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A heuristic, mentalization based model of psychosis pathogenesis. Together with a constitutional liability caused by variant genes, developmental factors such as childhood abuse and insults, and intermediate factors such as insecure attachment and impaired mentalizing comprise a fertile ground for social difficulties to sensitize the mesolimbic dopamine system. Dismissing or disorganized attachment relationships to caregivers and peers may result in distress and poor co-regulation of emotions when in the proximity of others. This complicates social interaction, and may lead to isolation or withdrawal, and thus more stress and impaired mentalizing. The sensitization of the dopamine system in turn results in aberrant experiences. Due to epistemic mistrust, interpretation of these experiences may become progressively idiosyncratic and tenacious. If individuals attribute extreme certainty to sensory-affective experiences, this results in proper hallucinations. On the other hand, sensory-affective information or the viewpoint of others may not be used to update cognitive beliefs, resulting in delusional ideation
Source publication
Social functioning can be severely impaired in non-affective psychotic disorder (NAPD). Current models of psychosis pathogenesis do not tend to focus on social dysfunction and pharmacological treatment fails to ameliorate it. In this article, we propose that mentalization theory provides a valuable contribution to the understanding and treatment of...
Citations
... It is recognized as a core element for healthy personality development and social cognition, as it plays a major role in one's ability to feel/express empathy, to communicate, to regulate emotions and impulse control, to experience wellbeing, as well as in entertaining relationships and overall interpersonal functioning [3,5,6]. As such, a lack or de ciency in mentalizing ability was shown to be signi cantly linked to a range of psychopathology, such as psychotic disorders [7] -including at the early stages of disease progression [8]-, bipolar disorders [9], Major depressive disorders [10], eating disorders [11], borderline personality disorder [12], and substance use disorders [13]. Mentalising de cits has also been found to be involved in the psychological functioning within a range of psychiatric conditions, including autism and psychosis [14]. ...
Background: The lack of sound measures to assess mentalising in Arabic-speaking adults is a significant gap that can substantially constrain understanding of the expression and difficulties in the mentalising processes across the lifespan in the Arab world, and of the cross-cultural. Therefore, this study aimed to investigate the psychometric properties of an Arabic translation of the FIMI in a multi-national sample of non-clinical adults.
Methods: A sample of 8,408 adults (74.5% females, mean age 24.70 ± 8.44 years) from the general population of twelve Arab countries was surveyed to examine the psychometric properties of the Arabic FIMI.
Results: CFA indicated that fit of the one-factor model of FIMI scores was excellent: RMSEA = .035 (90% CI .023, .048), SRMR = .012, CFI = .996, TLI = .989, and had adequate internal consistency reliability (ω = .68; α = .65). Indices suggested that configural, metric, and scalar invariance was supported across sex and country groups. Finally, correlational analyses provided support for construct validity of the Arabic-language version of the FIMI, by showing significant positive correlations between mentalising and self-reported autistic traits scores.
Conclusion: Findings suggest that the Arabic FIMI is valid, reliable ad suitable for use among Arabic-speaking adults. The scale may raise awareness among clinicians and researchers of the possibilities to easily and accurately assess mentalising in order to enable the development, testing and monitoring of tailored Mentalising-based treatments aimed at addressing impaired mentalising and managing a range of mental disorders in Arab settings.
... Improving mentalization can be considered as the core of all treatment models [22]. PIH-Pegasus combines the most important elements of PIH and mentalization-based therapy, being a focus on currently felt affect, careful adjustment to the patient's level of mentalization and arousal, a 'not-knowing' therapeutic stance and unassuming interventions [23,24]. In addition, family sessions are included based on the most important elements of system therapy in families with a member with autism: to repair and improve relationships and cooperation and to create a context of hope and empowerment [25]. ...
