Reflective functioning in anorexia nervosa: Does it differ from healthy controls and how is its relation to psychopathology?

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Lara Kanstinger, Almut Zeeck, Armin Hartmann, Anne Marie Eyschen, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7115479/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Dec, 2025 Read the published version in Journal of Eating Disorders → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Previous studies found an impairment in the capacity to mentalize (operationalized as " reflective functioning ", RF) in patients with anorexia nervosa (AN), but only few studies used a validated interview procedure. The aim of this study was an assessment of RF in patients with anorexia nervosa in comparison to healthy subjects, using both an expert-rated measure as well as a self-report measure. Further, the study aimed to explore the relationship between RF and various aspects of psychopathology. Methods: 30 patients with AN and 30 matched healthy control subjects were assessed and compared regarding their level of RF using the Brief Reflective Functioning Interview (BRFI) and the Mentalization Questionnaire (MZQ). The correlations between RF values and eating disorder psychopathology (BMI, EDI, EDE-Q), body experience (DKB-35), general psychopathology (PHQ-9, PHQ-15, GAD-7) and impairment in personality functioning (OPD-SQS) were explored using simple linear regression analyses. Results: Regarding mentalizing on the RF-Scale (RF-BRFI), RF was M = 3.63 (SD = .67) in the patient group and M = 4.13 (SD = .94) in the healthy controls (HC). It showed to be significantly lower for patients with AN than for HCs (t(52.5) = 2.38; p = .011). Mentalizing in the MZQ was M = 3.24 (SD = .71), demonstrating significantly worse self-reported mentalizing for the patients (t(49.1) = − 9.38; p < .0001) compared to HCs (M = 1.73; SD = .45). Higher expert-rated RF was associated with better self-reported mentalizing (r = − .38; p = .006), but no significant correlation for the individual groups of patients ond controls could be found. RF as measured with the BRFI was only correlated to the EDI-subscale “weight concern”, while RF values of the MZQ were correlated with various aspects of psychopathology except depressive symptoms and BMI. Conclusion: The study could replicate the finding that patients with AN show impaired mentalizing. However, it seems likely, that observer-rated and self-report measures for mentalizing cover different aspects of the construct of mentalizing and should be regarded as complementary rather than interchangable. This may also explain different associations with features of psychopathology. Trial registration DRKS00031108 anorexia nervosa reflective functioning mentalizing psychopathology BRFI Figures Figure 1 Figure 2 Plain English summary The aim of the study was an assessment of the mentalizing capacity (" reflective functioning ", RF) in patients with AN in comparison to healthy controls (HC), using a validated interview as well as a self-report measure. Aditionally, correlations of RF with various aspects of psychopathology were explored. 30 patients with AN and 30 HC were assessed and compared regarding RF using the Brief Reflective Functioning Interview (BRFI) for an expert rating and the Mentalization Questionnaire (MZQ) for a self-reported measurement. The RF values were correlated with eating disorder psychopathology, body experience, general psychopathology and impairment in personality functioning. On the BRFI-RF as well as in the MZQ, patients with AN showed significantly lower mentalizing capacity than HC. Higher expert-rated RF was associated with better self-reported mentalizing. However, no significant correlation for the individual groups of patients ond controls could be found. BRFI-RF was only hardly correlated to any aspects of AN-related or general psychopathology, while mentalizing in the MZQ correlated with various aspects of psychopathology. In conclusion, it seems likely, that observer-rated and self-report measures for mentalizing are not interchangeable. They rather seem to cover partially different aspects of an individual’s mentalizing capacity. Background Anorexia nervosa (AN) is a severe illness with one of the highest mortality rates among all mental disorders [1], a wide range of associated medical complications [2] and a significant reduction in health-related quality of life [3]. The partial ego-syntonic nature of the disease and a commonly found ambivalence towards change contribute to the maintenance of the disorder and difficulties in its treatment [4, 5]. Only about half of the patients achieve full recovery [6], a percentage that probably has not changed over the last decades. Thus, the prognosis of AN is still relatively poor. Even though the empirical research on effective treatment for AN is growing, there is still a need to further advance and optimize common therapeutic approaches [5, 7], especially by taking into account the specific mechanisms underlying the disease, which include biological, cognitive as well as social-emotional factors [8, 9]. In this context, increasing attention has recently been placed on the mentalization model and how it can be employed for both, the conceptualization and the treatment of AN and other eating disorders (ED) (e.g. [10–12]). The construct of mentalizing refers to the ability to be aware of mental states such as thoughts, feelings, wishes, and intentions in oneself and others, and to perceive and interpret these mental states in relation to how they underly and, thus, explain human actions and behaviors [13]. Mentalizing is thought to play a pivotal role not only in the regulation and organization of the self, but also in the formation of interpersonal relationships and greater social arrangements [14, 15]. Due to its broad overlap with various related constructs and abilities, such as empathy, Theory of Mind (ToM), alexithymia, and mindfulness, mentalizing is often viewed as an umbrella concept [14]. Mentalizing is a complex, multi-facetted capacity rather than a single entity. As evidenced by neuroscientific research, the following four distinct dimensions of mentalizing can be differentiated [14, 16]: (1) Automatic vs. controlled mentalizing, (2) cognitive vs. affective mentalizing, (3) mentalizing oneself vs. mentalizing others and (4) mentalizing with focus on external indicators vs. mentalizing based directly on (assumed) internal processes. According to the mentalizing model, various shapes of psychopathology involve a different set of imbalances between these dimensions or a certain “mentalizing profile” that is distinctive for the respective disorder [14, 17]. Furthermore, mentalizing is described as a dynamic, interactive capacity that is both context and relationship dependent and typically increasingly difficult to access in situations with heightened, often attachment-related arousal [13, 14]. In situations of high emotional arousal, mentalizing becomes disrupted and individuals tend to backslide into prementalizing modes of subjective experience that developmentally precede the full, “mature” capacity for mentalizing [13, 16]. These prementalizing modes include the psychic equivalence mode (inner, mental experiences and external reality are equalized), the teleological mode (mental states are only recognized if they are accompanied by an exterior, observable indicator) and the pretend mode (mental states and outer reality are disconnected) [14, 16]. When it resurfaces in adulthood, the pretend mode often involves pseudomentalizing, which describes a state, in which individuals present elaborate, apparently reflective narratives on mental states that are in fact not connected to the persons´ subjective reality and therefore ultimately remain insignificant to them [13]. The ability to mentalize is operationalized as Reflective Functioning (RF) and can be measured with the Reflective Functioning Scale (RF-Scale; [18]). While its application to transcripts of the Adult Attachment Interview (AAI; [19]) is considered the gold standard measure for the assessment of mentalizing, the RF-Scale (or slightly adapted versions of it) can also be coded based on other semi-structured interviews such as the Brief Reflective Functioning Interview (BRFI; [20]) or it can be used for the RF-rating in therapy sessions [21]. Besides the interview based coding systems, a range of other methods for an assessment of RF is available, including self-report measures, experimental tasks or performance-based measures [17]. Within the mentalizing model, eating disorders (EDs) such as AN and bulimia nervosa (BN) are conceptualized as “self-disorders” [12]: In light of a poorly integrated psychic reality, the body functions as medium for the expression of unprocessed states of mind and might thereby acquire an excessive importance for the maintenance of an overall week sense of self, ultimately leading to a wide range of typical ED symptoms [10, 15]. It is assumed, that the impaired mentalizing abilities in patients with an ED relate to a vast occurrence of prementalizing modes of experiencing subjectivity [10, 12]. In line with this, previous research suggests, that the capacity to mentalize is impaired in people suffering from AN [22]. Compared to healthy individuals, patients with AN seem to be characterized by lower RF-levels in interview-based assessments of their overall mentalizing abilities [23–25] and higher levels of alexithymia [26], which refers to difficulties in identifying and describing one´s own emotions. Mesaures of alexithymia can be regarded as proxy measures for mentalizing in the self-dimension [14]. However, the findings are less consistent regarding the ability to mentalize with respect to others which e. g. can be captured by assessing the related construct of ToM [17]: While two older meta-analysis found deficits in ToM or the understanding of mental states in others, respectively, in patients with AN compared to healthy individuals [26, 27], some more recent reviews are more skeptical regarding possible impairments in ToM or in “mentalizing others” in patients with AN [22, 28]. Additionally, there is some evidence indicating that patients with AN might not be homogenous regarding deficiencies in both, overall mentalizing and its dimensions, but that different subgroups with varying mentalizing profiles have to be differentiated [29, 30]. Harrison et al. (2010; [31]), for example, found that impairments in the ability to recognize emotions in others were more severe in patients with restricting AN than in patients with binge-purging AN, suggesting that the subtype of the illness might play a role when discussing mentalizing profiles in AN. Another study by Rommel et al. (2013; [32]) points in the same direction: Only patients with the restricting subtype of AN demonstrated difficulties in the emotional awareness of others, while patients with binge-purging behavior (binge-purging AN and bulimia nervosa) did not differ significantly from healthy control subjects. Furthermore, there is some evidence that greater impairments in the capacity to mentalize are at least to some extent associated with a greater severity of ED symptoms and/or ED related psychological traits (e.g. [23, 24]). However, findings on the association of mentalizing and ED symptomatology are still inconsistent as some studies found no correlation between these variables (e.g. [33, 34]). Moreover, the relation between mentalizing abilities and other aspects of psychopathology, such as alterations in body experience or impairments in personality functioning which shares a broad conceptual and empirical overlap with the construct of mentalization [35–38], has rarely been studied in this patient group. Additionally, given that AN is frequently associated with a wide range of psychiatric comorbidities [39] including affective disorders which in turn have been linked to impairments in the ability to mentalize [40, 41], a connection between low RF-levels and comorbid depressive symptoms might be worth examining. Recently, in both research and clinical practice there has been a broad use of self-report measures such as the Reflective Functioning Questionnaire [42] and the Mentalization Questionnaire [43] for the assessment of the overall capacity to mentalize. However, even though those measures are well validated, evidence of their relation to an observer-rating on the RF-Scale is still scarce. At the same time, in light of the frequent conceptualization of AN and other EDs as “Self-Disorders” [12], combining an expert-rating with the patients´ own view might be of particular interest for the assessment of mentalizing and its relation to psychopathology in this particular group of patients. Study aims and hypotheses The first aim of the current study was to compare the mentalizing abilities of patients with AN to a healthy control group using both an observer-rated as well as a self-report measure to capture RF. We hypothesized that patients with AN will show lower RF levels in an expert rating as well as in a self-report measure compared to healthy individuals. The study´s second aim was to examine the association between the patients´ mentalizing abilities and various aspects of ED and general psychopathology. We postulated that lower levels in RF will be associated with more ED specific as well as general psychopathology and a lower BMI. Finally, it was aimed to explore possible differences in mentalizing capacities between AN-subtypes. Methods Study design A sample of adult female patients with AN was compared with a matched non-clinical control group of healthy adult females. For a multi-method RF measurement, an expert rating and a questionnaire (self-report) were combined. Thus, the participants took part in a video-recorded interview, and filled in a set of questionnaires named below. In terms of psychopathology, the following aspects were examined: ED psychopathology including BMI and body experience, depressive symptoms and personality functioning. The clinical group included 30 female, adult patients with AN, recruited at the Department of Psychosomatic Medicine and Psychotherapy, Freiburg University Hospital, Germany and at private psychotherapy practices over a period of two years. All patients met the ICD-10 [44] criteria for either AN (F50.0) or atypical AN (F50.1). Inclusion criteria were female gender, an age between 18 and 60 years and written consent to participate in the study. Exclusion criteria were a current or lifetime diagnosis of psychotic disorder, bipolar disorder, substance abuse disorder, intellectual disability or organic brain disease as well as an insufficient understanding of the German language. The control group consisted of 30 healthy, female adults that were recruited among university students and employees of the University Hospital Freiburg. They were required to have no lifetime history of any psychiatric illness and to show no indication of an ED or another mental disorder in two screening questionnaires (SEED, PHQ, see below). Both the patients and the healthy controls received 30 Euros for their participation in the study. After a comprehensive explanation of the study´s aims and methodology as well as the procedures to ensure data protection, all participants gave their written informed consent to participate in the study. The study was approved by the local ethics committee of the University Hospital Freiburg (vote 22-1096; 22-1096_1). The interviews were conducted by two students/research assistents, which were trained before, and videotaped using two small cameras directed towards the interviewer and the interviewee, respectively. The videos´ audio tracks interviews were transcribed and the BRFI-transcripts were coded on the RF-Scale by two of the authors (IL, AZ) who were trained and reliable raters of the RF-scale. Difficult passages were discussed with the other rater, and a consensus of rating was found. Both raters were blind to the interviewees´ group allocation and to the results of the self-report measures. The gold standard was prepared by LH and a collegue, two certified RF raters. For this purpose, 10 BRFIs were rated and a consensus was reached. The interrater-correlation between IL and the gold standard was .82 (p < .001) and between AZ and the gold-standard .90 (p < .001), respectively. Measures Mentalizing The