ORIGINAL ARTICLE
Mentalizing in Self vs. Parent Representations and Working
Models of Parents as Risk and Protective Factors
From Distress and Eating Disorders
Lily Rothschild-Yakar, PhD,*Þ Ariela Waniel, PhD,*þ and Daniel Stein, MD*§
Abstract: This study examined whether low developmental level of mentalization and symbolization, manifested as low ability to represent and reflect
on mental states of the self and parents as well as malevolent working models
of parents, may be risk factors in the genesis of eating disorders (EDs). We
examined 71 female adolescent inpatients with ED and 45 controls without ED
using the Object Representation Inventory and self-report measures assessing
emotional distress and ED symptoms. The results indicated that the patients
with ED presented with a significantly lower level of mentalization and symbolization and with more malevolent working models of their parents in comparison
with the controls without ED. A more benevolent parental representation, specifically with the father, combined with better mentalization abilities, was found to
indirectly predict lower ED symptoms, via the reduction of distress levels. These
findings suggest that adequate mentalization and benevolent working models of
parents may serve as a protective factor reducing the level of ED symptoms.
Key Words: Mentalization, reflective function, symbolization, working
models of parents, eating disorders.
(J Nerv Ment Dis 2013;201: 510Y518)
E
ating disorders (EDs) reflect complex, interdependent, multidimensional causalities. Some studies ascribe the genesis of EDs
as entailing a combination of psychobiological developmental deficiency manifested by low interoceptive awareness (e.g., low ability to
identify and process bodily and emotional states), inaccuracy in concept
development, deficient social competence, and lack of individuation
(Bruch, 1988; Fassino et al., 2004). Other studies go further and tie the
concrete somatic ED symptoms to a developmental deficiency in the
cognitive-affective arenas of symbolization (McDougall, 1989) and
mentalization (Rothschild-Yakar et al., 2010; Skårderud, 2007).
The ability to put words and images to somatic experience, to
transform physiological and somatic experiences into symbolic mental
representations, in the service of creating psychological meaning related to these experiences was termed as the ability for mentalization
or reflective functioning by Fonagy and his colleagues (Fonagy and
Target, 1996; Fonagy et al., 1998, 2002). Fonagy’s use of the term
combines the psychoanalytic idea of symbolization with the socialcognitive concept of ‘‘theory of mind.’’
MENTALIZATION AND REFLECTIVE FUNCTIONING
Mentalization involves both a self-reflective and an interpersonal component. It refers to the capacity to reflect and interpret one’s
own behavior, as well as the behaviors of others, as caused by intentional internal mental states such as thoughts, feelings, and beliefs. A
well-developed ability to form and use mature mental representations
*Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel; †Department
of Psychology, University of Haifa, Haifa, Israel; ‡Department of Education, Bar
Ilan University, Ramat Gan, Israel; and §Sackler Faculty of Medicine, Tel-Aviv
University, Tel Aviv, Israel.
Send reprint requests to Lily Rothschild-Yakar, PhD, Department of Psychology,
University of Haifa, Haifa 31905, Israel. E-mail: Lilyrot@yahoo.com.
Copyright * 2013 by Lippincott Williams & Wilkins
ISSN: 0022-3018/13/20106Y0510
DOI: 10.1097/NMD.0b013e3182948316
510
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of the self and others enables people to think about and cope with
external and internal stressors and to form good interpersonal relationships (Fonagy et al., 1998). Fixation in primitive modes of
representing experience causes difficulties in identifying and acknowledging internal states, correctly perceiving and interpreting interpersonal relations, and differentiating reality from fantasy and
physical from psychic reality (Fonagy et al., 2002).
With regard to EDs, impaired mentalization can be conceptualized as reflecting primitive modes of experience, in which psychic
reality is poorly integrated and ideas and even words mean very little.
In such a condition, the body and ED symptoms may serve as concrete
means to represent and enact feelings and thoughts as well as to regulate drives and emotions (Bleiberg, 2001). The few studies that have
previously investigated mentalization ability in patients with ED have
found low levels of reflective functioning, both in patients (Fonagy and
Target, 1996; Rothschild-Yakar et al., 2010; Ward et al., 2001) and in
their mothers (Ward et al., 2001). In anorexia nervosa (AN), this fixation in primitive modes of experience was also manifested as elevated
use of concrete body metaphors and an inability to distinguish between
a metaphor and the phenomenon it represents (Skårderud, 2007),
suggesting a cognitive-developmental deficiency in symbolization.
A major factor facilitating children’s attainment of the ability to
mentalize is associated with the caregiver’s mirroring of the infant’s
subjective experiences in a secure attachment relationship (Fonagy et al.,
2002). Children’s representations of themselves and of their inner experiences are based on their parents’ capacity to represent and imagine
their own minds, thus providing a secure base for the child to develop
mentalization and symbolic abilities (Meins et al., 1998; Slade, 2005;
Taylor, 2010). In contrast, children who lack secure attachment relationships and, thereby, attuned mirroring of their affective states cannot
create representations of those experiences, likely placing them at a
greater risk for remaining fixated in primitive modes for representing
subjectivity (Fonagy et al., 2002).
