Mentalization Profiles of Adolescents with Internalizing Disorders: Domain-specific Differences Compared to Typically Developing Adolescents

Abstract

Background:

Adolescence is a sensitive period for mentalization development and also marks the onset and exacerbation of psychiatric conditions. Mentalization impairments are transdiagnostic, but the literature primarily focuses on younger children and adults in Western cultures, with limited exploration in adolescents. This study aimed to explore the differences between mentalization profiles of adolescents with internalizing disorders (AID) and typically developing adolescents (TDA) in India.

Methods:

The sample included 166 adolescents (aged 12–17), divided into the AID group (n = 83) diagnosed with either depression, anxiety, or somatoform/dissociative disorders, and the TDA group (n = 83) without any psychiatric illness, group-matched on age, gender, and years of formal education. The Mentalization Scale (MentS), the Reflective Functioning Questionnaire for Youth (RFQ-Y), and the Strengths and Difficulties Questionnaire (SDQ) were administered to both groups. In contrast, the Depression Anxiety and Stress Scale for Youth was administered only to the AID group to assess symptom severity.

Results:

Mann–Whitney U tests revealed the AID group had significantly lower “self-mentalization” (r_rb = 0.177) and “Overall mentalization Ability” (r_rb = 0.311). No significant differences were found in “other-mentalization” and “motivation to Mentalize.” Spearman’s Rank-Order Correlation revealed that “Overall mentalization ability” was significantly negatively correlated with internalizing and externalizing problems on the SDQ, whereas “motivation to Mentalize” was significantly positively correlated with emotional symptoms on the SDQ.

Conclusion:

This study highlights differential impairments in mentalization domains between AID and TDA, providing novel insights into mentalization profiles of adolescents through a developmental lens with theoretical and clinical implications in addressing this transdiagnostic vulnerability.

Keywords

Adolescent reflective functioning internalizing disorders self-mentalization other-mentalization motivation to mentalize

Key Messages:

Question: What are the domain-specific differences in the mentalization profiles of adolescents with internalizing disorders (AID) compared to typically developing adolescents (TDA) aged 12–17 years?

Findings: Self-mentalization and overall mentalizing ability were lower in AID compared to TDA. Overall, mentalization negatively correlated with internalizing and externalizing problems, while motivation to mentalize was positively associated with emotional symptoms.

Meaning: The article reveals mentalization profile differences between AID and TDA, connecting them to adolescent strengths and difficulties, with important implications for theory, research, and clinical practice.

Mentalization, operationalized as reflective functioning (RF), is defined as perceiving and understanding behavior in terms of intentional mental states.¹ It is a complex ability that comprises domains, namely the self versus other domains (elaborates on “who” is being mentalized), cognitive versus affective domains (elaborates on “what” is being mentalized, i.e., thoughts or emotions), internally-focused versus externally-focused domains (elaborates on “which” kind of cues are being used to mentalize) and automatic/implicit versus controlled/explicit domains (elaborates on “how” one is mentalizing).¹ Mentalization impairments are considered transdiagnostic, with each disorder showing distinct mentalizing profiles (i.e., having different combinations of predominant mentalizing domains), making it essential to study in the psychiatric setting.²

Mentalization is also continuously developing with adolescence serving as a sensitive period for its development, owing to several unique neurobiological and psychosocial changes.^2–4 Adolescence is accompanied by uneven cognitive development in the frontolimbic system, which is associated with an enhanced capacity for perspective-taking.^3,4 This, along with the increased value placed on peers, is associated with increased other-focused mentalization. However, underdeveloped prefrontal cortex function can impede the regulation of these cognitive capacities, increasing the risk of mentalizing failures, particularly under stress.⁴ Studies support this, showing that adolescent mentalization is more vulnerable to impairments than that of adults, making it essential to study in different developmental stages.⁵

Along with being a sensitive period for the mentalization development, the onset of adolescence also has a significant role in the emergence, organization, or exacerbation of clinical disorders, especially internalizing disorders.^3,6 Internalizing disorders, which include symptoms that are directed inwards and/or distress that is felt internally/privately, like in disorders of depression, anxiety, and somatoform/dissociative disorders,⁷ are highly prevalent among adolescents. The lifetime prevalence for anxiety disorders in adolescence is 31.9%, whereas that of major depressive disorder is 11.7%–20.4%.^8,9 In the Indian context, the National Mental Health Survey (NMHS-2015–2016) reported a current prevalence of 2.6% for depressive disorders and 3.6% for anxiety disorders for adolescents¹⁰ with a recent study found a much higher prevalence of 13% for anxiety disorders and 25% for depression.¹¹ Somatoform symptoms and disorders show prevalence rates of 13%–15% in adolescents globally¹² with 0.9% in India for children and adolescents.¹³ Additionally, in Indian psychiatric settings, dissociative and conversion disorders show high prevalence rates ranging from 12% to 31% in children and adolescents.¹⁴

Existing literature on mentalization impairments in internalizing disorders shows mixed findings.^5,15–18 Additionally, few studies globally have explored RF in adolescents with internalizing disorders (AID) compared with typically developing adolescents (TDA). To the best of our knowledge, no such study has been published in India, making the present study a novel contribution.

