Background: Psychotherapy patients can be more or less disabled by their psychological symptoms. The present study investigated whether mentalization and self-efficacy contribute to the association between psychological symptom severity and disabilities in activities and participation. Methods: The data of 216 psychotherapy inpatients were examined in a cross-sectional design. Bootstrapping-enhanced mediation analyses were performed to investigate whether self-efficacy and mentalization are mediators between psychological symptom severity and disabilities in activities and participation. The Hamburg Modules for the Assessment of Psychosocial Health-49 were used to measure psychological symptom severity and self-efficacy, mentalization was assessed with the Mentalization Questionnaire, and disabilities in activities and participation were operationalized with the ICF-Mental-A & P questionnaire. Results: Mentalization as well as self-efficacy functioned as mediators between psychological symptom severity and disabilities in activities and participation (p < 0.05). They were equally strong mediators, and both remained significant mediators when statistically controlling for the other mediator (p < 0.05). Conclusions: Mentalization as well as self-efficacy explain a significant proportion of the relationship between psychological symptom severity and disabilities in activities and participation. Working on mentalizing and self-efficacy might be important mechanisms to reduce disability due to symptoms. The cross-sectional design is a limitation of the study.

1.
Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, Angermeyer MC, Bernert S, de Girolamo G, Morosini P, Polidori G, Kikkawa T, Kawakami N, Ono Y, Takeshima T, Uda H, Karam EG, Fayyad JA, Karam AN, Mneimneh ZN, Medina-Mora ME, Borges G, Lara C, de Graaf R, Ormel J, Gureje O, Shen Y, Huang Y, Zhang M, Alonso J, Haro JM, Vilagut G, Bromet EJ, Gluzman S, Webb C, Kessler RC, Merikangas KR, Anthony JC, Von Korff MR, Wang PS, Brugha TS, Aguilar-Gaxiola S, Lee S, Heeringa S, Pennell BE, Zaslavsky AM, Ustun TB, Chatterji S; WHO World Mental Health Survey Consortium: Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004;291:2581-2590.
2.
Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, Olesen J, Allgulander C, Alonso J, Faravelli C, Fratiglioni L, Jennum P, Lieb R, Maercker A, van Os J, Preisig M, Salvador-Carulla L, Simon R, Steinhausen HC: The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011;21:655-679.
3.
Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, Charlson FJ, Norman RE, Flaxman AD, Johns N, Burstein R, Murray CJ, Vos T: Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-1586.
4.
Ormel J, Petukhova M, Chatterji S, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Bromet EJ, Burger H, Demyttenaere K, de Girolamo G, Haro JM, Hwang I, Karam E, Kawakami N, Lépine JP, Medina-Mora ME, Posada-Villa J, Sampson N, Scott K, Ustün TB, Von Korff M, Williams DR, Zhang M, Kessler RC: Disability and treatment of specific mental and physical disorders across the world. Br J Psychiatry 2008;192:368-375.
5.
Scott KM, Von Korff M, Alonso J, Angermeyer MC, Bromet E, Fayyad J, de Girolamo G, Demyttenaere K, Gasquet I, Gureje O, Haro JM, He Y, Kessler RC, Levinson D, Medina Mora ME, Oakley Browne M, Ormel J, Posada-Villa J, Watanabe M, Williams D: Mental-physical co-morbidity and its relationship with disability: results from the World Mental Health Surveys. Psychol Med 2009;39:33-43.
6.
Konecky B, Meyer EC, Marx BP, Kimbrel NA, Morissette SB: Using the WHODAS 2.0 to assess functional disability associated with DSM-5 mental disorders. Am J Psychiatry 2014;171:818-820.
7.
World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, WHO, 1992.
8.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, APA, 2013.
9.
World Health Organization: International Classification of Functioning, Disability and Health. Geneva, WHO, 2001.
10.
Kroenke K, Spitzer RL, Williams JB: The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-613.
11.
Üstün TB, Kostanjsek N, Chatterji S, Rehm J: Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). Geneva, WHO, 2010.
12.
Luciano JV, Ayuso-Mateos JL, Fernández A, Serrano-Blanco A, Roca M, Haro JM: Psychometric properties of the twelve item World Health Organization Disability Assessment Schedule II (WHO-DAS II) in Spanish primary care patients with a first major depressive episode. J Affect Disord 2010;121:52-58.