Several studies have shown that patients with AN or bulimia
nervosa (BN) have a history of insecure attachment relationships (Troisi
et al., 2006; Ward et al., 2001). Social-cognition research on emotion
recognition has further shown that individuals with EDs show impairment in the ability to identify their own emotions and to represent and be
aware of others’ emotional experiences (e.g., Bydlowski et al., 2005).
Thus, at times of developmental stress, adolescents with a history of
insecure attachment, lacking representations of their inner experiences,
may find themselves unable to recognize and conceptualize their own
subjective experiences at the level of verbal thought. They may therefore
misinterpret emotional distress as a concrete bodily distress that can be
relieved mainly by an excessive preoccupation with eating, appearance,
or exercise (Bleiberg, 2001; McDougall, 1989). These data further
highlight the theory that developed mentalization is related to the ability to form and use a developed self and other representations (Meins
et al., 1998; Skårderud, 2007).
SELF AND OBJECT REPRESENTATIONS
The term object representations refers to the internal models
of the self and others and the relations of the self with others. These
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The Journal of Nervous and Mental Disease
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Mentalization in ED
internal models are expressions of the subjective processing of interpersonal experiences and interactions, which, in turn, plays an important
role in adequately interpreting behavior, conflicts, and emotional and
cognitive processes in one’s relationships with others (Blatt et al., 1997).
From a cognitive psychology perspective, these representations are
termed schemas and are assumed to influence social information
processing in a top-down process, where previous knowledge affects
the perception and organization of new social information and also
plays a role in regulating behavior and decision making (Dodge and
Rabiner, 2004).
Blatt et al. (1993, 1992, 1979) proposed a multidimensional
approach for assessing the mental representations of the self and
others, in which they incorporated cognitive-developmental and affective aspects. From a cognitive-developmental perspective, the development of object representations is hypothesized as progressing from
early forms on the basis of the object’s actions and need-gratifying
functions to higher differentiated and symbolic object representations.
This developmental path can be conceptualized according to the terms
of Lieberman (2007), distinguishing between internally focused cognitions, referring to mental processes that focus on one’s own or
another’s inner psychological worlds, such as thoughts and feelings,
and externally focused cognitions, referring to mental processes that
focus on one’s own or another’s physical and visible features and actions. This distinction has been supported by findings in social-cognitive
neuroscience, in which brain imaging showed that representing psychological traits (internal) were associated with the activation of brain
areas other than those activated in response to descriptions of observable
behavior (external).
The affective aspect of representations is examined by assessing
the quality of representations of parents as attachment models. Parents
may be described along several factors such as benevolent, punitive,
and striving. For example, the benevolence factor measured the affective tone attributed to the parents such as being affectionate and
nurturing (Blatt et al., 1992).
In a summary of studies, Blatt et al. (1997) suggested that the
developmental level of descriptions given by young adults of their
parents was related to their quality of attachment style. For example,
securely attached individuals presented more developmentally mature
and symbolic representations of significant others than did their insecurely attached counterparts. This data is in line with the suggestions
raised by Fonagy et al. (Fonagy and Target, 1996; Fonagy et al., 1998,
2002) proposing that developed mentalization ability is related to secure attachment relationships.
the self versus mentalizing about others. In healthy development,
these processes are connected, but these also involve different processes aiming to create a differentiated experience of me and not-me
(Fonagy and Luyten, 2009). Moreover, the ORI allowed for assessment
of the quality of working models of parents as attachment figures. As
previously discussed, attachment and mentalization ability are interrelated, and both constructs have been linked to the ability to regulate
affects (Taylor, 2010).
In the present study, our first aim was to examine the reflective-symbolization levels in three subtypes of ED patients compared
with controls without ED, as well as the affective quality of representations of parents. We hypothesized that the inpatients of all three
subtypesVAN-B/P, BN, and restricting type of AN (AN-R)Vwould
provide less developmentally mature descriptions of the self and of
the parents with respect to the ability to reflect on internal symbolic
attributes and that the affective quality of parental representations
would be more malevolent and punitive compared with the controls
without ED. Because the patients with AN-B/P and BN symptoms
may present with more pathological personality disorders than the
patients with AN-R and may exhibit more deficient impulse and affect regulation as well as less integrated perceptions of themselves
and others (Klump et al., 2000), we hypothesized that the patients
with AN-R would show better reflective symbolization capacities
and less malevolent representations of their parents than both the
patients with AN-B/P and those with BN.
Inasmuch as several studies ascribe the development of ED
symptoms to a deficient ability to represent, identify, and cope with
emotional distress (Bleiberg, 2001; Kaye et al., 2004), our second aim
was to explore how the level of mentalization and the quality of parental representations would associate with the patients’ level of distress and severity of ED symptoms. We hypothesized that a higher
ability to reflect on internal symbolic characteristics of the self and
parents and secure working models of the parents would serve directly
to attenuate ED symptoms and indirectly as a resource for regulating
distress and, thus, as a protective factor from turning to ED symptoms.
To the best of our knowledge, no previous studies have examined the developmental ability to reflect on internal symbolic
characteristics of the self and parents, as well as the quality of the
working models provided in parental descriptions, as potential protective factors in the development of an ED.
