Abstract
Patients with schizophrenia appear to experience higher levels of childhood trauma and lower levels of mentalization capacities. However, no studies have discussed the factors underlying the way in which childhood trauma impacts upon mentalization in schizophrenia. This study aimed to examine the impact of childhood trauma on mentalization in schizophrenia, and to determine the possible mediating role of attachment and alexithymia in this relationship. The study group included 194 schizophrenia patients. The Mentalization Questionnaire, Childhood Trauma Questionnaire (CTQ-SF), 20-item Toronto Alexithymia Scale (TAS-20) and Experiences in Close Relationships- Relationship Structures Scale (ECR-RSS) were administered to all participants. Mediation and path models were constructed, taking childhood trauma as independent variables, attachment avoidance and anxiety as mediators, and mentalization as the dependent variable. In addition, a sequential mediation model was tested, with attachment insecurity and alexithymia as mediators of the association between childhood trauma and mentalization. The findings supported the attachment avoidance and anxiety fully mediated the effect of childhood trauma on mentalization in schizophrenia patients. The sequential mediation model was established by using attachment and alexithymia as mediators between the relationship of childhood trauma and mentalization. The cross-sectional design of this study was a limitation in terms of determining the causality of the identified relationships. The results supported the hypothesis of sequential mediation via attachment insecurity and alexithymia. Accordingly, attachment insecurity and alexithymia should be discussed as the theme of psychotherapy for schizophrenia patients.
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References
Adanty, C., Qian, J., Wang, Y., Remington, G., Shakeri, A., Borlido, C., Gerretsen, P., Graff-Guerrero, A., & De Luca, V. (2022). Childhood trauma exposure and personality traits in schizophrenia patients. Schizophrenia Research, 241, 221–227. https://doi.org/10.1016/j.schres.2022.01.039
Akyuz, G., Sar, V., Kugu, N., & Dogan, O. (2005). Reported childhood trauma, attempted suicide and self-mutilative behavior among women in the general population. European Psychiatry : The Journal of the Association of European Psychiatrists, 20(3), 268–273. https://doi.org/10.1016/j.eurpsy.2005.01.002
Bagby, R. M., & Taylor, P. J. GJ (1994). The twenty-item Toronto Alexithymia Scale: I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23–32.
Bateman, A., F. P (2004). Psychotherapy for Borderline personality disorder: Mentalization-based treatment. Oxford University Press.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy Human Development. The Journal of Nervous and Mental Disease. https://doi.org/10.1097/00005053-199001000-00017
Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult romantic attachment: An integrative overview. Rholes (eds.), attachment theory and close relationships (pp. 46–76). Guilford. InJ. A. Simpson.
Brune, M. (2005). Theory of mind in schizophrenia: A review of the literature. Schizophrenia Bulletin, 31(1), 21–42. https://doi.org/10.1093/schbul/sbi002
Brune, M., Abdel-Hamid, M., Lehmkamper, C., & Sonntag, C. (2007). Mental state attribution, neurocognitive functioning, and psychopathology: What predicts poor social competence in schizophrenia best? Schizophrenia Research, 92(1–3), 151–159. https://doi.org/10.1016/j.schres.2007.01.006
Brune, M., Walden, S., Edel, M. A., & Dimaggio, G. (2016). Mentalization of complex emotions in borderline personality disorder: The impact of parenting and exposure to trauma on the performance in a novel cartoon-based task. Compr Psychiatry, 64, 29–37. https://doi.org/10.1016/j.comppsych.2015.08.003