Reflective Functioning Scale (RF-Scale) The RF-Scale[18] was developed for the assessment of RF based on transcripts of the AAI [19]. The scale ranges from − 1 to 9, with only the odd numbers representing defined categories, while the even numbers serve as intermediate stages allowing for a more refined evaluation [45]. A rating of -1 (“negative RF”) refers to bizarre, inappropriate or unintegrated mental state attributions or to a hostile, rejecting stance towards RF, while a score of 9 (“exceptional RF”) corresponds to an extraordinarily sophisticated, original and consistent understanding of mental states and the way in which they underlie behavior. A score of 5 (“ordinary RF”), however, is supposed to be the most common rating in a healthy population and requires clear examples of mentalizing, even if RF remains relatively simple. In order to facilitate the rating, the Reflective Functioning Manual [18] provides the following qualitative markers as indicators for the presence of moderate to high RF (scores of ≥ 4): (1) Recognizing the characteristics of mental states, including their opaqueness and their susceptibility to disguise, (2) making an effort to find plausible links between behaviors and underlying mental states, (3) being aware of developmental aspects of mental states and (4) demonstrating an understanding of mental states in relation to the interviewer. In the course of the scoring procedure, the questions of the interview transcript are first rated individually on the RF-Scale. In a second step, the RF-ratings of the individual questions are aggregated into a global score with the main focus being on the results from the demand questions. However, the global score does not simply represent the arithmetic mean of the single ratings, but rather it´s obtained by regarding the interview as a whole and individually weighting each passage [18, 46]. The Brief Reflective Functioning Interview (BRFI) The BRFI [20] is a short, semi-structured interview designed to capture mentalizing on the RF-Scale. It was developed on the basis of the AAI [19] with the intention to reduce administration, transcription and coding times and is therefore thought to provide a time- and costeffective alternative to the AAI for the interview-based assessment of RF [47]. The english version of the BRFI comprises a total of eleven, the german version a total of ten questions, the first eight of which refer to one freely chosen parent. Participants are asked to reflect on the personality of this parent, on their relationship with him or her and on the ways in which this parent has influenced their lives. The final two questions require the interviewees to deliberate on another person who is currently important to them in order to allow an assessment of their mentalizing in the context of a non-parental relationship [48]. RF is coded on the RF-Scale in accordance with the general principles outlined in the Reflective Functioning Manual [18] that were described above (in the following named “RF-BRFI”). However, since every question of the BRFI is designed to explicitly prompt RF, all of them are rated as “demand-questions” and must therefore be considered in the formation of the global rating [47]. In several studies, the RF-scores obtained using the BRFI show a strong correlation with those obtained using the AAI (r = .71 to .88), indicating the validity of the measure [47, 48]. Both the English and the German version of the BRFI have shown an excellent internal consistency (Cronbach´s α = .92 to .97) and a good interrater reliability for the total score (ICC = .79 to .85) [47, 48]. The Mentalization Questionnaire (MZQ) The MZQ [43] is a self-rated instrument originally designed for the assessment of mentalization in patients with mental disorders. It consists of 15-Items that are answered on a five-point Likert scale ranging from 1 (“don´t agree at all”) to 5 (“agree completely”) and that can be assigned to the following four subscales: “refusing self-reflection”, “emotional awareness”, “psychic equivalence mode” and “regulation of affect”. However, for the purpose of this study only the total score of the MZQ representing the arithmetic mean of all its items was used for further analyses. It is important to note, that in contrast to the RF-Scale, higher scores in the MZQ indicate greater impairment in the capacity to mentalize. The reliability of the MZQ-total score is good, with an internal consistency of α = .81 and a retest-reliability of r = .76 in the original evaluation of the questionnaire in a clinical population[43] and similar results for the assessment in a non-clinical population [36]. Convincing evidence for the convergent and divergent validity of the measure was found in several studies using both clinical and community samples [36, 43]. Eating Disorder Symptoms and Psychopathology Eating Disorder Inventory (EDI) The EDI [49, 50] is a self-report questionnaire that measures behavioral and attitudinal components of eating disorder psychopathology. The original version of the questionnaire consists of 64 items that are answered on a six-point Likert scale and generate the following 8 subscales addressing both core eating disorder symptomatology and associated psychological traits: “drive for thinness”, “bulimia”, “body dissatisfaction”, “ineffectiveness”, “perfectionism”, “interpersonal distrust”, “interceptive awareness” and “maturity fears”. With regard to the items´ polarity, sum scores are calculated for each subscale with higher scores indicating a greater severity of ED psychopathology. The EDI has repeatedly demonstrated good validity and reliability. For patients with an ED, all EDI subscales showed excellent internal consistencies (α = .82 to .90; [49]). Eating Disorder Examination – Questionnaire (EDE-Q) The EDE-Q [51] is a self-report measure for the assessment of eating disorder psychopathology and behaviors in the past 28 days. It contains 22 items that address core attitudinal aspects of eating disorder psychopathology and are scored on a seven-point rating scale ranging from 0 (“no days”) to 6 (“every day”). Those 22 items constitute four subscales (“restraint”, “eating concern”, “weight concern” and “shape concern”) which are computed by calculating the average of the contributing items. In addition, a total score representing the mean of all 22 items can be obtained. For both the subscales and the global score, higher values indicate a greater severity of symptomatology. Furthermore, the EDE-Q contains 6 additional items to assess eating disorder behaviors (e.g. self-induced vomiting, binge eating, misuse of laxatives) in terms of their frequency within the past 28 days. Those items do not contribute to any of the subscales or the global score. The German version of the EDE-Q [52] showed a good internal consistency (α = .85 to .97), significant test-retest correlations (r = .67 to .88) and strong indications for convergent und discriminant validity for both the subscales and the total score [53]. Short Evaluation of Eating Disorders (SEED) The SEED [54] is a self-rated measure developed for a fast assessment of core eating disorder symptomatology. It comprises six items that allow the calculation of a total severity index for AN and BN symptoms, respectively, ranging from 0 (“no symptoms”) to 3 (“extreme symptoms”). The SEED was validated for both a clinical and a non-clinical population [54]. In this study, the SEED was used to screen for possible ED symptoms in the healthy control group. Healthy controls surpassing a total severity score of 1 for either AN or BN were excluded from the study. Personality Functioning Operationalized Psychodynamic Diagnosis – Structure Questionnaire Short Form (OPD-SQS) The OPD-SQS [55] is a self-report measure for the assessment of personality functioning based on the Level of Structural Integration Axis by the OPD. The questionnaire comprises 12 Items to be answered on a five-point scale ranging from 0 (“fully disagree”) to 4 (“fully agree”). In the end, a total sum score (0 to 48) is calculated with higher values indicating a more severe personality dysfunction. The OPD-SFK has shown good reliability and validity for both clinical and non-clinical samples [55, 56]. The internal consistency for the total scale was α = .88 in the original sample [55]. Body experience Dresden Body Image Inventory – 35 (DKB-35) The DKB-35 [57] is a self-report measure to assess five dimensions of body experience. We prefer the term “body experience” over the term “body image”, for the dimensions cover a broder concept of how the body is precepted and psychially experienced rather than just “imaged”. The dimensions covered in the DKB-35 incule “vitality”, “self-acceptance”, “sexual fulfillment”, “self-aggrandisement” and “physical closeness”. Its 35 items are rated on a five-point Likert scale. Subscale-scores are computed by calculating the average score of all contributing items, respectively. With regard to the items´ polarity, higher scores indicate a more positive body experience. Reliability and validity of the DKB-35 was confirmed for both clinical and non-clinical samples [58, 59]. General Psychopathology Patient Health Questionnaire (PHQ) Parts of the PHQ[60, 61] were applied for an assessment of general psychopathology: the PHQ-9[62] was used to evaluate symptoms of depression, the PHQ-15[63] was administered to capture somatic symptoms and the GAD-7[64] was applied to assess symptoms of anxiety. The items of the PHQ-9 and the GAD-7 are answered on a four-point scale, ranging from 0 (“not at all”) to 3 (“nearly every day”), while the 15 somatic symptoms of the PHQ-15 are scored from 0 (“not bothered at all”) to 2 (“bothered a lot”). For both the PHQ-15 and the GAD-7, scores of 5, 10, 15 represent cutoff points for mild, moderate and severe symptom severity, respectively. For the PHQ-9, scores of 5, 10, 15, 20 indicate the presence of mild, moderate, moderately severe and severe depressive symptoms, respectively. The PHQ-9, the PHQ-15 and the GAD-7 were all validated and demonstrated an excellent internal consistency with a Cronbach´s α of .89, .80 and .92, respectively . Statistical analysis Means, standard deviations and frequencies were calculated for the description of the sample. A T-standardization based on the representative sample of Kordy et al. (2001; [65]) was performed to provide easily interpretable scores (A T-value of 50 is equal to the mean of the representative sample, +/- 10 T-points equal +/1 one SD). The control participants were matched to the patient group by age and educational level (school education). Between-group differences in sociodemographic characteristics were analyzed using chi-square tests. In order to compare group means for age, BMI and mentalizing variables, we employed one- and two-sided t-Tests for independent samples after testing for variance homogeneity with Levene´s tests. Pearson correlation coefficients (r) and simple linear regression analyses were used to examine and quantify the association between numeric variables. Effect sizes of r = .10, r = .30 and r = .50 were considered small, medium and large in magnitude [66]. Since this study was partially exploratory and hypothesis generating, we did not adjust the alpha level (α = .05) for multiple testing. Instead, we considered effect sizes and the explained variance in the interpretation of the statistical results. Analyses were conducted in SAS-JMP, version 13.2.1. Results Sample Table 1 shows sociodemographic and clinical characteristics of the two study groups. Regarding age, the t-test for independent samples showed no significant difference between patients (M = 26.2 ± 10.1 years; range: 18–57 years) and healthy participants (M = 27.4 ± 9.9 years; range: 20–57 years; t(58) = .46; p = .644). School education was distributed equally. Chi-square tests revealed no significant between-group differences in school professional education (chi 2 = 6.9; df = 3; p = .076) or marital status (chi 2 = .41; df = 2 p = .812). As expected, the mean BMI was significantly lower in the patient group (M = 17.1 ± 2.2 kg/m 2 ; range: 13.4–23.8 kg/m 2 ) than in the HC group (M = 22.2 ± 3.1 kg/m 2 ; range: 18.7–33.9 kg/m 2 ; t = 7.33; df = 58; p < .0001). Clinical history and psychopathology of patients with AN are shown in Table 2. The patients were diagnosed with either AN restricting type (n = 14), AN binge-purge type 8 (n = 7) or atypical AN (n = 9). Out of the nine patients with atypical AN, six showed a restrictive symptomatology and three binge eating and / or purging behavior. Comorbid diagnoses in the patient group included affective disorders (n = 16; 53.3%), posttraumatic stress disorder (n = 6; 20%) and anxiety disorders (n = 2; 6.7%). The mean duration of illness was M = 6.4 years (SD = 5.9 years) and two third of the patients (n = 20) had previously received professional treatment for AN. Between-group differences in mentalizing Descriptively, the mean RF (RF-BRFI) was M = 3.63 (SD = .67; Range = 2 to 5) in the patient group and M = 4.13 (SD = .94; Range = 3 to 6) in the HC group. The distribution of the global ratings on the RF-Scale for both groups is depicted in Figure 1. The self-reported mentalizing in the MZQ was M = 3.24 (SD = .71) for the patients and M = 1.73 (SD = .45) for the HC participants. For a comparison of group means of the RF-BRFI and of the self-reported mentalizing in the MZQ see Table 3. In line with the first hypotheses, results showed, that the mean RF-BRFI value was significantly lower for the patients than for the HC participants. Furthermore and in accordance with our second hypotheses, the between-group difference of the MZQ total score was also significant with patients demonstrating significantly worse self-reported mentalizing (i.e. higher scores in the MZQ) than the HC participants. Table 3 Between-group differences in mentalizing HC M (SD) (N = 30) AN M (SD) (N = 30) t df p RF-BRFI 4.13 (.94) 3.63 (.67) 2.38 52.5 .011 MZQ-total score* 1.73 (.45) 3.24 (.71) − 9.38 49.1 < .0001 Note. * Missing data for 8 control participants: N(HC) = 22; Expecting mentalizing to be impaired in the patient sample, t-Tests were performed one-sided. M mean; SD standard deviation; df degrees of freedom; HC healthy control; AN anorexia nervosa; N sample size; RF Reflective Functioning; BRFI Brief Reflective Functioning Interview; MZQ Mentalization Questionnaire. We additionally examined the relationship between the RF-BRFI and the MZQ total score by means of Pearson´s product-moment correlations. For the whole sample, a significant negative correlation with moderate effect size was found between the RF-BRFI and the MZQ total score indicating that higher expert-rated RF was associated with better self-reported mentalizing (r = − .38; p = .006). However, as visualized in Fig. 2, for both individual groups, no significant correlation was found between the two measures of mentalizing (r = .07 for the control group and r = − .14 for the patient group; both n.s.). Association of mentalizing with ED symptoms and aspects of general psychopathology For correlations between ED symptomatology (EDE-Q, EDI, BMI), aspects of general psychopathology (personality functioning, depression) as well as body experience and the two mentalizing measures (RF-BRFI and MZQ total score) see Table 4. Table 4 Correlation between mentalizing and dimensions of psychopathology RF-BRFI MZQ-total score Eating disorder symptomatology EDE-Q EDE-Q – Total score − .31 .40 * EDE-Q – Restraint − .10 .01 EDE-Q – Eating concern − .26 .51 ** EDE-Q – Weight concern − .39 * .45 * EDE-Q – Shape concern − .33 .41 * EDI-2 EDI-2 – Drive for thinness − .34 .31 EDI-2 – Bulimia − .14 .34 EDI-2 – Body dissatisfaction 1 − .29 .35 EDI-2 – Ineffektiviness .05 .63 *** EDI-2 – Perfektionism .34 .35 EDI-2 – Interpersonal distrust .02 .62 *** EDI-2 – Interceptive awareness − .15 .80 *** EDI-2 – Maturity fears − .13 .37 * BMI .02 .00 Personality functioning OPD-SQS total score .01 .79 *** Depressive symptoms PHQ-9 1 − .11 .30 Body experience DKB-35 – Vitality − .28 − .16 DKB-35 – Self-acceptance .20 − .41 * DKB-35 – Sexual fulfillment .17 − .58 *** DKB-35 – Self-aggrandisement .10 − .44 * DKB-35 – Physical closeness .21 − .54 ** Note. Sample size (N) was N = 30 with the exceptions of the instances marked with ` 1 ´ where sample size was N = 29. RF Reflective Functioning; BRFI Brief Reflective Funcitoning Interview; MZQ Mentalization Questionnaire; EDE-Q Eating Disorder Examination – Questionnaire; EDI-2 Eating Disorder Inventory – 2; BMI Body-Mass-Index ; OPD-SQS Operationalized Psychodynamic Diagnosis – Structure Questionnaire, Short Version; PHQ Patient Health Questionnaire; DKB-35 Dresden Body Image Inventory – 35; * p < .05; ** p < .01; *** p < .001. Regarding the RF-BRFI, a significant negative correlation was found only for the subscale “weight concerns” of the EDE-Q. Regarding the association of the MZQ total score and the EDE-Q-variables, significant positive correlations with moderate to large effect sizes were found for the EDE-Q total score as well as for subscales “eating concerns”, “weight concerns” and “shape concerns”. Among the EDI-subscales, the subscales “ineffectiveness”, “interpersonal distrust”, “interceptive awareness” and “maturity fears” were significantly correlated with the MZQ total score. No significant association was found between both measures of mentalizing and the BMI. Personality functioning as measured with the OPD-SQS was significantly positively and with a large effect size correlated with the MZQ total score, indicating that a lower level of self-reported mentalizing was associated with more severe impairment in personality functioning. However, no significant correlation was found between the OPD-SQS and the RF-BRFI. Neither expert-rated nor self-reported mentalizing was correlated with symptoms of depression as measured with the PHQ-9. Similarly, there was no significant correlation between expert-rated mentalizing (RF-BRFI) and either one of the DKB-35-subscales for the assessment of body experience. In contrast, self-reported mentalizing (MZQ total score) was negatively and with moderate to large effect sizes associated with different aspects of body experience as assessed with the DKB-35. Mentalizing in AN-subgroups While there were no significant differences between the restrictive and the binge-purging subgroup in the RF-BRFI values (t(28) = .38; p = .707), patients with restrictive behavior (N = 20; M = 3.03; SD = .76) showed significantly better self-reported mentalizing (i.e. lower scores in the MZQ total score) than patients with binge-purge behavior (N = 10; M = 3.67; SD = .31; t(27.3) = 3.28; p = .003). Discussion The aim of this study was to examine the level of mentalizing abilities among patients with AN in comparison with matched healthy control participants using both an expert-rated and a self-reported measure for the assessment of RF. Additionally, the study focused on investigating the relation between mentalizing and various aspects of ED-related and general psychopathology. The matching procedure was fully successful concering age, school education and marital status. Given the same age distribution, the AN sample trended towards more ongoing professional education with less university degrees (p = .76). We attribute this trend to the interruptions and delays caused by the illness (e.g. inpatient treatments). In accordance with our hypothesis, RF was significantly lower among the patients than among the HC participants. This is in line with other studies, that also found lower RF levels in patients with AN compared to a healthy control group [23–25]. However, the absolute difference in expert-rated RF (RF-BRFI) between the two groups was relatively small. On the one hand, the mean RF in the patient-group was well below a score of “5” which corresponds to the average RF-level in the general population [18], indicating that the patients did indeed, as expected, demonstrate difficulties recognizing and interpreting mental states. On the other hand, the deficits in their ability to mentalize were not quite as severe as results of other studies suggest [23–25]. This could be partially attributed to the fact, that this study included a considerable number of outpatients while previous research mostly focused on inpatients with AN (e.g.[23–25] ). However, the overall severity of ED-psychopathology in the present sample was still substantial. Another contributing factor could be a methodological one. While in previous studies, the scoring of patients´ mentalizing ability on the RF-Scale was mostly based on transcripts of the AAI, we used the BRFI as an abbreviated version of it. However, the RF-scores obtained by using the AAI and those obtained by using the BRFI were shown to be highly correlated [47, 48]. Therefore, it seems unlikely that the use of the BRFI in the present study would have influenced the results in the direction of higher RF. Another relevant factor could be that the long duration of illness and the high number of previously received treatments which characterizes the patient sample of this study might have impeded and to some extent distorted the assessment of the patients´ RF since it might have led to an increased occurrence of “pseudomentalizing”. Individuals who pseudomentalize may talk elaborately and at first glance in a mentalizing manner about mental states but their words are severed from their emotional experience and, thus, carry little true meaning [13, 14]. Pseudomentalizing can be difficult to differentiate from genuine mentalizing. Furthermore, it has previously been discussed as a challenge in the psychotherapeutic treatment of patients with AN and other EDs[10, 12] and has also empirically been shown in individuals with AN [67]. It may be possible that pseudomentalizing is more difficult to detect in the BRFI compared to the AAI due to its short and compact nature, which leaves less space to reflect on oneself and relationships. At the same time, the RF level in the control group (M = 4.13) was surprisingly low. However, it still goes along with previous studies which also found a mean RF below 5 (which is generally considered the average rating in a healthy population [18]) in non-clinical samples (e.g. [25, 33] for a use of the AAI and [47, 48] for a use of the BRFI). The two study groups also differed significantly regarding self-assessed mentalizing (MZQ total score) with the higher scores in the patient group, indicating a lower RF level. Interestingly, the between-group differences in self-assessed mentalizing were much more pronounced than the differences in expert-rated mentalizing. Also, when compared with the MZQ total scores found in other mental disorders (e.g. spectrum of 2.6 to 3.4 in a study of Riedl et al. 2023 [68]), the mean score in the patient sample of this study (M = 3.24) ranges at the upper end of the spectrum (indicating worse mentalizing abilities), while their expert rated-RF (M = 3.63) lies in the mid-range when compared to RF scores in other diagnostic groups (e.g. range of 2.7 to 3.9 in a study of Fonagy et al. 1996 [69]). On the one hand, this might further validate the assumption of a slight distortion of the patients´ actual RF-BRFI due to pseudomentalizing. Another possible explanation for the differences in RF-measures could be that even though both BRFI and MZQ tap into various dimensions of mentalizing [17] the MZQ is most commonly regarded as a measure which predominantly assesses self-focused mentalizing (e.g. [70, 71]). In patients with AN (and other ED) empirical evidence indicates that mentalizing with regard to the self might be particularly impaired [22, 25, 72]. These findings are also in line with the general assumption that EDs are best understood as self-disorders. Based on this, the particularly pronounced impairment in self-assessed mentalizing found in the patient sample of this study can be considered in accordance with previous research. We further examined the association of expert-rated and self-assessed mentalizing by means of a Pearson correlation analysis and found a significant correlation of the two measures for the whole sample, but not within the groups. This indicates that the association found for the RF-BRFI and the MZQ in the whole sample was actually due to the substantial between-group differences in both of the correlated variables. Therefore, our results do not suggest that expert-rated and self-assessed mentalizing were correlated in the present sample.. The finding of the correlation for the whole sample is in accordance with a study of Andreas et al. (2022; [47]) who were able to demonstrate that participants with an above-average RF-level in an interview-based assessment (AAI and BRFI) also showed significantly better self-assessed mentalizing in the MZQ than participants who were assigned a below-average RF score in the expert-rating. However, they did not regard the clinical and the non-clinical group separately. Other studies that investigated the association of an expert-rated and a self-report instrument for parental mentalizing, offered mixed results regarding the correlation of the two measures [73, 74]. Taken together, it seems possible, that observer-rated and self-report measures for mentalizing in general as well as the BRFI and the MZQ in particular tap into slightly different aspects of the overarching construct of mentalizing. Thus, they might best be regarded complementary rather than interchangeable. Their combined use may contribute to a more comprehensive understanding of an individual´s capacity to mentalize, if it can be worked out what exactly they measure. At the same time, this implicates that research results on mentalizing might be difficult to compare or to merge if they are based on different measures, especially as long as it is not well-defined which measure captures which aspects of the overall construct. Next, we examined the relation between mentalizing and ED symptoms and ED-related psychological traits, respectively. As expected, we found significant correlations of both mentalizing measures with various scales of the EDI and the EDE-Q. However, these correlations were much more numerous and larger in effect size for self-reported mentalizing than for the observer-rated RF-BRFI. This difference between the two measures of mentalizing is continued when looking at the additional, explorative analyses regarding the association of mentalizing and body experience: A more negative body experience was strongly and in several of its dimensions correlated with the self-assessment of mentalizing abilities, but not with the expert-rating on the RF-Scale. The overall weak, rather selective and therefore in total hardly convincing correlation of the RF-BRFI with ED symptomatology is in accordance with several previous studies that also found few or no indication of an association between expert-rated (global) RF and severity of ED symptoms (e.g. [33, 34]). Based on the assumption, that the MZQ primarily captures self-focused mentalizing, its consistent and pronounced correlation with various aspects of both ED symptoms and ED-related psychological characteristics is also in line with previous research: Rothschild-Yakar et al. (2018; [72]) assessed self-focused mentalizing in patients with ED and healthy controls using both an RF-expert-rating as well as a self-report questionnaire for alexithymia as a proxy measure. While in the total sample, both measures of mentalizing the self were significantly and with moderate effect sizes correlated with ED-symptoms, the association was not or only marginally significant for mentalizing regarding others and general, expert-rated RF, respectively. Similar results were found in a later study [25]. Overall, these empirical findings suggest, that deficits in self-focused mentalizing might be of particular relevance to the severity of AN and other EDs. Furthermore, they align with the theoretical conceptualization of ED as self-disorders. Within the framework of the mentalizing model, it could be argued, that a particularly weak and incoherent sense of self and identity might involve a more pronounced impairment of the self-dimension of mentalizing and at the same time predispose to a greater severity of ED-symptoms and related psychological traits. Another aim of this study was to investigate the relation between mentalizing and personality functioning. While in accordance with our hypothesis, lower self-reported mentalizing abilities in the MZQ were significantly and with a large effect size correlated with more severe impairment in personality functioning (OPD-SQS), no such association was found with regard to the expert-rating of RF. The later finding is in contrast to a study by Zettl et al. (2020; [35]), who found the RF-BRFI and the OPD-SQS total score to be correlated, even though the effect size was small after controlling for symptom severity. In general, the conceptual overlap between mentalizing and personality functioning is well established. The correlation of both constructs was demonstrated in several studies [35–38] and the findings in the present study are, with respect to the particular measures, the MZQ and OPD-SQS, also in accordance with previous research [36]. Interestingly, the strength of this association considerably surpasses the effect sizes found for other, interview-based measures of both constructs ([37][38]). Based on previous research that indicated that the impairments in mentalizing abilities of patients with AN might be associated with their low bodyweight [11, 75] as well as the known impact of starvation on cognitive functions [76], we expected anassociation between the measures of mentalizing and the patients´ BMI. However, we found no association between low bodyweight and mentalizing. Although this is in accordance with other studies [33, 77], it should be considered that our sample was not ideal for such an analysis: Due to the inclusion of outpatients and patients with atypical AN, the BMI of many patients was comparably high and it may be possible that malnutrition in our sample had no considerable impact on mentalizing. Furthermore, we found no significant association of depressive symptoms with either of the mentalizing measures. For the RF-BRFI, this is in accordance with previous research: Several studies found no correlation between expert-rated RF and the severity of depressive symptomatology in samples of patients with depression [40, 78]. However, greater impairment in mentalizing as measured with the MZQ was quite consistently found to be associated with more severe depressive symptoms (e.g. [79, 80]). In our sample, a medium effect size of correlation between MZQ and PHQ-9 was found, even though it did not turn out to be significant which is possibly due to the small sample size. This again may indicate a difference within the construct of mentalizing measured with the BRFI and the MZQ as discussed above. Finally, our explorative analysis yielded significantly lower self-reported mentalizing abilities (i.e. higher scores in the MZQ) among the patients with binge-purge behavior than among those with only restricting behavior. This is in line with previous research suggesting that patients with AN and other EDs might not be homogenous regarding their impairments in the ability to mentalize [30]. However, these subgroup-differences were only found for the MZQ but not the BRFI. At the same time, only the MZQ was strongly associated with the OPD-SQS, other than the BRFI. Given that there is some evidence that personality functioning might also be more impaired in patients with the binge-purging subtype of AN than in those with the restricting subtype [81], these results might also be regarded as a correlate of a greater personality dysfunction in patients with binge-purge AN. There are several important limitations to the present study. First, the sample size was rather small and, thus, the statistical power was limited. Especially the results of the explorative analyses should be interpreted with caution. Furthermore, since this study only included adult women, the findings cannot be generalized to other patient groups such as male, transgender or adolescent individuals. Future studies using larger and more diverse samples might allow for a more differentiated assessment of mentalizing among subgroups of patients with AN. Secondly, the majority of patients included in the present study had already received professional treatment for their AN in the past and have been suffering from the disorder for many years which might be a complicating factor to the interview-based assessment of RF, by predisponing for “pseudomentalization”. Future studies might therefore need to employ different recruitment strategies to allow for the assessment of mentalizing abilities