STUDY AIMS AND HYPOTHESES
The research sample comprised a total of 116 female adolescents in two groups, with and without an ED. The experimental group
consisted of 71 female Israeli adolescent inpatients aged 14 to 19 years
who were hospitalized in an inpatient ED department located in a
general hospital. All patients met the criteria for a full-blown ED diagnosis based on the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). The patients were diagnosed with one of three ED subtypes: AN-R, 31; AN-B/P, 18; and BN, 22.
Patients were excluded from the study if they had a lifetime or
current diagnosis of bipolar disorder, schizophrenic spectrum disorder,
organic brain syndrome, mental retardation, or any physical disorder
with a potential to affect appetite or weight (e.g., thyroid disorders or
diabetes mellitus). An analysis of the prevalence of comorbid DSM-IV
axis I psychiatric diagnoses (assessed by the Structured Clinical Interview for DSM-IV Axis I DisordersYPatient Edition [SCID-I/P] version 2.0; First et al., 1995) revealed that 41 (57.75%) of the 71 patients
with ED were diagnosed with a comorbid depressive disorder; and
20 (28.17%), with a comorbid obsessive-compulsive disorder.
The control sample comprised 45 female high school students
aged 14 to 19 years who volunteered to participate in this study. All of
The aim of the present study was to assess mentalization capacities and the affective quality of internal working models of parents in patients with ED. In our research group’s previous study using
other measures, including the Reflective Function (RF) Scale
(Fonagy et al., 1998), we found that patients with bingeing/purging
type AN (AN-B/P) demonstrated significantly lower mentalization
levels and reported in a self-report measure a lower quality of current relationships with parents compared with controls without ED
(Rothschild-Yakar et al., 2010). In the present study, we aimed to
expand our inquiry to examine three subgroups of inpatients with
ED. We also implemented a multidimensional assessment measure to
examine mentalization level in line with Choi-Kain and Gunderson’s
(2008) assertion that mentalization’s broad and multifaceted nature
requires the use of a multidimensional approach and allows for its
measurement through related constructs. Thus, in the current study,
we administered the multidimensional Object Representation Inventory (ORI; Blatt et al., 1993, 1992, 1979) to examine the level of
symbolization, which overlaps conceptually with cognitive aspects
of mentalizing. The use of the ORI also enabled separate assessment of mentalization ability while processing representations about
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METHOD
Participants
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Rothschild-Yakar et al.
The Journal of Nervous and Mental Disease
these students passed a screening process involving a brief interview
and a questionnaire to exclude potential participants with ED symptoms or a lifetime or current psychiatric or medical illness.
A comparison of the four study groups’ demographic and clinical characteristics revealed no significant differences for the percentage of mothers with an academic education (AN-R, 48.39%; AN-B/P,
61.11%; BN, 68.18%; nonpatients, 40.00%), or for the percentage of
fathers with an academic education (AN-R, 64.52%; AN-B/P, 55.56%;
BN, 63.64%; nonpatients, 42.22%). A significant difference did
emerge for age, where the patients with AN-R were younger than
the other groups (mean T SD, AN-R, 15.19 T 1.77; AN-B/P, 16.44 T
1.77; BN, 16.22 T 1.19; nonpatients, 16.11 T 1.35; F = 4.17; p G 0.01).
As expected, a significant between-group difference emerged for body
mass index, where the patients with BN and the controls presented a
significantly higher index than the patients with AN-R and AN-B/P
(mean T SD, AN-R, 15.52 T 1.62; AN-B/P, 16.00 T 1.54; BN,
20.52 T 2.23; nonpatients, 20.84 T 2.04; F(4,111) = 52.72; p G 0.001;
G = 0.60).
Measures
This study included two independent variables (level of mentalization in the self and parent representations and affective quality of
representation of parents) and two dependent variables (ED symptoms
and emotional distress symptoms).
Independent Variables
The ORI (Blatt et al., 1993, 1992, 1979) was designed for multidimensional assessment of object representations (of the self and others),
examining both cognitive-developmental and affective aspects. In the
current study, using the Assessment of Self measure (Blatt et al., 1993),
the participants were asked to openly and spontaneously describe themselves. Using the Assessment of Qualitative and Structural Dimensions
of Object Representations measure (Blatt et al., 1992), the participants
were asked to openly and spontaneously describe their mother and their
father. The cognitive component of the ORI, deriving from cognitive developmental theory, enabled examination of the participants’
maturity level of reflective symbolization (mentalization), measured
separately for the self and for the mother and the father. The ORI
qualitative (content) scales of parental representations, deriving from
attachment and psychoanalytic theory, assess the affective quality of
parents’ representations.
Previous interrater reliabilities for cognitive-developmental and
qualitative-affective scores were good (Blatt et al., 1992, 1979). The
empirical validity of the ORI has been supported; for example, low
symbolization level and low benevolence level of parents’ representations were found to be associated with somatoform symptoms and
stress in patients in primary care (Porcerelli et al., 2006).
In the present study, the narratives provided by the participants in
response to the ORI were analyzed by two coders, who were trained by
the second author and were blinded to the participants’ group (ED and
non-ED) and subtype (AN-R, BN, and AN-B/P) and to the other coder’s
scoring. Each coder scored 40 protocols independently, 15 protocols
from the control group and 25 from the ED inpatient group. The
coders analyzed each narrative twice, once for the Conceptual Level
(CL) scale examining the reflective symbolization level and once for
the content subscales. Intraclass correlation coefficients indicated fair
to excellent interrater reliability for the CL scales (0.88 for selfdescription and 0.80 for parents’ descriptions) and for the content
subscales (ranging from 0.72 to 0.90).