Rationale for the Study

Despite the transdiagnostic implications of mentalization, adolescence is a sensitive period for its development, as well as an essential period for the onset and exacerbation of several psychiatric disorders.^3,6 There is minimal literature that has explored mentalization in adolescents with clinical conditions. Most studies have only focused on young children or adults with personality vulnerabilities.^19,20 Additionally, the existing limited studies have been in the Western setting, with several gaps such as a lack of extensive exploration of the self-domain of mentalization in AID, as well as a lack of matched control groups and/or clinically diagnosed adolescents when exploring mentalization differences.

Further, considering the socio-cultural differences between the West and Southeast Asia (characterized by more diffuse boundaries in families, overinvolvement from parents, and overall different family and societal structures).^21,22 There can be unique manifestations of adolescent mentalization in a collectivistic community like India, warranting separate research considering its implications for planning culturally informed interventions.

Aim

The current study aimed to examine differences in the Mentalizing Profiles of AID compared with TDA. We hypothesized that there would be significant differences in the mentalization profiles of AID compared with TDA.

Methods

Ethical Considerations

Ethical approval was obtained from the Institutional Ethics Committee. The parents of all participants provided written informed consent, and all participants provided written informed assent to participate in the study and to allow the use of data collected for publication. If any participant required further consultation/intervention, appropriate referrals were provided after discussion with the adolescent and parents.

Study Design and Sample

The study employed a two-group comparative design, with two groups: AID and TDA. Data collection occurred from February 2024 to October 2025.

The required sample size was calculated using G*Power based on findings from a similar prior study.¹⁶ The effect size was calculated as 0.53.¹⁶ Applying the Bonferroni correction with a power of 80%, the required sample size was at least 79 adolescents per group. The current study’s sample comprised 166 adolescents aged 12–17 years, with n = 83 in each of the AID and TDA groups. Purposive sampling was used for the AID group, and convenience sampling was used for the TDA group (Figure 1).

Figure 1.

^aAID = Adolescents with internalizing disorders; ^bTDA = Typically developing adolescents.

Figure 1 describes the recruitment process for both groups.

The inclusion criteria for the AID group were that adolescents were aged between 12 and 17 years, currently diagnosed with an internalizing disorder (i.e., depressive episode, recurrent depressive disorder, dysthymia, mixed anxiety and depressive disorder, phobic anxiety disorders, panic disorder, generalized anxiety disorder, separation anxiety disorder, dissociative disorders and/or somatoform disorders) by a psychiatrist as per ICD-10²³ currently living with both parents for most of the past 2 years and studying at an English-medium school. Adolescents currently in remission, those with any other comorbid Axis 1 disorders, with psychotic symptoms, head injury, uncontrolled epilepsy, or any other neurosurgical conditions that resulted in disability were excluded. Further, those with vision, hearing, or speech disability, with subnormal intelligence (determined through clinical observation and parent report), and those who received more than five sessions of structured psychotherapy in the last 6 months were excluded.

For the TDA group, adolescents aged 12–17 years who have lived with parents for the majority of the past 2 years, are currently studying at an English-medium school or college, and are of all genders were included. Those diagnosed with any psychiatric or neurological condition that affected participation in the study, adolescents with any vision, hearing, or speech disability, head injury, uncontrolled epilepsy, or any other neurosurgical conditions that resulted in disability, and subnormal intelligence (determined through clinical observation and parent report) were excluded.

The AID group was recruited from a tertiary mental health hospital in both inpatient and outpatient settings. In contrast, the TDA group was recruited from the community, including a pre-university college.

Both groups were matched on age, gender, and academic grade levels.