also in untreated patients shortly after the onset of the illness. Third, the evaluation of a possible association between impairments in mentalizing and low bodyweight was limited due to the specific composition of the present sample. Larger studies including a sufficient number of patients in all BMI categories are required, to evaluate the effect of starvation on mentalizing. Finally, another important limitation lies in the study´s cross-sectional design. Both mentalizing abilities as well as symptom severity were assessed only at one point in time. Therefore, we could not say whether the deficits found in the patients´ capacity to mentalize represent a state or rather a trait-like characteristic. Future studies with a longitudinal design are necessary to show whether RF changes over time, with weight gain and during the course of a treatment as well as if improvement in RF relates to a reduction of symptom severity and an overall better outcome. To address these important questions, prospective studies are needed that involve a repeated assessment of mentalizing abilities during the therapy process as well as after recovery. Since the iterated use of the same interview protocol might be neither feasible nor reasonable to monitor changes in RF over time, different assessment methods such as the evaluation of mentalizing abilities during psychotherapeutic sessions (In-session RF) might be useful in this context [82]. Conclusions Patients with AN showed a lower capacity to mentalize compared to healthy individuals. An expert rating and a self report measure of RF did correlate in the whole sample but not within the subgroups of patients and controls. Aditionally, they showed different profiles of correlation to aspects of ED-related and general psychopathology. In conclusion, it seems likely, that observer-rated and self-report measures for RF cover partially different aspects of the mentalizing construct and should be regarded complementary rather than interchangable. Abbreviations AN: anorexia nervosa; BMI: Body Mass Index; BN: bulimia nervosa; BRFI: Brief Reflective Functioning Interview; HC: healthy control; ED: eating disorder; EDE: Eating Disorder Inventory; EDE-Q: Eating Disorder Inventory – Questionnaire; EDI: Eating Disorder Inventory; MZQ: Mentalization Questionnaire; PHQ: Patient Health Questionnaire; RF: Reflective Functioning Declarations Ethics approval and consent to participate The study protocol was approved by the local ethics committee of the University Hospital of Freiburg (No 22-1096 and No 22-1096_1). Subjects gave their written informed consent after receiving a comprehensive description of the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The study was supported by the Heidehof Stiftung GmbH (No. 59055.04.1/1.22). The Heidehof Stiftung GmbH had no role in the design and conduct of the study, collection of data, data management, data analysis or interpretation of results. She played no role in preparation, revision and the decision to submit the manuscript for publication. Authors´ contributions LK conducted most of the interviews and was responsible for data analysis. She wrote the first draft of the manuscript. IL supervised the project, she rated most of the BRFI-interviews. AZ designed the study and was the primary investigator, she also rated BRFI-interviews. AME conducted interviews and helped with data management. AH supervised the statistical analyses. SA made the German version of the BRFI available, LH made and the gold standard available. All authors critically read and commented on the manuscript. Acknowledgements We thank the patients that were involved in the study and Elvira Bozkaya, who helped with data monitoring and Denis Bozkaya who took part in the transcription of the audios. We also thank Pauline Leonie Herrmann for her contributions the BRFI-Gold-Standard. Furthermore, we thank the Heidehofstiftung for their financial support. References Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13:153–60. doi:10.1002/wps.20128. Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med. 2016;129:30–7. doi:10.1016/j.amjmed.2015.06.031. Winkler LA-D, Christiansen E, Lichtenstein MB, Hansen NB, Bilenberg N, Støving RK. Quality of life in eating disorders: a meta-analysis. Psychiatry Res. 2014;219:1–9. doi:10.1016/j.psychres.2014.05.002. Treasure J, Zipfel S, Micali N, Wade T, Stice E, Claudino A, et al. Anorexia nervosa. 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Front Psychiatry. 2023;14:1150422. doi:10.3389/fpsyt.2023.1150422. Fonagy P, Leigh T, Steele M, Steele H, Kennedy R, Mattoon G, et al. The relation of attachment status, psychiatric classification, and response to psychotherapy. J Consult Clin Psychol. 1996;64:22–31. doi:10.1037//0022-006x.64.1.22. Peters M, Schulz H. Comparing Mentalizing Abilities in Older Adults with and without Common Mental Disorders. Psychopathology. 2022;55:235–43. doi:10.1159/000522309. Schwarzer N-H, Nolte T, Fonagy P, Gingelmaier S. Mentalizing and emotion regulation: Evidence from a nonclinical sample. Int Forum Psychoanal. 2021;30:34–45. doi:10.1080/0803706X.2021.1873418. Rothschild-Yakar L, Peled M, Enoch-Levy A, Gur E, Stein D. "Eating Me Up from Inside": A Pilot Study of Mentalization of Self and Others and Emotion Regulation Strategies among Young Women with Eating Disorders. Isr J Psychiatry. 2018;55:35-43. PMID: 29916405. Anis L, Perez G, Benzies KM, Ewashen C, Hart M, Letourneau N. Convergent Validity of Three Measures of Reflective Function: Parent Development Interview, Parental Reflective Function Questionnaire, and Reflective Function Questionnaire. Front Psychol. 2020;11:574719. doi:10.3389/fpsyg.2020.574719. Carlone C, Milan S, Decoste C, Borelli JL, McMahon TJ, Suchman NE. Self-report measure of parental reflective functioning: A study of reliability and validity across three samples of varying clinical risk. Infant Ment Health J. 2023;44:240–54. doi:10.1002/imhj.22046. Zeeck A, Taubner S, Gablonski TC, Lau I, Zipfel S, Herzog W, et al. In-Session-Reflective-Functioning in Anorexia Nervosa: An Analysis of Psychotherapeutic Sessions of the ANTOP Study. Front Psychiatry 2022. doi:10.3389/fpsyt.2022.814441. Keys A, Brozek J, Henschel A, Mickelsen O, Taylor H. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950. Zeeck A, Lau I, Endorf K, Schaefer L, Euler S, Lahmann C, Hartmann A. Mentalizing in psychotherapeutic processes of patients with eating disorders. Front Psychiatry. 2024;15:1367863. doi:10.3389/fpsyt.2024.1367863. Taubner S, Kessler H, Buchheim A, Kächele H, Staun L. The role of mentalization in the psychoanalytic treatment of chronic depression. Psychiatry. 2011;74:49–57. doi:10.1521/psyc.2011.74.1.49. Nonweiler J, Doval E, Barrantes-Vidal N, Ballespí S. Spanish Adaptation of the Mentalization Questionnaire (MZQ) in Community Adolescents and Adults. Psicothema. 2024;36:174–83. doi:10.7334/psicothema2023.47. Frank J, Kirchner E, Padberg F, Huber D. Psychische Struktur und Mentalisierungsfähigkeit bei stationären depressiven Patienten im Langzeitverlauf. Z Psychosom Med Psychother. 2021;67:256–70. doi:10.13109/zptm.2021.67.oa6. 81. Rohde J, Hofmann T, Voigt B, Rose M, Obbarius A. Measurement of Personality Structure by the OPD Structure Questionnaire Can Help to Discriminate Between Subtypes of Eating-Disorders. Front Psychol. 2019;10:2326. doi:10.3389/fpsyg.2019.02326. Talia A, Miller-Bottome M, Katznelson H, Pedersen SH, Steele H, Schröder P, et al. Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process. Psychother Res. 2019;29:652–65. doi:10.1080/10503307.2017.1417651. Table 1 and 2 Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1and2.docx Cite Share Download PDF Status: Published Journal Publication published 01 Dec, 2025 Read the published version in Journal of Eating Disorders → Version 1 posted Editorial decision: Revision requested 25 Aug, 2025 Reviews received at journal 21 Aug, 2025 Reviewers agreed at journal 01 Aug, 2025 Reviews received at journal 29 Jul, 2025 Reviewers agreed at journal 22 Jul, 2025 Reviewers invited by journal 16 Jul, 2025 Editor assigned by journal 15 Jul, 2025 Submission checks completed at journal 15 Jul, 2025 First submitted to journal 13 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7115479","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486368386,"identity":"889d5b0d-2b95-430f-9f05-ac8bd4cc7f1a","order_by":0,"name":"Lara Kanstinger","email":"","orcid":"","institution":"University of Freiburg","correspondingAuthor":false,"prefix":"","firstName":"Lara","middleName":"","lastName":"Kanstinger","suffix":""},{"id":486368388,"identity":"31b55591-c3b4-4c44-aea2-0f2e4a16d3f8","order_by":1,"name":"Almut Zeeck","email":"","orcid":"","institution":"University of Freiburg","correspondingAuthor":false,"prefix":"","firstName":"Almut","middleName":"","lastName":"Zeeck","suffix":""},{"id":486368389,"identity":"e0b0141e-8aec-40d2-956c-eb17dd41ba59","order_by":2,"name":"Armin Hartmann","email":"","orcid":"","institution":"University of Freiburg","correspondingAuthor":false,"prefix":"","firstName":"Armin","middleName":"","lastName":"Hartmann","suffix":""},{"id":486368391,"identity":"cff22dc7-6a3d-4769-818e-86b6a68ea3e8","order_by":3,"name":"Anne Marie Eyschen","email":"","orcid":"","institution":"University of Freiburg","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"Marie","lastName":"Eyschen","suffix":""},{"id":486368392,"identity":"77a4d40d-02ba-46f1-aa5d-3156c86871c7","order_by":4,"name":"Sylke Andreas","email":"","orcid":"","institution":"University of Klagenfurt","correspondingAuthor":false,"prefix":"","firstName":"Sylke","middleName":"","lastName":"Andreas","suffix":""},{"id":486368393,"identity":"6d968981-3008-41a0-82a4-2127a8680f19","order_by":5,"name":"Lotta Hüwe","email":"","orcid":"","institution":"University of Klagenfurt","correspondingAuthor":false,"prefix":"","firstName":"Lotta","middleName":"","lastName":"Hüwe","suffix":""},{"id":486368394,"identity":"23bfa59b-d5a5-4468-8dbc-63b2301fb203","order_by":6,"name":"Claas Lahmann","email":"","orcid":"","institution":"University of Freiburg","correspondingAuthor":false,"prefix":"","firstName":"Claas","middleName":"","lastName":"Lahmann","suffix":""},{"id":486368395,"identity":"a8b82416-1e83-4bb5-8cc0-ef2d05300436","order_by":7,"name":"Inga Lau","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABOElEQVRIie3RPWuDQBgH8EcEXXxZL7SlX+GBLE79LB4ZslgRXISG9KRglkBXh0C/ghDorBTMcpR2E7oYujrYqZ1CT2m6qJkL9T/cwT3347kXgDFj/mCUdvQATDFlzCOgaAA1ALHbijZEEGDCGoItkeJTBI4EUwCJYburITBIjLPVaw14RbfFdZbFaLmGlkp3QWC5+LZ7gSroHuyc+wRwRh8L184SJL6iMynknPj47HjShncJcWxBZEEczEokNDLNz30YEZpwzZb1qI/MvgBv6Tb+JSCF4eFIDj1knosuTzQhgiQNaQ4Wsoaoqayzvi6KZeNuGvMKxfUFEdcPWU78Cdcg2+QdchnP34s6uLm4XznTj3WwpA9rW5DF0jW4ui+rRfeVQcOfL+grpb3rajkATpbGjBkz5j/lG9fhbuq3ol2kAAAAAElFTkSuQmCC","orcid":"","institution":"University of Freiburg","correspondingAuthor":true,"prefix":"","firstName":"Inga","middleName":"","lastName":"Lau","suffix":""}],"badges":[],"createdAt":"2025-07-13 21:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7115479/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7115479/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40337-025-01465-x","type":"published","date":"2025-12-01T15:56:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87364407,"identity":"eb74bf73-4697-4964-9817-8c8e4da98461","added_by":"auto","created_at":"2025-07-23 06:15:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32135,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of global RF-Scores on the BRFI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNote. Frequency of expert-rated global RF-Scores are indicated in dark grey for Patients with AN and in light grey for healthy controls. The most common rating for patients with AN was RF = 4 while for HCs it was RF = 5. \u0026nbsp;\u003cem\u003eRF\u003c/em\u003e Reflective Functioning; \u003cem\u003eBRFI \u003c/em\u003eBrief Reflective Functioning Interview; \u003cem\u003eAN\u003c/em\u003e Anorexia nervosa; \u003cem\u003eHC\u003c/em\u003e Healthy control.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7115479/v1/49e4ccf0644759034f8f0113.png"},{"id":87365004,"identity":"21375d95-14d6-4b3f-9886-8ea4abfb1a39","added_by":"auto","created_at":"2025-07-23 06:23:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40713,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociation between the RF-BRFI and the MZQ total score\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNote. Expert-rated global RF-Scores (RF-BRFI) and correspondant scores of self-reported mentalizing (MZQ total score) are indicated in dark grey for patients with AN and in light grey for healthy controls. While for the whole sample, a significant negative correlation with moderate effect size was found between the RF-BRFI and the MZQ total score indicating that higher expert-rated RF was associated with better self-reported mentalizing, no significant correlation was found between the two measures of mentalizing within the individual groups. \u003cem\u003eRF\u003c/em\u003e Reflective Functioning; \u003cem\u003eBRFI \u003c/em\u003eBrief Reflective Functioning Interview; \u003cem\u003eMZQ\u003c/em\u003e Mentalization Questionnaire; \u003cem\u003eAN\u003c/em\u003eAnorexia nervosa; \u003cem\u003eHC\u003c/em\u003e Healthy contro\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7115479/v1/d541dc974dd558d1f519940e.png"},{"id":97723732,"identity":"412d4b23-71f9-41e8-b2d1-fb2f7510b926","added_by":"auto","created_at":"2025-12-08 15:58:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1204769,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7115479/v1/560e659b-cbeb-47a4-9735-f6e19619e8b6.pdf"},{"id":87365003,"identity":"e2b80314-c905-4090-9119-79a8fea5e51b","added_by":"auto","created_at":"2025-07-23 06:23:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21947,"visible":true,"origin":"","legend":"","description":"","filename":"Table1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7115479/v1/19bba11512b59b31ffdaea12.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reflective functioning in anorexia nervosa: Does it differ from healthy controls and how is its relation to psychopathology?","fulltext":[{"header":"Plain English summary ","content":"\u003cp\u003eThe aim of the study was an assessment of the mentalizing capacity (\u0026quot;\u003cem\u003ereflective functioning\u003c/em\u003e\u0026quot;, RF) in patients with AN in comparison to healthy controls (HC), using a validated interview as well as a self-report measure. Aditionally, correlations of RF with various aspects of psychopathology were explored.\u003c/p\u003e\n\u003cp\u003e30 patients with AN and 30 HC were assessed and compared regarding RF using the Brief Reflective Functioning Interview (BRFI) for an expert rating and the Mentalization Questionnaire (MZQ) for a self-reported measurement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe RF values were correlated with eating disorder psychopathology, body experience, general psychopathology and impairment in personality functioning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the BRFI-RF as well as in the MZQ, patients with AN showed significantly lower mentalizing capacity than HC. Higher expert-rated RF was associated with better self-reported mentalizing. However, \u0026nbsp;no significant correlation for the individual groups of patients ond controls could be found. BRFI-RF was only hardly correlated to any aspects of AN-related or general psychopathology, while mentalizing in the MZQ correlated with various aspects of psychopathology.\u003c/p\u003e\n\u003cp\u003eIn conclusion, it seems likely, that observer-rated and self-report measures for mentalizing are not interchangeable. They rather seem to cover partially different aspects of an individual\u0026rsquo;s mentalizing capacity.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eAnorexia nervosa (AN) is a severe illness with one of the highest mortality rates among all mental disorders [1], a wide range of associated medical complications [2] and a significant reduction in health-related quality of life [3]. The partial ego-syntonic nature of the disease and a commonly found ambivalence towards change contribute to the maintenance of the disorder and difficulties in its treatment [4, 5]. Only about half of the patients achieve full recovery [6], a percentage that probably has not changed over the last decades. Thus, the prognosis of AN is still relatively poor. Even though the empirical research on effective treatment for AN is growing, there is still a need to further advance and optimize common therapeutic approaches [5, 7], especially by taking into account the specific mechanisms underlying the disease, which include biological, cognitive as well as social-emotional factors [8, 9]. In this context, increasing attention has recently been placed on the mentalization model and how it can be employed for both, the conceptualization and the treatment of AN and other eating disorders (ED) (e.g. [10–12]).