Cognitive-Developmental Aspects: Maturity of Reflective Symbolization (Mentalization) in the Self and Parent Representations. In
this study, we used the CL subscales of the object (Blatt et al., 1992)
and self-representation (Blatt et al., 1993) to examine the reflective
symbolization level. There is an ORI subscale of reflective functioning
designed only for the self-representation scales (Blatt et al., 1993). We
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decided to use the CL scale because it enables the assessment of the
self and also others’ representations. Moreover, high correlation (0.79)
was found between the self-reflective subscale and the CL scale (Blatt
et al., 1993).
The participants’ developmental level of reflective symbolization was coded separately for the self and for the mother and the
father on the CL’s 9-point ordinal scale, ranging from 1 (developmentally immature representations) to 9 (developmentally mature representations). Level 1 (sensorimotor-preoperational) primarily reflects
descriptions of parents’ activity in reference to the gratification or
frustration they provide, and the parental object is not experienced as
separated from the respondent. Level 3 (concrete-perceptual) indicates that the self and the object are experienced as separate. Descriptions articulate properties in concrete physical terms without
ascribing any mental activity. Level 5 (external iconic) focuses on
specific part properties of the self and the parents, often in terms of
their functional activities. Level 7 (internal iconic) involves description of internal states, for example, what the objects think and feel
rather than their activities. Level 9 (conceptual) refers to complex
descriptions combining external and internal characteristics of the
self and parents. Scores of 2, 4, 6, and 8 are used when criteria for a
particular level are not fully achieved.
The Pearson’s correlation between the self, mother, and father
scale scores showed only moderate correlations (between mother
and father, r = 0.62, p G 0.001; between the self and mother, r = 0.52,
p G 0.001; between the self and father, r = 0.39, p G 0.001). Thus, we
analyzed the reflective symbolization level of the representations separately for the self, mother, and father.
Affective Aspects: Quality of Representations of Parents (Attachment Models). The qualitative aspects of parental representations
were assessed from the ORI narratives using content analysis by the
Qualitative Dimensions of Parental Representations for the three
factors identified by Blatt et al. (1992): benevolent, punitive, and
striving representations.
In the present study, we examined only the benevolence factor
because 112 participants related to themes of maternal benevolence
and 109 related to themes of paternal benevolence, but only 26 related to themes of maternal punitive attributes; 37, to paternal punitive attributes; 43, to maternal strivings; and 40, to paternal strivings.
Low benevolence scores indicated that the respondent viewed the father
or the mother as malevolent, threatening, abusive, and abandoning (e.g.,
‘‘My parents don’t get along. My father is always drinking and sometimes beats my mother up’’). High scores showed that the individual
holds a spectrum of supportive and beneficial emotional attributions of
that parent (e.g., ‘‘My mother is a loving mother. We are very close, turn
to each other for help’’). The Pearson’s correlations calculated between
the mothers’ and fathers’ benevolence subscales revealed only a moderate correlation, r = 0.31, p G 0.001; hence, we used the mother and the
father scores separately.
As previously discussed, mentalization ability and attachment
are interrelated. The Pearson’s correlations between the different CL
scales (the self, mother, and father) and the benevolence subscales
(mother and father) were tested, both within each group (ED and nonED) and across groups (see Table 1). The data show that, across all
participants and within the nonpatient group, consistency emerged in
the level of reflective symbolization, evident in the significant correlations for the conceptual scores (CLs) of all three representations.
In the patients with ED, by contrast, a significant correlation emerged
only between the CL for the mother and the CL levels for the self
and the father but not between the CL of the father and the self. Across
all participants, the affective quality of the mother’s representation did
not correlate significantly with the reflective symbolization level
of representations, whereas the quality of representation of the father
did, indicating that a higher level of paternal benevolence correlated
positively with the CL level of all three representations. Positive
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Mentalization in ED
TABLE 1. Pearson’s Correlations for the ORI Conceptual and Benevolence Scales for Representations of the Self and Parents
Quality of Representation
(Benevolent Content)
Reflective Symbolization (CL)
Scale
Mother
Father CL
Self CL
Mother benevolencea
Father benevolenceb
0.53**
0.40**
0.01
0.20
Father CL
Self CL
Mother benevolence
Father benevolencec
0.64***
0.55***
0.10
0.16
Father CL
Self CL
Mother benevolenced
Father benevolencee
0.62***
0.52***
0.15
0.35***
Father
Self
Patients with ED (n = 71)
1.00
0.22
0.22
1.00
0.04
0.11
0.30*
0.08
Nonpatients (n = 45)
1.00
0.51**
0.51**
1.00
j0.11
j0.10
0.00
0.12
Total sample (N = 116)
1.00
0.40***
0.40***
1.00
0.12
0.15
0.38***
0.25**
Mother
Father
0.04
0.11
1.00
0.07
0.30*
0.08
0.07
1.00
j0.11
j0.10
1.00
0.42**
0.00
0.12
0.42**
1.00
0.12
0.15
1.00
0.31**
0.38***
0.25**
0.31**
1.00
a
n = 67.
n = 66.
c
n = 43.
d
n = 112.
e
n = 109.
