The NOURISHED randomised controlled trial comparing mentalisation-based treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder

Mentalizing in psychotherapeutic processes of patients with eating disorders

Background

Improvement in the capacity to mentalize (i.e., reflective functioning/RF) is considered both, an outcome variable as well as a possible change mechanism in psychotherapy. We explored variables related to (in-session) RF in patients with an eating disorder (ED) treated in a pilot study on a Mentalization-Based Treatment (MBT) - oriented day hospital program. The research questions were secondary and focused on the psychotherapeutic process: What average RF does the group of patients show in sessions and does it change over the course of a single session? Are differences found between sections in which ED symptomatology is discussed and those in which it is not? Does RF increase after MBT-type interventions?

Methods

1232 interaction segments from 77 therapy sessions of 19 patients with EDs were rated for RF by reliable raters using the In-Session RF Scale. Additionally, content (ED symptomatology yes/no) and certain MBT interventions were coded. Statistical analysis was performed by mixed models.

Results

Patients showed a rather low RF, which increased on average over the course of a session. If ED symptomatology was discussed, this was associated with significantly lower RF, while MBT-type interventions led to a significant increase in RF.

Conclusions

Results suggest that in-session mentalizing can be stimulated by MBT-typical interventions. RF seems to be more impaired when disorder-specific issues are addressed. Further studies have to show if improving a patient´s ability to mentalize their own symptoms is related to better outcomes.

Advancing randomized controlled trial methodologies: The place of innovative trial design in eating disorders research

Randomized controlled trials can be used to generate evidence on the efficacy and safety of new treatments in eating disorders research. Many of the trials previously conducted in this area have been deemed to be of low quality, in part due to a number of practical constraints. This article provides an overview of established and more innovative clinical trial designs, accompanied by pertinent examples, to highlight how design choices can enhance flexibility and improve efficiency of both resource allocation and participant involvement. Trial designs include individually randomized, cluster randomized, and designs with randomizations at multiple time points and/or addressing several research questions (master protocol studies). Design features include the use of adaptations and considerations for pragmatic or registry-based trials. The appropriate choice of trial design, together with rigorous trial conduct, reporting and analysis, can establish high-quality evidence to advance knowledge in the field. It is anticipated that this article will provide a broad and contemporary introduction to trial designs and will help researchers make informed trial design choices for improved testing of new interventions in eating disorders. PUBLIC SIGNIFICANCE: There is a paucity of high quality randomized controlled trials that have been conducted in eating disorders, highlighting the need to identify where efficiency gains in trial design may be possible to advance the eating disorder research field. We provide an overview of some key trial designs and features which may offer solutions to practical constraints and increase trial efficiency.

Evidence of effectiveness of specialist supportive clinical management for anorexia nervosa in routine clinical practice: Outcomes from a clinical case series

OBJECTIVE

This study provides a preliminary report on the effectiveness of Specialist Supportive Clinical Management (SSCM) in a clinical case series of adults with anorexia nervosa, to supplement evidence of efficacy from controlled trials.

METHOD

Body mass index (BMI), eating disorder symptoms, mood and anxiety were measured at the start and end of treatment for 42 adults who received SSCM in a community eating disorders service.

RESULTS

Significant improvements were observed on all outcome measures, with larger effect sizes for symptom change than BMI. Recovery rates appear similar to those in clinical trials.

DISCUSSION

The study offers preliminary support for the effectiveness of SSCM in routine settings and identifies several areas for further research.

Differences and similarities in personality functioning across different types of eating disorders

Objective

The classification of anorexia nervosa (AN) into subtypes is relevant due to their different symptomatology. However, subtypes (restricting type: AN-R; purging type: AN-P) differ also in terms of their personality functioning. Knowledge about these differences would allow for better treatment stratification. A pilot study indicated differences in structural abilities that can be assessed by the operationalized psychodynamic diagnosis (OPD) system. The aim of this study was therefore to systematically explore differences in personality functioning and personality between the two AN subtypes and bulimia nervosa (BN) using three personality (functioning) constructs.

Methods

A total of N = 110 inpatients with AN-R (n = 28), AN-P (n = 40), or BN (n = 42) were recruited in three clinics for psychosomatic medicine. Assignment to the three groups was performed using a comprehensive questionnaire validated for diagnostic purposes (Munich-ED-Quest). Personality functioning was examined using OPD Structure Questionnaire (OPD-SQ), personality by using the Personality Inventory for DSM-5-Brief Form and Big Five Inventory-10. (M)ANOVAs were used to examine differences across eating disorder groups. In addition, correlation and regression analyses were conducted.

Results

We observed differences on several sub- and main scales of the OPD-SQ. Whereas patients with BN showed the lowest levels, AN-R patients displayed the highest levels of personality functioning. On some sub- and main scales, such as "affect tolerance," the subtypes of AN differed from BN, whereas on the scale "affect differentiation," AN-R, differed from the other two groups. The total eating disorder pathology score of the Munich-ED-Quest best predicted overall personality structure [stand. β = 0.650; t(104) = 6.666; p < 0.001] and self-regulation [stand. β = 0.449; t(104) = 3.628; p < 0.001].

Discussion

Our findings confirm most of the results of the pilot study. These findings can facilitate the development of stratified treatment approaches for eating disorders.

Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.

Mentalizing and epistemic trust as critical success factors in psychosomatic rehabilitation: results of a single center longitudinal observational study

Background

Inpatient psychosomatic rehabilitation is a key treatment for patients with mental health issues. However, knowledge about critical success factors for beneficial treatment outcomes is scarce. The aim of this study was to evaluate the association of mentalizing and epistemic trust with the improvement of psychological distress during rehabilitation.

