Journal of Anxiety Disorders 92 (2022) 102641

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

Review

A meta-analysis of mentalizing in anxiety disorders, obsessive-compulsive

and related disorders, and trauma and stressor related disorders
Mèlanie Sloover a, b, *, Leanne A.C. van Est b, c, Petrus G.J. Janssen a, b, Mirrian Hilbink b, d,
Elisa van Ee a, b
a
Behavioural Science Institute, Radboud University Nijmegen, Thomas van Aquinostraat 4, 6525 GD Nijmegen, the Netherlands
b
Psychotraumacentrum Zuid Nederland, Reinier van Arkel, Bethaniëstraat 10, 5211 LJ ’s-Hertogenbosch, the Netherlands
c
Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, the Netherlands
d
Jeroen Bosch Academy Research, Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223 GZ ‘s-Hertogenbosch, the Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The number of studies that have researched the ability to mentalize in individuals with anxiety and
Mentalization related disorders is limited. Often, no distinction is made between different anxiety and related disorders in the
Anxiety disorders examination of mentalization.
Obsessive-compulsive and related disorders
Objective: The goal of this study was to obtain insight into mentalization in anxiety and related disorders, and to
Trauma and stressor related disorders
compare this ability between these disorders.
Method: A systematic literature search was performed to identify studies in which performance on a mentali­
zation task was compared between a patient group diagnosed with an anxiety or a related disorder, and a control
group. Meta-analyses were performed on the included articles.
Results: The initial search yielded 2844 articles, of which 26 studies on 1056 patients were included. Patients
diagnosed with anxiety and related disorders showed a deficit in mentalization when compared to healthy
controls (SMD = − 0.60, p 0.001). A deficit was found in all patient groups: Patients with anxiety disorders (SMD
= − 0.39, p = 0.007), obsessive-compulsive and related disorders (SMD = − 0.78, p = 0.01), and trauma and
stressor related disorders showed significant deficits (SMD = − 0.77, p = 0.02) as compared to healthy controls.
Conclusion: The results indicated impaired mentalization in anxiety and related disorders, with specific de­
ficiencies in posttraumatic stress disorder, social anxiety, and obsessive-compulsive disorders. Mentalization
could provide a clinical target in treatment of these disorders.

1. Introduction Thus, examining factors contributing to relationship quality in these

patient groups is important.
Anxiety and related disorders, currently subdivided in DSM-5 One key factor affecting interpersonal functioning may be the ability
(American Psychiatric Association, 2013) as anxiety disorders, to mentalize, as it appears to be essential for successful human re­
obsessive-compulsive and related disorders, and trauma and stressor lationships, providing a sort of bridge between the psychological expe­
related disorders, are some of the most common mental disorders riences of two persons (Levenson & Ruef, 1992; Smither, 1977).
(Baxter et al., 2013). It has been estimated that anxiety disorders have a Mentalizing can be understood as a process of making sense of mental
lifetime prevalence rate of 21.1% within Europe and 31.0% within the states (thoughts and feelings) in oneself and others and it requires the
United States (Kessler et al., 2007; Wittchen & Jacobi, 2005). Research ability to take the perspective of another person (e.g., Allen, 2003;
has also shown that high levels of impaired social functioning are Luyten et al., 2020). In literature, the term mentalization is often used
observed in patients with anxiety and related disorders (Olatunji et al., interchangeably with theory of mind. However, Fonagy et al. (2007)
2007). For example, patients with anxiety disorders experience more suggest that mentalization is broader than merely theory of mind, as the
relationship distress and lower relationship quality (McLeod, 1994; latter fails to capture the interpersonal and emotion regulation aspects
Pankiewicz et al., 2012; Whisman & Baucom, 2012; Zaider et al., 2010). of interpreting behavior in terms of mental states. Mentalization theory

* Correspondence to: Radboud University, Thomas van Aquinostraat 4, 6525 GD Nijmegen, the Netherlands.
E-mail address: melanie.sloover@ru.nl (M. Sloover).

