Mentalizing in and out of awareness: A meta-analytic review of implicit and explicit mentalizing.

BACKGROUND: Mentalizing, making sense of mental states, is hypothesized to have a central role in self-organization and social learning. Findings support this notion, but the extent of the association between mentalizing and various correlates has not been meta-analyzed. Furthermore, mentalizing presumably occurs with (explicit) and without (implicit) awareness but few studies have attempted to disentangle these aspects. We conducted a meta-analysis of implicit and explicit mentalizing in relation to the domains of attachment security, personality, affect, psychopathology, and functioning. METHODS: We searched for studies of adult mentalizing in PsycINFO and in related reviews. Overall, 511 studies (N = 78,733) met criteria and were analyzed using multi-level meta-analysis. RESULTS: Implicit (r = 0.19-0.29) and explicit (r = 0.26-0.40) mentalizing were moderately correlated with psychopathology, functioning, personality, affect, and attachment security. The correlations of implicit mentalizing were stronger with more objectively measured correlates (b = 0.02, p < .001) while the correlations of explicit mentalizing were not (b = -0.07, p = .21). CONCLUSIONS: Mentalizing is associated with better intra- and interpersonal functioning. Implicit mentalizing is more strongly associated with objectively measured correlates. These findings underscore the importance of an integrative approach considering both implicit and explicit mentalizing.

Identification of red flag child sexual grooming behaviors.

BACKGROUND: Sexual Grooming is the deceptive process wherein a would-be perpetrator prepares a child for sexual abuse (CSA) and prevents disclosure and detection. It is often difficult to detect sexual grooming because some grooming behaviors resemble normal adult-child interactions. To prevent CSA, it is vital to identify sexual grooming behaviors that can be considered "red flag" behaviors. OBJECTIVE: This study compared reported sexual grooming behaviors between adults who experienced CSA and those with no CSA history to identify which behaviors differed between the two groups. Further we explored whether the relationship to the adult male in the Non-CSA group impacted reported behaviors. PARTICIPANTS AND SETTING: Participants were recruited online through Prolific and included adults who experienced CSA (n = 411) and those with no CSA history (n = 502). METHODS: Participants who reported CSA completed the Sexual Grooming Scale - Victim Version (SGS-V) about their CSA experience. Those with no CSA history were randomly assigned to one of three conditions (family member/non-family member/community member) and completed a modified version of the SGS-V about an adult male with whom they had the most interpersonal contact before age 18. RESULTS: Numerous sexual grooming behaviors that differentiated the behaviors of adults who engaged in CSA and those who did not were identified. The relationship to the adult was an important consideration. CONCLUSIONS: Red flag sexual grooming behaviors, specifically those related to desensitizing the child to physical contact and sexual content, can be identified in cases of CSA and have an important role in prevention.

A Theoretical Endogenous Opioid Neurobiological Framework for Co-occurring Pain, Trauma, and Non-suicidal Self-injury.

PURPOSE OF REVIEW: Individuals with chronic pain are significantly more likely to have experienced overwhelming trauma early and often in key developmental years. There is increasing acknowledgment that childhood trauma disrupts how individuals process and cope with both physical and emotional pain. Emerging studies acknowledge elevated rates of non-suicidal self-injury (NSSI) in chronic pain populations. This review provides a theoretical framework to understand the relationship between NSSI behavior and pain experience in persons with chronic pain and childhood trauma histories. We discuss how NSSI may act to regulate neurobiological (e.g., endogenous opioid systems) and psychological (e.g., heightened negative affect and emotion dysregulation) systems affected by childhood trauma, leading to temporary pain relief and a cycle of negative reinforcement perpetuating NSSI. As these concepts are greatly understudied in pain populations, this review focuses on key areas relevant to chronic pain that may provide a testable, conceptual framework to support hypothesis generation, future empirical investigation, and intervention efforts. RECENT FINDINGS: See Fig. 1. See Fig. 1.

My problem or yours? Interpersonal problems and marital quality.