Methods

In this naturalistic longitudinal observational study, patients completed routine assessments of psychological distress (BSI), health-related quality of life (HRQOL; WHODAS), mentalizing (MZQ), and epistemic trust (ETMCQ) before (T1) and after (T2) psychosomatic rehabilitation. Repeated measures ANOVA (rANOVAs) and structural equation models (SEMs) were calculated to investigate the association of mentalizing and epistemic trust with the improvement in psychological distress.

Results

A total sample of n = 249 patients were included in the study. Improvement in mentalizing was correlated with improvement in depression (r = 0.36), anxiety (r = 0.46), and somatization (r = 0.23), as well as improved cognition (r = 0.36), social functioning (r = 0.33), and social participation (r = 0.48; all p < 0.001). Mentalizing partially mediated changes in psychological distress between T1 and T2: the direct association decreased from β = 0.69 to β = 0.57 and the explained variance increased from 47 to 61%. Decreases in epistemic mistrust (β = 0.42, 0.18-0.28; p < 0.001) and epistemic credulity (β = 0.19, 0.29-0.38; p < 0.001) and increases in epistemic trust (β = 0.42, 0.18-0.28; p < 0.001) significantly predicted improved mentalizing. A good model fit was found (χ2 = 3.248, p = 0.66; CFI = 0.99; TLI = 0.99; RMSEA = 0.000).

Conclusion

Mentalizing was identified as a critical success factor in psychosomatic inpatient rehabilitation. A key component to increase mentalizing in this treatment context is the improvement of epistemic mistrust.

Emotional dysregulation in childhood and disordered eating and self-harm in adolescence: prospective associations and mediating pathways

BACKGROUND

Emotional dysregulation may be a risk factor for disordered eating and self-harm in young people, but few prospective studies have assessed these associations long-term, or considered potential mediators. We examined prospective relationships between childhood emotional dysregulation and disordered eating and self-harm in adolescence; and social cognition, emotional recognition, and being bullied as mediators.

METHODS

We analysed Avon Longitudinal Study of Parents and Children data on 3,453 males and 3,481 females. We examined associations between emotional dysregulation at 7 years and any disordered eating and any self-harm at 16 years with probit regression models. We also assessed whether social cognition (7 years), emotional recognition (8 years) and bullying victimisation (11 years) mediated these relationships.

RESULTS

Emotional dysregulation at age 7 years was associated with disordered eating [fully adjusted probit B (95% CI) = 0.082 (0.029, 0.134)] and self-harm [fully adjusted probit B (95% CI) = 0.093 (0.036, 0.150)] at age 16 years. There was no evidence of sex interactions or difference in effects between self-harm and disordered eating. Mediation models found social cognition was a key pathway to disordered eating (females 51.2%; males 27.0% of total effect) and self-harm (females 15.7%; males 10.8% of total effect). Bullying victimisation was an important pathway to disordered eating (females 17.1%; males 10.0% of total effect), but only to self-harm in females (15.7% of total effect). Indirect effects were stronger for disordered eating than self-harm.

CONCLUSIONS

In males and females, emotional dysregulation in early childhood is associated with disordered eating and self-harm in adolescence and may be a useful target for prevention and treatment. Mediating pathways appeared to differ by sex and outcome, but social cognition was a key mediating pathway for both disordered eating and self-harm.

Perspectives on Dialectical Behavior Therapy and Mentalization-Based Therapy for Borderline Personality Disorder: Same, Different, Complementary?

Current evidence suggests that individuals with borderline personality disorder (BPD) are likely to benefit from specialized, or BPD-specific, treatments. Dialectical behavior therapy (DBT) and mentalization-based treatment (MBT) are currently the most intensively researched BPD treatments. Reviewing the current research, this paper highlights similarities and differences between the two treatments, and discusses possible ways they could complement each other. As the effectiveness of specialized treatments for BPD in general has been determined with some certainty, research now tends towards individualized approaches, identifying predictors of optimal treatment response. However, it is still to be settled who might profit from a combination of or sequential treatment with DBT and MBT.

Borderline personality disorder symptoms in individuals with eating disorder: Association with severity, psychological distress, and psychosocial function

We aimed to determine the prevalence of borderline personality disorder (BPD) symptoms in a sample of eating disorder (ED) outpatients and assess how BPD symptoms correlate with severity, distress, and function. A total of 119 individuals were assessed and divided into high BPD symptoms (H-BPD) and low BPD symptoms (L-BPD) using a cut-off score of seven on the McLean Screening for Borderline Personality Disorder (MSI-BPD). Groups were compared on ED diagnosis, age at ED onset, age at assessment, illness duration, body mass index (BMI), ED symptomatology, psychological distress, and psychosocial function. Correlation analyses were performed to assess the relationship between BPD symptoms and these variables. The 45.4% of the participants scored ≥7 on the MSI-BPD, indicating a diagnosis of BPD. There were no differences between the H-BPD (N = 54) and L-BPD (N = 65) groups on age at onset, age at assessment, duration of illness, BMI, or proportion of ED diagnosis. The H-BPD group reported significantly higher ED symptomatology, psychological distress, and poorer psychosocial functioning. MSI-BPD scores were positively associated with these variables. This study suggests a high prevalence of BPD symptoms within outpatients seeking ED treatment, and use of a brief screening instrument for BPD in this group may contribute to a greater understanding of the patient.

Specialist supportive clinical management for anorexia nervosa: Analysis of therapy content and relation to outcome

OBJECTIVE

Psychotherapy for anorexia nervosa (AN) is complex and multifaceted, with little known about likely effective components of treatments. The current study explored the spoken content of specialist supportive clinical management (SSCM) for AN, a treatment with evidence of effectiveness in several randomized clinical trials.

METHOD

One hundred seventy-eight therapy sessions constituting all ten therapist-patient dyads of those who completed SSCM treatment in the original clinical trial of SSCM, were transcribed verbatim. Themes were developed and content analyzed using qualitative content analysis of complete therapy sessions by four analysts, with 10% of sessions cocoded for interrater agreement.

RESULTS

Over three quarters of session content was within the clinical management theme, the largest subtheme relating to normalizing eating, followed by weight, mechanics of SSCM, and encouragement of self-care. Approximately 20% of total content was in the supportive psychotherapy theme, half about relationships. The relative proportion of clinical management content remained high, decreasing during the last five sessions. Those achieving good outcome did not have a lower ratio of clinical management to supportive psychotherapy content.

DISCUSSION

The current study revealed strong clinical management focus on core symptoms of AN-normalization of eating and weight gain-throughout SSCM for AN.

PUBLIC SIGNIFICANCE

Six clinical trials have found SSCM to be effective in treating AN. Content of SSCM sessions in the original trial was classified using qualitative content analysis. Study findings revealed strong clinical management focus on core AN symptoms-normalization of eating and weight gain-throughout SSCM, with the ratio of clinical management to supportive psychotherapy greater for those with a good outcome.

Conceptualising specialist supportive clinical management (SSCM): current evidence and future directions

BACKGROUND

Current evidence-based treatments for adult anorexia nervosa (AN) have limitations, with high attrition, very poor outcomes for 20% of people, and no clearly superior manualised therapy for adults with AN. Specialist Supportive Clinical Management (SSCM) was designed as a control treatment but has evolved as a valid first line treatment. The present paper aims to provide an overview of the evidence base for SSCM and a pedagogical reconceptualization with expansion by theoretical integration (TI). BODY: A secondary meta-analysis endorses SSCM as a promising treatment. This paper positions SSCM as a manualised therapy for adult AN with six unique features, namely (1) a philosophy which is person-centred, non-prescriptive, and informed by the person's strengths and values, (2) a focus on the person through inclusion of supportive psychotherapy and problem (clinical management), within target symptoms as defined in relation to AN, (3) a flexible and responsive therapy that could be delivered by a variety of clinicians with experience treating AN (4) a commitment to reversing starvation though a directional approach and a defined yet flexible stance on dietetic intervention (5) a commitment to the therapeutic relationship within all three phases of treatment, and (6) a therapy 'uncluttered' by specific mandates. In addition, this paper positions SSCM as a treatment that may be strengthened by other modalities and may also be adapted to the treatment of other eating disorders (ED), not just AN. The level of therapist sophistication to deliver upon the supportive psychotherapy component is explored and future directions are offered.

CONCLUSION

SSCM is a unique and valid first line treatment for AN and would benefit from further expansion in line with emerging understandings of AN to strengthen it as a treatment. Speculation on aspects of potency would benefit from further testing. The proposed re-conceptualisation of SSCM in the context of its evidence may strengthen it as a treatment overall, position it as adaptable for treatment of other eating disorders and make it more accessible to clinicians.

Psychometric evaluation of the German version of the Brief Reflective Functioning Interview

OBJECTIVES

To measure mentalization in a feasible manner, various instruments have been designed in recent years. The Brief Reflective Functioning Interview (BRFI) is a short interview that is based on the Adult Attachment Interview (AAI). The aim of both studies was to examine the psychometric properties of the German version of the BRFI and to compare them to those of the AAI.

METHODS

In Study 1, we examined 60 students using the BRFI and the AAI. In Study 2, the validity of the BRFI was examined using a mixed sample of students and patients (N = 149). Trained coders evaluated the Reflective Functioning Scale (RFS) for the BRFI and the AAI.

RESULTS

We found a significant positive correlation between the RFS total scores of the BRFI and those of the AAI. In addition, both interviews showed excellent internal consistency. We could also show that persons with mental disorders exhibit lower levels of RF score than mentally stable individuals. Women had higher RF scores in the BRFI than men in both samples. Persons whose mentalization capacity was rated below average in either the BRFI or the AAI also reported significantly lower mentalization ability in the self-assessment (p < .01).

CONCLUSIONS

Our results revealed that the RFS scores measured by the BRFI are highly comparable to those measured by the AAI. Our findings support the results of previous studies, suggesting that the BRFI is a reliable, valid and easy-to-administer alternative to the AAI.

PRACTITIONER POINTS

The German version of the Brief Reflective Functioning Interview (BRFI) proved to be a reliable and valid instrument for the assessment of reflective functioning that is shorter in terms of time to complete and the evaluation process than the measurement via the Adult Attachment Interview (AAI). Reflective functioning is negatively associated with psychopathology.

The mind-in-mind study: A pilot randomised controlled trial that compared modified mentalisation based treatment with supportive clinical management for patients with eating disorders without borderline personality disorder

OBJECTIVE

Mentalisation-based treatment (MBT) aims to improve reflective functioning. There is a growing evidence base outlining positive clinical outcomes for the use of MBT in eating disorder patients with co-morbid borderline personality disorder (BPD). The use of MBT has not been studied for eating disorder patients without BPD. This pilot study is an exploratory randomised controlled trial in which outcomes from MBT are compared with standard clinical management in a cohort of patients diagnosed with an eating disorder but not BPD. The main objectives were two-fold-to explore the use of MBT as a therapeutic modality and to test the acceptability and feasibility of the protocol design.

