in both programmes. Attachment dimensions were not associated with dropout, consistent with the principle that MBT is tailored to each individual's needs. More research is needed, however, to investigate to what extent attachment is a dynamic context-bound adaptive process rather than a static personality feature.

Mentalizing individuals, families and systems: Towards a translational socioecological approach

Mentalization-based treatment (MBT) is a spectrum of interventions that share a central focus on improving the capacity for mentalizing. Although MBT was originally developed as a treatment for individuals with borderline personality disorder, its scope and focus have been broadened to become a socioecological approach that stresses the role of broader sociocultural factors in determining the closely related capacities for mentalizing and epistemic trust. This special issue brings together some of the newest developments in MBT that illustrate this shift. These contributions also highlight several current limitations in mentalization-based approaches, providing important pointers for further research. In this editorial, we first outline the broadening scope of the mentalizing approach, and then provide a discussion of each of the contributions to this special issue in the context of the need for further research concerning some of the key assumptions of mentalization-based approaches and their implementation in clinical practice. We close this editorial with considerations concerning future research.

A thematic analysis of the subjective experiences of mothers with borderline personality disorder who completed Mother-Infant Dialectical Behaviour Therapy: a 3-year follow-up

BACKGROUND

Perinatal borderline personality disorder (BPD) is a common condition in perinatal mental health settings with few specialised treatment options, and little is known about the enduring effects of available treatment programs. This study explored the follow-up experiences of women with BPD after completing Mother-Infant Dialectical Behaviour Therapy (MI-DBT).

METHODS

Semi-structured interviews were conducted with eight women who had completed MI-DBT 3 years prior. Reflexive Thematic Analysis was used to analyse the interviews to gain a richer understanding of these mothers' lived experience.

RESULTS

A thematic analysis generated four main themes which indicated that participants found that MI-DBT improved their ability to hold their child in mind, be aware of their own internal state and behaviours, manage their own emotional reactions and stay calm, and manage interpersonal interactions within adult relationships. Mothers with perinatal borderline personality disorder also highlighted the need for ongoing support in the context of parenting.

CONCLUSIONS

This study is the first of its kind to explore the longer-term experiences of mothers following such an intervention, giving voice to this vulnerable group of women. The findings of this study provide a greater understanding of the complex challenges experienced as part of parenting for mothers with borderline personality disorder, and provides both insight into mothers' experiences of life after MI-DBT and the impact of the program on their lives. The clinical and research implications of the study's findings are discussed.

TRIAL REGISTRATION

This research was retrospectively registered on 07/03/2024, ACTRN12624000225516.

Associations between neurolinguistic deficits and personality traits in people with epilepsy

Introduction

People with epilepsy (PWE) have been hypothesized to have higher prevalence of personality disorders and cognitive disorders. The objective of this study was to investigate the controversial notion of "epileptic personality," a series of supposedly specific personality traits of people with epilepsy (PWE).

Methods

For this purpose, 29 individuals with Mesial Temporal lobe Epilepsy (MTLE) and 23 with Juvenile myoclonic epilepsy (JME) as confirmed by electroencephalography (EEG), MRI scans and clinical examination, underwent a thorough neuropsychological and personality assessment. The resulting neuropsychological profiles were statistically analyzed considering possible personality disorders, character traits, cognitive and linguistic deviations from 20 healthy controls (HC).

Results

Our findings suggest accumulative cognitive and linguistic deficits in individuals with epilepsy compared to controls. It is possible that these might be misinterpreted as personality disorders. Specifically, personality traits (p = 0.049) and verbal fluency (p = 0.013), were significantly different between PWEs and controls. Also, the type of epilepsy and lateralization seem to affect executive function (p = 0.049) and pragmatology scores (p < 0.001), exhibiting differences in subgroup analysis.

Discussion

Different theories are considered as plausible pathophysiological explanations for the aforementioned differences. This research might serve as a basis to further investigate the cognitive aspects of epilepsy and possible pharmacological interventions, which are currently lacking.

Change in emotion-based narrative as a potential mechanism of change in a brief treatment for borderline personality disorder

Background: The move from inconsistent and problematic autobiographical narrative to a more coherent and reality-based narrative construction of the Self has been discussed as potential mechanism of change in psychotherapies for personality disorders. So far, little empirical evidence exists that demonstrates in a time-dependent design the role of narrative construction in the treatment of borderline personality disorder, in particular when it comes to understanding the integration of body-related information from the affective system with the autobiographical narrative. The present study aims at demonstrating change in emotion-based narrative markers over brief psychiatric treatment and to assess the impact of these changes on subsequent symptom change. Methods: A total of N = 57 clients with borderline personality disorder were assessed at three timepoint over the course of four months of brief psychiatric treatment, within the context of a secondary process-outcome analysis of a randomized controlled trial. Symptom change was assessed using the OQ-45.2 and emotion-narrative change was assessed using the Narrative-Emotion Process Coding System to code client's in-session speech in terms of problem, transition and change markers. Results: All three emotion-based marker categories evidenced significant changes in the assumed direction. The reduction in problem emotion-based narrative markers (e.g., empty story telling) between session 1 and 5 into the treatment predicted the symptom reduction assessed between session 5 and 10. Conclusions: Emotion-based narrative construction may be a suitable method to study the pathway of change toward a more coherent and reality-based narrative construction of the Self-in-interaction-with-the-Other. Reduction of emotion-based problem-marker may be a promising candidate for a mechanism of change in treatments for personality disorders which should be tested in a time-dependent controlled design.

