Signe Holm Pedersen

Reflective Functioning in 70 Patients Suffering from Bulimia Nervosa

OBJECTIVE This study is the first to evaluate the reflective functioning abilities of patients suffering from bulimia nervosa (BN). METHOD Seventy patients fulfilling Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BN were interviewed with the Adult Attachment Interview, which was subsequently coded for reflective functioning (RF). RESULTS On average, the sample of patients suffering from BN had close to normal mentalizing abilities. However, the distribution of RF scores was significantly different from the distribution of RF in a non-clinical control group, showing a more polarized pattern with more low and high RF scores. CONCLUSION The study indicates that the theory of mentalization may contribute to understanding BN. However, bulimic pathology may develop and be maintained despite good mentalizing abilities.

Anxiety levels in clinically referred children and their parents: Examining the unique influence of self‐reported attachment styles and interview‐based reflective functioning in mothers and fathers

OBJECTIVE Although much is known about childhood anxiety disorders, the differential contributions by mothers and fathers to child anxiety is poorly understood. This study examined the relation between child anxiety and parental level of psychopathology, attachment style, and reflective functioning (RF). DESIGN Thirty-eight clinically anxious children aged 7-12 years (55.3% female) referred for treatment and their parents (37 mothers, 34 fathers) participated in the study. METHOD Reflective functioning was coded based on Adult Attachment Interviews. Self-report questionnaires on attachment and psychopathology were administered. RESULTS Paternal psychopathology, attachment avoidance, and attachment anxiety as well as maternal attachment anxiety were associated with child anxiety. Mothers had higher RF abilities than fathers. Lower levels of RF in mothers and higher levels of attachment avoidance in fathers explained 42% of the variance in anxiety levels of the child. CONCLUSION Mothers and fathers may provide unique contributions to the development of child anxiety. The findings highlight the importance of considering fathers as well as mothers in research and treatment for childhood anxiety disorders.

Eating Disorders and Mentalization: High Reflective Functioning in Patients with Bulimia Nervosa.

The theory of mentalization has recently been applied in the area of eating disorders (Skårderud 2012). This article reports a qualitative study based on interviews with five women suffering from bulimia nervosa. All five scored high on the Reflective Functioning Scale, indicating a highly developed ability to mentalize. The present qualitative study, which focuses on the women’s capacity to relate to and regulate affects, supports the finding that they are relatively skilled at reflecting on their own and others’ thoughts and emotions. However, this highly developed capacity for mentalization is apparently not helping them regulate their emotions. This suggests that the capacity to mentalize may not be as closely related to the capacity to regulate affects as Fonagy et al. (2002) have proposed. Indeed, the concept of mentalization may be overinclusive and in need of stricter definition. Thus, it might be envisaged that while the ability to mentalize is closely related to the ability to put feelings into words (the opposite of alexithymia), an ability to mentalize may not necessarily entail a capacity to regulate affects. Finally, the study illustrates that far from all eating-disordered patients have problems mentalizing.

Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process

Abstract Objective: In this paper, we test the reliability and validity of two novel ways of assessing mentalizing in the therapy context: the Reflective Functioning scale (RF) applied to code psychotherapy transcripts (In-session RF), and the Exploring scale of the Patient Attachment Coding System (PACS), which measures in-session autonomy and is linked with secure attachment in psychotherapy. Method: Before treatment, 160 patients in different types of psychotherapy and from three different countries were administered the Adult Attachment Interview (AAI), which was rated with the RF scale. One early psychotherapy session for each patient was independently rated with the In-session RF scale and with the PACS Exploring scale. Results: Both scales were found to be reliable and to have concurrent validity with the RF scale rated on the AAI, with the PACS Exploring scale found to be a better predictor of RF on the AAI. Conclusions: These results suggest that the PACS Exploring scale might be a practical method for assessing RF in psychotherapy research and a way for researchers and clinicians to track patients’ RF on an ongoing basis. These results also provide information regarding the ways in which differences in RF manifest during psychotherapy sessions. Clinical or methodological significance of this article Researchers and clinicians can assess patients’ mentalizing based on any single psychotherapy transcript, in many therapeutic modalities The Exploring scale of the Patient Attachment Coding System can yield a reliable measure of reflective functioning based on any single psychotherapy transcript, in many therapeutic modalities Client differences in mentalizing manifest in part independently of the therapist’s contributions