OBJECTIVE: Research has consistently illustrated the impact of personality on marital quality. Given the inherent dyadic nature of relationships, recent investigations have integrated spouse-rated personality to account for both spouses' perspectives. Grounded in Contemporary Integrative Interpersonal Theory, we viewed personality through an interpersonal lens and conceptualized maladaptive interpersonal functioning as interpersonal problems. The present study examined the incremental validity of spouse-rated interpersonal problems beyond self-reported interpersonal problems to predict marital quality within an expanded actor-partner interdependence model (APIM). METHOD: Within a community sample of heterosexual, married couples (N = 110), we used expanded APIMs, integrating both self-report and spouse-rating, to test the incremental validity of spouse-perceived interpersonal problems over self-perceived interpersonal problems on marital quality through a model comparison approach. We tested for possible gender differences in effects. RESULTS: Spouse perception, notably spouse-rated partner effects, appears to be the most frequent predictor of marital quality, and self-perception had less impact. CONCLUSION: Given the implications marital quality has on health and well-being, intervention efforts capitalizing on acceptance of spouses' perspectives are likely to lead to greater improvements in quality and overall health.

The revised suicide crisis inventory (SCI-2): Validation and assessment of prospective suicidal outcomes at one month follow-up.

BACKGROUND AND AIM: The Suicide Crisis Syndrome (SCS) is an evidence-based pre-suicidal cognitive and affective state predictive of short-term suicide risk. The most recent SCS formulation, proposed as a suicide-specific DSM diagnosis, features a feeling of Entrapment accompanied by four additional symptom clusters: Affective Disturbance; Loss of Cognitive Control; Hyperarousal; and Social Withdrawal. The aim of the present study was to revise the Suicide Crisis Inventory (SCI; Barzilay et al., 2020), a self-report measure assessing the presence of the SCS,in accordance with the current SCS formulation, as well as to assess the psychometric properties and clinical utility of its revised version, the Suicide Crisis Inventory-2 (SCI-2). METHODS: The SCI-2, a 61-item self-report questionnaire, was administered to 421 psychiatric inpatients and outpatients at baseline. Prospective suicidal outcomes including suicidal ideation, preparatory acts, and suicidal attempts were assessed after one month. Internal structure and consistency were assessed with confirmatory factor analysis, convergent, discriminant, and current criterion validity. Receiver-operating characteristic (ROC) curves with Area under the Curve (AUC) were used to examine the predictive validity of the SCI-2 to prospective outcomes. Exploratory analyses assessed the predictive validity of the five SCI-2 dimensions. RESULTS: The SCI-2 demonstrated excellent internal consistency (Cronbach's α = 0.971), good convergent, discriminant, and current criterion validity. The SCI-2 significantly predicted all three outcomes, and was the only significant predictor of suicidal attempts with AUC = 0.883. DISCUSSION: The results of this study indicate that the SCI-2 is a valid and reliable tool to assess the presence and intensity of the Suicide Crisis Syndrome and to predict short-term prospective suicidal behaviors and attempts among psychiatric outpatients and inpatients regardless of patients' readiness to disclose suicidal ideation.

Future directions in personality pathology development research from a trainee perspective: Suggestions for theory, methodology, and practice.

Research on personality disorder (PD) development has received increased attention in the last two decades, spurring reconceptualization in theoretical models of etiology, use of advanced methods, and development of effective treatments. The current manuscript briefly reviews the state of the field and proposes avenues of new research on the development of personality pathology in theoretical, methodological, and clinical veins. We identify the need to adopt a unifying and comprehensive theory to describe PD development across the lifespan, novel statistical methods to complement traditional methods relied on thus far, and the adoption of developmentally sensitive interventions that are disseminated to professionals and trainees alike. These directions for future research aim to augment prevention efforts to reduce the burden of PDs earlier in life.

Exploring the links among borderline personality disorder symptoms, trauma, and pain in patients with chronic pain disorders.

OBJECTIVE: Chronic pain and borderline personality disorder (BPD) are commonly comorbid and jointly associated with increased symptoms of both disorders and clinical and functional impairment. Little is known, however, about specific links between these disorders. In a cross-sectional study of patients with chronic pain, we compared participants high or low on BPD symptoms on patterns of pain experience and types of child and adult traumas. METHODS: Adults (N = 181) with chronic pain completed self-reports of pain severity, dimensions of pain experiencing, body coverage of pain, and clinical indicators of central sensitization (i.e., chronic hypersensitivity of the central nervous system), as well as measures of child and adult physical abuse, sexual abuse, trauma, and neglect. Participants also completed the McLean Screening Instrument for BPD. RESULTS: Participants with clinically significant BPD symptoms (n = 32) reported more childhood sexual trauma, punishment, and neglect, as well as adult physical/sexual trauma, than those without elevated BPD symptoms. Among participants with clinically significant BPD symptoms, affective pain and central sensitization were elevated, potentially explained by heightened negative affect in BPD. CONCLUSION: BPD symptoms are associated with increased clinical severity among patients with chronic pain as well as a unique manifestation of pain experiencing (i.e., increased affective pain and central sensitization in particular). Childhood trauma of all types is associated with chronic pain and BPD co-occurrence. Researchers and clinicians should assess for BPD in people with chronic pain to enhance conceptual models of the transaction between these disorders and to improve clinical care.