METHOD

Thirty-two participants were randomised to receive either MBT or standard treatment during an inpatient eating disorders program. All patients enrolled in the study were diagnosed with an eating disorder but did not meet DSM-5 criteria for BPD. On admission patients were categorised as very underweight (BMI 15.0-16.4 kg/m² ), underweight (BMI 16.5-18.4 kg/m² ) or healthy weight range (BMI ≥ 18.5-24.9 kg/m² ). Upon discharge participants were further categorised as weight restored (BMI ≥ 18.5 kg/m² ) or non-weight restored (BMI < 18.5 kg/m² ). The primary outcome was the subscale score on the Reflective Functioning Questionnaire (RFQ-8). Secondary outcomes were subscale scores on the Eating Disorder Examination Questionnaire and the Depression, Anxiety and Stress Scale (DASS)-21. Participants were assessed at baseline and on discharge. Statistical significance was determined using repeated measurements analysis of variance (ANOVA).

RESULTS

Both groups experienced improvements in eating disorder symptoms and measures of psychological well-being. Participants within the MBT group exhibited greater improvements in reflective capacity as defined by the RFQ-8 however these benefits appeared to be limited to patients who achieved weight restoration at discharge. The eligibility criteria-which excluded comorbid BPD-led to challenges in recruitment which limited the power of the study analysis. As participants with a range of different eating disorder diagnoses were included this led to complexities in estimating the treatment effect within a defined cohort.

CONCLUSIONS

Although the small sample size must be noted as a limitation-the finding that weight restoration appears to be associated with improvements in reflective capacity in MBT would be worth exploring in a subsequent larger study. Modification of eligibility criteria and recruitment from a defined cohort may increase the efficiency of a future study.

In-Session-Reflective-Functioning in Anorexia Nervosa: An Analysis of Psychotherapeutic Sessions of the ANTOP Study

OBJECTIVE

Previous research suggests that patients with anorexia nervosa (AN) show an impaired capacity to mentalize (reflective functioning, RF). RF is discussed as a possible predictor of outcome in psychotherapeutic processes. The study aimed to explore RF in sessions of patients with AN and its association with outcome and type of treatment.

METHODS

A post-hoc data analysis of selected cases from a randomized trial on outpatient psychotherapy for AN was conducted. Transcripts from 84 sessions of 28 patients (early phase, middle phase, and end of treatment) were assessed using the In-Session-Reflective-Functioning-Scale [14 cognitive-behavior therapy, enhanced (CBT-E); 14 focal psychodynamic therapy (FPT); 16 with good, 12 with poor outcome after 1 year]. Relations between the level of RF, type of treatment, and outcome were investigated using mixed linear models. Additionally, associations with depressive symptoms, weight gain, and therapeutic alliance were explored.

RESULTS

Mean in-session RF was low. It was higher in FPT when compared to CBT-E treatments. The findings point to an association between RF increase and a positive outcome. An increase in BMI in the first half of treatment was associated with higher subsequent in-session RF. There was no association between RF and depressive symptoms or the therapeutic alliance.

DISCUSSION

Patients with AN show a low capacity to mentalize in sessions, which seems to be at least partly dependent on the degree of starvation. The results suggest a possible relationship between an increase in in-session RF and outcome, which has to be replicated by further studies.

Mentalization-Based Treatment in Groups for Adults With Autism Spectrum Disorder

In order to successfully interact with others in social encounters, we have to be attentive to their mental states. This means, we have to implicitly and explicitly interpret our own actions as well as the actions of others as meaningful on the basis of the ascription of intentional mental states. However, this ability, often referred to as mentalizing, seems to be impaired in autism spectrum disorder (ASD). Individuals with ADS show specific deficits relating to the representation of mental states of others. Especially, the spontaneous, intuitive attribution of and reaction to others' mental states seem to be impaired. Mentalization-Based Treatment (MBT) is a form of psychotherapy in individual and group settings that focuses on the education and enhancement of mentalizing. Although the scope of MBT is broad and MBT has been already proven to be useful in a variety of mental disorders, no attempt has been made to apply MBT in patients with ASD. In our study, we adapted MBT for adults with ASD in a therapeutic group setting to examine the feasibility as well as the effectiveness of the treatment in this patient group. During 15-20 weeks of weekly group therapy, we surveyed the patients' acceptability of the intervention. Additionally, changes in mentalizing difficulties were measured before and after treatment. Results show a high acceptance of the treatment and an improvement in the patients' mentalizing abilities, presenting MBT as a promising treatment option for ASD.

Systematic Review on Mentalization as Key Factor in Psychotherapy

Background: Mentalization processes seem to be of high relevance for social learning and seem important in all psychotherapies. The exact role of mentalization processes in psychotherapy is still unknown. The aim of the present systematic review is to investigate whether mentalization is related to the therapeutic outcome and, if so, whether it has a moderating, mediative, or predictive function. Method: A systematic review with an electronic database search was conducted. A total of 2567 records were identified, and 10 studies were included in the final synthesis. Results: Psychotherapy research is still in an initial phase of examining and understanding the impact of mentalization on psychotherapy outcome. The small number of studies and the executed study designs and statistical analyses indicate the possible role that mentalization has in psychotherapy. Conclusion: Generally, strongly elaborated study designs are needed to identify the role of mentalization in psychotherapy. Mentalization seems to be differently represented in differential treatment approaches. Nevertheless, it should be noted that the patient’s mentalizing capacity seems to be relevant to the psychotherapy process. Psychotherapies should be adapted to this.