\u003c/p\u003e\u003cp\u003eThe construct of mentalizing refers to the ability to be aware of mental states such as thoughts, feelings, wishes, and intentions in oneself and others, and to perceive and interpret these mental states in relation to how they underly and, thus, explain human actions and behaviors [13]. Mentalizing is thought to play a pivotal role not only in the regulation and organization of the self, but also in the formation of interpersonal relationships and greater social arrangements [14, 15]. Due to its broad overlap with various related constructs and abilities, such as empathy, Theory of Mind (ToM), alexithymia, and mindfulness, mentalizing is often viewed as an umbrella concept [14]. Mentalizing is a complex, multi-facetted capacity rather than a single entity. As evidenced by neuroscientific research, the following four distinct dimensions of mentalizing can be differentiated [14, 16]: (1) \u003cem\u003eAutomatic\u003c/em\u003e vs. \u003cem\u003econtrolled\u003c/em\u003e mentalizing, (2) \u003cem\u003ecognitive\u003c/em\u003e vs. \u003cem\u003eaffective\u003c/em\u003e mentalizing, (3) mentalizing \u003cem\u003eoneself\u003c/em\u003e vs. mentalizing \u003cem\u003eothers\u003c/em\u003e and (4) mentalizing with focus on \u003cem\u003eexternal\u003c/em\u003e indicators vs. mentalizing based directly on (assumed) \u003cem\u003einternal\u003c/em\u003e processes. According to the mentalizing model, various shapes of psychopathology involve a different set of imbalances between these dimensions or a certain “mentalizing profile” that is distinctive for the respective disorder [14, 17]. Furthermore, mentalizing is described as a dynamic, interactive capacity that is both context and relationship dependent and typically increasingly difficult to access in situations with heightened, often attachment-related arousal [13, 14]. In situations of high emotional arousal, mentalizing becomes disrupted and individuals tend to backslide into prementalizing modes of subjective experience that developmentally precede the full, “mature” capacity for mentalizing [13, 16]. These prementalizing modes include the \u003cem\u003epsychic equivalence mode\u003c/em\u003e (inner, mental experiences and external reality are equalized), the \u003cem\u003eteleological mode\u003c/em\u003e (mental states are only recognized if they are accompanied by an exterior, observable indicator) and the \u003cem\u003epretend mode\u003c/em\u003e (mental states and outer reality are disconnected) [14, 16]. When it resurfaces in adulthood, the pretend mode often involves pseudomentalizing, which describes a state, in which individuals present elaborate, apparently reflective narratives on mental states that are in fact not connected to the persons´ subjective reality and therefore ultimately remain insignificant to them [13].\u003c/p\u003e\u003cp\u003eThe ability to mentalize is operationalized as Reflective Functioning (RF) and can be measured with the Reflective Functioning Scale (RF-Scale; [18]). While its application to transcripts of the Adult Attachment Interview (AAI; [19]) is considered the gold standard measure for the assessment of mentalizing, the RF-Scale (or slightly adapted versions of it) can also be coded based on other semi-structured interviews such as the Brief Reflective Functioning Interview (BRFI; [20]) or it can be used for the RF-rating in therapy sessions [21].\u003c/p\u003e\u003cp\u003eBesides the interview based coding systems, a range of other methods for an assessment of RF is available, including self-report measures, experimental tasks or performance-based measures [17].\u003c/p\u003e\u003cp\u003eWithin the mentalizing model, eating disorders (EDs) such as AN and bulimia nervosa (BN) are conceptualized as “self-disorders” [12]: In light of a poorly integrated psychic reality, the body functions as medium for the expression of unprocessed states of mind and might thereby acquire an excessive importance for the maintenance of an overall week sense of self, ultimately leading to a wide range of typical ED symptoms [10, 15]. It is assumed, that the impaired mentalizing abilities in patients with an ED relate to a vast occurrence of prementalizing modes of experiencing subjectivity [10, 12].\u003c/p\u003e\u003cp\u003eIn line with this, previous research suggests, that the capacity to mentalize is impaired in people suffering from AN [22]. Compared to healthy individuals, patients with AN seem to be characterized by lower RF-levels in interview-based assessments of their overall mentalizing abilities [23–25] and higher levels of alexithymia [26], which refers to difficulties in identifying and describing one´s own emotions. Mesaures of alexithymia can be regarded as proxy measures for mentalizing in the self-dimension [14]. However, the findings are less consistent regarding the ability to mentalize with respect to others which e. g. can be captured by assessing the related construct of ToM [17]: While two older meta-analysis found deficits in ToM or the understanding of mental states in others, respectively, in patients with AN compared to healthy individuals [26, 27], some more recent reviews are more skeptical regarding possible impairments in ToM or in “mentalizing others” in patients with AN [22, 28]. Additionally, there is some evidence indicating that patients with AN might not be homogenous regarding deficiencies in both, overall mentalizing and its dimensions, but that different subgroups with varying mentalizing profiles have to be differentiated [29, 30]. Harrison et al. (2010; [31]), for example, found that impairments in the ability to recognize emotions in others were more severe in patients with restricting AN than in patients with binge-purging AN, suggesting that the subtype of the illness might play a role when discussing mentalizing profiles in AN. Another study by Rommel et al. (2013; [32]) points in the same direction: Only patients with the restricting subtype of AN demonstrated difficulties in the emotional awareness of others, while patients with binge-purging behavior (binge-purging AN and bulimia nervosa) did not differ significantly from healthy control subjects.\u003c/p\u003e\u003cp\u003eFurthermore, there is some evidence that greater impairments in the capacity to mentalize are at least to some extent associated with a greater severity of ED symptoms and/or ED related psychological traits (e.g. [23, 24]). However, findings on the association of mentalizing and ED symptomatology are still inconsistent as some studies found no correlation between these variables (e.g. [33, 34]). Moreover, the relation between mentalizing abilities and other aspects of psychopathology, such as alterations in body experience or impairments in personality functioning which shares a broad conceptual and empirical overlap with the construct of mentalization [35–38], has rarely been studied in this patient group. Additionally, given that AN is frequently associated with a wide range of psychiatric comorbidities [39] including affective disorders which in turn have been linked to impairments in the ability to mentalize [40, 41], a connection between low RF-levels and comorbid depressive symptoms might be worth examining.\u003c/p\u003e\u003cp\u003eRecently, in both research and clinical practice there has been a broad use of self-report measures such as the \u003cem\u003eReflective Functioning Questionnaire\u003c/em\u003e [42] and the \u003cem\u003eMentalization Questionnaire\u003c/em\u003e [43] for the assessment of the overall capacity to mentalize. However, even though those measures are well validated, evidence of their relation to an observer-rating on the RF-Scale is still scarce. At the same time, in light of the frequent conceptualization of AN and other EDs as “Self-Disorders” [12], combining an expert-rating with the patients´ own view might be of particular interest for the assessment of mentalizing and its relation to psychopathology in this particular group of patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy aims and hypotheses\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe first aim of the current study was to compare the mentalizing abilities of patients with AN to a healthy control group using both an observer-rated as well as a self-report measure to capture RF. We hypothesized that patients with AN will show lower RF levels in an expert rating as well as in a self-report measure compared to healthy individuals.\u003c/p\u003e\u003cp\u003eThe study´s second aim was to examine the association between the patients´ mentalizing abilities and various aspects of ED and general psychopathology. We postulated that lower levels in RF will be associated with more ED specific as well as general psychopathology and a lower BMI.\u003c/p\u003e\u003cp\u003eFinally, it was aimed to explore possible differences in mentalizing capacities between AN-subtypes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA sample of adult female patients with AN was compared with a matched non-clinical control group of healthy adult females. For a multi-method RF measurement, an expert rating and a questionnaire (self-report) were combined. Thus, the participants took part in a video-recorded interview, and filled in a set of questionnaires named below. In terms of psychopathology, the following aspects were examined: ED psychopathology including BMI and body experience, depressive symptoms and personality functioning.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe clinical group\u003c/em\u003e included 30 female, adult patients with AN, recruited at the Department of Psychosomatic Medicine and Psychotherapy, Freiburg University Hospital, Germany and at private psychotherapy practices over a period of two years. All patients met the ICD-10 [44] criteria for either AN (F50.0) or atypical AN (F50.1).\u003c/p\u003e\u003cp\u003eInclusion criteria were female gender, an age between 18 and 60 years and written consent to participate in the study. Exclusion criteria were a current or lifetime diagnosis of psychotic disorder, bipolar disorder, substance abuse disorder, intellectual disability or organic brain disease as well as an insufficient understanding of the German language.\u003c/p\u003e\u003cp\u003eThe \u003cem\u003econtrol group\u003c/em\u003e consisted of 30 healthy, female adults that were recruited among university students and employees of the University Hospital Freiburg. They were required to have no lifetime history of any psychiatric illness and to show no indication of an ED or another mental disorder in two screening questionnaires (SEED, PHQ, see below).\u003c/p\u003e\u003cp\u003eBoth the patients and the healthy controls received 30 Euros for their participation in the study.\u003c/p\u003e\u003cp\u003eAfter a comprehensive explanation of the study´s aims and methodology as well as the procedures to ensure data protection, all participants gave their written informed consent to participate in the study.\u003c/p\u003e\u003cp\u003e The study was approved by the local ethics committee of the University Hospital Freiburg (vote 22-1096; 22-1096_1).\u003c/p\u003e\u003cp\u003eThe interviews were conducted by two students/research assistents, which were trained before, and videotaped using two small cameras directed towards the interviewer and the interviewee, respectively. The videos´ audio tracks interviews were transcribed and the BRFI-transcripts were coded on the RF-Scale by two of the authors (IL, AZ) who were trained and reliable raters of the RF-scale. Difficult passages were discussed with the other rater, and a consensus of rating was found. Both raters were blind to the interviewees´ group allocation and to the results of the self-report measures. The gold standard was prepared by LH and a collegue, two certified RF raters. For this purpose, 10 BRFIs were rated and a consensus was reached. The interrater-correlation between IL and the gold standard was .82 (p \u0026lt; .001) and between AZ and the gold-standard .90 (p \u0026lt; .001), respectively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMeasures\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMentalizing\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Reflective Functioning Scale (RF-Scale)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe RF-Scale[18] was developed for the assessment of RF based on transcripts of the AAI [19]. The scale ranges from − 1 to 9, with only the odd numbers representing defined categories, while the even numbers serve as intermediate stages allowing for a more refined evaluation [45]. A rating of -1 (“negative RF”) refers to bizarre, inappropriate or unintegrated mental state attributions or to a hostile, rejecting stance towards RF, while a score of 9 (“exceptional RF”) corresponds to an extraordinarily sophisticated, original and consistent understanding of mental states and the way in which they underlie behavior. A score of 5 (“ordinary RF”), however, is supposed to be the most common rating in a healthy population and requires clear examples of mentalizing, even if RF remains relatively simple. In order to facilitate the rating, the \u003cem\u003eReflective Functioning Manual\u003c/em\u003e[18] provides the following qualitative markers as indicators for the presence of moderate to high RF (scores of ≥ 4): (1) Recognizing the characteristics of mental states, including their opaqueness and their susceptibility to disguise, (2) making an effort to find plausible links between behaviors and underlying mental states, (3) being aware of developmental aspects of mental states and (4) demonstrating an understanding of mental states in relation to the interviewer.\u003c/p\u003e\u003cp\u003eIn the course of the scoring procedure, the questions of the interview transcript are first rated individually on the RF-Scale. In a second step, the RF-ratings of the individual questions are aggregated into a global score with the main focus being on the results from the demand questions. However, the global score does not simply represent the arithmetic mean of the single ratings, but rather it´s obtained by regarding the interview as a whole and individually weighting each passage [18, 46].\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Brief Reflective Functioning Interview (BRFI)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe BRFI [20] is a short, semi-structured interview designed to capture mentalizing on the RF-Scale. It was developed on the basis of the AAI [19] with the intention to reduce administration, transcription and coding times and is therefore thought to provide a time- and costeffective alternative to the AAI for the interview-based assessment of RF [47]. The english version of the BRFI comprises a total of eleven, the german version a total of ten questions, the first eight of which refer to one freely chosen parent. Participants are asked to reflect on the personality of this parent, on their relationship with him or her and on the ways in which this parent has influenced their lives. The final two questions require the interviewees to deliberate on another person who is currently important to them in order to allow an assessment of their mentalizing in the context of a non-parental relationship [48].\u003c/p\u003e\u003cp\u003eRF is coded on the RF-Scale in accordance with the general principles outlined in the \u003cem\u003eReflective Functioning Manual\u003c/em\u003e [18] that were described above (in the following named “RF-BRFI”). However, since every question of the BRFI is designed to explicitly prompt RF, all of them are rated as “demand-questions” and must therefore be considered in the formation of the global rating [47].