Race and ethnicity considerations in traumatic brain injury research: Incidence, reporting, and outcome.

PRIMARY OBJECTIVE: This study has three goals: to determine whether there is a higher rate of traumatic brain injury (TBI) for people of color (POC), whether TBI studies report racial/ethnic demographics, and whether there is a discrepancy in discharge destinations between Whites and POC. We examined whether 1) a higher percentage of POC would sustain head injuries than expected, 2) the majority of TBI studies examined (>50%) would not include racial/ethnic demographics, and 3) Whites would be discharged to further treatment over POC. RESEARCH DESIGN: Retrospective study and literature review. METHODS AND PROCEDURES: Data from the Pennsylvania Trauma System Foundation was used to determine the number of POC with TBI using X2 analysis, as well as where patients with TBI were being discharged using a configural frequency analysis. PubMed was used for the literature search to examine the frequency of reporting race/ethnicity in TBI literature. MAIN OUTCOMES AND RESULTS: Results demonstrated that Blacks sustain more TBIs than would be expected (p < .05), the majority of scientific studies (78%) do not report racial/ethnic demographic information, and Whites are discharged to further care more often than POC. CONCLUSIONS: These findings highlight differences in incidence and treatment of TBI between White individuals and POC, raising important considerations for providers and researchers.

Identifying unstable and empty phenotypes of borderline personality through factor mixture modeling in a large nonclinical sample.

Borderline personality disorder (BPD) is serious, prevalent, and symptomatically heterogeneous. Identifying distinct phenotypes of BPD features promises useful diagnostic and treatment implications. Although a series of subtyping studies exist, only two have examined BPD symptom configurations while taking into account BPD severity. We used factor mixture modeling to identify discrete subtypes of BPD features, simultaneously considering symptom severity, in the largest nonclinical young adult sample to date. Undergraduates (N = 20,010; 63.86% women; Mage = 18.75, SD = 1.73) completed the McLean Screening Instrument for BPD, which was condensed to measure the 9 Diagnostic and Statistical Manual of Mental Disorders BPD criteria dichotomously. We used a model comparison approach to determine the optimal latent factor and class structure of BPD symptoms and validated classes via BPD-relevant constructs. The sample consisted of three subtypes: Asymptomatic (70%), Unstable (19%), and Empty (11%). The Unstable and Empty classes displayed elevated BPD symptomatology along a single continuum of BPD severity. Individuals in the Empty class displayed the highest levels of emptiness and dissociation, emotional distress, and attachment avoidance, whereas individuals in the Unstable class displayed a high frequency of reckless and self-damaging behaviors. Our results suggest the importance of a hybrid dimensional/categorical conceptualization of BPD as displayed in a nonclinical sample. Unstable and Empty classes may be associated with different treatment targets for subthreshold BPD presentations. The findings are discussed in terms of their clinical implications regarding diagnosis, treatment, and theoretical conceptualization of BPD. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Somatic symptoms in treatment-naïve Hispanic and non-Hispanic patients with major depression.