Background
For people with autism spectrum disorder (ASD), daily life can be highly stressful with many unpredictable events that can evoke emotion dysregulation (ED): a strong difficulty with appropriately negative affect regulation. For some of the patients with ASD, treatment as usual does not prove to be effective for ED. They may be at risk of life-long impairment, development of other disorders and loss of motivation for most regular forms of therapy. A highly promising method that may prove effective for therapy-resistant individuals with ASD is Psychotherapy incorporating horses (PIH). PIH uses the interactions of the horse and the patients on the ground and does not include horseriding. While often met with prejudgment and scepticism, reports from parents and therapists as well as a recent systematic review suggest that PIH may have beneficial effects on youths with ASD. Therefore, we examine clinical outcomes both in the short and in the long terms of PIH offered to adolescents with ASD and severe ED despite regular therapy.
Methods
A total of 35 adolescents aged 11–18 years with ASD will receive PIH during 15 sessions once a week with randomization to five different groups differentiating in baseline phase from 2 to 6 weeks. PIH uses horses to promote social awareness and self-awareness as well as relationship management and self-management. The primary outcome is the response to treatment on the Emotion Dysregulation Index (EDI). The secondary outcome measures include ASD symptom severity, quality of life, self-esteem, global and family functioning, and goal attainment. Assessments take place at the baseline (T0), at the end of baseline phase A (T1), after completion of intervention phase B (T2), after the end of post-measurement phase C (T3) and after one year (T4). Qualitative interviews of participants, parents and therapists will be held to reveal facilitators and barriers of PIH and a cost-effectiveness study will be performed.
Discussion
This study aims at contributing to clinical practice for adolescents with ASD and persistent emotion regulation problems despite 1.5 year of treatment by offering Psychotherapy incorporating horses in a study with series of randomised, baseline controlled n-of-1 trials.
Trial registration
www.ClinicalTrials.gov NCT05200351, December 10th 2021.
... Specific factors might represent psychopathological dimensions devoid of overlap with other dimensions, effectively studying 'pure' problem domains (Caspi et al., 2014). In this case, 'pure' psychoticism might reflect the degree of disorganized thought, a feature that parallels RF since both involve metacognitive abilities (Weijers et al., 2020). Nonetheless, the mediation model did not show an acceptable fit to the data, nor did the specific psychoticism factor show acceptable levels of reliable, so we caution these interpretations. ...
Background
The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression.
Methods
A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires.
Results
Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression.
Conclusions
These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.
... Fonagy and Allison (2014) have argued that a secure attachment may lower a sense of epistemic hypervigilance, enabling the person to learn from others while still having confidence in their own perspectives. This basic difficulty in updating one's beliefs or personal life narrative in response to new experiences may be linked to observed deficits in mentalization or metacognition in psychosis Weijers et al., 2020) or potential fears about being harmed by the foreign ideas of others (Rosenfeld, 1947). These theoretical models could inform connections between childhood trauma and impaired metacognition (Fonagy et al., 2017), given high rates of childhood trauma in individuals who experience psychosis (Kelleher et al., 2013). ...
... To navigate the initial stages of therapy with a mistrustful patient, we propose three main caveats. First, therapists should consider the simultaneous importance and pitfalls of therapist warmth, given that many patients with psychosis are mistrustful and fearful of closeness and attachment (Weijers et al., 2020). Research studies have found that therapist warmth and caring are factors that can promote trust and closeness (Laugharne et al., 2012;Pipkin et al., 2021). ...
... For instance, a patient might become increasingly mistrustful when interacting with others who irritate them, which may be driven by the patient's tendency to project their guilt and anger onto others, exacerbating perceptions of threat. Helping the patient register their emotions by linking it to bodily sensations might enable the patient to begin to recognize that emotions might influence their perceptions of others (Weijers et al., 2020). Furthermore, greater emotional experience and regulation within psychotherapy sessions has been linked with better outcome, including improved metacognition, in MERIT (Igra et al., 2022). ...