Tools

The following tools were employed in the current study:

Reflective Functioning Questionnaire for Youth²⁴

The Reflective Functioning Questionnaire for Youth (RFQ-Y) is a 46-item self-report measure designed initially to assess RF in adolescents aged 12–17 years. It is adapted from the adult measure, with the wording being more developmentally appropriate. The RFQ-Y has demonstrated good psychometric properties, including criterion validity, internal consistency (0.71), and convergent and construct validity.²⁵ RFQ-Y has two scales that differ only in the scoring method. Scale A uses a median scale, with the optimal RF score set at the midpoint (six answer options: 2–4–6–6–4–2; selecting the middle option yields a higher score). Scale B consists of 23 Likert-type items (each item score ranging from 1 to 6), where higher scores indicate higher levels of RF. Scale B was later revised to include five items (RFQ-5).²⁶ Hence, for the current study, the 28-item version (23 items from Scale A and five items from Scale B) was used to reduce the time required to complete the questionnaires. The total score is computed by summing the average scores for Scale A and Scale B, with a higher total indicating a more optimal RF.

The Mentalization Scale²⁷

The Mentalization Scale (MentS) consists of 28 self-report items with Likert-type rating (1–5) which provide scores over three domains, that is, self-mentalization (8 items; score ranges from 8 to 40), other-mentalization (10 items; score ranges from 10 to 50), and motivation to mentalize (10 items; score ranges from 10 to 50), with a higher score representing a higher self-focused mentalization, other-focused mentalization and motivation to mentalize, respectively. It demonstrates good construct validity and internal consistency, with Cronbach’s alpha ranging from 0.75 to 0.84.^27,28

Depression Anxiety Stress Scales–Youth Version²⁹

The Depression Anxiety Stress Scales–Youth version (DASS-Y) is a 21-item self-report scale that comprehensively assesses negative affect in children and adolescents. It yields scores across three domains: Depression, Anxiety, and Stress. Each domain has a score ranging from 0 to 21, and the total score ranges from 0 to 63. A higher score indicates a higher severity of the difficulties. The three-factor model has shown a good fit. DASS-Y has good psychometric properties that suggest its reliability and validity in measuring depression, anxiety, and stress symptoms in children and adolescents.²⁹

Strengths and Difficulties Questionnaire³⁰

The Strengths and Difficulties Questionnaire (SDQ) is a 25-item questionnaire that assesses children aged 3–16 years and can also be used with older adolescents across five scales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. It can be completed by parents, teachers, or the youth. The scores on each scale range from 0 to 10, with higher scores indicating greater presence of those strengths/difficulties. The total difficulties score can be calculated by adding the scores on the domains of emotional symptoms, conduct problems, hyperactivity/inattention, and peer relationships, with a range of 0–40. It also yields a higher-order internalizing problems domain, obtained by summing scores on the emotional symptoms and peer problems scales, and an externalizing problems domain, obtained by summing scores on the conduct problems and hyperactivity subscales. The SDQ youth self-report was used in the present study. It has satisfactory internal consistency (Cronbach α: 0.73) and test-retest reliability after 4–6 months (mean: 0.62).

The STROBE reporting checklist for cross-sectional studies was used to prepare the manuscript (attached as Supplementary Online Material).

Statistical Analysis

The data was analyzed using the Statistical Package for Social Sciences (version 22)³¹ and Jamovi software.³² Descriptive statistics and the Shapiro-Wilk test of normality were conducted. Spearman’s rank-order correlation and Mann–Whitney U tests were used for inferential statistics. There was no missing data.

Results

The mean age in the AID and TDA groups was the same (15.4 years), with a slight variation in the SD (1.57 years for the AID group and 1.6 years for the TDA group). The median grade level for both groups was 10th grade, with mean years of education being 9.28 ± 1.88 for the AID group and 9.52 ± 1.65 for the TDA group. More participants in the AID group had completed 10th grade (25.3%), whereas most participants in the TDA group had completed 11th grade (36.1%). The Mann–Whitney U tests revealed no significant differences between the two groups in age (Statistic = 3433, p = .971) or grade level (Statistic = 3156, p = .341).

Both groups had a majority of females (n = 54, 65% in the AID group; and n = 52, 63% in the TDA group). This is in accordance with the higher prevalence rates of internalizing disorders seen among females.³³ In terms of syllabus of education, the more adolescents were from the CBSE syllabus in both the group (n = 46, 55% in the AID group; and n = 38, 46% in the TDA group), followed by the State syllabus (n = 25, 30% in the AID group; and n = 30, 36% in the TDA group), ICSE syllabus (n = 9, 11% in the AID group; and n = 9, 11% in the TDA group) and the least being from other syllabi like the IGCSE and IB curricula (n = 3, 4% in the AID group; and n = 6, 7% in the TDA group). Chi-square tests of independence showed no significant differences in gender distribution (χ² = 0.104, p = .747) or educational syllabus (χ² = 2.22, p = .529) between the two groups.

The clinical diagnosis of the AID group is summarized in Table 1

Table 1.