https://doi.org/10.1016/j.janxdis.2022.102641
Received 3 August 2021; Received in revised form 3 October 2022; Accepted 11 October 2022
Available online 14 October 2022
0887-6185/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

namely has several dimensions, but one important distinction is made The way mentalization deficits are expressed can vary between
between cognitive and affective mentalization (Liljenfors & Lundh, different anxiety and related disorders. Whereas all patients with anxi­
2015). Cognitive mentalization refers to the ability to reason about ety and related disorders overestimate threat and try to avoid their fear
someone’s mental states or their beliefs, while affective mentalization is (Abramowitz & Jacoby, 2015), patients with obsessive-compulsive and
the ability to empathize with another person’s mental states (Fonagy related disorders can be distinguished by their obsessions and/or re­
et al., 2012). Cognitive mentalization seems to be more closely related to petitive behaviors. Moreover, patients with trauma-and stressor related
the concept of theory of mind, as it is commonly defined in literature disorders can be distinguished by the experience of a traumatic event
(Baron-Cohen et al., 2008), while theory of mind does not encompass and resulting feelings other than anxiety such as anhedonia, aggression,
affective mentalization. Both aspects of mentalization however are or dissociation (APA, 2013; Stein et al., 2014). Thus, despite sharing
crucial in building and maintaining social relationships. some key features, these disorders differ in a number of ways (Abra­
Previous work suggests that the ability to mentalize is potentially mowitz & Jacoby, 2015). This can be observed for example in the focus
impaired in patients with anxiety and related disorders (e.g., Buhlmann of fear, with a focus on social situations in SAD, on physical appearance
et al., 2015; López-del-Hoyo et al., 2019; Lysaker et al., 2015; Pertusa in BDD, on intrusions in PTSD, or on arousal-related body sensations in
et al., 2012). An explanation for this deficit could be a change in the PD. In addition, maladaptive safety behaviors are also different across
focus of attention. In order to attribute mental states to a person, it is anxiety disorders, examples being avoiding eye contact in SAD, fixating
necessary to focus attention on a person, identify their focus of attention, on appearance in BDD, avoiding trauma-related triggers in PTSD, and
and keep track of their experiences (Kampis et al., 2017). It could be avoiding arousal-related body sensations in PD. Finally, there are dif­
argued, however, that for all these disorders, patients focus their ferences in which domains are most strongly affected: For example,
attention more on their own anxieties than on other aspects of their family life in OCD and social life in SAD (Lochner et al., 2003). Only one
environment (Nakajima et al., 2017). Also, when being confronted with study so far has taken these differences into account when studying
their anxieties, stress and arousal increase, resulting in a switch from mentalization. In their meta-analysis, Plana and colleagues (2014)
controlled mentalizing to automatic mentalizing (Luyten et al., 2020). found larger impairments in mentalizing for patients with PTSD than for
The latter is advantageous for an arising fight/flight response, but patients with SAD or OCD, but they did not include studies on other
problematic in our complex interpersonal world. Automatic mentalizing anxiety and related disorders. Although this study was very informative,
results in overly simplistic, and thus often biased, assumptions about self it is important to study the differences in mentalization between anxiety
and others (Luyten et al., 2020). Furthermore, mentalizing deficits could and related disorders more extensively. This will provide knowledge
be a way in which anxiety disorders are maintained. For example, that helps to better understand similarities and differences between the
anxiety increases in a person with posttraumatic stress disorder (PTSD) disorders. This added knowledge could eventually help provide more
that encounters a trauma trigger (Kleim et al., 2013). An example of carefully planned interventions to aid anxious individuals in their close