Mistrust is a significant problem for people with psychosis and can interfere with their capacity to engage in psychosocial treatment. In this article, the developmental trajectory of mistrust is outlined, including the impact that attachment disruption, childhood trauma, attributional biases, internalized stigma, and discrimination can have on the person's capacity to form trusting bonds with others. After this review, three elements are described that may allow for the restoration of trust: the therapist's openness to understanding the patient's experience and agenda for therapy, the therapist's effort to honestly disclose their thoughts to encourage dialogue and mutual reflection, and therapist's attempt to promote metacognition through helping the patient develop more complex representations of the minds of others. These elements are framed in the context of metacognitive reflection and insight therapy, an integrative therapy that is well suited to address mistrust through its explicit focus on metacognition and intersubjectivity.
... Second, interventions are grounded in the present and especially attuned to the patient's feelings and bodily sensation, as they evolve over the course of a session (Weijers et al., 2020). Keeping an eye on the emergence and escalation of emotion can help the therapist and patient collaboratively assess how feelings affect the patient's thinking and experience of the therapeutic relationship. ...
... MBT for psychosis is a treatment that is 18 months long and includes weekly group therapy and half-hour individual sessions once per two weeks that is offered in an outpatient setting (Weijers et al., 2020). The intensity of the individual and group therapy sessions is usually attenuated to avoid overwhelming the patients with mentalization interventions. ...
Although mentalization-based treatments have been applied to persons diagnosed with schizophrenia spectrum disorders, there is minimal literature on how mentalization-based treatment might be adapted to persons with schizotypal personality disorder (SPD). Persons with SPD often struggle to reflect upon their own mental states and the mental states of others, which can result in social anxiety, confusion, and interpersonal withdrawal. Such problems in mentalization might also be linked to early experiences of adversity and emotional abuse, experiences that are commonly reported by persons with SPD. In this chapter, some key areas of vulnerability for persons with SPD will be outlined, including impaired mentalization, emotional deficits, and social anxieties that can be addressed in the context of a secure therapeutic relationship. The authors will provide brief clinical vignettes to illustrate mentalization-informed techniques that can boost reflective functioning, enhance emotional awareness, and reduce social anxiety and confusion that can interfere with the development of meaningful interpersonal connections.
... Impairments in the ways people think about themselves and the others are a central diagnostic feature of psychotic disorders (Davidson, 2020;Korsbek, 2016;Lysaker et al., 2021). These impairments have been described as deficits in social cognition (Green et al., 2015), mentalization (Weijers et al., 2020), or metacognition (Moritz and Lysaker, 2018). Failure to maintain a nuanced, complex, and integrated understanding of one's own and others' mental states has been reported in various personality disorders (PDs) as well (Herpertz and Bertsch, 2014;Luyten and Fonagy, 2015;Semerari et al., 2014), and specifically in schizotypal PD (Cheli, 2020;Salaminios et al., 2021). ...
Psychoticism is a multidimensional personality construct involving odd or eccentric behavior, quasi-psychotic experiences, mistrust, interpersonal detachment, and liability for schizophrenia-spectrum disorders, as well as significant distress. Recent advances suggest it can be understood as a dimension that is continuously distributed in the population, leading to questions about factors that contribute to distress and dysfunction among people with a schizotypal liability. We investigated in a large nonclinical sample of young adults whether associations between psychoticism and psychological distress would increase in the presence of threatening beliefs. In our study ( N = 2127), we found that the association between psychoticism and psychological distress is moderated by threatening beliefs including self-criticism, fear of compassion, and socially prescribed perfectionism. These results suggest that distress increases among people with schizotypal traits in the context of negative beliefs about self and others. We discuss implications for clinical practice and directions for further research.
... Additionally, as suggested elsewhere (30) we believe that MBT for SCZ should be given for a longer period of time, as it takes SCZ patients more time to feel secure enough to start exploring feeling states. For more in-depth recommendations regarding approach and technique, please refer to Weijers et al. (67). ...
Introduction
There is robust evidence that both patients with schizophrenia (SCZ) and borderline personality disorder (BPD) display mentalizing difficulties. Less is known however about differences in the way mentalization based treatment (MBT) impacts mentalizing capacity in SCZ and BPD patients. This study compares the impact of MBT on mentalizing capacity in individuals with SCZ and BPD.