13.
Brütt AL, Schulz H, Andreas S: Psychometric properties of an instrument to measure activities and participation according to the ICF concept in patients with mental disorders. Disabil Rehabil 2015;37:259-267.
14.
Brütt AL, Schulz H, Andreas S: Replication of the psychometric properties of the ICF-MentalA&P. Rehabilitation 2015;54:38-44.
15.
Tugade MM, Fredrickson BL: Resilient individuals use positive emotions to bounce back from negative emotional experiences. J Pers Soc Psychol 2004;86:320-333.
16.
Fredrickson BL: What good are positive emotions? Rev Gen Psychol 1998;2:300-319.
17.
Fredrickson BL: The role of positive emotions in positive psychology: the broaden-and-build theory of positive emotions. Am Psychol 2001;56:218-226.
18.
Schwarzer R, Warner LM: Perceived self-efficacy and its relationship to resilience; in Prince-Embury S, Saklofske D (eds): Resilience in Children, Adolescents, and Adults. The Springer Series on Human Exceptionality. New York, Springer, 2013, pp 139-150.
19.
Hamill SK: Resilience and self-efficacy: the importance of efficacy beliefs and coping mechanisms in resilient adolescents. Colgate Univ J Sci 2003;35:115-146.
20.
Stein H: Does mentalizing promote resilience? In Allen JG, Fonagy P (eds): Handbook of Mentalization-Based Treatment. Chichester, Wiley, 2006, pp 307-326.
21.
Bak PL, Midgley N, Zhu JL, Wistoft K, Obel C: The Resilience Program: preliminary evaluation of a mentalization-based education program. Front Psychol 2015;6:753.
22.
Maciejewski PK, Prigerson HG, Mazure CM: Self-efficacy as a mediator between stressful life events and depressive symptoms. Differences based on history of prior depression. Br J Psychiatry 2000;176:373-378.
23.
Tak YR, Brunwasser SM, Lichtwarck-Aschoff A, Engels RCME: The prospective associations between self-efficacy and depressive symptoms from early to middle adolescence: a cross-lagged model. J Youth Adolesc 2017;46:744-756.
24.
Denison E, Asenlöf P, Lindberg P: Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care. Pain 2004;111:245-252.
25.
Sinikallio SH, Helminen EE, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP: Multiple psychological factors are associated with poorer functioning in a sample of community-dwelling knee osteoarthritis patients. J Clin Rheumatol 2014;20:261-267.
26.
Bandura A: Perceived self-efficacy in cognitive development and functioning. Educ Psychol 1993;28:117-148.
27.
Lee H, Hübscher M, Moseley GL, Kamper SJ, Traeger AC, Mansell G, McAuley JH: How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain 2015;156:988-997.
28.
Allen JG, Fonagy P, Bateman AW: Mentalizing in Clinical Practice. Arlington, American Psychiatric Publishing, 2008.
29.
Allen JG: Restoring Mentalizing in Attachment Relationships. Arlington, American Psychiatric Publishing, 2013.
30.
Achim AM, Ouellet R, Lavoie MA, Vallières C, Jackson PL, Roy MA: Impact of social anxiety on social cognition and functioning in patients with recent-onset schizophrenia spectrum disorders. Schizophr Res 2013;145:75-81.
31.
Van Rheenen TE, Rossell SL: Objective and subjective psychosocial functioning in bipolar disorder: an investigation of the relative importance of neurocognition, social cognition and emotion regulation. J Affect Disord 2014;162:134-141.
32.
Fonagy P, Gergely G, Jurist EL, Target M: Affect Regulation, Mentalization, and the Development of the Self. New York, Other Press, 2002.
33.
MacIntosh HB: Mentalizing and its role as a mediator in the relationship between childhood experiences and adult functioning: exploring the empirical evidence. Psihologija 2013;46:193-212.
34.
Hausberg MC, Schulz H, Piegler T, Happach CG, Klöpper M, Brütt AL, Sammet I, Andreas S: Is a self-rated instrument appropriate to assess mentalization in patients with mental disorders? Development and first validation of the Mentalization Questionnaire (MZQ). Psychother Res 2012;22:699-709.