\u003c/p\u003e\u003cp\u003eIn several studies, the RF-scores obtained using the BRFI show a strong correlation with those obtained using the AAI (r = .71 to .88), indicating the validity of the measure [47, 48]. Both the English and the German version of the BRFI have shown an excellent internal consistency (Cronbach´s α = .92 to .97) and a good interrater reliability for the total score (ICC = .79 to .85) [47, 48].\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Mentalization Questionnaire (MZQ)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe MZQ [43] is a self-rated instrument originally designed for the assessment of mentalization in patients with mental disorders. It consists of 15-Items that are answered on a five-point Likert scale ranging from 1 (“don´t agree at all”) to 5 (“agree completely”) and that can be assigned to the following four subscales: “refusing self-reflection”, “emotional awareness”, “psychic equivalence mode” and “regulation of affect”. However, for the purpose of this study only the total score of the MZQ representing the arithmetic mean of all its items was used for further analyses. It is important to note, that in contrast to the RF-Scale, higher scores in the MZQ indicate greater impairment in the capacity to mentalize.\u003c/p\u003e\u003cp\u003eThe reliability of the MZQ-total score is good, with an internal consistency of α = .81 and a retest-reliability of r = .76 in the original evaluation of the questionnaire in a clinical population[43] and similar results for the assessment in a non-clinical population [36]. Convincing evidence for the convergent and divergent validity of the measure was found in several studies using both clinical and community samples [36, 43].\u003c/p\u003e\u003cp\u003e\u003cb\u003eEating Disorder Symptoms and Psychopathology\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEating Disorder Inventory (EDI)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe EDI [49, 50] is a self-report questionnaire that measures behavioral and attitudinal components of eating disorder psychopathology. The original version of the questionnaire consists of 64 items that are answered on a six-point Likert scale and generate the following 8 subscales addressing both core eating disorder symptomatology and associated psychological traits: “drive for thinness”, “bulimia”, “body dissatisfaction”, “ineffectiveness”, “perfectionism”, “interpersonal distrust”, “interceptive awareness” and “maturity fears”. With regard to the items´ polarity, sum scores are calculated for each subscale with higher scores indicating a greater severity of ED psychopathology. The EDI has repeatedly demonstrated good validity and reliability. For patients with an ED, all EDI subscales showed excellent internal consistencies (α = .82 to .90; [49]).\u003c/p\u003e\u003cp\u003e\u003cb\u003eEating Disorder Examination – Questionnaire (EDE-Q)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe EDE-Q [51] is a self-report measure for the assessment of eating disorder psychopathology and behaviors in the past 28 days. It contains 22 items that address core attitudinal aspects of eating disorder psychopathology and are scored on a seven-point rating scale ranging from 0 (“no days”) to 6 (“every day”). Those 22 items constitute four subscales (“restraint”, “eating concern”, “weight concern” and “shape concern”) which are computed by calculating the average of the contributing items. In addition, a total score representing the mean of all 22 items can be obtained. For both the subscales and the global score, higher values indicate a greater severity of symptomatology.\u003c/p\u003e\u003cp\u003eFurthermore, the EDE-Q contains 6 additional items to assess eating disorder behaviors (e.g. self-induced vomiting, binge eating, misuse of laxatives) in terms of their frequency within the past 28 days. Those items do not contribute to any of the subscales or the global score.\u003c/p\u003e\u003cp\u003eThe German version of the EDE-Q [52] showed a good internal consistency (α = .85 to .97), significant test-retest correlations (r = .67 to .88) and strong indications for convergent und discriminant validity for both the subscales and the total score [53].\u003c/p\u003e\u003cp\u003e\u003cb\u003eShort Evaluation of Eating Disorders (SEED)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe SEED [54] is a self-rated measure developed for a fast assessment of core eating disorder symptomatology. It comprises six items that allow the calculation of a total severity index for AN and BN symptoms, respectively, ranging from 0 (“no symptoms”) to 3 (“extreme symptoms”). The SEED was validated for both a clinical and a non-clinical population [54].\u003c/p\u003e\u003cp\u003eIn this study, the SEED was used to screen for possible ED symptoms in the healthy control group. Healthy controls surpassing a total severity score of 1 for either AN or BN were excluded from the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePersonality Functioning\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOperationalized Psychodynamic Diagnosis – Structure Questionnaire Short Form (OPD-SQS)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe OPD-SQS [55] is a self-report measure for the assessment of personality functioning based on the Level of Structural Integration Axis by the OPD. The questionnaire comprises 12 Items to be answered on a five-point scale ranging from 0 (“fully disagree”) to 4 (“fully agree”). In the end, a total sum score (0 to 48) is calculated with higher values indicating a more severe personality dysfunction.\u003c/p\u003e\u003cp\u003eThe OPD-SFK has shown good reliability and validity for both clinical and non-clinical samples [55, 56]. The internal consistency for the total scale was α = .88 in the original sample [55].\u003c/p\u003e\u003cp\u003e\u003cb\u003eBody experience\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDresden Body Image Inventory – 35 (DKB-35)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe DKB-35 [57] is a self-report measure to assess five dimensions of body experience. We prefer the term “body experience” over the term “body image”, for the dimensions cover a broder concept of how the body is precepted and psychially experienced rather than just “imaged”. The dimensions covered in the DKB-35 incule “vitality”, “self-acceptance”, “sexual fulfillment”, “self-aggrandisement” and “physical closeness”. Its 35 items are rated on a five-point Likert scale. Subscale-scores are computed by calculating the average score of all contributing items, respectively. With regard to the items´ polarity, higher scores indicate a more positive body experience. Reliability and validity of the DKB-35 was confirmed for both clinical and non-clinical samples [58, 59].\u003c/p\u003e\u003cp\u003e\u003cb\u003eGeneral Psychopathology\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient Health Questionnaire (PHQ)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParts of the PHQ[60, 61] were applied for an assessment of general psychopathology: the PHQ-9[62] was used to evaluate symptoms of depression, the PHQ-15[63] was administered to capture somatic symptoms and the GAD-7[64] was applied to assess symptoms of anxiety. The items of the PHQ-9 and the GAD-7 are answered on a four-point scale, ranging from 0 (“not at all”) to 3 (“nearly every day”), while the 15 somatic symptoms of the PHQ-15 are scored from 0 (“not bothered at all”) to 2 (“bothered a lot”). For both the PHQ-15 and the GAD-7, scores of 5, 10, 15 represent cutoff points for mild, moderate and severe symptom severity, respectively. For the PHQ-9, scores of 5, 10, 15, 20 indicate the presence of mild, moderate, moderately severe and severe depressive symptoms, respectively. The PHQ-9, the PHQ-15 and the GAD-7 were all validated and demonstrated an excellent internal consistency with a Cronbach´s α of .89, .80 and .92, respectively .\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eMeans, standard deviations and frequencies were calculated for the description of the sample. A T-standardization based on the representative sample of Kordy et al. (2001; [65]) was performed to provide easily interpretable scores (A T-value of 50 is equal to the mean of the representative sample, +/- 10 T-points equal +/1 one SD).\u003c/p\u003e\u003cp\u003eThe control participants were matched to the patient group by age and educational level (school education). Between-group differences in sociodemographic characteristics were analyzed using chi-square tests. In order to compare group means for age, BMI and mentalizing variables, we employed one- and two-sided t-Tests for independent samples after testing for variance homogeneity with Levene´s tests.\u003c/p\u003e\u003cp\u003ePearson correlation coefficients (r) and simple linear regression analyses were used to examine and quantify the association between numeric variables. Effect sizes of r = .10, r = .30 and r = .50 were considered small, medium and large in magnitude [66].\u003c/p\u003e\u003cp\u003eSince this study was partially exploratory and hypothesis generating, we did not adjust the alpha level (α = .05) for multiple testing. Instead, we considered effect sizes and the explained variance in the interpretation of the statistical results. Analyses were conducted in SAS-JMP, version 13.2.1.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 shows sociodemographic and clinical characteristics of the two study groups. Regarding age, the t-test for independent samples showed no significant difference between patients (M = 26.2 ± 10.1 years; range: 18–57 years) and healthy participants (M = 27.4 ± 9.9 years; range: 20–57 years; t(58) = .46; p = .644). School education was distributed equally. Chi-square tests revealed no significant between-group differences in school professional education (chi\u003csup\u003e2\u003c/sup\u003e = 6.9; df = 3; p = .076) or marital status (chi\u003csup\u003e2\u003c/sup\u003e = .41; df = 2 p = .812). As expected, the mean BMI was significantly lower in the patient group (M = 17.1 ± 2.2 kg/m\u003csup\u003e2\u003c/sup\u003e; range: 13.4–23.8 kg/m\u003csup\u003e2\u003c/sup\u003e) than in the HC group (M = 22.2 ± 3.1 kg/m\u003csup\u003e2\u003c/sup\u003e; range: 18.7–33.9 kg/m\u003csup\u003e2\u003c/sup\u003e; t = 7.33; df = 58; p \u0026lt; .0001).\u003c/p\u003e\n\u003cp\u003eClinical history and psychopathology of patients with AN are shown in Table 2. The patients were diagnosed with either AN restricting type (n = 14), AN binge-purge type 8 (n = 7) or atypical AN (n = 9). Out of the nine patients with atypical AN, six showed a restrictive symptomatology and three binge eating and / or purging behavior. Comorbid diagnoses in the patient group included affective disorders (n = 16; 53.3%), posttraumatic stress disorder (n = 6; 20%) and anxiety disorders (n = 2; 6.7%). The mean duration of illness was M = 6.4 years (SD = 5.9 years) and two third of the patients (n = 20) had previously received professional treatment for AN.\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003e\u003cstrong\u003eBetween-group differences in mentalizing\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDescriptively, the mean RF (RF-BRFI) was M = 3.63 (SD = .67; Range = 2 to 5) in the patient group and M = 4.13 (SD = .94; Range = 3 to 6) in the HC group. The distribution of the global ratings on the RF-Scale for both groups is depicted in Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThe self-reported mentalizing in the MZQ was M = 3.24 (SD = .71) for the patients and M = 1.73 (SD = .45) for the HC participants.\u003c/p\u003e\n\u003cp\u003eFor a comparison of group means of the RF-BRFI and of the self-reported mentalizing in the MZQ see Table 3. In line with the first hypotheses, results showed, that the mean RF-BRFI value was significantly lower for the patients than for the HC participants. Furthermore and in accordance with our second hypotheses, the between-group difference of the MZQ total score was also significant with patients demonstrating significantly worse self-reported mentalizing (i.e. higher scores in the MZQ) than the HC participants.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBetween-group differences in mentalizing\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHC\u003c/p\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e(N = 30)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAN\u003c/p\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e(N = 30)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRF-BRFI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.13 (.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.63 (.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMZQ-total score*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.73 (.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.24 (.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e− 9.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; .0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eNote. \u003cem\u003e* Missing data for 8 control participants: N(HC) = 22; Expecting mentalizing to be impaired in the patient sample, t-Tests were performed one-sided. M\u003c/em\u003e mean; \u003cem\u003eSD\u003c/em\u003e standard deviation; \u003cem\u003edf\u003c/em\u003e degrees of freedom; \u003cem\u003eHC\u003c/em\u003e healthy control; \u003cem\u003eAN\u003c/em\u003e anorexia nervosa; \u003cem\u003eN\u003c/em\u003e sample size; \u003cem\u003eRF\u003c/em\u003e Reflective Functioning; \u003cem\u003eBRFI\u003c/em\u003e Brief Reflective Functioning Interview; \u003cem\u003eMZQ\u003c/em\u003e Mentalization Questionnaire.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eWe additionally examined the relationship between the RF-BRFI and the MZQ total score by means of Pearson´s product-moment correlations. For the whole sample, a significant negative correlation with moderate effect size was found between the RF-BRFI and the MZQ total score indicating that higher expert-rated RF was associated with better self-reported mentalizing (r = − .38; p = .006). However, as visualized in Fig. 2, for both individual groups, no significant correlation was found between the two measures of mentalizing (r = .07 for the control group and r = − .14 for the patient group; both n.s.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation of mentalizing with ED symptoms and aspects of general psychopathology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor correlations between ED symptomatology (EDE-Q, EDI, BMI), aspects of general psychopathology (personality functioning, depression) as well as body experience and the two mentalizing measures (RF-BRFI and MZQ total score) see Table 4.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCorrelation between mentalizing and dimensions of psychopathology\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRF-BRFI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMZQ-total score\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEating disorder symptomatology\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eEDE-Q\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDE-Q – Total score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDE-Q – Restraint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDE-Q – Eating concern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDE-Q – Weight concern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .39 *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDE-Q – Shape concern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eEDI-2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Drive for thinness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Bulimia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Body dissatisfaction\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Ineffektiviness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Perfektionism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Interpersonal distrust\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Interceptive awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEDI-2 – Maturity fears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonality functioning\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOPD-SQS total score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepressive symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHQ-9\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBody experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDKB-35 – Vitality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDKB-35 – Self-acceptance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDKB-35 – Sexual fulfillment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDKB-35 – Self-aggrandisement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDKB-35 – Physical closeness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e− .54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eNote. Sample size (N) was N = 30 with the exceptions of the instances marked with `\u003csup\u003e1\u003c/sup\u003e´ where sample size was N = 29.