Neural correlates of distress and comfort in individuals with avoidant, anxious and secure attachment style: an fMRI study

Despite a growing literature, experiments directly related to attachment are still needed. We explored brain processes involved in two aspects of attachment, distress and comfort. Seventy-eight healthy adult males with different attachment styles (secure, avoidant, and anxious) viewed distress, comfort, complicity-joy and neutral images (picture database BAPS-Adult) in an fMRI block design. ROIs from the modules described in the functional Neuro-Anatomical Model of Attachment (Long et al. 2020) were studied. Secure participants used more co- and self-regulation strategies and exhibited a higher activation of the reward network in distress and comfort viewing, than insecure participants. Avoidant participants showed the lower brain activations. Their approach and reward modules were the least activated in distress and comfort. Anxious participants presented both higher activations of the approach and aversion modules during complicity-joy. In addition, comfort and complicity-joy were processed differently according to attachment styles and should be differentiated among positive stimuli to disentangle attachment processes.

A meta-analysis on the neuropsychological correlates of Borderline Personality Disorder: An update

Previous research on Borderline Personality Disorder (BPD) demonstrated dysfunction across a broad range of cognitive domains. However, the limited number of neuropsychological studies on BPD and their occasionally conflicting results have precluded a clear characterization of the neuropsychological features associated with this personality disorder. Therefore, the main aim of the present study is to provide an updated overview of neuropsychological functions related to BPD. A meta-analysis of 36 studies was performed, comparing the performance of BPD patients and healthy controls (HCs) across several cognitive domains. Significant differences between BPD patients and HCs in multiple cognitive domains were found. The smallest effect size was observed for general executive function, while the largest effect sizes were found in the long-term spatial memory and inhibition domains. In conclusion, the neuropsychological profile of BPD, characterized by deficits in inhibition as well as attention, memory, and executive functions, can result in difficulties in performing everyday activities. Accordingly, assessing neuropsychological functions could assist clinicians in developing more targeted non-pharmacological treatments.

The complexity of interpersonal physiology during rupture and repair episodes in the treatment of borderline personality disorder: a proof-of-concept multimethod single case study of verbal and non-verbal interactional dynamics

Introduction

The aim of this proof-of-concept multimethod exploratory single case study is to increase knowledge of the underlying mechanisms of alliance ruptures and repairs in Borderline Personality Disorder treatment across and within the psychotherapeutic treatment process.

Method

The multimethod includes outcome assessment of patient self-reporting questionnaires (the Affect Integration Inventory, the Hopkins Symptom Checklist), observation-based ratings of sessions with the Rupture Resolution Rating System, quantitative analysis of heart rate variability using recurrence quantification analysis, and a qualitative multimodal interaction analysis of within-session dynamics.

Result

Results reveal how patterns of heart rate synchrony between patient and therapist reflect periodical patterns of emotional interaction corresponding to key therapeutic alliance processes throughout the treatment process. Particularly, heart rate synchronization and desynchronization correspond with increasing rupture resolution ratings and positive outcome measures in the last part of the therapy process, indicating increased productivity, affectivity, and positive change. The qualitative microanalysis highlights context sensitivity to alliance management within sessions. Physiological arousal is found to underlie important alliance processes, including emotion regulation, relatedness, security, empathic responding, sense-making, and validation in correspondence with different therapist verbal and non-verbal markerbs.

Discussion

Clinical implications and study limitations are discussed. Recommendations are made for future directions in relation to applying multimethod approaches when studying rupture and repair processes in psychotherapy.

Reflective functioning and emotion regulation in adolescents with a history of sexual offending: a comparative study with a non-offending control group

BACKGROUND

Sexual offenses encompass a diverse array of behaviors across various contexts, affecting numerous individuals. Despite the prevalence of sexual offending among adolescents, there is still a limited understanding of this population. To contribute further to the literature in this field, the present study was conducted to compare a group of male adolescents convicted of sexual offenses with a control group in terms of reflective functioning (RF), emotion regulation (ER) strategies, and emotion dysregulation (ED).

METHODS

60 male adolescents aged 12 to 18 years (M = 16.90; SD = 0.97) who had been convicted of at least one serious sexual offense were recruited from male adolescents referred by juvenile courts to the Legal Medicine Organization in Mashhad, Iran, and compared with a control group of non-offending adolescents consisting of 60 male adolescents aged 12 to 18 years (M = 16.97; SD = 0.82) who were attending school. The groups were matched on age and education level.