Diagnostic Categories for the Adolescents in the Adolescents with Internalizing Disorder (AID) Group (n = 83).

Diagnostic Category	Counts	% of Total
Depressive disorder	26	31.3
Anxiety disorder	14	16.9
Somatoform/dissociative disorder	13	15.7
Depressive disorder, somatoform/dissociative disorder	8	9.6
Depressive disorder, anxiety disorder	8	9.6
Somatoform/dissociative disorder, anxiety disorder	7	8.4
Mixed depressive and anxiety disorder	4	4.8
Depressive disorder, dissociative disorder, anxiety disorder	3	3.6

As seen in Table 1, the maximum percentage of adolescents were diagnosed with depressive disorders (31.3%), followed by anxiety disorders (16.9%) and then somatoform/dissociative disorders (15.7%). About 34% of the adolescents had one or more comorbidities, with the least number of participants having all three comorbidities of depressive, anxiety and somatoform/dissociative disorders (3.6%).

The DASS-Y was also administered with the AID group to understand the symptom severity. The descriptives of the scores on DASS-Y are summarized in Table 2.

Table 2.

Descriptive Scores on the Depression Anxiety Stress Scale-youth Among the Adolescents with Internalizing Disorders Group (n = 83).

	Depression Subscale	Anxiety Subscale	Stress Subscale	Total Score
Mean	12.4	11.6	12.9	36.9
Median	14.0	13.0	13.0	39.0
Standard deviation	6.36	6.64	5.70	16.6
Inter quartile range	11.0	11.5	7.50	27.0

As seen in Table 2, the mean scores for depression were 12.4 ± 6.36 indicative of moderate severity of depression (scores between 9 and 13); for anxiety were 11.6 ± 6.64 indicative of moderate levels of anxiety (scores between 8 and 12); for stress were 12.9 ± 5.7 indicative of mild levels of stress (scores between 12 and 13); and total score were 36.9 ± 16.6 indicative of moderate level of difficulties (scores between 30 and 39).

Following the descriptives, the Shapiro-Wilk test of normality was conducted for the subdomains of the SDQ, MentS, and RFQ-Y scores. All variables except the total difficulties score in SDQ for the AID group were not normally distributed (p < .05). Most variables of mentalization were normally distributed (p > .05) except for the other-mentalization subdomain in the TDA group and the RFQ-Y score in the AID group. Since a few variables were not normally distributed, non-parametric tests were used to analyze the data.

Table 3 summarizes the results of the Mann–Whitney U tests conducted on the subdomains of MentS and the RFQ-Y score.

Table 3.

Mann–Whitney U Tests Were Used to Compare Subdomain Scores on the Mentalization Scale (MentS) and the Reflective Functioning Questionnaire for Youth (RFQ-Y) Between the AID and TDA Groups.

Mentalization Variable		Mean	Median	Statistic	p	Rank Biserial Effect Size
Self-mentalization	TDA^a	22.7 ± 6.4	23	2835	.049	0.1771
Self-mentalization	AID^b	20.8 ± 6.5	21
Other-mentalization	TDA	37.4 ± 6.0	37	3116	.288	0.0955
Other-mentalization	AID	35.8 ± 7.4	37
Motivation to mentalize	TDA	36.1 ± 5.4	36	3406	.902	0.0112
Motivation to mentalize	AID	36.0 ± 7.3	36
RFQ-Y^c score	TDA	8.95 ± 0.74	9.01	2374	<.001	0.311
RFQ-Y^c score	AID	8.41 ± 1.07	8.56

Bold highlight indicates the significant values.

^aTDA = Typically developing adolescents.

^bAID = Adolescents with internalizing disorders.

^cRFQ-Y = Reflective functioning questionnaire for youth.

As seen in Table 3, TDA scored significantly higher than the AID group on the subdomain of self-mentalization on MentS (m = 22.7 ± 6.4 for the TDA group; m = 20.8 ± 6.5 for the AID group; p = .049) with a small effect size of 0.177. This indicates that AIDs have significantly greater difficulty understanding their own mental states, such as thoughts, emotions, intentions, and wishes, compared with the TDA group. However, the small effect size indicates marginal impairments.

Second, TDA also scored significantly higher on the RFQ-Y than AID (m = 8.95 ± 0.74 for the TDA group; m = 8.41 ± 1.07 for the AID group; p < .001) with a moderate effect size of 0.311. This indicates that AID also had significantly greater difficulties than TDA in overall mentalizing, that is, in understanding mental states in general and in maintaining optimal, balanced mentalizing that is flexible across domains.

There were no significant differences in the subdomains of other-mentalization and motivation to mentalize on the MentS, indicating that both groups had comparable drives to mentalize and perceived abilities to understand others’ mental states.