Implementation of mentalization-based treatment in a day hospital program for eating disorders-A pilot study

OBJECTIVE

Aim of the pilot study was to evaluate the effectiveness of a day hospital program for eating disorders (EDs) after implementation of mentalization-based treatment (MBT), including a comparison to a historical matched control group.

METHOD

All consecutively admitted patients with an ED were included in a prospective, observational study over a period of 2 years. Main outcome criteria were eating and overall psychopathology. Furthermore, changes in the capacity to mentalize (reflective functioning [RF]), difficulties with affect regulation and interpersonal problems were assessed at admission, discharge and a three months follow-up.

RESULTS

Thirty-eight out of fourty patients could be included. The program led to significant reductions in eating and general pathology. There was significant improvement in RF, difficulties in emotion regulation and interpersonal functioning. However, there was no advantage in comparison to a matched control group (main outcomes). ED symptoms showed a slight renewed increase after discharge, while body mass index further increased. RF change was predictive of change in overall psychopathology, but not ED symptoms. Drop-out rate was 13.2%.

CONCLUSION

The program showed no advantage in comparison to a historical control group concerning a reduction in eating and overall psychopathology. However, it was associated with low drop-out rates, and changes which MBT targets: An increase in RF and a reduction of interpersonal problems as well as difficulties in emotion regulation.

Single-session Mentalization-based Treatment Group for Law Enforcement Officers

Law enforcement violence has emerged as a leading public health concern, and law enforcement officers are themselves at greater risk for a range of psychiatric disorders. Drawing on the significant empirical support for mentalization-based treatment (MBT), this paper explores the use of MBT as a transdiagnostic psychotherapy for law enforcement professionals. By helping patients to mentalize-that is, to "read," access, and reflect on mental states in oneself and other people-MBT could be useful as a dual-focus treatment, able to simultaneously impact psychiatric illness among law enforcement officers while also indirectly impacting the problem of law enforcement violence in the broader society. The core psychotherapeutic principles of MBT are reviewed, along with common vulnerabilities in mentalizing likely to arise for law enforcement professionals in the context of high emotional and interpersonal intensity. The authors outline a novel application of MBT which has implications for psychiatric treatment as well as police training: the single-session psychoeducation and psychotherapy group, where law enforcement officers practice both self-reflection and empathy in situations of relational conflict. Utilizing group process from a residential treatment program for first responders with mental health and substance use disorders, a case example is offered to illustrate this intervention.

Mentalization-Based Treatment Versus Specialist Treatment as Usual for Borderline Personality Disorder: Economic Evaluation Alongside a Randomized Controlled Trial With 36-Month Follow-Up

The authors present an economic evaluation performed alongside a randomized controlled trial of mentalization-based treatment in a day hospital setting (MBT-DH) versus specialist treatment as usual (S-TAU) for borderline personality disorder (BPD) with a 36-month follow-up period. Ninety-five patients from two Dutch treatment institutes were randomly assigned. Societal costs were compared with the proportion of BPD remissions and quality-adjusted life years (QALYs) measured using the five-dimensional EuroQol instrument. The incremental societal costs for one additional QALY could not be calculated. The costs for one additional BPD remission with MBT-DH are approximately €29,000. There was a 58% likelihood that MBT-DH leads to more remitted patients at additional costs compared with S-TAU, and a 35% likelihood that MBT-DH leads to more remissions at lower costs. MBT-DH is not cost-effective compared with S-TAU with QALYs as the outcome, and slightly more cost-effective than S-TAU at 36 months with BPD symptoms as the outcome.

Mentalization-based treatment in groups for adolescents with Borderline Personality Disorder: 3- and 12-month follow-up of a randomized controlled trial

Mentalization-based treatment in groups (MBT-G) has never been tested in adolescents with Borderline Personality Disorder (BPD) in a randomized controlled trial. The current study aimed to test the long-term effectiveness of MBT-G in an adolescent sample with BPD or BPD features (≥ 4 DSM-5 BPD criteria). Hundred and eleven patients with BPD (n = 106) or BPD features (n = 5) were randomized to either (1) a 1-year modified MBT-G program comprising three MBT introductory sessions, five individual case formulation sessions, 37 weekly MBT group sessions, and six MBT-Parent sessions, or (2) treatment as usual (TAU), defined as at least 12 individual monthly treatment sessions with follow-up assessments at 3 and 12 months post treatment. The primary outcome was the score on the Borderline Personality Features Scale for Children (BPFS-C), and secondary outcomes included clinician-rated BPD symptoms and global level of functioning as well as self-reported self-harm, depression, externalizing and internalizing symptoms, and caregiver reports. There were no statistically significant differences between MBT-G and TAU on the primary outcome measure or any of the secondary outcomes. Both groups showed improvement on the majority of clinical and social outcomes at both follow-up points, although remission rates were modest with just 35% in MBT-G and 39% in TAU 2 years after inclusion into the study. MBT-G was not superior to TAU in improving borderline features in adolescents. Although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent BPD features, general psychopathology and decreased functioning in the follow-up period, which points to a need for more research and better understanding of effective components in early intervention programs. The ClinicalTrials.gov identifier is NCT02068326.