Psychodynamic profile and reflective functioning in patients with bulimia nervosa

OBJECTIVE The aim of this study was to examine the general psychological functioning of patients suffering from bulimia nervosa (BN) using the Karolinska Psychodynamic Profile (KAPP). Furthermore, KAPP data and data from the Reflective Functioning scale (RF), measuring the ability to mentalize, were combined in order to examine differences in alexithymia, impulse control and affect regulation in patients with high or low RF. METHOD Seventy patients with BN were interviewed with both the KAPP and the Adult Attachment Interview (AAI) from which RF is coded. Differences in KAPP scores of patients with high or low RF were analyzed. RESULTS Most of the patients with BN were found to have a personality structure within the normal or neurotic range (n=50 of 70). BN patients with a high RF had significantly lower scores on KAPPs alexithymia scale than patients with a low RF score, demonstrating that poor mentalizing is related to alexithymia. Concurrently, patients with high RF showed problems with impulse control and coping with aggressive affects according to KAPP scores. CONCLUSION Although BN patients with high RF showed good capacities for describing their mental states, they still had difficulties regulating the emotions and impulses related to these states. SIGNIFICANT OUTCOME Among patients suffering from BN, patients with high RF were significantly less alexithymic than low RF patients. LIMITATIONS The findings of this study are limited by the relatively small numbers of participants especially in the RF subgroups, posing a danger of not finding as significant existing differences in character pathology between high and low RF groups.

Fonagy and Freud. Psychological versus psychic reality

Peter Fonagy and Mary Target present their Playing with reality theory as a developmental theory centred on the concept of psychic reality. This paper compares Fonagy and Targets use of the concept of psychic reality with Freuds original concept. It is argued that the concept of psychic reality has been redefined from delineating a psychic reality stemming from the unconscious to denoting a kind of conscious or preconscious psychological reality characterized by an experience of equality between the internal and the external worlds. The theoretical discussion is illustrated by being applied to eating disorder pathology, which by Fonagy and colleagues is described as associated with thought processes characterized by psychic reality.

Attachment and the driving force of development: A critical discussion of empirical infant research

Abstract Empirical infant research has led to an enormous expansion of our knowledge of the psychological functions of the infant. From a psychoanalytic perspective, however, it must be questioned whether this research has increased our knowledge of internal psychic life and helped answer the questions of what initiates and drives development. In the first part of this article, we argue that psychoanalysis must necessarily adopt a critical stance towards a scholarly ideal that rests on the positivist empirical tradition. Psychoanalysis has as its object unconscious processes that cannot be directly observed. In the following section, we take as our point of departure the project of attachment theory that Peter Fonagy and his colleagues have developed in an attempt to reconcile psychoanalysis with the empirical and experimental study of small children, and we demonstrate concretely the limitations of such a project vis-à-vis the exploration of the psychic reality of the child. Our line of reasoning continues to demonstrate how drive theory can be shaped so as to contain an object relations theoretical perspective – as has taken place in Jean Laplanches reinterpretation of the theory of seduction – without abandoning the psychoanalytic theory of the drive and the unconscious.

Too much – not enough. The representation of the body and the meaning of symptoms in patients with eating disorders

ABSTRACT Eating disorders cover different clinical syndromes, all of which are characterized by an immense focus on food, body and weight, an endless attempt to combat the body and by a fluctuation between ‘too much and not enough’ on different levels (e.g., behaviourally, mentally, physically). The aim of this article is to contribute to the psychoanalytic understanding of eating disorders, to highlight the vital importance of the symptoms as a psychological survival strategy and to illustrate similarities between eating disordered patients as well as the very different pathways that can lead to an eating disorder. Two clinical cases are presented, one very shortly and one in more detail.