In addition to the above, a correlational analysis was conducted between the scores on the subdomains of SDQ and mentalization variables (Table 4).

Table 4.

Spearman Rank-order Correlation Between Subdomains of Mentalization Scale (MentS), Reflective Functioning Questionnaire for Youth (RFQ-Y), and Strengths and Difficulties Questionnaire (SDQ) Scores for both Groups Combined (n = 166).

	Self-mentalization		Other- mentalization		Motivation to Mentalize		RFQ-Y^a
	Spearman’s Rho	p Value	Spearman’s Rho	p Value	Spearman’s Rho	p Value	Spearman’s Rho	p Value
Emotional symptoms scale	−0.375	<.001	0.102	.189	0.261	<.001	−0.167	.032
Conduct problems scale	−0.108	.166	−0.07	.369	−0.094	.228	−0.318	<.001
Hyperactivity	−0.266	<.001	0.016	.84	0.096	.219	−0.099	.205
Peer problems scale	−0.06	.442	−0.008	.914	−0.078	.32	−0.236	.002
Prosocial scale	0.113	.147	0.371	<.001	0.358	<.001	0.149	.055
Total difficulties score	−0.324	<.001	0.023	.766	0.094	.23	−0.263	<.001
Internalizing problems	−0.283	<.001	0.057	.468	0.138	.075	−0.220	.004
Externalizing problems	−0.245	.001	−0.053	.500	−0.004	.962	−0.238	.002

Bold highlight indicates the significant values.

^aRFQ-Y = Reflective functioning questionnaire for youth.

As seen in Table 4, self-mentalization was significantly, negatively correlated with emotional symptoms, (Spearman rho = −0.375, p < .001, moderate correlation), hyperactivity (Spearman’s rho = −0.266, p < .001, weak correlation), total difficulties (Spearman’s rho = −0.324, p < .001, moderate correlation) as well as the internalizing (Spearman’s rho = −0.283, p < .001, weak correlation) and externalizing problems (Spearman rho = −0.245, p = .001, weak correlation) domains indicating that when there is an increase in emotional and behavioral difficulties, there is a decrease in the ability to mentalize the self (understand one’s own mental states).

Other-Mentalization (Spearman’s rho = 0.371, p < .001, moderate correlation) and motivation to Mentalize (Spearman’s rho = 0.358, p < .001, moderate correlation), were significantly positively correlated with the prosocial scale indicating that as the prosocial behavior increases, there is also an increase in one’s perceived ability to understand other’s mental states and motivation to mentalize (drive to understand mental states).

Motivation to Mentalize was also significantly positively correlated with emotional symptoms (Spearman’s rho = 0.261, p < .001; weak correlation), indicating that increases in emotional symptoms were associated with greater motivation to engage in mentalizing.

Lastly, Overall Mentalizing ability (RFQ-Y) was significantly negatively correlated with emotional symptoms (Spearman’s rho = −0.167, p = .032, weak correlation), peer problems (Spearman’s rho = −0.236, p = .002, weak correlation), conduct problems (Spearman’s rho = −0.318, p < .001, moderate correlation), total difficulties (Spearman’s rho = −0.263, p < .001, weak correlation) as well as internalizing (Spearman’s rho = −0.220, p = .004, weak correlation and externalizing problems (Spearman’s rho = −0.238, p = .002, weak correlation), which indicated that an increase in emotional and behavioral difficulties are also related to a decreased ability to understand mental states or engage in balanced, flexible mentalizing.

Discussion

Considering the objective of exploring group differences in AID compared to TDA, the discussion will primarily focus on explaining the AID groups’ reduced scores on self and overall mentalizing and the links between internalizing disorders of depressive, anxiety, and somatoform/dissociative disorders with mentalization.

Mentalizing Ability and Links with Internalizing Disorders

Overall, mentalization is the general ability to understand mental states and to engage in optimal, balanced, flexible, and curious mentalizing. It involves maintaining a balance between the different domains of mentalization. One of the domains, namely self-mentalization, has been defined as the ability to perceive and understand one’s own mental states, such as thoughts, emotions, wishes, intentions, and attitudes.³⁴ In essence, it entails awareness of one’s own cognitions and emotions.

The findings showed that the AID diagnosed with depression, anxiety, or somatoform/dissociative disorders had significantly lower self-mentalization and overall mentalizing ability when compared to TDA. In the SDQ as well, internalizing and externalizing problems were negatively linked to overall mentalizing and the self-domain of mentalizing, indicative of the strong links between increased emotional difficulties and a reduced ability to understand mental states behind an action, especially one’s own mental states, which align with previous findings.^{15,16,20,35–38} There was no significant correlation between internalizing or externalizing problems with domains of other-mentalization or motivation to Mentalize.