Chatziioannidis, S., Andreou, C., Agorastos, A., Kaprinis, S., Malliaris, Y., Garyfallos, G., & Bozikas, V. P. (2019). The role of attachment anxiety in the relationship between childhood trauma and schizophrenia-spectrum psychosis. Psychiatry Research, 276, 223–231. https://doi.org/10.1016/j.psychres.2019.05.021
Citak, C., & Erten, E. (2021). Impact of Childhood Trauma and Attachment on Resilience in Remitted Patients with Bipolar Disorder. J Affect Disord, 280(Pt A), 219–227. https://doi.org/10.1016/j.jad.2020.11.025
Collaborators., G. D. (2017). Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: A systematic analysis for the global burden of Disease Study 2016. The Lancet, 390(10100), 1211–1259. https://doi.org/10.1016/s0140-6736(17)32154-2
De Young, A. C., Kenardy, J. A., & Cobham, V. E. (2011). Trauma in early childhood: A neglected population. Clinical Child and Family Psychology Review, 14(3), 231–250. https://doi.org/10.1007/s10567-011-0094-3
Dimitrijevic, A., Hanak, N., Dimitrijevic, A., A., & Jolic Marjanovic, Z. (2018). The mentalization scale (MentS): A self-report measure for the Assessment of Mentalizing Capacity. Journal of Personality Assessment, 100(3), 268–280. https://doi.org/10.1080/00223891.2017.1310730
Duno, R., Pousa, E., Miguelez, M., Montalvo, I., Suarez, D., & Tobena, A. (2009). Suicidality connected with mentalizing anomalies in schizophrenia: A study with stabilized outpatients. Annals of the New York Academy of Sciences, 1167, 207–211. https://doi.org/10.1111/j.1749-6632.2009.04602.x
Ensink, K., Normandin, L., Target, M., Fonagy, P., Sabourin, S., & Berthelot, N. (2015). Mentalization in children and mothers in the context of trauma: An initial study of the validity of the child reflective functioning scale. British Journal of Developmental Psychology, 33(2), 203–217. https://doi.org/10.1111/bjdp.12074
Ensink, K., Begin, M., Normandin, L., & Fonagy, P. (2016). Maternal and child reflective functioning in the context of child sexual abuse: Pathways to depression and externalising difficulties. Eur J Psychotraumatol, 7, 30611. https://doi.org/10.3402/ejpt.v7.30611
Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355–1381. https://doi.org/10.1017/S0954579409990198
Fonagy, P., Jurist, G. G., & Target, E. L. (2002). M. Affect regulation, mentalization, and the development of the self. New York (NY): Other Press.
Gabinio, T., Ricci, T., Kahn, J. P., Malaspina, D., Moreira, H., & Veras, A. B. (2018). Early trauma, attachment experiences and comorbidities in schizophrenia. Trends Psychiatry Psychother, 40(3), 179–184. https://doi.org/10.1590/2237-6089-2017-0005
Garcia-Fernandez, L., Cabot-Ivorra, N., Romero-Ferreiro, V., Perez-Martin, J., & Rodriguez-Jimenez, R. (2020). Differences in theory of mind between early and chronic stages in schizophrenia. Journal of Psychiatric Research, 127, 35–41. https://doi.org/10.1016/j.jpsychires.2020.05.009
Goodall, K., Rush, R., Grunwald, L., Darling, S., & Tiliopoulos, N. (2015). Attachment as a partial mediator of the relationship between emotional abuse and schizotypy. Psychiatry Research, 230(2), 531–536. https://doi.org/10.1016/j.psychres.2015.09.050
Gross, J. J. (1998). Antecedent- and response-focused emotion regulation: Divergent consequences for experience, expression, and physiology. J Pers Soc Psychol, 74(1), 224–237. https://doi.org/10.1037//0022-3514.74.1.224
Hacioglu Yildirim, M., Yildirim, E. A., Kaser, M., Guduk, M., Fistikci, N., Cinar, O., & Yuksel, S. (2014). The relationship between adulthood traumatic experiences and psychotic symptoms in female patients with schizophrenia. Compr Psychiatry, 55(8), 1847–1854. https://doi.org/10.1016/j.comppsych.2014.08.049
Hayes, A. F. (2017). Introduction to Mediation, Moderation, and Conditional Process Analysis A Regression-Based Approach.
Heshmati, R., Jafari, E., Hoseinifar, J., & Ahmadi, M. (2010). Comparative study of alexithymia in patients with schizophrenia spectrum disorders, non-psychotic disorders and normal people. Procedia - Soc Behav Sc, 5, 1084–1089.