such a trigger might be another person unexpectedly putting a hand on relationships.
their shoulder. A correcting experience would be the realization that the In the current study, the goal was to sum up what is known from the
trigger is not dangerous in itself because that person may intend to existing studies about the mentalization processes of individuals with an
comfort them, even though it is a reminder of the trauma. A mentali­ anxiety and a related disorder by means of a meta-analysis, and to
zation deficit however could result in the person not being able to take compare mentalizing between the different disorders.
the perspective of the other, because the thought ‘I’m anxious, and thus
this trigger is dangerous’ is more pressing. This mentalization deficit 2. Method
results in continuous fear generalization over time (Lorenzini et al.,
2019) and maintains the anxiety. The reporting of this study is based on the Preferred Reporting Items
Despite previous evidence for mentalizing deficits in patients with for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher
anxiety and related disorders (e.g., Buhlmann et al., 2015; et al., 2009).
López-del-Hoyo et al., 2019; Lysaker et al., 2015; Pertusa et al., 2012),
the results are based on a limited number of studies and not as clear-cut 2.1. Literature search
for specific anxiety and related disorders. For example, in a
meta-analysis by Plana and colleagues (2014) mentalizing deficits were An electronic database search was performed on May 31, 2021 using
also shown for anxiety disorders, but the number of available studies the following databases: Embase, PTSDpubs, PsycINFO, PubMed, Ovid
included in the meta-analysis was small; one for social anxiety disorder MEDLINE, and Web of Science. The following key search terms were
(SAD) and posttraumatic stress disorder (PTSD), two for obsessive used: “social phobia”, “social anxiety disorder”, “panic disorder”,
compulsive disorder (OCD), and none for other anxiety related disorders “agoraphobia”, “generalized anxiety disorder”, “specific phobia”, “sep­
(e.g., generalized anxiety disorder (GAD), panic disorder (PD), body aration anxiety disorder”, “selective mutism”, “obsessive compulsive
dysmorphic disorder (BDD)). The study on social anxiety showed that disorder”, “hoarding disorder”, “trichotillomania”, “hair pulling”,
mentalization was impaired in patients with SAD as compared to healthy “excoriation disorder”, “skin picking”, “dermatillomania”, “post­
controls (Jacobs et al., 2008). However, the results for OCD were less traumatic stress disorder”, “reactive attachment disorder”, “disinhibited
clear-cut. One study showed a mentalization deficit in patients with OCD social engagement disorder”, “acute stress disorder”, “adjustment dis­
compared to healthy controls (Bozikas et al., 2009), while another study order”, “persistent complex grief disorder”, “prolonged grief disorder”
found no difference in mentalization between patients with OCD and along with “mentalization”, “theory of mind” and “perspective taking”.
healthy controls (Sayın et al., 2010). In addition, Jansen et al. (2020) In addition, reference lists of eligible studies were screened to identify
also noted discrepancies in results on mentalization in OCD and high­ additional articles for inclusion.
lighted the importance of more and larger studies on the matter. The
finding that patients with PTSD show mentalization deficits was sup­ 2.2. Eligibility criteria
ported by a larger and more recent meta-analysis (Stevens & Jovanovic,
2019). Sharp et al. (2012) suggest that the role of mentalization is Articles eligible for inclusion were: (1) peer-reviewed articles written
essential in explaining responses to trauma and emphasize the need of in English, (2) that reported or provided data on request to calculate
more research on the role of mentalization in PTSD. The limited number between-group standardized mean difference (SMD) estimates (i.e.,
of studies and the mixed findings on mentalization in the different sample size, means and standard deviations), (3) in which the perfor­
anxiety disorders, emphasize the need to conduct further analyses on the mance was compared on a validated mentalization task, (4) between
relationship between mentalization and anxiety disorders. two groups. One group had to be a clinical group, primarily diagnosed