*p G 0.05.
**p G 0.01.
***p G 0.001.
b
correlations also emerged in the patients with ED between paternal
benevolence and CL level for fathers.
Dependent Variables
ED Symptoms. The Eating Disorders InventoryY2 (EDI-2;
Garner, 1991) is a self-report measure assessing core ED-related
symptomatic and personality attributes. It includes 91 items grouped
into 11 subscales, each rated on a 7-point Likert scale ranging from
never (0) to always (6). We used 2 of the 11 subscales. The 7-item drive
for thinness (DT) subscale assessed excessive concern with dieting,
pursuit of thinness, and preoccupation with weight. The 9-item body
dissatisfaction subscale (BD) assessed dissatisfaction with weight and
physical appearance.
The Pearson’s correlations among the two EDI-2 subscales revealed a high significant correlation between the EDI-2YDT and EDI2YBD subscales (r = 0.85, p G 0.001). Thus, we constructed a combined self-report ED measure (SR-ED), comprising the standardized
scores of the DT and BD subscales to examine the second hypothesis
(Cronbach’s > = 0.90 for this combined measure).
Emotional Distress Measures. We collected self-report data on
the participants’ state anxiety and depressive symptoms.
Self-reported state anxiety. We used the 20-item state anxiety
subscale of the State-Trait Anxiety Inventory (STAI-S; Spielberger
et al., 1970) to measure the participants’ self-reported anxiety at the
time of evaluation. The participants rated items on a 4-point scale
ranging from never (1) to very much (4).
Self-reported depressive symptoms. The 21-item self-reported
Beck Depression Inventory (BDI; Beck et al., 1961) was used to
measure the severity of depressive symptoms. The participants rated
items on a 4-point scale ranging from rarely (1) to often (4).
The Pearson’s correlation between the two distress measures
was 0.80. Thus, a combined self-report emotional distress variable
(SR-distress) was constructed, comprising the standardized scores of
* 2013 Lippincott Williams & Wilkins
the BDI and STAI-S subscales to examine the second hypothesis
(Cronbach’s > = 0.89 for this combined measure).
Procedure
All participants, and their parents in the case of minors younger
than 18 years, gave their written informed consent to participate in this
study. This study was approved by the Ethics (Helsinki) Committee of
the Sheba Medical Center.
Two experienced child and adolescent psychiatrists independently interviewed the inpatients. ED diagnosis was established using
the Eating Disorders Family History Interview (Strober, 1987) and the
SCID-I/P version 2.0 within 14 days of admission, when the patients
were considered medically stable as determined by routine comprehensive physical, neurological, and laboratory examinations.
For the control group, a first session was held individually to
screen out potential participants with ED symptoms. In this session,
the control participants completed the self-reported Eating Attitude
Test (EAT-26; Garner et al., 1982) and reported their weight and height.
Only those 45 control participants with no pathological scores (i.e., G20)
on the EAT-26 and with a normal reported body mass index (body
weight divided by height squared) of at least 18.5 kg/m2 continued with
the study procedure, as administered to the ED group.
The self-report questionnaires and the ORI were administered
individually by trained licensed clinical psychologists and interns in
clinical psychology, who were blinded to the patients’ self-report
outcomes.
RESULTS
Before examining the study hypotheses, we determined the
extent to which the study groups (inpatients with ED and controls
without ED) differed in ED symptoms (EDI-2) and emotional distress symptoms (STAI-S and BDI). Thus, we conducted two analyses
of covariance (ANCOVAs) on the self-report EDI-2 scales (EDI2YDT and EDI-2YBD) and two ANCOVAs for the emotional distress
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Rothschild-Yakar et al.
measures, with age as a covariate. The univariate ANCOVAs and the
significant between-group contrasts in ED and distress symptoms
according to post hoc Tukey’s tests are presented in Table 2. The
analyses revealed, as expected, a significant between-group difference in ED and in emotional distress symptoms.
Tukey-Kramer’s post hoc comparisons of the four groups (AN-R,
BN, AN-B/P, and non-ED) showed that the significant between-group
differences were caused by the nonpatient group’s significantly lower
scores on the EDI-2YDT and EDI-2YBD subscales and lower scores
on the reports of distress levels, in comparison with each of the three
ED subgroups ( p G 0.001). No significant contrast emerged between
any of the ED subgroups (see Table 2).
Reflective Symbolization Level and Parents’
Benevolence in the Three ED Subtypes and Controls
The first hypothesis, asserting that the reflective symbolization
level of the representations and the level of benevolence of parents’
representations would be lower among the ED groups than the controls, was examined with a between-group multivariate analysis of
variance for the CL scales of the ORI and with two separate betweengroup ANCOVAS for the benevolence scales, with age as a covariate.
The univariate ANCOVAs and the significant between-group contrasts revealed by the Tukey’s test are presented in Table 2. As expected, a significant between-group difference was found, in which
all three ED groups showed lower levels of reflective symbolization
in their representations of the self and of their parents, F(9,265) =
3.57, p G 0.001, and also ascribed their parental representations
(mother and father) with a lower level of benevolence.
