An attachment perspective on the risk for psychosis: Clinical correlates and the predictive value of attachment patterns and mentalization

Abstract

Background: In a longitudinal design, the present study examined: (a) the nature of attachment patterns and reflective functioning (RF) in individuals at ultra-high risk for psychosis (UHR); (b) the association between RF subclinical psychotic symptoms; and (c) the psychosis-predictive value of attachment patterns, RF, and the interaction between these factors. Method: The sample comprised 57 UHR subjects and 53 clinical controls (non-UHR). UHR subjects were followed over a mean period of 14 months (SD = 2.7; range 11-19), during which time 11.5% developed psychosis. Attachment patterns and RF were measured. Hierarchical logistic regression was used to examine the predictive value of variables in the transition to psychosis. Results: At baseline, significant differences were found between groups in secure attachment patterns and RF. RF was negatively associated with the attenuated psychotic symptoms described by the Unusual Thought Content/Delusional Ideas, Suspiciousness/Persecutory Ideas, and Disorganized Communication subscales. Moreover, poor mentalization was related to an increased likelihood of developing a psychotic disorder (OR = .427, 95% CI [.188, .970]); conversely, no predictive effects of the attachment variables and their interaction with RF on the transition to psychosis were found. Notably, an optimal threshold value of RF = 1.25 was found to distinguish UHR subjects who made the transition to psychosis from those who did not develop this pathology. Conclusion: The results suggest that aberrant mentalizing patterns can predict the development of psychosis. Clinical implications of these results for the development of preventive treatments are discussed.

Construct Validity of the Mentalization Scale (MentS) Within a Mixed Psychiatric Sample

“…Nonetheless, the economic assessment of mentalizing could be greatly utilized in specific clinical contexts like, for instance, in specialized departments for patients at ultra-high risk for developing a psychosis (UHR patients). In a recent longitudinal study, Boldrini et al ( 2020 ) could highlight the predictive value of RF (measured with the RFS) in a sample of UHR patients for developing psychosis. Prediction models, in that case, are of great importance for early interventions and for influencing the course of illness.…”

Personality Traits and Disorders in Adolescents at Clinical High Risk for Psychosis: Toward a Clinically Meaningful Diagnosis

“…To date, mentalizing difficulties in CHR individuals have been primarily investigated in terms of neurocognition, using theory of mind (ToM; i.e., the ability to infer the mental states of others) tasks to demonstrate significant moderate deficits in affect recognition and discrimination of faces, voices, and verbal ToM (64). Moreover, recent findings have also shown that impaired mentalization [as assessed by the Reflective Functioning Scale (RFS) (65)-a quantified index of mentalization ability that is applied to clinical interview transcripts] is more severe in CHR individuals compared to help-seeking clinical controls, strongly associated with APS (SIPS scales), and a significant predictor of the transition to psychosis (66).…”

Expressed emotion and reflective functioning across the schizotypy spectrum: Developmental experiential factors.

“…Another study longitudinally examined individuals at very high risk for psychosis, and whether or not they had transitioned to having their first psychotic episode. Poor mentalization, measured by the Reflective Functioning Scale (RFS), was related to a higher likelihood of having a psychotic episode and developing a psychotic disorder (Boldrini et al, 2020). Using the RFS allows for a narrative-based assessment of mentalization, which lends itself to use in clinical settings while also measuring mentalization in a multidimensional way.…”