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M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

with an anxiety or related disorder based on formal criteria of the rates. Scores were assessed in such a way that a lower score meant a
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; Amer­ higher mentalization dysfunction.
ican Psychiatric Association [APA], 2013). That includes anxiety dis­ Between-study heterogeneity was examined using a chi-square test
orders (i.e., social phobia, social anxiety disorder, panic disorder, of significance and the I2 statistic. The latter indicates the percentage of
agoraphobia, generalized anxiety disorder, specific phobia, separation variance between studies that is due to differences between studies
anxiety disorder, selective mutism), obsessive-compulsive and related rather than chance (Higgins et al., 2003). I2 was interpreted as low
disorders (i.e., obsessive compulsive disorder, hoarding disorder, (25%), moderate (50%) or substantial (75%).
trichotillomania, hair pulling, excoriation disorder, skin picking, der­ Pre-specified subgroup analyses between anxiety disorders,
matillomania), or trauma and stressor related disorders (i.e., post­ obsessive-compulsive and related disorders, and trauma and stressor
traumatic stress disorder, reactive attachment disorder, disinhibited related disorders were performed, using a random effects model. An I-
social engagement disorder, acute stress disorder, adjustment disorder, squared statistic was also computed for subgroup differences. Review
persistent complex grief disorder, prolonged grief disorder). The other Manager 5 software (Version 5.4, The Nordic Cochrane Centre, Copen­
group had to be a non-clinical comparison group without such a hagen, Denmark) was used to perform meta-analyses and to generate
diagnosis. forest plots. In addition, sensitivity analyses were conducted for the
Studies were excluded if they did not meet inclusion criteria and if overall effect of all articles grouped together and the subgroups of
(1) the mentalization task was not validated, (2) a self-report measure different anxiety and related disorders. When study outliers appeared,
was used to assess mentalization, (3) a diagnosis for an anxiety or related sensitivity analyses were performed excluding outliers. Studies were
disorder was not verified, (4) the article was a review or a case study, (5) considered outliers if the CI of a study did not overlap with the CI of the
the full-text was not available, or (6) the control group did not consist of overall pooled estimate. (Viechtbauer & Cheung, 2010). In addition,
healthy individuals without clinically relevant symptoms. sensitivity analyses were performed only including the articles reporting
on an adult population.
2.3. Data extraction
3. Results
Three authors (LvE, PJ, and MS) independently assessed the eligi­
bility of retrieved articles by screening title and abstract. Possible The literature search resulted in 2844 records (see Fig. 1). A total
eligible articles were assessed full-text, given the inclusion criteria. number of 1521 records remained when duplicates were removed. 1415
Disagreements were firstly resolved through discussion and next by records were further excluded by title and abstract and the full text of 95
consulting the last author (EvE) for arbitration. A standardized spread­ records was examined. Two additional records were identified by
sheet was used to extract the following variables per article: author(s), checking the references of the included studies. The search resulted in a
year of publication, study title, sample data (n, age, sex of anxiety and total inclusion of 26 eligible articles, including 1056 patients with an
related disorders and control groups), applied task(s), and task outcome anxiety or related disorder (Mage = 33.55, SDage = 8.86, rangeage: 13.90
data to calculate the between-group means and standard deviations. – 49.40, 39.7% males) and 1231 controls (Mage = 31.94, SDage = 8.91,