Tukey-Kramer’s post hoc comparisons of the four groups
showed that the reflective symbolization level in the description of
both parents in the nonpatient group was significantly higher than in
each of the ED subgroups. The reflective symbolization level for
mothers revealed contrasts with AN-R and BN at p G 0.01, and the
contrast with AN-B/P was p G 0.05; the reflective symbolization level
for fathers revealed contrasts with AN-B/P and BN at p G 0.05 and a
contrast with AN-R at p G 0.01. The reflective symbolization level
for the self revealed significant contrasts with patients with AN-R
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and BN ( p G 0.01). No significant contrasts emerged between the
ED subgroups. Because of the lack of differences between the ED
subgroups in most dependent and independent variables, we combined
all ED subgroups into one group of patients with ED when examining
the second study hypothesis.
Reflective Symbolization Level and Parents’
Benevolence as Predictors of Emotional Distress
and ED Symptoms
Before examining the research hypothesis concerning the
predictive value of the independent research variables, we computed
the Pearson’s correlations between the independent variables (the
ORI’s CL scales for the self, mother, and father and the benevolence
subscales for mother and father) and the dependent variables (SR-ED
and SR-distress measures). These correlations were tested both within
each group separately and across the research and control groups
(see Table 3).
As expected, the analyses across all participants yielded significant negative correlations between the SR-ED symptoms and the
benevolence level attributed to both parents. Nonetheless, a negative
correlation between SR-ED and the cognitive-developmental measures (ORI-CL) was found only for representations of the mother but
not for representations of the father or the self. These data showed
that the higher symbolization level evident in mothers’ descriptions
and the higher benevolence ascribed to both parents were correlated
with lower ED symptoms. Self-reported emotional distress symptoms (SR-distress) revealed significant negative correlations with the
reflective symbolization representations and the benevolence scales
of both parents but not with the CL score for self-representation (see
Table 3). A significant positive correlation also emerged between the
SR-distress and SR-ED symptoms, indicating that a higher emotional
distress level was correlated with more ED symptoms.
Path analysis was conducted for all four groups using SAS’s
Proc CALIS (SAS, 2004), to examine the second research hypothesis regarding the direct contribution of the ORI to the explained
between-group variance in ED-related symptoms and the indirect
effect of the ORI on ED symptoms mediated by the level of distress.
TABLE 2. Two-Way Analyses of Variance of the Study Variables for the ED Subgroups and the Nonpatient Controls
Variable
ED symptoms
DT
BD
Emotional distress symptoms
Depression
State anxiety
Representations
Reflective symbolization
Mother
Father
Self
Quality of representation
Mother benevolencea
Father benevolenceb
A
B
C
D
Nonpatients (n = 45)
AN-R (n = 31)
AN-B/P (n = 18)
BN (n = 22)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
F(4,111)
G2
Contrasts
3.08 (4.85)
5.80 (6.74)
12.86 (8.04)
16.31 (11.69)
15.09 (8.31)
18.50 (11.83)
12.83 (6.50)
16.76 (9.66)
22.33***
12.78***
0.37
0.25
A G B, C, D
A G B, C, D
5.67 (5.80)
34.50 (8.66)
23.01 (15.17)
51.49 (14.80)
29.97 (16.32)
55.13 (12.95)
29.95 (16.45)
54.91 (15.08)
26.95***
21.39***
0.42
0.37
A G B, C, D
A G B, C, D
5.13 (1.20)
5.05 (1.27)
5.59 (1.09)
3.86 (1.55)
3.79 (1.59)
4.59 (1.15)
4.03 (1.71)
3.83 (1.60)
5.19 (1.43)
3.68 (1.85)
3.78 (2.01)
4.30 (1.28)
6.73***
5.74**
7.25***
0.16
0.13
0.16
A 9 B, C, D
A 9 B, C, D
A 9 B, D
5.60 (1.17)
5.59 (0.82)
4.92 (1.10)
4.22 (1.29)
4.45 (1.55)
3.58 (1.70)
4.41 (1.23)
4.21 (1.29)
6.34***
16.26***
0.15
0.31
A 9 C, D
A 9 B, C, D
a
n = 112, df = 3,107.
n = 109, df = 3,104.
**p G 0.01.
***p G 0.001.
b
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Mentalization in ED
TABLE 3. Pearson’s Correlations Between Self-reported Symptoms of EDs and Emotional Distress and the Conceptual and
Benevolence Scales for Representations of the Self and Parents
Self-reported Symptom Scales
ORI
EDs
Reflective symbolization (CL)
Quality of representation (benevolence)
Reflective symbolization (CL)
Quality of representation (benevolence)
Reflective symbolization (CL)
Quality of representation (benevolence)
Patients with ED (n = 71)
Mother
Father
Self
Mothera
Fatherb
Nonpatients (n = 45)
Mother
Father
Self
Mother
Fatherc
Total sample (N = 116)
Mother
Father
Self
Motherd
Fathere
Emotional Distress
j0.10
0.13
0.19
j0.01
j0.15
j0.25*
j0.03
0.09
j0.17
j0.25*
0
0.02
0.06
j0.11
j0.34*
j0.07
j0.10
0.16
j0.11
j0.30*
j0.28**
j0.12
j0.07
j0.23*
j0.43***
j0.40***
j0.27**
j0.15
j0.34***
j0.51***
The self-reported symptom scale for EDs combined the means for the DT and the BD subscales. The self-reported symptom scale for distress combined the means for state anxiety
and depression.
a
n = 67.
b
n = 66.
c
n = 43.
d
n = 112.
e
n = 109.