Hoff, A. L., Svetina, C., Shields, G., Stewart, J., & DeLisi, L. E. (2005). Ten year longitudinal study of neuropsychological functioning subsequent to a first episode of schizophrenia. Schizophrenia Research, 78(1), 27–34. https://doi.org/10.1016/j.schres.2005.05.010
Huang, Y. L., Fonagy, P., Feigenbaum, J., Montague, P. R., & Nolte, T. (2020). Multidirectional pathways between attachment, Mentalizing, and posttraumatic stress symptomatology in the context of Childhood Trauma. Psychopathology, 53(1), 48–58. https://doi.org/10.1159/000506406
Jiang, W. J., Zhong, B. L., Liu, L. Z., Zhou, Y. J., Hu, X. H., & Li, Y. (2018). Reliability and validity of the Chinese version of the Childhood Trauma Questionnaire-Short Form for inpatients with schizophrenia. PLoS One, 13(12), e0208779. https://doi.org/10.1371/journal.pone.0208779
Kajanoja, J., Karukivi, M., Scheinin, N. M., Ahrnberg, H., Karlsson, L., & Karlsson, H. (2021). Early-life adversities and adult attachment in depression and alexithymia. Development and Psychopathology, 33(4), 1428–1436. https://doi.org/10.1017/S0954579420000607
Kim, D., Bae, H., Han, C., Oh, H. Y., & Macdonald, K. (2013). Psychometric properties of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) in Korean patients with schizophrenia. Schizophrenia Research, 144(1–3), 93–98. https://doi.org/10.1016/j.schres.2012.12.020
Koelkebeck, K., Pedersen, A., Suslow, T., Kueppers, K. A., Arolt, V., & Ohrmann, P. (2010). Theory of mind in first-episode schizophrenia patients: Correlations with cognition and personality traits. Schizophrenia Research, 119(1–3), 115–123. https://doi.org/10.1016/j.schres.2009.12.015
Korver-Nieberg, N., Berry, K., Meijer, C. J., & de Haan, L. (2014). Adult attachment and psychotic phenomenology in clinical and non-clinical samples: A systematic review. Psychol Psychother, 87(2), 127–154. https://doi.org/10.1111/papt.12010
Kristof, Z., Kresznerits, S., Olah, M., Gyollai, A., Lukacs-Miszler, K., Halmai, T., Fountoulakis, K. N., Tenyi, T., Dome, P., & Gonda, X. (2018). Mentalization and empathy as predictors of violence in schizophrenic patients: Comparison with nonviolent schizophrenic patients, violent controls and nonviolent controls. Psychiatry Research, 268, 198–205. https://doi.org/10.1016/j.psychres.2018.07.021
Kubota, M., Miyata, J., Hirao, K., Fujiwara, H., Kawada, R., Fujimoto, S., Tanaka, Y., Sasamoto, A., Sawamoto, N., Fukuyama, H., Takahashi, H., & Murai, T. (2011). Alexithymia and regional gray matter alterations in schizophrenia. Neuroscience Research, 70(2), 206–213. https://doi.org/10.1016/j.neures.2011.01.019
Langdon, R., Ward, P. B., & Coltheart, M. (2010). Reasoning anomalies associated with delusions in schizophrenia. Schizophrenia Bulletin, 36(2), 321–330. https://doi.org/10.1093/schbul/sbn069
Larsson, S., Andreassen, O. A., Aas, M., Rossberg, J. I., Mork, E., Steen, N. E., Barrett, E. A., Lagerberg, T. V., Peleikis, D., Agartz, I., Melle, I., & Lorentzen, S. (2013). High prevalence of childhood trauma in patients with schizophrenia spectrum and affective disorder. Compr Psychiatry, 54(2), 123–127. https://doi.org/10.1016/j.comppsych.2012.06.009
Leeb, R. T., Paulozzi, L., Melanson, C., Simon, T., & Arias, I. (2008). Child maltreatment surveillance: Uniform definitions for public health and recommended data elements,Version 1.0. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control, Atlanta (GA).
Li, X. B., Li, Q. Y., Liu, J. T., Zhang, L., Tang, Y. L., & Wang, C. Y. (2015). Childhood trauma associates with clinical features of schizophrenia in a sample of Chinese inpatients. Psychiatry Research, 228(3), 702–707. https://doi.org/10.1016/j.psychres.2015.06.001
Lysaker, P. H., Meyer, P. S., Evans, J. D., Clements, C. A., & Marks, K. A. (2001). Childhood sexual trauma and psychosocial functioning in adults with schizophrenia. Psychiatric Services (Washington, D. C.), 52(11), 1485–1488. https://doi.org/10.1176/appi.ps.52.11.1485
Mall, S., Platt, J. M., Temmingh, H., Musenge, E., Campbell, M., Susser, E., & Stein, D. J. (2019). The relationship between childhood trauma and schizophrenia in the Genomics of Schizophrenia in the Xhosa people (SAX) study in South Africa. Psychological Medicine, 50(9), 1570–1577. https://doi.org/10.1017/s0033291719001703
Meins, E., Fernyhough, C., Wainwright, R., Das Gupta, M., Fradley, E., & Tuckey, M. (2002). Maternal mind-mindedness and attachment security as predictors of theory of mind understanding.