Impact of comorbid borderline personality disorder on the outcome of inpatient treatment for anorexia nervosa: a retrospective chart review

BACKGROUND

Data on patients with anorexia nervosa (AN) and comorbid Borderline personality disorder (AN+BPD) are scarce. Therefore, we investigated (1) whether patients with AN and AN+BPD differ in characteristics related to admission to, discharge from, and course of specialized inpatient eating disorder treatment and (2) how comorbid BPD affects treatment outcome.

METHOD

One-thousand one-hundred and sixty inpatients with AN (97.2% female, 5.9% with comorbid BPD; mean age = 26.15, SD = 9.41) were administered the Brief Symptom Inventory (BSI), the Eating Disorder Inventory 2 (EDI-2), and the Global Assessment of Functioning (GAF) at admission and discharge. Data were extracted by a retrospective chart review of naturalistic treatment data. Age, sex, weekly weight gain, length of stay, and discharge characteristics were compared with independent t-tests and χ2-tests. Changes in outcome variables, including body mass index (BMI), were analyzed with longitudinal multilevel mixed-effects models.

RESULTS

No differences in age or sex were found between patients with AN and AN+BPD, but groups differed in previous inpatient treatments, BMI at admission, and frequency of at least one additional comorbidity with higher values for AN+BPD. Higher levels of disorder-specific and general psychopathology at admission were found for AN+BPD. Patients with AN showed statistically significant improvement in all examined variables, patients with AN+BPD improved in all variables except EDI-2 body dissatisfaction. Strongest improvements in patients with AN+BPD occurred in BMI (Cohen's d = 1.08), EDI-2 total score (Cohen's d = 0.99), EDI-2 interpersonal distrust (d = 0.84). Significant Group x Time Interactions were observed for BSI GSI, GAF, and EDI-2 body dissatisfaction, indicating a reduced benefit from inpatient treatment in AN+BPD. At discharge, no differences were found in weekly weight gain, BMI, length of stay, or discharge characteristics (e.g., ability to work, reason for discharge), however, patients with AN+BPD were more frequently treated with medication.

CONCLUSIONS

Patients with AN+BPD differ from patients with AN in that they show higher general and specific eating disorder psychopathology and only partially improve under specialized inpatient treatment. In particular, aspects of emotion regulation and core AN symptoms like body dissatisfaction and perfectionism need to be even more targeted in comorbid patients.

A mechanism-based group-psychotherapy approach to aggressive behaviour in borderline personality disorder: findings from a cluster-randomised controlled trial

BACKGROUND

Aggressive behaviour is a prevalent and harmful phenomenon in patients with borderline personality disorder (BPD). However, no short-term, low-cost programme exists that specifically focuses on aggression.

AIMS

Attuning therapy modules to pathogenetic mechanisms that underlie reactive aggression in BPD, we composed a 6 week mechanism-based anti-aggression psychotherapy (MAAP) approach for the group setting, which we tested against a non-specific supportive psychotherapy (NSSP).

METHOD

A cluster-randomised two-arm parallel-group phase II trial of N = 59 patients with BPD and overt aggressive behaviour was performed (German Registry for Clinical Trials, DRKS00009445). The primary outcome was the externally directed overt aggression score of the Modified Overt Aggression Scale (M-OAS) post-treatment (adjusted for pre-treatment overt aggression). Secondary outcomes were M-OAS irritability, M-OAS response rate and ecological momentary assessment of anger post-treatment and at 6 month follow-up, as well as M-OAS overt aggression score at follow-up.

RESULTS

Although no significant difference in M-OAS overt aggression between treatments was found post-treatment (adjusted difference in mean 3.49 (95% CI -5.32 to 12.31, P = 0.22), the MAAP group showed a clinically relevant decrease in aggressive behaviour of 65% on average (versus 33% in the NSSP group), with particularly strong improvement among those with the highest baseline aggression. Most notably, significant differences in reduction in overt aggression between MAAP and NSSP were found at follow-up.

CONCLUSIONS

Patients with BPD and aggressive behaviour benefited from a short group psychotherapy, with improvements particularly visible at 6 month follow-up. Further studies are required to show whether these effects are specific to MAAP.

The Mentalizing Approach to Psychopathology: State of the Art and Future Directions

Mentalizing is the capacity to understand others and oneself in terms of internal mental states. It is assumed to be underpinned by four dimensions: automatic–controlled, internally–externally focused, self–other, and cognitive–affective. Research suggests that mental disorders are associated with different imbalances in these dimensions. Addressing the quality of mentalizing as part of psychosocial treatments may benefit individuals with various mental disorders. We suggest that mentalizing is a helpful transtheoretical and transdiagnostic concept to explain vulnerability to psychopathology and its treatment. This review summarizes the mentalizing approach to psychopathology from a developmental socioecological evolutionary perspective. We then focus on the application of the mentalizing approach to personality disorders, and we review studies that have extended this approach to other types of psychopathology, including depression, anxiety, and eating disorders. We summarize core principles of mentalization-based treatments and preventive interventions and the evidence for their effectiveness. We conclude with recommendations for future research.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Specialist Supportive Clinical Management for anorexia nervosa: what it is (and what it is not)

OBJECTIVE

Specialist Supportive Clinical Management (SSCM) is a psychotherapy comprising a clinical management focus addressing anorexia nervosa (AN) symptoms and a supportive therapy component. SSCM has been an active control therapy in randomised controlled trials for AN, but has proven to be an effective therapy in its own right. There has been speculation about how this relatively straightforward therapy works. Some of the commentaries and descriptors used for SSCM, however, do not reflect the content or principles of SSCM. This paper clarifies areas of misunderstanding by describing what SSCM is and what it is not, particularly in relation to commentary about its constituent characteristics.