*p G 0.05.
**p G 0.01.
***p G 0.001.
The path model, presented in Figure 1, constructed common factors
of the measured scales yielding 22 df, with the chi-square goodnessof-fit (GFI) statistic, which compares the predicted and observed
covariance matrices, reaching a nonsignificant value indicating good
fit, W2 = 30.31, p = 0.11. The GFI index was 0.94 and the adjusted
GFI was 0.88, indicating acceptable fit. The root mean square error
of approximation, proposed by Browne and Cudeck (1989) to test the
null hypothesis of close fit as a more meaningful approximation than
the null hypothesis of perfect fit, was 0.059, indicating fair fit.
Standardized estimates for the model are presented in Figure 1.
The proposed direct path from the ORI to ED symptoms was not
found to be significant. Nonetheless, the indirect path from ORI
through emotional distress symptoms was supported by the model’s
parameter estimates (A = j0.71). The data showed that the ORI factor
had a significant attenuating effect on emotional distress. Examining
the loading of each general scale (benevolence and CL) on the ORI
factor and the loading of each ORI subscale on each general scale
yielded the following: the level of benevolence in the parents’ representations had a higher load on the general ORI factor than the reflective symbolization (CL) level of the self and parent representations.
In addition, father’s benevolence had a higher loading than mother’s
benevolence on the general benevolence factor. Reflective symbolization level for mother had the highest loading on the general reflective symbolization factor, whereas the level of symbolization of
self-representation had the lowest loading.
DISCUSSION
The first aim of this study was to examine several aspects of
mentalization in patients with ED through analysis of their narrative
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descriptions about the self and their parents. We examined the
cognitive-developmental level of the self and other representations
by investigating the participants’ maturity of reflective symbolization.
We also studied the affective quality of these female adolescents’
working models of their attachment figures. The second aim of this
study was to examine whether mentalization ability and the quality of
working models of parents may a) directly serve to protect these adolescents from turning to psychosomatic ED symptoms and b) indirectly serve as a protective factor by facilitating the participants’ ability
to regulate and cope with emotional distress, thus reducing the risk for
developing ED symptoms.
In accordance with the first research hypothesis, the patients
with ED demonstrated a lower developmental capacity for mentalization than the controls without ED, expressed in the ORI descriptions of the self and parents. The average reflective symbolization
(CL) level of between 5 and 6 found in our control group for the three
types of representations (father, mother, and the self ) indicates an
adequate capacity for mentalization in functional and internal mental
states. By contrast, the patients with ED showed an average level of
4 for the description of the self and of 4 or lower in their descriptions
of their parents. This indicates that the inpatients are mainly externally
focused, referring to their parents mostly in terms of their concrete
physical attributes. These findings reflect a developmental impairment
in the cognitive capacity of the adolescent patients with ED for
reflecting symbolically on the self and others.
A similar finding emerged for the adolescents’ affective quality
of parents’ representations: the nonpatients presented significantly
more benevolent and secure representations of both the mother and the
father than did the patients with ED. This result coincides with studies
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FIGURE 1. Reflective symbolization level and parents’ benevolence as direct and indirect protective resources from ED symptoms.
showing high prevalence of insecure attachment relationships in patients with ED (Troisi et al., 2006; Ward et al., 2001).
Attachment theories (Slade, 2005) and studies in the framework of social-cognition models (Bydlowski et al., 2005) assume the
likelihood of a congruence in developmental symbolization level between representations of the object and the self. However, the findings
in our total sample seemed to contradict this claim. For one, the reflective symbolization level of representations of the self was only
moderately correlated with the level of parents’ representations. Second, a significant but low correlation emerged in the reflective symbolization level between the self and father’s benevolence but not
between the self and mother’s benevolence.
Nonetheless, our data may lend support to the contention of
Fonagy et al. (1998) that mentalization ability may vary because of
conflicting relations across different situations and different persons.
Thus, although adolescents, primarily those diagnosed with an ED,
demonstrate an ability to internally focus on themselves, they are more
externally focused and concrete in their descriptions of their parents.
The lack of correlations between mother benevolence and the three CL
scales may correspond with Drodge (1997), who found no association
between the CL scale and the affective tone of adolescents’ relationships with parents.
The second part of the first hypothesis, concerning differences
among the subtypes of ED with respect to reflective symbolization
level and parental perception, was not confirmed. Several explanations
can be suggested to explain these data. Our data supported recent
claims that patients with ED of all subtypes share many core personality traits and tend to move across different diagnostic categories
during the course of their illness (Eddy et al., 2008). Moreover, most
studies assessing personality in EDs have been undertaken in adults.
Perhaps the relations between maladaptive personality attributes and
ED subtype (overcontrol-restricting versus undercontrol-B/P, Kaye
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et al., 2004) are greater in adult populations than in adolescents such
as those included in our study.