RESULTS

A comparison between these two groups revealed that adolescents with a history of sexual offending exhibited poorer RF capacity, greater use of suppression as an ER strategy, and higher scores in all ED domains (p's < 0.001) except non-acceptance of emotional responses compared with the control group.

CONCLUSIONS

Results suggest that RF, ER strategies, and ED need to be considered as important psychological factors in understanding and treating adolescents with a history of sexual offending.

The use of mentalization-based techniques in online psychodynamic child psychotherapy

Objective: Psychodynamic child psychotherapy is an evidence-based approach for a range of child mental health difficulties and needs to constantly adapt to meet the needs of children. This study is the first to investigate whether the use of mentalization-based interventions (i.e., a focus on promoting attention control, emotion regulation, and explicit mentalization) predicted a good therapeutic outcome in online psychodynamic child therapy sessions conducted during the COVID-19 pandemic. Methods: The sample included 51 Turkish children (Mage = 7.43, 49% girls) with mixed emotional and behavioral problems. Independent raters coded 203 sessions from different phases in each child's treatment using the Mentalization-Based Treatment for Children Adherence Scale (MBT-CAS). Results: Multilevel modeling analyses showed children with higher emotional lability benefited more from attention control interventions compared to those with lower emotional lability. Discussion: Interventions that focus on developing the basic building blocks of mentalizing may be effective components of therapeutic action for online delivery of psychodynamic child psychotherapy, especially for children with greater emotional lability.

A machine-learning approach for differentiating borderline personality disorder from community participants with brain-wide functional connectivity

BACKGROUND

Functional connectivity has garnered interest as a potential biomarker of psychiatric disorders including borderline personality disorder (BPD). However, small sample sizes and lack of within-study replications have led to divergent findings with no clear spatial foci.

AIMS

Evaluate discriminative performance and generalizability of functional connectivity markers for BPD.

METHOD

Whole-brain fMRI resting state functional connectivity in matched subsamples of 116 BPD and 72 control individuals defined by three grouping strategies. We predicted BPD status using classifiers with repeated cross-validation based on multiscale functional connectivity within and between regions of interest (ROIs) covering the whole brain-global ROI-based network, seed-based ROI-connectivity, functional consistency, and voxel-to-voxel connectivity-and evaluated the generalizability of the classification in the left-out portion of non-matched data.

RESULTS

Full-brain connectivity allowed classification (∼70 %) of BPD patients vs. controls in matched inner cross-validation. The classification remained significant when applied to unmatched out-of-sample data (∼61-70 %). Highest seed-based accuracies were in a similar range to global accuracies (∼70-75 %), but spatially more specific. The most discriminative seed regions included midline, temporal and somatomotor regions. Univariate connectivity values were not predictive of BPD after multiple comparison corrections, but weak local effects coincided with the most discriminative seed-ROIs. Highest accuracies were achieved with a full clinical interview while self-report results remained at chance level.

LIMITATIONS

The accuracies vary considerably between random sub-samples of the population, global signal and covariates limiting the practical applicability.

CONCLUSIONS

Spatially distributed functional connectivity patterns are moderately predictive of BPD despite heterogeneity of the patient population.

Attachment Problems and Mentalizing Capacity Relate to Parent-Child Informant Discrepancies in Female Adolescents with Borderline Personality Disorder

Parent-child informant discrepancies on psychopathology provide important knowledge on the parent-child relationship and the child's mental health, but mechanisms underlying parent-child informant discrepancies are largely unknown. Therefore, we investigated the relationship between attachment problems and mentalizing capacity and parent-child informant discrepancies on borderline personality disorder (BPD) severity, internalizing, and externalizing pathology in a clinical sample of 91 adolescent girls with BPD and their parents. Results showed that more attachment problems to parents and peers were related to adolescents reporting more severe BPD than parents. Adolescents who described more internalizing symptoms relative to parents, reported more parental attachment problems, but enhanced peer attachment, suggesting those adolescents who do not feel recognized by their parents might turn to their friends. When parents rated adolescents higher on externalizing behaviors, the adolescent reported more attachment problems to parents and lower mentalizing capacity, indicating that this sub-group of adolescents may reflect less about how their behavior affects others.

Exploring the relationships between dominance behavioral system, mentalization, theory of mind and assertiveness: analysis in a non-clinical sample

Introduction

The dominance behavioral system, a fundamental aspect of human behavior, orchestrates the drive for dominance, regulates dominant-subordinate dynamics, and shapes responses to perceived power dynamics. While the existing literature extensively delves into the components of this system, scant attention is paid to its interplay with mentalization, theory of mind, and assertiveness. Moreover, gender disparities in dominance behaviors are largely studied in terms of biological variables (levels of testosterone) and clinical populations. This study aims to understand the relationships between activation strategies of the dominance behavioral system, mentalization processes, theory of mind abilities, and levels of social discomfort in assertive communication. Moreover, to identify gender differences in the dominance behavioral system in a non-clinical sample.