Method
The thematic apperception test was used to measure mentalizing capacity. It was administered at the beginning and end of treatment to 26 patients with SCZ and 28 patients with BPD who enrolled in an 18-month long MBT program. For comparison a sample of 28 SCZ patients who did not receive MBT was also included. Using the social cognition and object-relations system, these narratives were analyzed and scored. Missing data was imputed and analyzed using intention-to-treat ANCOVAs with post-treatment measures of mentalizing capacity as dependent variables, group type as independent variable and baseline mentalizing capacities as covariates.
Results
Results showed that patients with BPD showed significantly more improvement on several measures of mentalizing, including complexity of representation (ηp² = 0.50, ppooled < 0.001), understanding of social causality (ηp² = 0.41, ppooled < 0.001) and emotional investment in relationships (ηp² = 0.41, ppooled < 0.001) compared to patients with SCZ who received MBT. No differences were found regarding affect-tone of relationships (ηp² = 0.04, ppooled = 0.36). SCZ patients who received MBT showed greater performance on understanding of social causality (ηp² = 0.12, ppooled = 0.01) compared to SCZ patients who did not receive MBT, but no differences were observed on complexity of representations, capacity for emotional investment or affect-tone of relationships.
Discussion
Patients with BPD performed better after receiving MBT on three dimensions of mentalizing capacity than SCZ patients who received MBT. Remarkably, SCZ patients who received MBT performed better on one dimension of mentalizing capacity compared to SCZ patients who did not receive MBT. Whereas MBT for BPD clearly involves improvement on most aspects of mentalizing, MBT for SCZ seems to thwart a further decline of other-oriented, cognitive mentalizing. Treatment goals should be adapted toward these disorder-specific characteristics.
... A range of evolving and novel evidence-based approaches to psychotherapy for people diagnosed with schizophrenia emphasize growth in reflective processes as a mechanism of change that promotes recovery and supports the development of an increasingly coherent sense of self (Brent, 2009;Hasson-Ohayon et al., 2021;Hasson-Ohayon & Lysaker, 2021a;Weijers et al., 2020). This emphasis is based on extensive research showing that people with schizophrenia often struggle to experience themselves as agents who can act in a meaningful way in the world (Lysaker, Minor, et al., 2020;McCarthy-Jones et al., 2013). ...
Background:
Research has suggested that people diagnosed with schizophrenia experience challenges in their abilities to reflect upon themselves, others and their actions in the world. One emerging approach to addressing these forms of subjective disturbance is Metacognitive Reflection and Insight Therapy (MERIT).
Aims:
In this study, a randomized delayed trial was conducted to assess the effects of MERIT upon metacognition, psychiatric symptoms and quality of life.
Materials and methods:
Following recruitment and randomization, data from 54 adults diagnosed with schizophrenia were analysed.
Results:
Findings included significant interaction effects between group (immediate intervention or waiting condition) and time (pre- and post intervention) with regard to the metacognition general score and its domain of mastery, as well as with regard to negative, positive and cognitive symptoms.
Discussion:
Participating in MERIT seems to improve one's ability to use reflective knowledge to cope with psychological challenges and to improve, or at least maintain, level of symptomatology.
Conclusions:
These findings are discussed within the framework of agency as an important aspect of recovery.
... Information processing errors are another untested factor from the larger TRV model, which increase the risk innocuous mental activity will be experienced as distressing UPEs, and may explain our findings (Strachan et al., 2023). For example, several psychological constructs, such as mentalisation, meta-cognition and self-disturbance involve information processing errors that limit the ability to understand and organise one's own cognitions (Nelson et al., 2014a(Nelson et al., , 2014bRidenour et al., 2019;Weijers et al., 2020). These constructs are associated with insecure attachment (Debbané et al., 2016) and dissociation (Liotti & Gumley, 2008) across the psychotic spectrum and mediate the relationship between trauma and psychosis risk (Gawęda et al., 2018). ...