rangeage: 13.40 – 48.29, 42.6% males). For obsessive-compulsive and
2.4. Risk of bias assessment related disorders specifically, 11 articles were included, including 505
patients (Mage = 34.34, SDage = 9.61, rangeage: 13.90– 49.40, 42.5%
To evaluate the quality of each of the included studies, a risk of bias males) and 524 controls (Mage = 33.13, SDage = 9.79, rangeage: 13.40–
assessment was performed. This was done using the criteria established 48.29, 45.8% males). For anxiety disorders 11 articles were included,
by the Agency of Healthcare Research and Quality (Agency for Health­ including 379 patients (Mage = 28.43, SDage = 7.07, rangeage: 14.28–
care Research and Quality, 2014). These criteria include: selection bias, 38.10, 35.9% males) and 476 controls (Mage = 26.67, SDage = 6.94,
performance bias, detection bias, attrition bias, and reporting bias. A rangeage: 14.38 – 37.40, 37.9% males). And lastly, for trauma and
more detailed overview of these criteria is provided in Appendix A. The stressor related disorders six articles were included, including 172 pa­
assessments were performed by three authors (MS, LvE, and PJ) so that tients (Mage = 41.25, SDage = 10.23, rangeage: 34.80 – 44.10, 40.5%
each article was independently rated by at least two authors. Any dis­ males) and 231 controls (Mage = 39.22, SDage = 10.23, rangeage: 31.70 –
agreements were solved through discussion. 48.29, 44.9% males). See Table 1 for a more detailed overview of
characteristics of included studies.
2.5. Meta-analysis procedure
3.1. Study characteristics
Standardized mean differences (SMD) including 95% confidence
intervals (CI) were estimated utilizing a random effects model. SMDs In almost all studies, the diagnosis was confirmed using a clinical
were weighted using the inverse variance method. The SMD involves the interview (n = 23), such as the Structured Clinical Interview for DSM-5
between-group (clinical disorder vs healthy controls) mean difference disorders (SCID-V; First et al., 2016). In the remaining three studies, it is
on mentalization task performance divided by the pooled standard de­ stated that the diagnoses are confirmed but the authors do not specify
viation. If needed, SMDs were inverted to ensure that a negative SMD how.
denoted inferior task performance in the clinical group compared to In addition, In over half of the studies it was determined there was no
controls. Based on Cohen (1988), SMDs can be interpreted as small (0.2), comorbid disorder (n = 14), as this was often an exclusion criterion in
medium (0.5), and large (0.8). these studies. Seven studies did report comorbidity, with mood disorders
In the case studies that used multiple measures to assess mentaliza­ such as major depressive disorder being the most prevalent, followed by
tion, task outcomes were pooled before analyses, resulting in one panic disorder and substance use disorders. Moreover, studies on patient
mentalization SMD estimate per study. When measure outcomes were groups with PTSD also report a few cases with comorbid anxiety disor­
represented by several subscale scores instead of a total score, those ders or with obsessive-compulsive and related disorders. The same is
subscale scores were also pooled before analyses. When multiple scores true for the other subgroups of patient population. The remaining
per task were used, and a total score was included, only the total score studies did not assess comorbidity (n = 5).
was used. In line with former meta-analytic studies with respect to Most studies did include a screening for their control group to ensure
mentalization deficits in anxiety disorders and related disorders (e.g., they were ‘healthy’ controls (n = 19). The other studies (n = 7) did often
Janssen et al., 2022; Stevens & Jovanovic, 2019), the performance mention history or presence of psychiatric disorders as an exclusion
outcome of mentalization was operationalized in terms of accuracy criterion, but there was no report of screening assessments for the