Methods

Our sample was composed of 67 students from a non-clinical population. They claimed the absence of any psychological, neurological, or developmental disorders.

Results

A regression analysis was performed, and we found that levels of mentalization predict levels of hyperactivation of dominance behavioral system, but no significant results for the deactivation levels of the system were found. Moreover, no gender differences were found in levels of activations of the dominance behavioral system.

Conclusion

These findings underscore the pivotal role of mentalization abilities in interpersonal dynamics, emphasizing the need for individuals to navigate social interactions adeptly. Furthermore, our research unveils implications for individual well-being and psychopathology, urging further investigation into how these dimensions intersect with various psychological disorders. By discerning the intricate mechanisms at play, we can develop targeted therapeutic interventions tailored to specific behavioral patterns, ultimately enhancing psychological resilience and fostering healthier social relationships in a non-clinical population.

The significance of connectedness: avoidant personality disorder patients' subjective experiences of change after attending a specialized treatment program

Objectives

This study aimed to inquire into the subjective experiences and meaning-making of change of people diagnosed with avoidant personality disorder (AvPD) after attending a treatment program developed for AvPD.

Methods

Eighteen AvPD patients were interviewed 1 year after completing their treatment using a semi-structured interview guide. The interviews were analyzed through reflexive thematic analysis.

Results

Three main themes were found to capture the various subjective experiences of change. The first main theme "being more alive" included the subthemes "talking and listening together" and "opening up and grounding into myself." The second main theme was "still longing for more," and the third main theme "I cannot even manage therapy" included the subthemes "as if we were together" and "capitulation."

Conclusion

Although these findings may not be specific to AvPD, they shed light on the importance of attending to the dynamic interplay of intersubjectivity, social motivations, and agency in a therapeutic context. Discovering a sense of agency within an interpersonal context in which the patient feels connected may lead to them opening up for development in accordance with their social motivational intentions.

Trauma-related symptoms in adolescents: the differential roles of sexual abuse and mentalizing

Introduction

Major gaps remain in our knowledge regarding childhood sexual abuse (CSA) related symptoms in adolescent psychiatric inpatients, as well as potential resilience factors like mentalizing. CSA is a risk factor for the early emergence of borderline personality features, posttraumatic stress, and sexual concerns. Mentalizing, which involves the capacity to understand our reactions and that of others in psychological terms, is a resilience factor for self and interpersonal functioning. The aim of this study was to address knowledge gaps by examining the contributions of CSA and mentalizing in a latent factor composed of borderline personality features, posttraumatic stress, and sexual concerns in a sample of adolescent psychiatric inpatients. We hypothesized that CSA and mentalizing would independently explain the variance in this latent factor.

Method

Participants were 273 adolescents aged 12-17 recruited from an adolescent inpatient psychiatric clinic. They completed the Reflective Function Questionnaire for Youth (RFQ-Y), the Trauma Symptom Checklist for Children (TSCC), and the Borderline Personality Features Scale for Children (BPFS-C). CSA was assessed using the Child Attachment Interview (CAI), the Computerized Diagnostic Interview Schedule for Children (C-DISC), as well as the Childhood Trauma Questionnaire (CTQ).

Results

27.5% of adolescent psychiatric inpatients reported CSA. CSA and mentalizing were independently associated with a latent factor consisting of posttraumatic stress, borderline personality features, and sexual concerns. CSA explained 5.0% and RF explained 16.7% of the variance of the latent factor. When we consider both the unique and the shared contribution of CSA and mentalizing, the model explained 23.0% of the variance of this factor.

Discussion

CSA and mentalizing independently explained variance in a latent factor constituted of borderline personality features, posttraumatic stress, and sexual concerns. The direct effect of mentalizing was stronger and mentalizing explained comparatively more variance of trauma-related symptoms in adolescent psychiatric inpatients. The findings are consistent with the theory that mentalizing is an internal resilience factor in adolescent psychiatric inpatients. By implication, clinical interventions focused on promoting the development of mentalizing, such as Mentalization Based Treatment, may palliate mental health difficulties manifested by adolescent psychiatric inpatients including those associated with CSA.

Uncertain reflective functioning, anxious attachment, and cumulative impact of early relational trauma as predictors of severity in borderline personality disorder

Background

The mentalization model of borderline personality disorder (BPD) utilizes a developmental psychopathology lens, emphasizing an unstable or reduced capacity to mentalize-stemming from early attachment disruptions and relational trauma-as the core feature of BPD. While the empirical evidence for the proposed intersections between mentalizing, attachment, and trauma and the development and manifestations of borderline personality is still limited, this knowledge is essential for developing effective assessments and interventions.

Aim

To examine mentalizing, attachment, and early relational trauma as predictors of the severity of symptoms in BPD.