The lower overall RF/mentalization found in AID across all diagnostic conditions of depression, anxiety, and somatoform/dissociation can be understood using the biobehavioral switch model of mentalization, which states that optimal mentalizing occurs at moderate levels of arousal.³⁴ Hyper-arousal can be seen in anxiety disorders, hypo-arousal can be seen in dissociative disorders, whereas both hypo-arousal and hyper-arousal may be seen in depressive disorders. Both these extremes of arousal levels contribute to difficulties in mentalizing. When one is hypo-aroused, it may manifest as a lack of motivation to mentalize or a lack of cognitive resources to engage in reflection (e.g., while in a dissociative episode). Alternatively, when one is hyper-aroused (e.g., in situations of heightened anxiety, there is increased internal noise and stress levels, which can interfere with the ability to engage in slow, introspective reflection. Hence, mentalization may shift from more controlled mentalizing (i.e., conscious, slow, effortful) to more automatic mentalizing (i.e., impulsive, reflexive, unconscious), which does not provide a conscious awareness of one’s own mental states.³⁹ Automatic mentalization may be appropriate for a fight-or-flight response, but can lead to overly simplistic explanations of one’s own mental world, contributing to mentalizing errors. This is supported by findings of a meta-analysis, which showed that the negative association between internalizing symptoms and mentalization was stronger when only controlled mentalization was assessed, versus when the assessment also tapped partially into automatic mentalizing.⁴⁰ This highlights the stronger negative relationship of depressive, anxiety, and somatoform/dissociative symptoms with controlled mentalizing in particular.⁴⁰

Another transdiagnostic mechanism that explains mentalization difficulties in AID is the attentional biases seen in anxiety and depressive disorders, where attention is focused more on negative/potentially threatening stimuli.⁴¹ There are also interpretive biases in which ambiguous stimuli are often interpreted negatively.⁴² Both of these biases contribute to heightened sensitivity to threat. They may lead to exaggerated stress responses, thereby increasing the risk of hyper- or hypo-arousal (due to experiential avoidance, as the associated emotions can be overwhelming), which in turn worsens non-mentalizing, resulting in a vicious cycle.³⁴

Anxiety Disorders and Mentalization

Individuals with anxiety disorders are seen to have a lower threshold for hyper-arousal, which can make them more prone to the switch to non-mentalizing, contributing to difficulties with overall RF.⁴³ Further, specifically, the difference in self-mentalization found in the current study is an especially novel and interesting finding, as most of the previous empirical literature related to anxiety disorders has focused more on its relationship with other-mentalization (or related constructs like theory of mind and empathy). With respect to anxiety disorders, the findings of this study actually contradict the self-absorption paradox that is described among children and adolescents with anxiety disorders in studies conducted in Western cultures.^18,20 The self-absorption paradox states that heightened anxiety and distress can be linked to increased self-consciousness and make an individual more aware of themselves, contributing to improved accuracy of self-perception and, by extension, more accurate mentalization of the self.⁴⁴ However, the opposite of this was found in the present study, which linked increased emotional symptoms and total difficulties negatively with self-mentalization and found significantly reduced self-mentalization among AID.

To understand it from a social-cognitive perspective, Banerjee (2008) combined the cognitive model of anxiety Beck and Clark’s (1991), with the social information processing models of Daleiden and Vasey’s (1991) to suggest that the social cognition of children with anxiety is often marked by hypervigilance, which is driven by the anticipated threat/ negative evaluations of the self by others.^45,46 This, in turn, can manifest as an excessive other-focus or an imbalanced other-mentalizing, as well as an undue focus on these anxieties, leaving little cognitive room for slow, conscious self-mentalizing.⁴⁷ This is similar to the “reflective training” effect described by Chevalier et al. (2021),¹⁸ often seen in individuals with generalized anxiety disorders. This effect states that due to their hypervigilance and perception of the environment as potentially threatening, individuals with anxiety may spend a lot of energy and time in trying to understand the other (supported by the finding that emotional symptoms were significantly positively correlated with motivation to mentalize in the present study and why there were no significant differences in motivation to mentalize) and become well-versed in other-focused RF/mentalizing. Still, this does not extend to self-mentalization abilities, which may not exhibit the same level of accuracy.⁴⁰ This may also explain why there were no significant differences seen in other-mentalization between the two groups, as both the adolescent age (a factor in both groups) and anxiety disorders (a factor in the AID group) are related to more concern and value placed on others’ mental states⁴ (with the group means tending toward a similar higher range for both groups).