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eRF\u003c/em\u003e Reflective Functioning; \u003cem\u003eBRFI\u003c/em\u003e Brief Reflective Funcitoning Interview; \u003cem\u003eMZQ\u003c/em\u003e Mentalization Questionnaire; \u003cem\u003eEDE-Q\u003c/em\u003e Eating Disorder Examination – Questionnaire; \u003cem\u003eEDI-2\u003c/em\u003e Eating Disorder Inventory – 2; \u003cem\u003eBMI\u003c/em\u003e Body-Mass-Index ; \u003cem\u003eOPD-SQS\u003c/em\u003e Operationalized Psychodynamic Diagnosis – Structure Questionnaire, Short Version; \u003cem\u003ePHQ\u003c/em\u003e Patient Health Questionnaire; \u003cem\u003eDKB-35\u003c/em\u003e Dresden Body Image Inventory – 35; \u003cem\u003e* p \u0026lt; .05; ** p \u0026lt; .01; *** p \u0026lt; .001.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegarding the RF-BRFI, a significant negative correlation was found only for the subscale “weight concerns” of the EDE-Q.\u003c/p\u003e\n\u003cp\u003eRegarding the association of the MZQ total score and the EDE-Q-variables, significant positive correlations with moderate to large effect sizes were found for the EDE-Q total score as well as for subscales “eating concerns”, “weight concerns” and “shape concerns”. Among the EDI-subscales, the subscales “ineffectiveness”, “interpersonal distrust”, “interceptive awareness” and “maturity fears” were significantly correlated with the MZQ total score. No significant association was found between both measures of mentalizing and the BMI.\u003c/p\u003e\n\u003cp\u003ePersonality functioning as measured with the OPD-SQS was significantly positively and with a large effect size correlated with the MZQ total score, indicating that a lower level of self-reported mentalizing was associated with more severe impairment in personality functioning. However, no significant correlation was found between the OPD-SQS and the RF-BRFI.\u003c/p\u003e\n\u003cp\u003eNeither expert-rated nor self-reported mentalizing was correlated with symptoms of depression as measured with the PHQ-9. Similarly, there was no significant correlation between expert-rated mentalizing (RF-BRFI) and either one of the DKB-35-subscales for the assessment of body experience. In contrast, self-reported mentalizing (MZQ total score) was negatively and with moderate to large effect sizes associated with different aspects of body experience as assessed with the DKB-35.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMentalizing in AN-subgroups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile there were no significant differences between the restrictive and the binge-purging subgroup in the RF-BRFI values (t(28) = .38; p = .707), patients with restrictive behavior (N = 20; M = 3.03; SD = .76) showed significantly better self-reported mentalizing (i.e. lower scores in the MZQ total score) than patients with binge-purge behavior (N = 10; M = 3.67; SD = .31; t(27.3) = 3.28; p = .003).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to examine the level of mentalizing abilities among patients with AN in comparison with matched healthy control participants using both an expert-rated and a self-reported measure for the assessment of RF. Additionally, the study focused on investigating the relation between mentalizing and various aspects of ED-related and general psychopathology.\u003c/p\u003e\u003cp\u003eThe matching procedure was fully successful concering age, school education and marital status. Given the same age distribution, the AN sample trended towards more ongoing professional education with less university degrees (p\u0026thinsp;=\u0026thinsp;.76). We attribute this trend to the interruptions and delays caused by the illness (e.g. inpatient treatments).\u003c/p\u003e\u003cp\u003eIn accordance with our hypothesis, RF was significantly lower among the patients than among the HC participants. This is in line with other studies, that also found lower RF levels in patients with AN compared to a healthy control group [23\u0026ndash;25]. However, the absolute difference in expert-rated RF (RF-BRFI) between the two groups was relatively small. On the one hand, the mean RF in the patient-group was well below a score of \u0026ldquo;5\u0026rdquo; which corresponds to the average RF-level in the general population [18], indicating that the patients did indeed, as expected, demonstrate difficulties recognizing and interpreting mental states. On the other hand, the deficits in their ability to mentalize were not quite as severe as results of other studies suggest [23\u0026ndash;25]. This could be partially attributed to the fact, that this study included a considerable number of outpatients while previous research mostly focused on inpatients with AN (e.g.[23\u0026ndash;25] ). However, the overall severity of ED-psychopathology in the present sample was still substantial. Another contributing factor could be a methodological one. While in previous studies, the scoring of patients\u0026acute; mentalizing ability on the RF-Scale was mostly based on transcripts of the AAI, we used the BRFI as an abbreviated version of it. However, the RF-scores obtained by using the AAI and those obtained by using the BRFI were shown to be highly correlated [47, 48]. Therefore, it seems unlikely that the use of the BRFI in the present study would have influenced the results in the direction of higher RF. Another relevant factor could be that the long duration of illness and the high number of previously received treatments which characterizes the patient sample of this study might have impeded and to some extent distorted the assessment of the patients\u0026acute; RF since it might have led to an increased occurrence of \u0026ldquo;pseudomentalizing\u0026rdquo;. Individuals who pseudomentalize may talk elaborately and at first glance in a mentalizing manner about mental states but their words are severed from their emotional experience and, thus, carry little true meaning [13, 14]. Pseudomentalizing can be difficult to differentiate from genuine mentalizing. Furthermore, it has previously been discussed as a challenge in the psychotherapeutic treatment of patients with AN and other EDs[10, 12] and has also empirically been shown in individuals with AN [67]. It may be possible that pseudomentalizing is more difficult to detect in the BRFI compared to the AAI due to its short and compact nature, which leaves less space to reflect on oneself and relationships.\u003c/p\u003e\u003cp\u003eAt the same time, the RF level in the control group (M\u0026thinsp;=\u0026thinsp;4.13) was surprisingly low. However, it still goes along with previous studies which also found a mean RF below 5 (which is generally considered the average rating in a healthy population [18]) in non-clinical samples (e.g. [25, 33] for a use of the AAI and [47, 48] for a use of the BRFI).\u003c/p\u003e\u003cp\u003eThe two study groups also differed significantly regarding self-assessed mentalizing (MZQ total score) with the higher scores in the patient group, indicating a lower RF level. Interestingly, the between-group differences in self-assessed mentalizing were much more pronounced than the differences in expert-rated mentalizing. Also, when compared with the MZQ total scores found in other mental disorders (e.g. spectrum of 2.6 to 3.4 in a study of Riedl et al. 2023 [68]), the mean score in the patient sample of this study (M\u0026thinsp;=\u0026thinsp;3.24) ranges at the upper end of the spectrum (indicating worse mentalizing abilities), while their expert rated-RF (M\u0026thinsp;=\u0026thinsp;3.63) lies in the mid-range when compared to RF scores in other diagnostic groups (e.g. range of 2.7 to 3.9 in a study of Fonagy et al. 1996 [69]). On the one hand, this might further validate the assumption of a slight distortion of the patients\u0026acute; actual RF-BRFI due to pseudomentalizing.\u003c/p\u003e\u003cp\u003eAnother possible explanation for the differences in RF-measures could be that even though both BRFI and MZQ tap into various dimensions of mentalizing [17] the MZQ is most commonly regarded as a measure which predominantly assesses self-focused mentalizing (e.g. [70, 71]). In patients with AN (and other ED) empirical evidence indicates that mentalizing with regard to the self might be particularly impaired [22, 25, 72]. These findings are also in line with the general assumption that EDs are best understood as self-disorders. Based on this, the particularly pronounced impairment in self-assessed mentalizing found in the patient sample of this study can be considered in accordance with previous research.\u003c/p\u003e\u003cp\u003eWe further examined the association of expert-rated and self-assessed mentalizing by means of a Pearson correlation analysis and found a significant correlation of the two measures for the whole sample, but not within the groups. This indicates that the association found for the RF-BRFI and the MZQ in the whole sample was actually due to the substantial between-group differences in both of the correlated variables. Therefore, our results do \u003cem\u003enot\u003c/em\u003e suggest that expert-rated and self-assessed mentalizing were correlated in the present sample.. The finding of the correlation for the whole sample is in accordance with a study of Andreas et al. (2022; [47]) who were able to demonstrate that participants with an above-average RF-level in an interview-based assessment (AAI and BRFI) also showed significantly better self-assessed mentalizing in the MZQ than participants who were assigned a below-average RF score in the expert-rating. However, they did not regard the clinical and the non-clinical group separately. Other studies that investigated the association of an expert-rated and a self-report instrument for parental mentalizing, offered mixed results regarding the correlation of the two measures [73, 74]. Taken together, it seems possible, that observer-rated and self-report measures for mentalizing in general as well as the BRFI and the MZQ in particular tap into slightly different aspects of the overarching construct of mentalizing. Thus, they might best be regarded complementary rather than interchangeable. Their combined use may contribute to a more comprehensive understanding of an individual\u0026acute;s capacity to mentalize, if it can be worked out what exactly they measure. At the same time, this implicates that research results on mentalizing might be difficult to compare or to merge if they are based on different measures, especially as long as it is not well-defined which measure captures which aspects of the overall construct.\u003c/p\u003e\u003cp\u003eNext, we examined the relation between mentalizing and ED symptoms and ED-related psychological traits, respectively. As expected, we found significant correlations of both mentalizing measures with various scales of the EDI and the EDE-Q. However, these correlations were much more numerous and larger in effect size for self-reported mentalizing than for the observer-rated RF-BRFI. This difference between the two measures of mentalizing is continued when looking at the additional, explorative analyses regarding the association of mentalizing and body experience: A more negative body experience was strongly and in several of its dimensions correlated with the self-assessment of mentalizing abilities, but not with the expert-rating on the RF-Scale.\u003c/p\u003e\u003cp\u003eThe overall weak, rather selective and therefore in total hardly convincing correlation of the RF-BRFI with ED symptomatology is in accordance with several previous studies that also found few or no indication of an association between expert-rated (global) RF and severity of ED symptoms (e.g. [33, 34]).\u003c/p\u003e\u003cp\u003eBased on the assumption, that the MZQ primarily captures self-focused mentalizing, its consistent and pronounced correlation with various aspects of both ED symptoms and ED-related psychological characteristics is also in line with previous research: Rothschild-Yakar et al. (2018; [72]) assessed self-focused mentalizing in patients with ED and healthy controls using both an RF-expert-rating as well as a self-report questionnaire for alexithymia as a proxy measure. While in the total sample, both measures of mentalizing the self were significantly and with moderate effect sizes correlated with ED-symptoms, the association was not or only marginally significant for mentalizing regarding others and general, expert-rated RF, respectively. Similar results were found in a later study [25]. Overall, these empirical findings suggest, that deficits in self-focused mentalizing might be of particular relevance to the severity of AN and other EDs. Furthermore, they align with the theoretical conceptualization of ED as self-disorders. Within the framework of the mentalizing model, it could be argued, that a particularly weak and incoherent sense of self and identity might involve a more pronounced impairment of the self-dimension of mentalizing and at the same time predispose to a greater severity of ED-symptoms and related psychological traits.\u003c/p\u003e\u003cp\u003eAnother aim of this study was to investigate the relation between mentalizing and personality functioning. While in accordance with our hypothesis, lower self-reported mentalizing abilities in the MZQ were significantly and with a large effect size correlated with more severe impairment in personality functioning (OPD-SQS), no such association was found with regard to the expert-rating of RF. The later finding is in contrast to a study by Zettl et al. (2020; [35]), who found the RF-BRFI and the OPD-SQS total score to be correlated, even though the effect size was small after controlling for symptom severity. In general, the conceptual overlap between mentalizing and personality functioning is well established. The correlation of both constructs was demonstrated in several studies [35\u0026ndash;38] and the findings in the present study are, with respect to the particular measures, the MZQ and OPD-SQS, also in accordance with previous research [36]. Interestingly, the strength of this association considerably surpasses the effect sizes found for other, interview-based measures of both constructs ([37][38]).\u003c/p\u003e\u003cp\u003eBased on previous research that indicated that the impairments in mentalizing abilities of patients with AN might be associated with their low bodyweight [11, 75] as well as the known impact of starvation on cognitive functions [76], we expected anassociation between the measures of mentalizing and the patients\u0026acute; BMI. However, we found no association between low bodyweight and mentalizing. Although this is in accordance with other studies [33, 77], it should be considered that our sample was not ideal for such an analysis: Due to the inclusion of outpatients and patients with atypical AN, the BMI of many patients was comparably high and it may be possible that malnutrition in our sample had no considerable impact on mentalizing.\u003c/p\u003e\u003cp\u003eFurthermore, we found no significant association of depressive symptoms with either of the mentalizing measures. For the RF-BRFI, this is in accordance with previous research: Several studies found no correlation between expert-rated RF and the severity of depressive symptomatology in samples of patients with depression [40, 78]. However, greater impairment in mentalizing as measured with the MZQ was quite consistently found to be associated with more severe depressive symptoms (e.g. [79, 80]). In our sample, a medium effect size of correlation between MZQ and PHQ-9 was found, even though it did not turn out to be significant which is possibly due to the small sample size. This again may indicate a difference within the construct of mentalizing measured with the BRFI and the MZQ as discussed above.