Materials and Methods

The sample included 60 individuals diagnosed with BPD, aged 18-45 years, recruited from inpatient and outpatient services in a tertiary care mental health center. Participants completed measures of mentalizing (Reflective Functioning Questionnaire, Interpersonal Reactivity Index, and Reading the Mind in the Eyes test), attachment (Attachment Style Questionnaire), early relational trauma (Complex Trauma Questionnaire), and symptom severity (Borderline Symptom List).

Results

The majority of the participants reported experiences of polyvictimization (93.3%) with the most common traumas being psychological abuse (93.3%), neglect (91.7%), and rejection (90.0%). Regression analyses revealed that uncertain reflective functioning, anxious attachment style, and the cumulative impact of trauma together predicted 53.1% of the variance in BPD symptom severity.

Conclusion

Impaired mentalizing, characterized by inflexible understanding of mental states, is a critical target for therapeutic interventions in BPD. The significant role of anxious attachment and the necessity of assessing the perceived impact of traumatic experiences highlight the importance of trauma-informed and mentalization-based interventions for this vulnerable group.

Interplay of Dyadic Consensus, Reflective Functioning, and Perinatal Affective Difficulties in Modulating Fear of COVID-19 among First-Time Mothers: A Mediation Analysis

BACKGROUND

The COVID-19 pandemic has exacerbated fears and anxieties, potentially influencing maternal perinatal mental health. This study addresses a gap in the literature on fear of COVID-19 in pregnant women, aiming to identify contributing factors.

METHOD

Participants were 401 primiparous women with an average age of 34 years (SD = 4.56) who were recruited through the National Health System during birth support courses. They completed a series of self-reported instruments via an online survey, providing information on their levels of reflective functioning, dyadic consensus, perinatal maternal affectivity, and fear of COVID-19. Pearson's correlation and mediation analysis via a generalized linear model were implemented to analyze the collected data.

RESULTS

The relationship between dyadic consensus and fear of COVID-19 was significant and negative. Furthermore, a significant parallel mediation involving perinatal maternal affectivity and reflective functioning was found to the extent that, when these factors were inserted into the model, the direct association between dyadic consensus and fear of COVID-19 became non-significant (total mediation).

CONCLUSIONS

The results highlight the importance of dyadic adjustment in alleviating maternal COVID-19 fear, emphasizing interventions promoting couple functioning, mentalization, and addressing affective difficulties. Such approaches are vital for supporting expecting mothers during challenging times like the COVID-19 pandemic.

Minding mentalizing - convergent validity of the Mentalization Breakdown Interview

Objectives

Mentalizing difficulties are central to borderline personality disorder (BPD), have severe consequences, and are an explicit focus in mentalization-based treatment. The significance of mentalizing capacity as a predictor or mediator of change is however still uncertain due to a scarcity of research. The Mentalization Breakdown Interview (MBI) was developed as a time saving tool for studying psychotherapy processes and outcome in borderline pathology. This study aimed to investigate the convergent validity of reflective functioning (RF) ratings based on the MBI (MBI-RF) by a comparison with the gold standard, i.e., RF assessments based on the Adult Attachment Interview (AAI-RF). A secondary aim was to investigate how MBI-RF relates to core symptoms of BPD, levels of functional impairment and symptom distress compared with AAI-RF.

Method

Forty-five patients with BPD or significant BPD traits were included. MBI-RF and AAI-RF were rated using the Reflective Functioning Scale. Levels of MBI-RF and AAI-RF and the correlation between the measures were calculated, as well as their associations with the Difficulties in Emotion Regulation Scale, Levels of Personality Functioning-Brief Form 2.0, Work and Social Adjustment Scale, Patient Health Questionnaire, Depression, Generalized Anxiety Disorder-7, self-harm, suicide attempts, and PD diagnostics.

Results

The correlation between MBI-RF and AAI-RF was 0.79 (p<0.01), indicating high convergent validity. There were few significant associations between MBI-RF and AAI-RF and clinical measures.

Conclusions

The study provides support for the convergent validity of the MBI as a BPD-focused RF assessment method. The MBI has the potential as a time saving, reliable and valid method to be applied in treatment research on patients with borderline pathology. The results indicate that measures of MBI-RF and AAI-RF are different from clinical symptoms.

Clinical trial registration

ClinicalTrials.gov ID NCT04157907.

Validation of the english version of the Multidimensional Mentalizing Questionnaire (MMQ)

BACKGROUND

Mentalizing refers to the ability to understand one's own and others' mental states. Mentalizing is considered a key component of social cognition and healthy personality development. A multinational assessment tools able to appraise the multidimensional and multifaceted aspects of this complex construct are needed.

OBJECTIVE

The present study had two aims: (a) validate an English version of the Multidimensional Mentalizing Questionnaire (MMQ, 33 items) which was designed to assess mentalizing based on an integrated and multilevel model of mentalizing; (b) explore the correlational relationships between the six dimensions of the MMQ and a set of sociodemographic, psycho-cognitive, mental health, and socio-functional variables.