Depressive Disorders and Mentalization

In terms of depressive disorders, two mechanisms of mentalizing become salient, namely, hypo-mentalizing and hyper-mentalizing.^34,48 Hypo-mentalizing is characterized by an impoverished ability to infer or attribute mental states behind actions. It may manifest as excessive ambiguity and uncertainty about mental states of oneself or others and an inability to interpret social cues, which can contribute to the feeling of helplessness, and forms one of the three core depressive cognitions.⁴¹ This can also link to a reduced perceived sense of agency/ ability to influence and can manifest as apathy and indifference, often seen in depressive disorders,⁴⁹ which can then maintain these mentalizing failures.⁴⁸ Alternatively, hyper-mentalization is characterized by an over-attribution of complex intentions and mental states to actions. It can manifest as being excessively sure of mental states, not recognizing the opaqueness of the mind, and being rigid in one’s assumptions about others’ mental states, which can lead to misattributions/misinterpretations contributing to interpersonal conflicts (supported by the negative relationship between peer problems and overall mentalizing found in the current study). These interpersonal difficulties also form a core mechanism in depressive episodes as described by the interpersonal therapy approach.⁵⁰

Mentalization theory also describes the etiology of depression arising from threats to attachment security with anticipated or real loss of secure attachment figures. These perceived/ actual threats of loss/separation to attachment security can contribute to depressed moods and increased arousal levels. This, in turn, can contribute to the “switching off” of mentalizing, leading to negative attributional styles, misinterpretation of interpersonal situations, and pre-mentalizing modes, furthering stress levels and a depressed mood, resulting in a cycle of non-mentalizing.³⁴ However, because studying attachment was beyond the scope of the current study, the researchers cannot comment further on this aspect; it could be a direction for future studies.

Somatoform/Dissociative Disorders and Mentalization

The nature of somatoform/Dissociative disorders in itself speaks of experiences that are non-mentalized and involve a cut-off from one’s own internal mental states to cope with overwhelming situations.^51,52 When an intrapsychic conflict and associated anxiety/mental states exceed one’s coping abilities, the individual may cope by splitting off these difficult experiences from conscious awareness using the defense of dissociation, or by conversion of these unpleasant mental states to physical symptoms through the defense of somatization; because, these may be perceived as less anxiety provoking than the intrapsychic conflict and a more socially acceptable/sanctioned way of expressing distress.^52–55 Somatoform disorders are also marked by poor body-mentalization, which is the ability to link physiological bodily responses to internal mental states, which may manifest as difficulties in mentalizing oneself and an overreliance on medical explanations of somatic symptoms.⁵⁶ Hence, the very nature of these disorders points to the unawareness of one’s own mental states, which result from protective defenses and can explain why self-mentalization was significantly lower in the AID than the TDA group.

Further, one’s own mental states may be viewed as threatening and hence, remain non-mentalizing; however, this does not necessarily extend to others’ mental states, as intrapsychic conflicts/anxieties will not be playing a role while mentalizing the other. This may explain why there were no significant differences in other-mentalization between the AID and TDA groups. Further, the motivation to mentalize also did not show significant differences between the two groups, which may be because the reduced self-mentalization in these disorders occurs unconsciously through ego defenses and may not translate to a conscious avoidance of mental states (which is what might have been tapped into while filling in the questionnaires).

Strengths and Difficulties and Mentalization

In addition to the discussion above, there was also a significant negative relationship between externalizing problems of hyperactivity with self-mentalization and conduct disorder with overall mentalization, which is corroborated by previous studies.^37,57 The lack of empathy can explain the latter, motivation to mentalize, and lack of interpersonal trust that accompanies conduct disorders, as well as the link between reduced self-mentalization and reduced regulation of one’s behaviors.^16,37 Further, increased hyperactivity can be accompanied by heightened cognitive hyperactivity, making it more challenging to engage in slow, effortful, and conscious self-reflection, which requires sustained attentional control.^6,58

Further, prosocial behaviors were positively linked with other-mentalization and motivation to mentalize, which may also highlight how increased motivation to understand mental states and increased ability to understand/focus on others’ mental states can manifest as more helpful acts toward them, which is established in previous literature studying related constructs of empathy and prosocial behaviors.⁵⁹

Limitations

The sampling technique for the TDA group was convenience sampling, which may increase the risk of sampling bias and limit generalizability. However, most mentalization variables were normally distributed, suggesting a more representative sample. Another limitation was that differences in mentalization across diagnostic groups in AID were not examined due to the limited sample size. As mentalization was being explored as a transdiagnostic factor, such an analysis was beyond the scope of the present study. However, future studies could conduct such an analysis to help elucidate diagnosis-specific impairments in RF.