Background:
A range of traumas have been linked to voices (auditory verbal hallucinations) and unusual perceptual experiences (UPEs) in other perceptual-sensory domains. Models of PTSD and positive symptoms of psychosis are insufficient in explaining the relationship between trauma and voices. The trauma-related voices (TRV) model was developed to generate novel research in this area.
Aims:
This study aimed to investigate pathways from trauma to the frequency of UPEs based on a subset of hypothesised relationships in the TRV model.
Materials:
The PTSD Diagnostic Scale for DSM-5, State Adult Attachment Measure, Depression Anxiety and Stress Scales-21, Perth Emotion and Regulation Competency Inventory, Dissociative Experiences Measure Oxford, and Multi-modality Unusual Perceptual Experiences Questionnaire.
Methods:
We used path analysis in a non-clinical sample (N = 528) to model indirect effects from diverse trauma experiences to the frequency of multi-sensory UPEs via a subset of mediators within the TRV model: insecure attachment, emotion regulation deficits, negative affect and dissociation.
Results:
Our model was an excellent fit to the data and accounted for 37.1% of variance in UPE frequency, and all direct (βs = .14-.61) and indirect pathways (βs = .01-.08) were significant (ps < .001).
Discussion:
Our findings suggest that insecure attachment may link diverse trauma experiences to emotion regulation deficits and negative affect, which are linked to UPE frequency via dissociation.
Conclusion:
Our findings provide preliminary evidence for a subset of relationships within the TRV model. Future studies are needed to gather stronger evidence of temporality and causation between these factors, and to test broader pathways within the TRV model.
... It has also been hypothesized that there is a reciprocity between sex hormones and social cognition in schizophrenia, where oxytocin, estrogens, and testosterone could have a role [30], and being exposed to these in fetal life might have an effect on the disorder [31]. An expanding body of literature has documented various deficits in both cognitive and affective facets of mentalizing in individuals diagnosed with psychosis, and the anomalies within this specific metacognitive domain are responsible for a significant portion of the compromised social functioning and poor social outcomes observed [32][33][34]. In our study, we aimed to assess the correlation between PR and independent variables, such as mentalization, disability, quality of life, orientation, tendency toward introspection, and antipsychotic (AP) side effects (SE) in a group of patients with schizophrenia. ...
... A considerable line of research in schizophrenia has highlighted alterations in the mentalization process, and this might explain some aspects of the patients' social dysfunction and poor social outcomes [34,44]. Deficits in ToM have been observed in psychotic patients with compromised social behavior [32,45,46] and with functional impairment especially in circumstances in which patients needed to cooperate with others [47]. For instance, it has been observed that individuals with psychosis may develop firm beliefs about others' intentions based just on their physical observable behavior, losing the capacity to consider alternative perspectives [42]. ...
Recovery is a broadly debated concept in the field of psychiatry research and in schizophrenia. Our study aims to understand the correlation between personal recovery from schizophrenia and factors such as mentalization, disability, quality of life, and antipsychotic side effects; Methods: Participants with schizophrenia (according to DSM-5 criteria) were consecutively recruited from the Psychiatry Unit of the University of Catania, Italy. Participants were assessed with the Recovery Assessment Scale (RAS), the Multidimensional Mentalizing Questionnaire (MMQ), the brief version of the WHO Disability Assessment Schedule (WHO-DAS), the EuroQoL-5 dimensions-5 levels, the Insight Orientation Scale (IOS) and the Glasgow Antipsychotic Side Effect Scale (GASS); Results: 81 patients were included. Our findings showed a positive correlation between RAS total scores and MMQ scores, especially in “good mentalizing” subdomains. IOS scores also had a positive association with RAS and MMQ scores. In contrast, poor mentalizing abilities negatively correlated with WHO-DAS 2.0 scores. While antipsychotic side effects influenced functioning, they did not impact perceived recovery. Conclusions: The study’s results identified potential predictors of personal recovery from schizophrenia. These findings could contribute to creating tailored interventions to facilitate the recovery process.