METHODS

Overall, 1823 individuals (age: 19-76 years old [M = 45; SD = 16]; sex: male = 48.51%, female = 50.57%, non-binary = 0.9%) participated in an online survey. While the participants came from 77 different countries, most of them were residents in UK and USA (95%). Data analytics include confirmatory factorial analysis and Pearson correlations.

RESULTS

The CFA results validated the factorial structure of a 28-items MMQ-English version, with acceptable goodness of fit indices. Regarding the psychometric properties, the MMQ-English version showed good internal reliability and significant positive correlation with another scale designed to assess an analogue construct showing a fair convergent validity. The findings indicated that males, individuals with lower levels of education, lower socio-economic status, depressed, and with a higher score of loneliness are significantly more likely to report poor mentalizing compared with females, individuals with higher education level, greater SES, happier, and with lower scores of loneliness.

CONCLUSION

The present study validated the English version of the MMQ.

Mentalization based treatment for a broad range of personality disorders: a naturalistic study

BACKGROUND

Several studies have observed that mentalization-based treatment (MBT) is an effective treatment for borderline personality disorder (BPD), but its effectiveness for other personality disorders (PDs) has hardly been examined. Additionally, the evidence supporting the claim that MBT improves mentalizing capacity is scarce. The present study examined whether (i) patients with a broad range of PDs enrolled in an MBT program would improve on several outcome measures (ii) mentalizing capacity would improve over time; (iii) patients with BPD would improve more than those with non-borderline PDs.

METHOD

Personality disorders, psychiatric symptoms, social functioning, maladaptive personality functioning and mentalizing capacity were measured in a group of individuals with various PDs (n = 46) that received MBT. Assessments were made at baseline and after 6, 12, and 18 months of treatment. The severity of psychiatric symptoms, measured using the Outcome Questionnaire 45, was the primary outcome variable.

RESULTS

Overall, enrollment in the MBT program was associated with a decrease in psychiatric symptoms and an improvement of personality functioning, social functioning for a mixed group of PDs (all p's ≤ .01). Bigger effect sizes were observed for BPD patients (n = 25) than for patients with non-BPD (n = 21), but the difference failed to reach statistical significance (p = 0.06). A primary analysis showed that the decrease in psychiatric symptoms was significant in BPD patients (p = 0.01), not in non-BPD (p = 0.19) patients. However, a sufficiently powered secondary analysis with imputed data showed that non-BPD patients reported a significant decrease in psychiatric symptoms too (p = 0.01). Mentalizing capacity of the whole group improved over time (d = .68 on the Toronto Alexithymia Scale and 1.46 on the Social Cognition and Object Relations System).

DISCUSSION

These results suggest that MBT coincides with symptomatic and functional improvement across a broad range of PDs and shows that MBT is associated with improvements in mentalizing capacity. As the study is not experimental in design, we cannot make causal claims.

CONCLUSION

Mentalization-based treatment may be an effective treatment for patients with a broad range of PDs.

TRIAL REGISTRATION

The study design was approved by the Leiden University Ethical Committee.

A Multi-Method Study of Interpersonal Complementarity and Mentalization

Research finds cross-sectional relationships between mentalizing impairments and maladaptive personality traits. The current study connects mentalizing impairments to dynamic interpersonal processes using a multi-method design. A sample of 218 participants completed the Movie for the Assessment of Social Cognition (MASC; Dziobek et al., 2006) to assess mentalizing ability. Subsequently, participants rated their agentic and communal behavior and their perception of interaction partners' agentic and communal behavior over 21-days. Mentalizing ability moderated the within-person relationship between behavior and perception for both agency and communion. Worse performance on the MASC was associated with weaker interpersonal complementarity, suggesting that mentalizing impairments lead to deviations from expected patterns of behavior and perception across interpersonal situations. These findings confirm the assumption of Contemporary Integrative Interpersonal Theory that mentalization impairments can disrupt normative interpersonal processes (Cain et al., 2024; Pincus & Hopwood, 2012).

Mind-mindedness in mothers of infants with excessive crying/sleeping/eating disorders

Introduction

Excessive crying, sleeping, and eating disorders are among the most prevalent mental health diagnoses in the first 3 years of life and involve significant health service use. Parents of infants with excessive crying/sleeping/eating disorders report high levels of stress, since they feel incapable of soothing and/or nurturing their baby. Infants' distress can lead to a breakdown in parents' mentalizing abilities and, more specifically, parental mind-mindedness in the parent-child interaction. Moreover, the signals of infants with excessive crying/sleeping/eating disorders tend to be equivocal and difficult to read. This also might contribute to lower parent-child interaction quality. Until now, parental mind-mindedness, which is regarded as a prerequisite for sensitivity, has not been investigated in mothers of infants with excessive crying/sleeping/eating disorders. We investigated whether mind-mindedness in mothers of infants with excessive crying, sleeping and/or eating disorders differed from a healthy control group. We supposed that mothers of infants with excessive crying/sleeping/eating disorders would use (1) less appropriate mind-related comments (AMRCs), and (2) more non-attuned mind-related comments (NAMRCs) than mothers in the control group.