Strengths and Implications

The study’s findings have important implications in the formulation and planning of therapeutic interventions for AID. Previous literature on RF has several gaps, such as a lack of exploration of the adolescent age group (especially those with clinical conditions), a lack of a control group in most comparison studies, not extensively studying differences in the domains of mentalizing, and a reduced focus on self-mentalizing. Further, there is a significant dearth of culturally specific Indian studies exploring adolescent RF. Hence, the current findings provide unique and novel insights, globally as well as for the Asian context. Furthermore, this study highlights links between domains of mentalizing and adolescents’ strengths and difficulties, thereby enriching the discussion of factors associated with impaired and improved mentalizing. This may indicate a promising scope for working with MBT and AID in the Indian context, although more culture-specific empirical studies are required.

Conclusions

This study highlights the importance of the transdiagnostic aspect of mentalization, which needs to be addressed during psychotherapy interventions for AID. In the current study, AID showed lower self and overall mentalization ability compared to TDA; however, the effect size for differences in self-mentalizing between the two groups was small. Further, there were no significant differences in domains of other-mentalization and motivation to mentalize. These highlight the domain-specific differences in mentalization profiles of AID compared to TDA. With Mentalization-based therapy (MBT) growing in evidence as a practical therapeutic approach for adolescents, these findings provide a step further in understanding the nuances of mentalization that need to be addressed in psychotherapy for adolescents.

Supplemental Material

Supplemental material for this article available online.

Footnotes

Acknowledgements

The authors acknowledge the adolescents and their parents for their participation in the study and thank colleagues for their valuable suggestions.

Data Availability

There are restrictions by the institution on sharing the participant data publicly. However, the de-identified participant data is available from the authors upon reasonable request (without the patient/control identifiable/confidential information) from the journal and the reviewers. The corresponding author, Dr Bangalore N Roopesh (E-mail ID: bn.roopesh@gmail.com, Ph No. 00918026995585), can be contacted for the same.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

No part of this article was written or generated by a generative AI tool. The authors take full responsibility for the accuracy, integrity, and originality of the published article.

Ethical Approval

Ethical approval for this study was obtained from the Institutional Ethics Committee, Behavioral Sciences Division, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India (Approval Ref. No. NIMH/DO/BEH. Sc. Div./2023–2024; dated November 20, 2023). All procedures were conducted in accordance with the Declaration of Helsinki of 1964, as revised in 2013.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Patient Consent

Written informed consent was obtained from the parents of all participants, and written informed assent was obtained from all participants for participation in the study and for publication of the data.

Prior Presentation

The findings of this study have not been presented previously.

PROSPERO/CTRI Registration

Not applicable.

Registration

The PhD study was registered with the PhD Registration Committee (Behavioral Sciences), National Institute of Mental Health and Neurosciences, in accordance with University Grants Commission guidelines (Registration No. NIMH/A&E-SA3-1469/Ph.D./CP/AW/2023–24; dated November 30, 2023).

Simultaneous Submission

This manuscript has not been published previously and is not under consideration for publication elsewhere.

Trial Registration

Not applicable, as this is not a clinical trial.

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Supplementary Material

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Mentalization Profiles of Adolescents with Internalizing Disorders: Domain-specific Differences Compared to Typically Developing Adolescents

Abstract

Background:

Methods:

Results:

Conclusion:

Keywords

Key Messages:

Rationale for the Study

Aim

Methods

Ethical Considerations

Study Design and Sample

Tools

Reflective Functioning Questionnaire for Youth 24

The Mentalization Scale 27

Depression Anxiety Stress Scales–Youth Version 29

Strengths and Difficulties Questionnaire 30

Statistical Analysis

Results

Discussion

Mentalizing Ability and Links with Internalizing Disorders

Anxiety Disorders and Mentalization

Depressive Disorders and Mentalization

Somatoform/Dissociative Disorders and Mentalization

Strengths and Difficulties and Mentalization

Limitations

Strengths and Implications

Conclusions

Supplemental Material

Footnotes

Acknowledgements

Data Availability

Declaration of Conflicting Interests

Declaration Regarding the Use of Generative AI

Ethical Approval

Funding

Patient Consent

Prior Presentation

PROSPERO/CTRI Registration

Registration

Simultaneous Submission

Trial Registration

References

Supplementary Material

Reflective Functioning Questionnaire for Youth²⁴

The Mentalization Scale²⁷

Depression Anxiety Stress Scales–Youth Version²⁹

Strengths and Difficulties Questionnaire³⁰