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. Guilford Press.
Mikulincer, M., Shaver, P., & Pereg, D. (2003). Attachment theory and affect regulation: The dynamics, development, and cognitive consequences of attachment-related strategies. Motiv Emot, 27, 77–102. https://doi.org/10.1023/A:1024515519160
Misiak, B., Moustafa, A. A., Kiejna, A., & Frydecka, D. (2016). Childhood traumatic events and types of auditory verbal hallucinations in first-episode schizophrenia patients. Compr Psychiatry, 66, 17–22. https://doi.org/10.1016/j.comppsych.2015.12.003
Ogle, C. M., Rubin, D. C., & Siegler, I. C. (2015). The relation between insecure attachment and posttraumatic stress: Early life versus adulthood traumas. Psychol Trauma, 7(4), 324–332. https://doi.org/10.1037/tra0000015
Penn, D. L., Sanna, L. J., & Roberts, D. L. (2008). Social cognition in schizophrenia: An overview. Schizophrenia Bulletin, 34(3), 408–411. https://doi.org/10.1093/schbul/sbn014
Pilton, M., Bucci, S., McManus, J., Hayward, M., Emsley, R., & Berry, K. (2016). Does insecure attachment mediate the relationship between trauma and voice-hearing in psychosis? Psychiatry Research, 246, 776–782. https://doi.org/10.1016/j.psychres.2016.10.050
Pos, K., Bartels-Velthuis, A. A., Simons, C. J., Korver-Nieberg, N., Meijer, C. J., de Haan, L., & Group (2015). Theory of mind and attachment styles in people with psychotic disorders, their siblings, and controls. Australian and New Zealand Journal of Psychiatry, 49(2), 171–180. https://doi.org/10.1177/0004867414546386
Rominger, C., Bleier, A., Fitz, W., Marksteiner, J., Fink, A., Papousek, I., & Weiss, E. M. (2016). Auditory top-down control and affective theory of mind in schizophrenia with and without hallucinations. Schizophrenia Research, 174(1–3), 192–196. https://doi.org/10.1016/j.schres.2016.05.006
Scherzer, P., Leveillé, E., Achim, A., Boisseau, E., & Stip, E. (2012). A study of theory of mind in paranoid Schizophrenia: A theory or many theories? Frontiers in Psychology, 3, https://doi.org/10.3389/fpsyg.2012.00432
Shannon, C., Douse, K., McCusker, C., Feeney, L., Barrett, S., & Mulholland, C. (2011). The association between childhood trauma and memory functioning in schizophrenia. Schizophrenia Bulletin, 37(3), 531–537. https://doi.org/10.1093/schbul/sbp096
Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., & Fonagy, P. (2011). Theory of mind and emotion regulation difficulties in adolescents with Borderline traits. Journal of the American Academy of Child and Adolescent Psychiatry, 50(6), 563–573. https://doi.org/10.1016/j.jaac.2011.01.017
Sheinbaum, T., Kwapil, T. R., & Barrantes-Vidal, N. (2014). Fearful attachment mediates the association of childhood trauma with schizotypy and psychotic-like experiences. Psychiatry Research, 220(1–2), 691–693. https://doi.org/10.1016/j.psychres.2014.07.030
Shohreh Babaei, M. N. M., Abouzari, F., & Saber Karami. (2023). The role of traumatic childhood experiences, mentalization and Alexithymia in Predicting Depression and suicidal thoughts in women suffering from the trauma of Marital Betrayal. Iranian Journal of Psychiatric Nursing, 10(6). https://doi.org/10.22034/IJPN.10.6.110
Sitko, K., Bentall, R. P., Shevlin, M., O’Sullivan, N., & Sellwood, W. (2014). Associations between specific psychotic symptoms and specific childhood adversities are mediated by attachment styles: An analysis of the National Comorbidity Survey. Psychiatry Research, 217(3), 202–209. https://doi.org/10.1016/j.psychres.2014.03.019
Struck, N., Krug, A., Feldmann, M., Yuksel, D., Stein, F., Schmitt, S., Meller, T., Brosch, K., Dannlowski, U., Meinert, S., Opel, N., Lemke, H., Waltemate, L., Nenadic, I., Kircher, T., & Brakemeier, E. L. (2020). Attachment and social support mediate the association between childhood maltreatment and depressive symptoms. Journal of Affective Disorders, 273, 310–317. https://doi.org/10.1016/j.jad.2020.04.041