Methods

Our sample consisted of 44 mothers and their infants who were patients in a socio-paediatric clinic in Germany. The children were diagnosed with excessive crying, sleeping and/or eating disorders according to DC:0-5 (= clinical group). The control group was composed of 64 healthy children and their mothers. Maternal mind-mindedness was coded during a free-play interaction.

Results

Results showed that mothers of infants with excessive crying, sleeping and/or eating disorders used both more AMRCs (p = .029) as well as more NAMRCs (p = .006) than mothers in the control group.

Discussion

The findings are discussed in terms of implications for interventions (e.g., enhancing mind-mindedness trough video-feedback).

Mentalization-based approach for schizophrenia spectrum disorders: a psychotherapeutic proposal for evolved schizophrenic trajectories and serious mental disorders

There is a growing interest in psychotherapeutic approaches to pre-psychotic high-risk states or first-episode psychosis, where mentalization-based treatment has shown its utility. This article presents a mentalization-based approach for the treatment of those individuals diagnosed with an evolved schizophrenia spectrum disorder, whose characteristics make them especially inaccessible to reflective psychotherapeutic treatment. A synthesis of the conceptual frameworks that justify the needs for technical modification of the mentalization-based treatment foundational techniques is carried out, followed by the proposal of adaptations, with a focus in self-agency and patient-therapist dyad. Therapeutic interventions are outlined, including illustrative examples. The mentalizing approach presented here holds promise for future research and treatment opportunities for patients with evolved schizophrenia and other serious mental disorders.

Two Sides of Theory of Mind: Mental State Attribution to Moving Shapes in Paranoid Schizophrenia Is Independent of the Severity of Positive Symptoms

BACKGROUND

Theory of Mind (ToM) impairment has repeatedly been found in paranoid schizophrenia. The current study aims at investigating whether this is related to a deficit in ToM (undermentalizing) or an increased ToM ability to hyperattribute others' mental states (overmentalizing).

METHODS

Mental state attribution was examined in 24 patients diagnosed with schizophrenia (12 acute paranoid (APS) and 12 post-acute paranoid (PPS)) with regard to positive symptoms as well as matched healthy persons using a moving shapes paradigm. We used 3-T-functional magnetic resonance imaging (fMRI) to provide insights into the neural underpinnings of ToM due to attributional processes in different states of paranoid schizophrenia.

RESULTS

In the condition that makes demands on theory of mind skills (ToM condition), in patients with diagnosed schizophrenia less appropriate mental state descriptions have been used, and they attributed mental states less often to the moving shapes than healthy persons. On a neural level, patients suffering from schizophrenia exhibited within the ToM network hypoactivity in the medial prefrontal cortex (MPFC) and hyperactivity in the temporo-parietal junction (TPJ) as compared to the healthy sample.

CONCLUSIONS

Our results indicate both undermentalizing and hypoactivity in the MPFC and increased overattribution related to hyperactivity in the TPJ in paranoid schizophrenia, providing new implications for understanding ToM in paranoid schizophrenia.

Offline and online parental mentalizing in mothers with symptoms of postpartum depression: Examining the association between self-reported parental reflective functioning and interactional mind-mindedness

Mentalizing is, to a certain extent, considered context specific. However, research on the association between parents' abilities to reflect upon their infant's mental states outside social interaction (offline) versus during ongoing parent-infant interaction (online) is currently limited. This study investigated the association between self-reported offline and online mentalizing in a sample of primarily ethnically Danish mothers (N = 142), with symptoms of postpartum depression, and their 1-11-month-old infants. Offline mentalizing was assessed with the Parental Reflective Functioning Questionnaire-Infant Version (PRFQ-I) and online mentalizing was assessed with interactional mind-mindedness. Ordinal logistic regressions showed that a higher score on the PRFQ-I prementalizing subscale was negatively related to number of overall mind-related comments and appropriate mind-related comments produced by mothers during interaction with their infant. Our results indicate partial overlaps between self-reported parental reflective functioning and mind-mindedness, that is, that particularly offline maladaptive mentalizing is associated with lower levels of mentalizing during interaction in mothers with symptoms of depression. Post-hoc examination of the interaction effect of postpartum depression showed that this association was only evident in mothers with medium to high levels of depression. Findings and implications are discussed.

Brain Activation for Social Cognition and Emotion Processing Tasks in Borderline Personality Disorder: A Meta-Analysis of Neuroimaging Studies

The present meta-analysis summarizes brain activation for social cognition and emotion-processing tasks in borderline personality disorder (BPD). We carried out two meta-analyses to elaborate on commonalities and potential differences between the two types of tasks. In the first meta-analysis, we implemented a more liberal strategy for task selection (including social and emotional content). The results confirmed previously reported hyperactivations in patients with BPD in the bilateral amygdala and prefrontal cortex and hypoactivations in bilateral inferior frontal gyri. When applying a stricter approach to task selection, focusing narrowly on social cognition tasks, we only found activation in prefrontal areas, particularly in the anterior cingulate and ventromedial prefrontal cortex. We review the role of these areas in social cognition in healthy adults, suggesting that the observed BPD hyperactivations may reflect an overreliance on self-related thought in social cognition.