\u003c/p\u003e\u003cp\u003eFinally, our explorative analysis yielded significantly lower self-reported mentalizing abilities (i.e. higher scores in the MZQ) among the patients with binge-purge behavior than among those with only restricting behavior. This is in line with previous research suggesting that patients with AN and other EDs might not be homogenous regarding their impairments in the ability to mentalize [30]. However, these subgroup-differences were only found for the MZQ but not the BRFI. At the same time, only the MZQ was strongly associated with the OPD-SQS, other than the BRFI. Given that there is some evidence that personality functioning might also be more impaired in patients with the binge-purging subtype of AN than in those with the restricting subtype [81], these results might also be regarded as a correlate of a greater personality dysfunction in patients with binge-purge AN.\u003c/p\u003e\u003cp\u003eThere are several important limitations to the present study. First, the sample size was rather small and, thus, the statistical power was limited. Especially the results of the explorative analyses should be interpreted with caution. Furthermore, since this study only included adult women, the findings cannot be generalized to other patient groups such as male, transgender or adolescent individuals. Future studies using larger and more diverse samples might allow for a more differentiated assessment of mentalizing among subgroups of patients with AN.\u003c/p\u003e\u003cp\u003eSecondly, the majority of patients included in the present study had already received professional treatment for their AN in the past and have been suffering from the disorder for many years which might be a complicating factor to the interview-based assessment of RF, by predisponing for \u0026ldquo;pseudomentalization\u0026rdquo;. Future studies might therefore need to employ different recruitment strategies to allow for the assessment of mentalizing abilities also in untreated patients shortly after the onset of the illness.\u003c/p\u003e\u003cp\u003eThird, the evaluation of a possible association between impairments in mentalizing and low bodyweight was limited due to the specific composition of the present sample. Larger studies including a sufficient number of patients in all BMI categories are required, to evaluate the effect of starvation on mentalizing.\u003c/p\u003e\u003cp\u003eFinally, another important limitation lies in the study\u0026acute;s cross-sectional design. Both mentalizing abilities as well as symptom severity were assessed only at one point in time. Therefore, we could not say whether the deficits found in the patients\u0026acute; capacity to mentalize represent a state or rather a trait-like characteristic. Future studies with a longitudinal design are necessary to show whether RF changes over time, with weight gain and during the course of a treatment as well as if improvement in RF relates to a reduction of symptom severity and an overall better outcome. To address these important questions, prospective studies are needed that involve a repeated assessment of mentalizing abilities during the therapy process as well as after recovery. Since the iterated use of the same interview protocol might be neither feasible nor reasonable to monitor changes in RF over time, different assessment methods such as the evaluation of mentalizing abilities during psychotherapeutic sessions (In-session RF) might be useful in this context [82].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePatients with AN showed a lower capacity to mentalize compared to healthy individuals. An expert rating and a self report measure of RF did correlate in the whole sample but not within the subgroups of patients and controls. Aditionally, they showed different profiles of correlation to aspects of ED-related and general psychopathology. In conclusion, it seems likely, that observer-rated and self-report measures for RF cover partially different aspects of the mentalizing construct and should be regarded complementary rather than interchangable.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAN: anorexia nervosa; BMI: Body Mass Index; BN: bulimia nervosa; BRFI: Brief Reflective Functioning Interview; HC: healthy control; ED: eating disorder; EDE: Eating Disorder Inventory; EDE-Q: Eating Disorder Inventory \u0026ndash; Questionnaire; EDI: Eating Disorder Inventory; MZQ: Mentalization Questionnaire; PHQ: Patient Health Questionnaire; RF: Reflective Functioning\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the local ethics committee of the University Hospital of Freiburg (No 22-1096 and No 22-1096_1).\u003cbr\u003eSubjects gave their written informed consent after receiving a comprehensive description of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by the Heidehof Stiftung GmbH (No. 59055.04.1/1.22).\u003c/p\u003e\n\u003cp\u003eThe Heidehof Stiftung GmbH had no role in the design and conduct of the study, collection of data, data management, data analysis or interpretation of results. She played no role in preparation, revision and the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026acute; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLK conducted most of the interviews and was responsible for data analysis. She wrote the first draft of the manuscript. IL supervised the project, she rated most of the BRFI-interviews. AZ designed the study and was the primary investigator, she also rated BRFI-interviews. AME conducted interviews and helped with data management. AH supervised the statistical analyses. SA made the German version of the BRFI available, LH made and the gold standard available. All authors critically read and commented on the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patients that were involved in the study and Elvira Bozkaya, who helped with data monitoring and Denis Bozkaya who took part in the transcription of the audios. We also thank Pauline Leonie Herrmann for her contributions the BRFI-Gold-Standard. Furthermore, we thank the Heidehofstiftung for their financial support.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13:153\u0026ndash;60. doi:10.1002/wps.20128.\u003c/li\u003e\n\u003cli\u003eWestmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. 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M\u0026uuml;nster: Verlag f\u0026uuml;r Psychotherapie; 2006.\u003c/li\u003e\n\u003cli\u003eHilbert A, Tuschen-Caffier B, Karwautz A, Niederhofer H, Munsch S. Eating Disorder Examination-Questionnaire: Evaluation der deutschsprachigen \u0026Uuml;bersetzung. Diagnostica. 2007;53:144\u0026ndash;54. doi:10.1026/0012-1924.53.3.144.\u003c/li\u003e\n\u003cli\u003eBauer S, Winn S, Schmidt U, Kordy H. Construction, scoring and validation of the Short Evaluation of Eating Disorders (SEED). Eur Eat Disord Rev. 2005;13:191\u0026ndash;200. doi:10.1002/erv.637.\u003c/li\u003e\n\u003cli\u003eEhrenthal JC, Dinger U, Schauenburg H, Horsch L, Dahlbender RW, Gierk B. Entwicklung einer Zw\u0026ouml;lf-Item-Version des OPD-Strukturfragebogens (OPD-SFK). Z Psychosom Med Psychother. 2015;61:262\u0026ndash;74. doi:10.13109/zptm.2015.61.3.262.\u003c/li\u003e\n\u003cli\u003eEhrenthal JC, Kruse J, Schmalbach B, Dinger U, Werner S, Schauenburg H, et al. Measuring personality functioning with the 12-item version of the OPD-Structure Questionnaire (OPD-SQS): reliability, factor structure, validity, and measurement invariance in the general population. Front Psychol. 2023;14:1248992. doi:10.3389/fpsyg.2023.1248992.\u003c/li\u003e\n\u003cli\u003eThiel P. Der Dresdner K\u0026ouml;rperbildfragebogen: Entwicklung und Validierung eines mehrdimensionalen Fragebogens. [Dissertationsschrift]: Medizinische Fakult\u0026auml;t der Technischen Universit\u0026auml;t Dresden; 2007.\u003c/li\u003e\n\u003cli\u003eP\u0026ouml;hlmann K, Roth M, Br\u0026auml;hler E, Joraschky P. Der Dresdner K\u0026ouml;rperbildfragebogen (DKB-35): Validierung auf der Basis einer klinischen Stichprobe. Psychotherapie. 2014;64:93\u0026ndash;100. doi:10.1055/s-0033-1351276.\u003c/li\u003e\n\u003cli\u003eMatthes J, Franke GH, J\u0026auml;ger S. Psychometrische Pr\u0026uuml;fung des Dresdner K\u0026ouml;rperbildfragebogens (DKB-35) in einer nicht-klinischen Stichprobe. 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Psychopathology. 2022;55:235\u0026ndash;43. doi:10.1159/000522309.\u003c/li\u003e\n\u003cli\u003eSchwarzer N-H, Nolte T, Fonagy P, Gingelmaier S. Mentalizing and emotion regulation: Evidence from a nonclinical sample. Int Forum Psychoanal. 2021;30:34\u0026ndash;45. doi:10.1080/0803706X.2021.1873418.\u003c/li\u003e\n\u003cli\u003eRothschild-Yakar L, Peled M, Enoch-Levy A, Gur E, Stein D. \u0026quot;Eating Me Up from Inside\u0026quot;: A Pilot Study of Mentalization of Self and Others and Emotion Regulation Strategies among Young Women with Eating Disorders. Isr J Psychiatry. 2018;55:35-43. PMID: 29916405.\u003c/li\u003e\n\u003cli\u003eAnis L, Perez G, Benzies KM, Ewashen C, Hart M, Letourneau N. Convergent Validity of Three Measures of Reflective Function: Parent Development Interview, Parental Reflective Function Questionnaire, and Reflective Function Questionnaire. Front Psychol. 2020;11:574719. doi:10.3389/fpsyg.2020.574719.\u003c/li\u003e\n\u003cli\u003eCarlone C, Milan S, Decoste C, Borelli JL, McMahon TJ, Suchman NE. Self-report measure of parental reflective functioning: A study of reliability and validity across three samples of varying clinical risk. Infant Ment Health J. 2023;44:240\u0026ndash;54. doi:10.1002/imhj.22046.\u003c/li\u003e\n\u003cli\u003eZeeck A, Taubner S, Gablonski TC, Lau I, Zipfel S, Herzog W, et al. In-Session-Reflective-Functioning in Anorexia Nervosa: An Analysis of Psychotherapeutic Sessions of the ANTOP Study. Front Psychiatry 2022. doi:10.3389/fpsyt.2022.814441.\u003c/li\u003e\n\u003cli\u003eKeys A, Brozek J, Henschel A, Mickelsen O, Taylor H. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.\u003c/li\u003e\n\u003cli\u003eZeeck A, Lau I, Endorf K, Schaefer L, Euler S, Lahmann C, Hartmann A. Mentalizing in psychotherapeutic processes of patients with eating disorders. Front Psychiatry. 2024;15:1367863. doi:10.3389/fpsyt.2024.1367863.\u003c/li\u003e\n\u003cli\u003eTaubner S, Kessler H, Buchheim A, K\u0026auml;chele H, Staun L. The role of mentalization in the psychoanalytic treatment of chronic depression. Psychiatry. 2011;74:49\u0026ndash;57. doi:10.1521/psyc.2011.74.1.49.\u003c/li\u003e\n\u003cli\u003eNonweiler J, Doval E, Barrantes-Vidal N, Ballesp\u0026iacute; S. Spanish Adaptation of the Mentalization Questionnaire (MZQ) in Community Adolescents and Adults. Psicothema. 2024;36:174\u0026ndash;83. doi:10.7334/psicothema2023.47.\u003c/li\u003e\n\u003cli\u003eFrank J, Kirchner E, Padberg F, Huber D. Psychische Struktur und Mentalisierungsf\u0026auml;higkeit bei station\u0026auml;ren depressiven Patienten im Langzeitverlauf. Z Psychosom Med Psychother. 2021;67:256\u0026ndash;70. doi:10.13109/zptm.2021.67.oa6.\u003c/li\u003e\n \u003cli class=\"CitaviBibliographyEntry\"\u003e\u003cspan lang=\"DE\"\u003e81. Rohde J, Hofmann T, Voigt B, Rose M, Obbarius A. Measurement of Personality Structure by the OPD Structure Questionnaire Can Help to Discriminate Between Subtypes of Eating-Disorders. Front Psychol. 2019;10:2326. doi:10.3389/fpsyg.2019.02326.\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eTalia A, Miller-Bottome M, Katznelson H, Pedersen SH, Steele H, Schr\u0026ouml;der P, et al. Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process. Psychother Res. 2019;29:652\u0026ndash;65. doi:10.1080/10503307.2017.1417651.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1 and 2","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"anorexia nervosa, reflective functioning, mentalizing, psychopathology, BRFI","lastPublishedDoi":"10.21203/rs.3.rs-7115479/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7115479/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003ePrevious studies found an impairment in the capacity to mentalize (operationalized as \"\u003cem\u003ereflective functioning\u003c/em\u003e\", RF) in patients with anorexia nervosa (AN), but only few studies used a validated interview procedure. The aim of this study was an assessment of RF in patients with anorexia nervosa in comparison to healthy subjects, using both an expert-rated measure as well as a self-report measure. Further, the study aimed to explore the relationship between RF and various aspects of psychopathology.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003e30 patients with AN and 30 matched healthy control subjects were assessed and compared regarding their level of RF using the Brief Reflective Functioning Interview (BRFI) and the Mentalization Questionnaire (MZQ). The correlations between RF values and eating disorder psychopathology (BMI, EDI, EDE-Q), body experience (DKB-35), general psychopathology (PHQ-9, PHQ-15, GAD-7) and impairment in personality functioning (OPD-SQS) were explored using simple linear regression analyses.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eRegarding mentalizing on the RF-Scale (RF-BRFI), RF was M\u0026thinsp;=\u0026thinsp;3.63 (SD\u0026thinsp;=\u0026thinsp;.67) in the patient group and M\u0026thinsp;=\u0026thinsp;4.13 (SD\u0026thinsp;=\u0026thinsp;.94) in the healthy controls (HC). It showed to be significantly lower for patients with AN than for HCs (t(52.5)\u0026thinsp;=\u0026thinsp;2.38; p\u0026thinsp;=\u0026thinsp;.011). Mentalizing in the MZQ was M\u0026thinsp;=\u0026thinsp;3.24 (SD\u0026thinsp;=\u0026thinsp;.71), demonstrating significantly worse self-reported mentalizing for the patients (t(49.1)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;9.38; p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) compared to HCs (M\u0026thinsp;=\u0026thinsp;1.73; SD\u0026thinsp;=\u0026thinsp;.45). Higher expert-rated RF was associated with better self-reported mentalizing (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.38; p\u0026thinsp;=\u0026thinsp;.006), but no significant correlation for the individual groups of patients ond controls could be found. RF as measured with the BRFI was only correlated to the EDI-subscale \u0026ldquo;weight concern\u0026rdquo;, while RF values of the MZQ were correlated with various aspects of psychopathology except depressive symptoms and BMI.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eThe study could replicate the finding that patients with AN show impaired mentalizing. However, it seems likely, that observer-rated and self-report measures for mentalizing cover different aspects of the construct of mentalizing and should be regarded as complementary rather than interchangable. This may also explain different associations with features of psychopathology.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eDRKS00031108\u003c/p\u003e","manuscriptTitle":"Reflective functioning in anorexia nervosa: Does it differ from healthy controls and how is its relation to psychopathology?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 06:15:06","doi":"10.21203/rs.3.rs-7115479/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-25T09:19:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T11:08:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337059357359881232642590457901581723222","date":"2025-08-01T11:08:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-29T08:49:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25128835992112421837607615206660493385","date":"2025-07-23T03:06:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-16T13:14:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-15T14:04:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-15T14:02:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2025-07-13T21:28:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c30c202a-012c-432f-9de3-9c4ba78b1cf3","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T15:58:33+00:00","versionOfRecord":{"articleIdentity":"rs-7115479","link":"https://doi.org/10.1186/s40337-025-01465-x","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2025-12-01 15:56:49","publishedOnDateReadable":"December 1st, 2025"},"versionCreatedAt":"2025-07-23 06:15:06","video":"","vorDoi":"10.1186/s40337-025-01465-x","vorDoiUrl":"https://doi.org/10.1186/s40337-025-01465-x","workflowStages":[]},"version":"v1","identity":"rs-7115479","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7115479","identity":"rs-7115479","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}