Tekden, M., Kilicoglu, A. G., Mutlu, C., & Karacetin, G. (2021). Mentalization in female adolescents with non-suicidal self-injury and alexithymic and depressive features in their parents. Clinical Child Psychology and Psychiatry, 26(4), 981–992. https://doi.org/10.1177/13591045211013871
Thewissen, V., Bentall, R. P., Oorschot, M., van Lierop, J. A. C., van Os, T., J., & Myin-Germeys, I. (2011). Emotions, self-esteem, and paranoid episodes: An experience sampling study. British Journal of Clinical Psychology, 50(2), 178–195. https://doi.org/10.1348/014466510X508677
Ucok, A., & Bikmaz, S. (2007). The effects of childhood trauma in patients with first-episode schizophrenia. Acta Psychiatrica Scand, 116(5), 371–377. https://doi.org/10.1111/j.1600-0447.2007.01079.x
van Dam, D. S., Korver-Nieberg, N., Velthorst, E., Meijer, C. J., de Haan, L., Genetic, F., R., & Outcome in, P (2014). Childhood maltreatment, adult attachment and psychotic symptomatology: A study in patients, siblings and controls. Social Psychiatry and Psychiatric Epidemiology, 49(11), 1759–1767. https://doi.org/10.1007/s00127-014-0894-0
van der Meer, L., van’t Wout, M., & Aleman, A. (2009). Emotion regulation strategies in patients with schizophrenia. Psychiatry Research, 170(2–3), 108–113. https://doi.org/10.1016/j.psychres.2009.07.010
van Winkel, R., van Nierop, M., Myin-Germeys, I., & van Os, J. (2013). Childhood trauma as a cause of psychosis: Linking genes, psychology, and biology. Canadian Journal of Psychiatry, 58(1), 44–51. https://doi.org/10.1177/070674371305800109
Vogel, M., Spitzer, C., Kuwert, P., Moller, B., Freyberger, H. J., & Grabe, H. J. (2009). Association of childhood neglect with adult dissociation in schizophrenic inpatients. Psychopathology, 42(2), 124–130. https://doi.org/10.1159/000204763
Zhang, L., Zhao, N., Zhu, M., Tang, M., Liu, W., & Hong, W. (2023). Adverse childhood experiences in patients with schizophrenia: Related factors and clinical implications. Frontiers in Psychiatry, 14, 1247063. https://doi.org/10.3389/fpsyt.2023.1247063
Zhu, X., Yi, J., Yao, S., Ryder, A. G., Taylor, G. J., & Bagby, R. M. (2007). Cross-cultural validation of a Chinese translation of the 20-item Toronto Alexithymia Scale. Compr Psychiatry, 48(5), 489–496. https://doi.org/10.1016/j.comppsych.2007.04.007
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This study was supported by the Fundamental Research Funds for the Central Universities of China (PA2022GDSK0066); the Research Fund of Anhui Institute of Translational Medicine (2022zhyx-C06); the Open Fund of Key Laboratory of Philosophy and Social Science of Anhui Province on Adolescent Mental Health and Crisis Intelligence Intervention (SYS2023A03); the National Key Research and Development Plan (2021YFC3300500); the National Natural Science Foundation of China (81971689); the Clinical Science Foundation of Anhui Medical University (2020xkj246); the Ministry of Education of Humanities and Social Science project (23YJAZH198) and Clinical Science Foundation of Hefei Fourth People’s Hospital (HFSY2023YB01)
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Yuebing Wang, Xiao Jiang and Wenmei Fang performed the statistical analyses, wrote, carried out the critical review and approved the final manuscript, they contributed to the work equally. Weixiang Zhao and Rongrong Xuan designed this questionnaire; Xianyong Zu, Huacheng Wang, Li Zhang, Sisi Xie, collected the data; Yi Dong put forward writing ideas and suggestions for revision; Nan Li and Lei Zhang, Kai Wang provided resources, finding acquisition.
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Wang, Y., Jiang, X., Zhao, W. et al. The role of attachment and alexithymia in the relationship between childhood trauma and mentalization in people with schizophrenia: a multicenter study. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-05855-3
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DOI: https://doi.org/10.1007/s12144-024-05855-3