BACKGROUND: Somatic complaints are a major driver of health care costs among patients with major depressive disorder (MDD). Some epidemiologic and clinical data suggest that Hispanic and non-Hispanic Black patients with MDD endorse higher levels of somatic symptoms than non-Hispanic White patients. METHODS: Somatic symptoms in 102 Hispanic, 61 non-Hispanic Black, and 156 non-Hispanic White patients with treatment-naïve MDD were evaluated using the somatic symptom subscale of the Hamilton anxiety rating scale (HAM-A). The other seven items of the HAM-A comprise the psychic anxiety subscale, which was also evaluated across ethnicities. RESULTS: Hispanic patients reported significantly greater levels of somatic symptoms than non-Hispanic patients, but levels of psychic anxiety symptoms did not differ by ethnicity. Levels of somatic symptoms did not significantly differ between Black and White non-Hispanic patients. Within the Hispanic sample, somatic symptom levels were higher only among those who were evaluated in Spanish; Hispanics who spoke English showed no significant differences versus non-Hispanics. CONCLUSIONS: In this medically healthy sample of patients with MDD, monolingual Spanish-speaking Hispanic patients endorsed high levels of somatic symptoms. Clinicians should be mindful that the depressive experience may manifest somatically and be judicious in determining when additional medical work-up is warranted for somatic complaints.

Posttraumatic Stress Symptoms Mediate the Effects of Trauma Exposure on Clinical Indicators of Central Sensitization in Patients With Chronic Pain.

OBJECTIVE: Evidence supports high rates of co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain disorders involving central sensitization (CS). The nature of this relationship, however, remains relatively unexplored. In this study, we aimed to (1) assess how both trauma exposure and current PTSD symptoms are related to clinical manifestations of CS, and (2) test whether PTSD symptoms explain the relationship between trauma exposure and CS. Because experiential avoidance has been shown to impact the relationship between trauma and health outcomes, we (3) explored experiential avoidance as a possible mediator or moderator of the trauma-CS relationship. METHODS: A sample of 202 adult patients (79% female) with chronic pain completed validated self-report measures of trauma exposure, current PTSD symptoms, experiential avoidance, and 3 manifestations of CS: widespread pain, greater pain severity, and polysomatic symptom reporting. We used path analysis and multivariate regression to assess our study aims. RESULTS: Both trauma exposure and PTSD symptoms were significantly associated with all 3 clinical indicators of CS. PTSD symptoms partially explained the relationship between trauma exposure and widespread pain, pain intensity, and polysomatic symptoms. Experiential avoidance did not mediate or moderate the trauma-CS relationship. CONCLUSIONS: Our findings suggest that trauma exposure is linked to elevated clinical markers of CS but a critical factor in this relationship is the mediating effect of current PTSD symptoms.

Posttraumatic stress disorder in interstitial cystitis/bladder pain syndrome: Relationship to patient phenotype and clinical practice implications.

PURPOSE: The relationship between exposure to abuse and interstitial cystitis/bladder pain syndrome (IC/BPS) is well-documented. However, studies have yet to examine posttraumatic stress disorder (PTSD), which develops following exposure to trauma and worsens health outcomes in chronic pain. We aimed to assess the prevalence and impact of PTSD in patients with IC/BPS, including their relation to genitourinary symptom presentation and widespread pain phenotype. MATERIALS AND METHODS: We recruited 202 participants with chronic pain from an academic medical center and classified 64 individuals as IC/BPS based on validated epidemiological criteria. Participants completed self-reported questionnaires assessing trauma exposure, PTSD symptoms, emotional distress, pain, and urinary symptoms. Wilcoxon rank-sum tests assessed study aims comparing IC/BPS to other chronic pain. RESULTS: Although elevated, IC/BPS trauma exposure rates were equivalent to that of other chronic pain conditions in the sample. Despite this equivalence, in comparison, IC/BPS patients had significantly higher rates of PTSD symptoms, with 42% meeting provisional diagnostic criteria for PTSD. Among IC/BPS, those meeting provisional criteria for PTSD had significantly higher incidence of lifetime sexual abuse, childhood trauma, and presentations consistent with the widespread pain phenotype. In IC/BPS, there was no association between PTSD and genitourinary symptoms, but provisional PTSD was associated with more pain, emotional distress, and poorer quality of life. CONCLUSIONS: We recommend that patients with IC/BPS and widespread pain have ongoing screening and monitoring of PTSD. We recommend using trauma-informed care practices with these patients to increase trust and safety, which could improve treatment compliance and follow-up.

Adult attachment as a predictor and moderator of psychotherapy outcome: A meta-analysis.

