Failure to resolve loss and compromised mentalizing in female inpatients with major depressive disorder.

Attachment and mentalizing are central concepts in research on the etiology, course, and treatment of depression. The goal of this cross-sectional study was to clarify the unique value of these constructs in characterizing the presence, severity, and chronicity of depression. We examined 50 female inpatients suffering from Major Depressive Disorder (MDD) in comparison to 47 matched healthy controls regarding their attachment states of mind, mentalizing capacities, and clinical variables indicating depression severity and chronicity (e.g. illness duration, number of hospitalizations). In the group of depressed patients, unresolved attachment with regard to loss was significantly overrepresented. Dimensionally, patients were more disorganized and more insecure, whereas there was no difference on the dismissing-preoccupied dimension between the two groups. Mentalizing was significantly lower in patients than in healthy controls. Logistic regression analysis revealed attachment insecurity, mentalizing deficits, and unresolved loss to be incrementally relevant to predict MDD. Correlations with clinical parameters in the group of depressed patients showed positive associations between mentalizing deficits, attachment insecurity, and variables indicating illness chronicity. Our findings highlight the relevance of the inability to resolve or reappraise loss experiences in depressive states.

Mentalization and Depression: Theoretical Concepts, Treatment Approaches and Empirical Studies - an Overview.

Objectives: The aim of this article is to outline the relevance of mentalization for the understanding of the dynamics and the psychotherapeutic treatment of depression, and to systematically review the literature on mentalization as it relates to the diagnosis of depression and the evaluation of depression treatment. Methods: The first part of the article consists of an overview of the theory of mentalization and its relevance for depression and its treatment. For the second part, a literature research was conducted in Scopus and PubMed to retrieve and then manually select empirical studies on depression and mentalization, focusing on studies applying the Reflective Functioning Scale based on the Adult Attachment Interview. Results: For our review, 15 studies were selected. These suggest that severe chronic and/ or treatment resistant depression is related to more pronounced mentalizing deficits. With respect to psychotherapy process and outcome, mentalization is a specific focus of psychodynamic therapy approaches, and proves to be an important mediating and moderating variable. Conclusion: Mentalization with its linkages to attachment theory offers rich possibilities for an in-depth understanding of the dynamics of depression and resulting mentalization based approaches to the treatment of the disorder. The small number of studies and their heterogeneous design allow only preliminary assumptions on the difference between severe, chronic and milder or episodic courses of depression with respect to mentalizing deficits and urge for further research.

Changes in Attachment Representation in Psychotherapy: Is Reflective Functioning the Crucial Factor?

OBJECTIVES: The study analyzed the interdependence of change in attachment representation and reflective functioning (RF) in psychotherapy. METHODS: RF data from 63 female borderline personality disorder (BPD) patients were analyzed with respect to change of attachment representation (from insecure to secure and from unresolved to resolved) fromthree angles: (1) RF as a moderator variable, (2) RF as an outcome variable, and (3) RF changes over one year of treatment. RESULTS: Patients who changed to a resolved attachment classification showed higher RF before treatment and at follow-up than patients who remained unresolved (RF = 3.0 vs. RF = 2.14, p = 0.039; and RF = 3.4 vs. RF = 2.36, p = 0.002). Similar results were found for changes from insecure to secure. CONCLUSION: A higher RF level before psychotherapy proved to be a moderator for change in attachment representation. Patients with unresolved attachment and low-level RF at the outset had the least chance for representational change during the first year of psychotherapy.

Men don't cry: The supporting role as necessary for women's well-being after termination of pregnancy.

OBJECTIVES: The present study investigated similarities and differences of grief between men and women as part of the parental couple 1 year after termination of pregnancy (TOP) following a diagnosis of fetal anomaly. METHODS: We applied a method triangulation approach. We assessed several aspects of perinatal grief, depressive symptoms, posttraumatic stress, and anxiety as well as health-related quality of life. In addition, we conducted qualitative interviews with the men to explore the fathers' roles in the partnership during pregnancy, the time of the diagnosis, TOP, and afterwards. RESULTS: Women showed a more elevated grief response compared with men. Qualitative data revealed that men in our sample were mainly concerned with their partners' well-being and concentrated on supporting their partners rather than on their own emotions. In addition, the supportive role of the male partner plays a central role in the well-being of women and the man's coping with the situation. CONCLUSION: In clinical work, but also when developing new questionnaires, the specific role of the male partners needs to be considered more thoroughly. Particular attention should be paid to identify the men who find it difficult to assume the supporting role.

[Mentalization and bonding in chronic pelvic pain patients: a pilot study]. / Mentalisierungsfähigkeit und Bindung bei Patientinnen mit chronischen Unterbauchschmerzen: eine Pilotstudie.

OBJECTIVES: The study assesses mentalization (reflective functioning, RF), parental bonding, psychiatric comorbidity, and experiences of violence in chronic pelvic pain patients (CPP). METHODS: Twenty-two CPP patients were investigated using SCID I and II as well as the German version of the parental bonding instrument (FEB). Experiences of violence were assessed by semistructured interviews. Adult attachment interviews (AAI) were rated according to the Reflective Functioning Scale (RF Scale). RESULTS: CPP patients showed a lower capacity of mentalization (RF=2.3) compared to that of healthy individuals (RF approximately 5). Maternal bonding was rated as affectionless control (36.4 %) and as neglectful parenting (31.8 %). 54 % of the women reported experiences of violence. Axis I comorbidity was prevalent in 54.5 %, and axis II comorbidity was prevalent in 36.4 %. CONCLUSIONS: Further psychoanalytic-psychosomatic research should focus on the low capacity of mentalization, adverse parenting, and experiences of violence in chronic pelvic pain patients.

[The capacity for mentalization in depressive patients: a pilot study]. / Mentalisierungsfähigkeit bei depressiven Patientinnen: Eine Pilotstudie.

OBJECTIVES: Mentalization has been primarily investigated in Borderline Personality Disorders. This pilot study takes the first step toward investigating mentalization in depressive patients. METHODS: First, we present the theoretical background of the concept of mentalization and previous studies. Secondly, we report the results of this pilot study. 20 female inpatients suffering from Major Depressive Disorder were investigated with SKIDI+II, depression-scales (HAM-D, BDI), cognitive tests (TMT, MCVCT), and the Adult Attachment Interview (AAI), rated according to the Reflective Functioning Scale (RF Scale). RESULTS: Depressed patients showed less capacity for mentalization (RF = 2.3) than did borderline patients (RF approximately 3) and healthy individuals (RF approximately 5). Comorbidity with dependent personality disorder correlated with higher RF scores, while comorbidity with schizoid personality disorder correlated with lower RF scores. CONCLUSIONS: Moderate to severe depression goes along with a breakdown of mental capacity. Further research should focus on investigating changes in the capacity for mentalization in remission and changes in the course of psychotherapeutic treatments.