CONCLUSIONS

SSCM utilises well established clinical management for AN (with a sustained focus on normalised eating and weight restoration) coupled with supportive therapy principles and strategies. Common factors across both arms include core counselling skills and a positive therapeutic alliance to promote adherence and retention in treatment for AN. Compared to other comparator therapies to date, SSCM is a simpler therapy without unique or novel theoretically derived strategies. Comparable outcomes with more complex psychotherapies raise the question of whether the combined core components of SSCM may be sufficient for many people with AN.

Is mentalization-based therapy effective in treating the symptoms of borderline personality disorder? A systematic review

OBJECTIVE

This review sought to systematically review evidence on the efficacy of mentalization-based therapy (MBT) for the treatment of borderline personality disorder (BPD), in particular, in decreasing psychiatric symptoms associated with BPD and its comorbid disorders.

METHOD

Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow-up papers.

RESULTS

Mentalization-based therapy was found to achieve either superior or equal reductions in psychiatric symptoms when compared with other treatments (supportive group therapy, treatment as usual/standard psychiatric care, structured clinical management, and specialized clinical management).

DISCUSSION

Mentalization-based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life. However, caution is required, as the need for better quality research such as randomized controlled trials is pressing. Research is also needed on the proposed mediators of MBT.

PRACTITIONER POINTS

Mentalization-based therapy (MBT) is increasingly being considered as a treatment for people with borderline personality disorder (BPD), and a systematic review was required to investigate its effectiveness. MBT was found to be equally as effective or superior to well-established comparison treatments of BPD, however, the majority of studies was of unsatisfying quality. Little is known about the mechanisms of MBT. Further, better quality trials are needed to investigate its efficacy in treating BPD.

Mentalization-based treatment and its evidence-base status: A systematic literature review

PURPOSE

This study reviewed the evidence-base status of mentalization-based treatment (MBT), its quality, strengths, and limitations. The aim was to pave the way for further MBT research.

METHOD

An electronic database and reference lists search identified MBT outcome papers, and these were systematically reviewed. The quality of the studies and the risk of bias were determined using two validated checklist tools.

RESULTS

Twenty-three studies were included in the review. This included nine randomized controlled trials, seven uncontrolled pre- and post-effectiveness studies, three retrospective cohort studies, two uncontrolled randomized trials, and two case studies. The methodological quality of almost half of the papers was assessed as fair (43%), followed by good (34%), poor (17%), and excellent (4%) ratings. Nevertheless, the review identified risk of confounding bias across the majority of studies (60%) and fidelity to treatment was poorly reported in almost half of the studies (47%). Most of the studies focused on borderline personality disorder (BPD), showing positive clinical outcomes for this population but the evidence-base for other presentations was still developing. The treatment of adolescents who self-harm and at-risk mothers in substance abuse treatment showed particularly promising results, as these are client groups that have previously shown limited positive response to psychological interventions.

CONCLUSIONS

Mentalization-based treatment is a potentially effective method across a wide range of clinical presentations but further research should focus on increasing the quality and the quantity of the MBT evidence outside the treatment of BPD.

PRACTITIONER POINTS

MBT can be a particularly effective intervention for the treatment of adults with a diagnosis of BPD and of adolescents who self-harm and mothers enrolled in substance abuse treatments. MBT can be an effective intervention for depression and eating disorders but the evidence is currently limited. Professionals supporting mothers of children at risk may benefit from receiving training in the principles of MBT.

The protective role of mentalizing: Reflective functioning as a mediator between child maltreatment, psychopathology and parental attitude in expecting parents

BACKGROUND

Childhood maltreatment impacts parenting and has intergenerational consequences. It is therefore crucial to identify clinically responsive resilience-promoting factors in pregnant women and expecting men with history of childhood maltreatment. Mentalization, or reflective functioning, appears as a promising concept to understand risk and resilience in the face of childhood maltreatment.

OBJECTIVE

This study evaluated the multivariate relationship between exposure to childhood maltreatment, reflective functioning, psychological symptoms and parental attitude in expecting parents.

METHODS

Two hundred and thirty-five pregnant women and 66 expecting fathers completed self-report assessment measures of childhood trauma, reflective functioning, depression, post-traumatic stress disorder, parental sense of competence and antenatal attachment. Twenty-eight percent (n = 85) of the community sample reported personal histories of childhood maltreatment.

RESULTS

Structural equation modeling indicated that reflective functioning (a) partially mediated the association between childhood maltreatment and psychological symptoms during pregnancy and (b) independently predicted participants' perception of parental competence and psychological investment toward the unborn child.

CONCLUSION

Overall, this study provides empirical evidence of the protective role of reflective functioning during the prenatal period in parents with histories of childhood maltreatment.

Reduced mentalizing in patients with bulimia nervosa and features of borderline personality disorder: A case-control study

BACKGROUND

Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in some mental disorders such as Borderline Personality Disorder (BPD). Some studies have suggested that Eating Disorders (EDs) may also be associated with impairments in mentalizing, but studies have not always yielded consistent results. This is the first study to systematically investigate mentalizing impairments in patients with Bulimia Nervosa (BN) compared with controls. In addition, we investigated whether impairments in mentalizing were related to BPD features, rather than BN per se, given the high comorbidity between BPD and BN.