35.
Rabung S, Harfst T, Kawski S, Koch U, Wittchen HU, Schulz H: Psychometric analysis of a short-form of the “Hamburg Modules for the Assessment of Psychosocial Health” (HEALTH-49). Z Psychosom Med Psychother 2009;55:162-179.
36.
Hayes AF: Introduction to Mediation, Moderation, and Conditional Process Analysis. New York, Guilford Press, 2013.
37.
Durlak JA: How to select, calculate, and interpret effect sizes. J Pediatr Psychol 2009;34:917-928.
38.
Turner JA, Holtzman S, Mancl L: Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain 2007;127:276-286.
39.
Slee N, Spinhoven P, Garnefski N, Arensman E: Emotion regulation as mediator of treatment outcome in therapy for deliberate self-harm. Clin Psychol Psychother 2008;15:205-216.
40.
Schönfeld P, Preusser F, Margraf J: Costs and benefits of self-efficacy: differences of the stress response and clinical implications. Neurosci Biobehav Rev 2017;75:40-52.
41.
Maxwell SE, Cole DA: Bias in cross-sectional analyses of longitudinal mediation. Psychol Methods 2007;12:23-44.
42.
Maxwell SE, Cole DA, Mitchell MA: Bias in cross-sectional analyses of longitudinal mediation: partial and complete mediation under an autoregressive model. Multivariate Behav Res 2011;46:816-841.
43.
Badoud D, Luyten P, Fonseca-Pedrero E, Eliez S, Fonagy P, Debbané M: The French version of the Reflective Functioning Questionnaire: validity data for adolescents and adults and its association with non-suicidal self-injury. PLoS One 2015;10:e0145892.
44.
Fonagy P, Luyten P, Moulton-Perkins A, Lee YW, Warren F, Howard S, Ghinai R, Fearon P, Lowyck B: Development and validation of a self-report measure of mentalizing: the Reflective Functioning Questionnaire. PLoS One 2016;11:e0158678.
45.
Kalisch R, Müller MB, Tüscher O: A conceptual framework for the neurobiological study of resilience. Behav Brain Sci 2015;38:e92.
46.
Ramanathan DM, Wardecker BM, Slocomb JE, Hillary FG: Dispositional optimism and outcome following traumatic brain injury. Brain Inj 2011;25:328-337.
47.
Probst T, Neumeier S, Altmeppen J, Angerer M, Loew T, Pieh C: Depressed mood differentially mediates the relationship between pain intensity and pain disability depending on pain duration: a moderated mediation analysis in chronic pain patients. Pain Res Manag 2016;2016:3204914.
48.
Andreas S, Theisen P, Mestel R, Koch U, Schulz H: Validity of routine clinical DSM-IV diagnoses (axis I/II) in inpatients with mental disorders. Psychiatry Res 2009;170:252-255.
49.
Luyten P, Fonagy P, Lowyck B, Vermote R: The assessment of mentalization; in Bateman A, Fonagy P (eds): Handbook of Mentalizing in Mental Health Practice. Washington, APA, 2012, pp 43-65.
50.
Kirchmann H, Nolte T, Runkewitz K, Bayerle L, Becker S, Blasczyk V, Lindloh J, Strauss B: Associations between adult attachment characteristics, medical burden, and life satisfaction among older primary care patients. Psychol Aging 2013;28:1108-1114.
51.
Probst T, Pryss R, Langguth B, Schlee W: Emotional states as mediators between tinnitus loudness and tinnitus distress in daily life: results from the “TrackYourTinnitus” application. Sci Rep 2016;6:20382.
52.
Radziej K, Probst T, Limburg K, Dinkel A, Dieterich M, Lahmann C: The longitudinal effect of vertigo and dizziness symptoms on psychological distress: symptom-related fears and beliefs as mediators. J Nerv Ment Dis, in press.
53.
Probst T, Dinkel A, Schmid-Mühlbauer G, Radziej K, Limburg K, Pieh C, Lahmann C: Psychological distress longitudinally mediates the effect of vertigo symptoms on vertigo-related handicap. J Psychosom Res 2017;93:62-68.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.