The current findings did confirm our second study hypothesis. Accordingly, the presence of secure benevolent working models
with parents and of better-developed reflective symbolization ability of
the self and parents was found to indirectly predict lower levels of ED
symptoms, by reducing the level of distress. Interestingly, secure
working models with parents had greater value in predicting emotional
distress than did reflective symbolization level. In the absence of internalization of calming, benevolent parental representations that could
assist in coping with negative moods, patients may turn to ED-related
preoccupations and behaviors as a means to escape emotional distress.
These data coincide with the association found between body dissatisfaction and an insecure style of attachment in women with AN and
BN (Troisi et al., 2006).
Our findings further show that, for the participants both with
and without ED, the representation of the father as secure, but not
the mother, correlated negatively with emotional distress (SRdistress) and with ED symptoms (SR-ED). This suggests that, for
female teens, whether ill or healthy, secure relationships with the father
are crucial. Female adolescents experience the developmental process of separation-individuation and identity integration, which are
associated with conflicting relationships, mostly with the mother. In
the case of the female patients with ED, these data may further underscore the importance of a secure father-child relationship as
protecting the adolescent from distress (Mountford et al., 2007) and
hence, indirectly, as reducing the severity of ED symptoms. In line
with Mountford et al. (2007), the current data suggest that insecure,
negative childhood experiences, with the father seen as ignoring or
responding negatively to the communication of negative emotions, are
a key factor leading to the development of an ED, with emotional
distress intolerance as a mediating factor.
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The Journal of Nervous and Mental Disease
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An important finding of this study is the lack of significant
correlations in the adolescent sample as a whole between the ability to
mentalize and symbolize self-experiences and ED psychopathology.
This stands in contrast to the significant correlations found in the total
sample between both parents’ reflective symbolization level and distress and between mother’s symbolization level and ED symptoms as
well as between mother’s reflective symbolization level and distress in
the inpatients with ED. These findings may suggest that, in the developmental phase of adolescence, a developed symbolic understanding of the attachment figures’ ideas and experiences is a regulating,
calming, and crucial predictor of the ability to cope with stress and to
protect against the development and maintenance of ED symptoms.
Moreover, these findings may highlight the importance of the
interplay between two domains of relating to the self and others: the
domain of mentalization of the self and others and the domain of investment in the self versus others. Thus, a higher reflective symbolization level and a developed awareness to attributes of the self do not
necessarily mean an investment in self needs. In addition, our data
show that, in the group of patients with ED, a developed awareness to
the mental attributes of the mothers but not of the fathers may protect
from distress. These data may be in line with studies of EDs within the
framework of self-psychology (Goodsit, 1997), family therapy (Minuchin
et al., 1978), and recent empirical self-psychology findings (Bachar
et al., 2010, 2008), suggesting that attunement to the mother’s needs
and characteristics and not to one’s own perspective may be associated with the development and maintenance of an ED.
Note that self-psychology examines the extent of selflessness
and of the readiness to ignore one’s own needs and to serve as selfobject for others, as either a predisposing (in higher levels of selflessness) or a protective (in normal and lower levels of selflessness)
factor in EDs. Similarly, our paradigm suggests that different reflective
symbolization levels may act as either predisposing (low reflective
symbolization levels) or protective (high reflective symbolization
levels) factors in the development and maintenance of an ED. Future
studies should examine the interplay between these two domains: the
developmental reflective symbolization domain and the selflessness
domain in the predisposition to an ED.
Conclusions and Clinical Implications
Recent clinical observations and empirical research emphasize
that secure attachments in childhood and adulthood and well-developed
capacities for symbolization and mentalization promote resilience to
stressful events (Taylor, 2010). Our study has shown that these capacities
are also of considerable relevance in the development and maintenance
of an ED. As noted earlier, our findings likely have important implications for prevention and treatment. For example, the contribution of
high symbolization and mentalization to a reduction in ED symptoms
may suggest that treatment strategies focused on the development of
mentalization should be integrated alongside interventions addressing ED symptoms.
Our findings also point to the importance of treatment of adolescent patients with ED, to address relationships not only with the
mother but also, most importantly, with the father. This is particularly
relevant in the case of adolescents who are hospitalized because of an
ED, who likely show considerable difficulties in separation from
their primary parental figures. Thus, therapeutic interventions in EDs
may do well to focus on promoting secure relationships with the father, to enhance regulation ability and reduce ED symptoms.
Limitations and Recommendations for
Further Research
First, our research design is cross-sectional and performed in
acutely ill patients, which allows for inferences about associations but
not causation. Second, we assessed mentalization abilities and working
models of parents only via the ORI because this multidimensional tool
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Mentalization in ED
is a highly acceptable measure in the study of symbolization and the
affective quality of representations, as well as in separately examining
reflective ability about the self versus significant others. Although the ORI
thereby permitted assessment of several components of mentalization,
future studies should, nevertheless, implement additional measures
of mentalization components. Third, our inclusion of only inpatients
in our sample does not enable direct generalization of our results to
outpatients with less severe ED pathology. Future research should
be longitudinal and prospective and should examine whether improvement in mentalization ability and the quality of working models
of parents influence the process and outcome of an ED.
DISCLOSURE
The authors declare no conflict of interest.
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