METHODS

Patients with BN (n = 53) and healthy controls (HCs; n = 87) completed a battery of measures assessing mentalizing including the Reflective Function Questionnaires (RFQ), the Object Relations Inventory (ORI; Differentiation-Relatedness Scales) and the Reading The Mind in The Eyes Test (RMET).

RESULTS

Patients with BN scored significantly lower than HCs on all tests of mentalizing, with moderate to large between-group effect sizes. These differences were partially accounted for by BPD features as assessed with the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and partially by bulimic symptoms measured with the Eating Disorder Examination Questionnaire (EDE-Q).

CONCLUSIONS

Patients with BN have significantly lower levels of mentalizing as assessed with a broad range of tests compared to HCs. These differences were related to both bulimic symptoms and BPD features. Although further research in larger samples is needed, if replicated, these findings suggest that poor mentalizing may be a significant factor in BN patients and should be addressed in treatment, regardless of the presence of BPD features.

Mentalization-Based Treatment for Personality Disorders: Efficacy, Effectiveness, and New Developments

PURPOSE OF THE REVIEW

This review aims to outline the most recent evidence on the efficacy and effectiveness of mentalization-based treatment (MBT) for personality disorders (PD) from 2015 to 2018 and to describe new treatment developments.

RECENT FINDINGS

Since 2015, 14 new-primarily effectiveness-MBT trials have been published. The main body of studies investigated adult populations (n = 11), patients with a borderline personality disorder (BPD) diagnosis (n = 8), and compared MBT with another psychotherapeutic treatment (n = 6). The majority of studies suggest that MBT has the potential to improve the clinical outcomes for adolescents and adults with a PD diagnosis, particularly BPD, and also with comorbid diagnoses and there are indications for changes in mentalizing being a specific mechanism of change promoted by MBT. Despite promising findings, there is an urgent need for methodological sound and sufficiently powered studies to investigate both the efficacy and effectiveness of MBT, especially beyond BPD.

Impact of comorbid borderline personality disorder on inpatient treatment for bulimia nervosa: analysis of routine data

BACKGROUND

A substantial rate of patients with bulimia nervosa (BN) also suffer from Borderline personality disorder (BN + BPD). It is widely unknown how these comorbid patients with BN + BPD present and respond to inpatient treatment. Aims of the study were to examine (1) specific characteristics of patients with BN + BPD at admission, discharge, and during treatment, and (2) differential effects of inpatient treatment for BN vs. BN + BPD.

METHOD

We analyzed routine data of inpatients admitted for the treatment of BN between 2013 and 2017 in a specialized hospital for eating disorders. (1) Cross-sectional differences were examined with independent t-tests and χ2-tests; and (2) treatment effects pertaining to eating disorders symptoms, depression, psychosocial functioning and general psychopathology with repeated measures analysis of variance.

RESULTS

Of 1298 inpatients (96% female), 13.2% also had a diagnosis of BPD. (1) Patients with BN + BPD had more previous inpatient treatments (p = 0.001), had a longer length of stay (p = 0.003), gained more weight during treatment (p = 0.006), and were more often irregularly discharged (p = 0.018) as well as rated as unfit to work at discharge (p = 0.003). (2) Both groups improved in all examined variables (all main effects treatment p <  0.001). Patients with BN + BPD showed worse symptoms aggregated across admission and discharge (all main effects diagnosis p <  0.05). Patients with BN + BPD showed smaller improvements (interaction treatment×discharge) in depressive symptoms (p = 0.018), perfectionism (p = 0.009), and asceticism (p = 0.035) and discharge scores mostly lay in the range of the admission scores of the BN-only group.

CONCLUSION

Patients with BN + BPD improve during intense and specialized inpatient treatment, yet, retain pronounced impairment at discharge despite longer treatment. Treatment needs to be improved and should focus on transdiagnostic symptoms of BN and BPD.

Recovery from eating disorder 1 year after start of treatment is related to better mentalization and strong reduction of sensitivity to others

PURPOSE

To investigate whether recovery from an eating disorder is related to pre-treatment attachment and mentalization and/or to improvement of attachment and mentalization during treatment.

METHOD

For a sample of 38 anorexia nervosa (AN) and bulimia nervosa (BN) patients receiving treatment the relations between attachment security, mentalization, comorbidity and recovery status after 12 months (not recovered or recovered), and after 18 months (persistently ill, relapsed, newly recovered, or persistently recovered) were investigated. Attachment security and mentalization were assessed by the Adult Attachment Interview at the start of the treatment and after 12 months. Besides assessing co-morbidity-for its effect on treatment outcome-we measured psycho-neuroticism and autonomy because of their established relations to both eating disorder symptoms and to attachment security.

RESULTS

Recovery both at 12 months and at 18 months was related to higher levels of mentalization; for attachment, no significant differences were found between recovered and unrecovered patients. Patients who recovered from AN or BN also improved on co-morbid symptoms: whereas pre-treatment symptom severity was similar, at 12 months recovered patients scored lower on co-morbid personality disorders, anxiety, depression, self-injurious behaviour and psycho-neuroticism than unrecovered patients. Improvement on autonomy (reduced sensitivity to others; greater capacity to manage new situations) in 1 year of treatment was significantly higher in recovered than in unrecovered patients.

CONCLUSION

A focus on enhancing mentalization in eating disorder treatment might be useful to increase the chances of successful treatment. Improvement of autonomy might be the mechanism of change in recovering from AN or BN.

LEVEL OF EVIDENCE

Level III cohort study.