Clinical profiles of adolescent personality pathology: a latent structure examination of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) in a help-seeking sample

BACKGROUND

Despite the introduction of dimensional conceptualisations of personality functioning in the latest classification systems, such as Criterion A of the Alternative Model of Personality Disorders in the DSM-5, heterogeneous clinical presentation of personality pathology remains a challenge. Relatedly, the latent structure of personality pathology as assessed by the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) has not yet been comprehensively examined in adolescents. Therefore, this study aimed to examine the latent structure of the STiP-5.1, and, based on those findings, to describe any unique clinical profiles that might emerge.

METHODS

The final sample comprised 502 participants aged 11-18 years consecutively recruited from a specialised personality disorder outpatient service, as well as general day clinic and inpatient wards at the University Hospital University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Bern, Switzerland. Participants were assessed using the STiP-5.1, as well as a battery of other psychological measures by clinical psychologists or trained doctoral students. Variations of Factor Analysis, Latent Class Analysis and Factor Mixture Models (FMM) were applied to the STiP-5.1 to determine the most appropriate structure.

RESULTS

The best fitting model was an FMM comprising four-classes and two factors (corresponding to self- and interpersonal-functioning). The classes differed in both overall severity of personality functioning impairment, and in their scores and clinical relevance on each element of the STiP-5.1. When compared to the overall sample, classes differed in their unique clinical presentation: class 1 had low impairment, class 2 had impairments primarily in self-functioning with high depressivity, class 3 had mixed levels of impairment with emerging problems in identity and empathy, and class 4 had severe overall personality functioning impairment.

CONCLUSIONS

A complex model incorporating both dimensional and categorical components most adequately describes the latent structure of the STiP-5.1 in our adolescent sample. We conclude that Criterion A provides clinically useful information beyond severity (as a dimensional continuum) alone, and that the hybrid model found for personality functioning in our sample warrants further attention. Findings can help to parse out clinical heterogeneity in personality pathology in adolescents, and help to inform early identification and intervention efforts.

Observer-based and computerized measures of the patient's mentalization in psychotherapy: A scoping review

OBJECTIVE

In recent decades, mentalizing has found its permanent place both in therapeutic practice and in psychotherapy research. Inconsistent results and null results are often found. Therefore, the different methodological approaches should be examined in more detail. A scoping review was conducted to provide an overview of the approaches that measure the patient's mentalizing ability based on therapy sessions or in the course of psychotherapy.

METHOD

For the scoping review, a literature search was conducted in four databases. A total of 3217 records were identified.

RESULTS

We included 84 publications from 43 independent studies. Most studies used the Reflective Functioning Scale and applied the scale to therapy sessions or the Adult Attachment Interview. The other identified approaches used a computerized text analysis measure or clinician-report measures. Mostly good psychometric properties of the measures were reported. The Reflective Functioning Scale applied to the Adult Attachment Interview was the only measure that proved to be sensitive to change.

CONCLUSION

More economical variants to the time-consuming Reflective Functioning Scale applied to the Adult Attachment Interview are being developed continuously. In some cases, there is no standardized approach, or the measures are used only sporadically and require further and more comprehensive psychometric evaluations.

What aspects of mindfulness and emotion regulation underpin self-harm in individuals with borderline personality disorder?

BACKGROUND

Self-harm presents significant risk for individuals with borderline personality disorder (BPD). Both self-harm and BPD are associated with deficits in mindfulness and emotion dysregulation. Previous research suggests that thought suppression and emotional inexpressivity may underpin self-harm in people with BPD, suggesting potential links to self-harm functions common for those with BPD. More research is needed to strengthen our understanding of this relationship.

AIMS

This study examines how BPD symptoms, mindfulness, emotion dysregulation and self-harm functions are related.

METHODS

Australian community outpatients diagnosed with BPD (N = 110) completed measures of mindfulness, emotion dysregulation and self-harm functions. Serial mediation analyses were conducted to examine relationships between variables.

RESULTS

BPD symptoms, chronic emptiness, mindfulness skills, describing and non-reacting, emotion dysregulation areas of emotion regulation strategies and poor emotional clarity were associated with recent self-harm. Various combinations of describing, strategies and clarity mediated the path between emptiness and self-harm functions more likely to be endorsed by individuals with a diagnosis of BPD. Describing was associated with all but anti-suicide function, while strategies was associated with all but anti-dissociation.

CONCLUSION

The study highlights how individuals with BPD experiencing chronic emptiness may benefit from treatment targeting describing skills and adaptive emotion regulation strategies.