Bowlby's attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Attachment patterns have been characterized as secure (healthy interdependence with others), anxious (overdependence on others), and avoidant (difficulty relying on others). We update a previous meta-analysis to determine the association of patient attachment with psychotherapy outcome. Meta-analysis of 36 studies (3,158 patients) suggested that patients with secure attachment pretreatment show better psychotherapy outcome than insecurely attached patients. Further, improvements in attachment security during therapy may coincide with better treatment outcome. Finally, preliminary moderator analyses suggest that those who experience low pretreatment attachment security may find better treatment outcome in therapy that incorporates a focus on interpersonal interactions and close relationships. The article closes with research limitations, diversity considerations, and therapeutic practices.

The Role of Negative Affect and Self-Concept Clarity in Predicting Self-Injurious Urges in Borderline Personality Disorder Using Ecological Momentary Assessment.

Deficits in identity as well as negative affect have been shown to predict self-injurious and suicidal behaviors in individuals with borderline personality disorder (BPD). However, less is known about the interactive effects of these two predictors. We examined the moderating effect of a particular component of identity, self-concept, on the relationship between negative affect and self-injurious urges utilizing ecological momentary assessments. Outpatients diagnosed with either BPD (n = 36) or any anxiety disorder but no BPD (n = 18) completed surveys throughout the day over a 21-day period. Higher levels of momentary negative affect predicted greater subsequent urges to self-injure, but only when self-concept clarity was low (z = -3.60, p < .01). This effect did not differ between diagnostic groups. The results suggest that self-concept clarity has a protective effect against self-injurious urges in light of high negative affect, and that this effect may be transdiagnostic.

Self-Control Capacity as a Predictor of Borderline Personality Disorder Features, Problematic Drinking, and Their Co-occurrence.

Borderline personality disorder (BPD) and alcohol use disorder (AUD) share impulsivity as an etiological factor. However, impulsivity is ill-defined, often overlapping with self-control capacity. This study attempts to disentangle these constructs and their associations with alcohol use and BPD. Undergraduates (n = 192) completed the Five Factor Model Rating Form, which generated two-dimensional scales of BPD, the Self-Control Scale, the UPPS-P (self-reported impulsivity), and the stop-signal and delay discounting tasks (laboratory-measured impulsivity). Self-control appeared as a major predictor of BPD features and drinking, explaining as much or more variance in outcome than impulsivity. Co-occurrence of elevated BPD features and problem drinking was also best explained by self-control. Laboratory measures of impulsivity were not correlated with BPD scales or alcohol use. Self-regulatory capacity may be an important but overlooked factor in BPD and alcohol use and should be considered alongside impulsivity in future research.

Mediators of sexual functioning and marital quality in chronically depressed adults with and without a history of childhood sexual abuse.

INTRODUCTION: Sexual dysfunction is common among depressed adults. Childhood sexual abuse (CSA) and depressive symptomology are among the risk factors for sexual dysfunction, and these factors may interact to predict adult relationship functioning. Several models have been developed postulating interactions between these variables. AIM: We tested models of the effects of CSA and elucidate the associations between CSA, sexual dysfunction, depression severity, anxiety, and relationship quality in chronically depressed adults. METHODS: Baseline data from 808 chronically depressed outpatients enrolled in the Research Evaluating the Value of Augmenting Medication with Psychotherapy study were evaluated using structural equation modeling. MAIN OUTCOME MEASURES: The Inventory of Depressive Symptomology, self-report version (IDS-SR) assessed depression severity, and the Mood and Anxiety Symptom Questionnaire Anxious Arousal subscale assessed anxiety. Sexual function was assessed with the Arizona Sexual Experiences Scale (ASEX), and the Quality of Marriage Index (QMI) assessed relationship quality for patients in stable relationships. RESULTS: CSA scores predicted depression severity on the IDS-SR, as well as lower relationship quality and sexual satisfaction. ASEX scores were significantly associated with depression severity but were not correlated with the QMI. Two models were evaluated to elucidate these associations, revealing that (i) depression severity and anxious arousal mediated the relationship between CSA and adult sexual function, (ii) anxious arousal and sexual functioning mediated the association between CSA and depression symptoms, and (iii) when these models were combined, anxious arousal emerged as the most important mediator of CSA on depression which, in turn, mediated associations with adult sexual satisfaction and relationship quality. CONCLUSIONS: Although CSA predicts lower relationship and sexual satisfaction among depressed adults, the long-term effects of CSA appear to be mediated by depressive and anxious symptoms. It is important to address depression and anxiety symptoms when treating patients with CSA who present with sexual dysfunction or marital concerns.