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M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

Fig. 1. Flow diagram (Page et al., 2021).

control group. with anxiety and related disorders as compared to controls.

Over half the studies used more than one instrument to assess
mentalization (n = 14). The most commonly used instrument was the 3.3.1. Anxiety and related disorders
Reading the Mind in the Eyes Test (n = 17). Other used instruments 26 studies compared mentalization between patients with an anxiety
included the Faux-Pas task (n = 4), the Movie for Assessment of Social and related disorder versus controls (Ayribas et al., 2020; Bozikas et al.,
Cognition (n = 4), the Strange Stories task (n = 4), Hinting task (n = 4), 2009; Buhlmann et al., 2015; Hendriks et al., 2020; Hezel & McNally,
False-Belief task (n = 2), the Cartoon task (n = 2), the Emotion Attri­ 2014; Jacobs et al., 2008; Janke et al., 2018; Janssen et al., 2014;
bution task (n = 2), Yoni task (n = 1), a Deictic Framing task (n = 1), the Kücükparlak et al., 2021; Liu et al., 2017; López-del-Hoyo et al., 2019;
Mayer-Salovey-Caruso Emotional Intelligence Test (n = 1), the Test of Lysaker et al., 2015; Maleki et al., 2020; Mazza et al., 2012; Mısır et al.,
Emotional Intelligence (n = 1), the Interpersonal Perception Task 2018; Nazarov et al., 2014; Nietlisbach et al., 2010; Özturk et al., 2020;
(n = 1), and the Bell-Lysaker Emotion Recognition Task (n = 1). A more Pertusa et al., 2012; Pino et al., 2016; Sayın et al., 2010; Schmidt &
detailed description of each of these tasks is provided in Appendix B. Zachariae, 2009; Tulacı et al., 2018; Washburn et al., 2016; Yazici &
See Table 1 for additional characteristics and the effect sizes of the Yazici, 2019; Zainal & Newman, 2018). Mentalization was significantly
included studies. and moderately impaired in the patient group relative to controls (SMD
= − 0.60, 95% CI [− 0.88, − 0.31], p < .001). Significant substantial
heterogeneity was observed (T2 = 0.55, χ2(29) = 291.18, p < .001; I2
3.2. Risk of bias assessment
= 90%). There was no significant difference between subgroups
(χ2(2) = 2.12, p = .35, I2 = 5.8%).
In five of the included studies, there was no risk of bias and all
In addition, sensitivity analyses were performed excluding five study
criteria were rated as ‘good’. Most studies (n = 19) scored ‘fair’ on one
outliers (Hendriks et al., 2020; Liu et al., 2017; López-del-Hoyo et al.,
or more criteria and ‘good’ on the other criteria. There seemed to be an
2019; Schmidt & Zachariae, 2009; Zainal & Newman, 2018). These
especially prevalent reporting bias with 14 articles scoring ‘fair’ and one
outliers were removed as CIs of these studies and the overall estimate did
article scoring ‘poor’. This was mainly due to no reports on conflicts of
not overlap. The remaining between-group estimate of mentalization
interest. As for selection bias, 13 articles were rated as ‘fair’ and two as
was significant (SMD = − 0.48, 95% CI [− 0.63, − 0.34], p < .001). Sig­
‘poor’. This was mainly due to lack of screening for psychiatric disorders
nificant moderate heterogeneity was found (T2 = 0.07, χ2(24) = 53.96
in the control group and/ or no clear report on inclusion/ exclusion
p < .001; I2 = 56%). There remained no significant difference between
criteria. See Table 2 for a full overview of the risk of bias assessment per
subgroups regarding heterogeneity (χ2(2) = 1.84, p = .40, I2 = 0%).
included study.
An additional sensitivity analysis was performed, excluding articles
that include child and adolescent samples (Özturk et al., 2020; Yazici &
3.3. Meta-analysis results Yazici, 2019). Mentalization was significantly and moderately impaired
in the patient group relative to controls (SMD = − 0.58, 95% CI [− 0.89,
Fig. 2 shows the results for the mentalizing abilities of individuals

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M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

Table 1 Table 1 (continued )

Characteristics and Effect Sizes of Included Studies. Articles Disorder n nC % Mean Effect
Articles Disorder n nC % Mean Effect PT Men age size
PT Men age size (PT/ (PT/C) (SMD)
(PT/ (PT/C) (SMD) C) [95%
C) [95% CI]
CI]
Obsessive compulsive related disorders
Obsessive compulsive related disorders
32/ 37.8/ -0.35 [−
Ayribas, Ayhan, OCD 38 38 37/ 33.5/ -0.90 [− 51 37.4 0.88,
Topcuoglu, Kose, 40 34.7 1.37, − 0.17]
and Sayar (2020) 0.43] Washburn, Wilson, SAD 12 43 42/ 19.8/ -0.47 [−
Bozikas et al. (2009) OCD 25 25 40/ 32.7/ -0.00 [− Roes, Rnic, and 35 18.7 1.11,
56 33.4 0.56, Harkness (2016) 0.18]
0.55] Zainal and Newman GAD 69 102 9/26 18.8/ 0.11 [−
Buhlmann et al. BDD 35 35 40/ 33.5/ -0.71 [− (2018) 19.0 0.19,
(2015) 40 32.7 1.20, − 0.42]
0.23] Trauma and stressor related
Buhlmann et al. OCD 35 35 51/ 34.0/ -0.14 [− disorders
(2015) 40 32.7 0.61, Janke, Driessen, PTSD 41 63 17/ 34.8/ -0.85 [−
0.33] Behnia, 37 31.7 1.26, −
Liu et al. (2017) OCD 40 38 45/ 34.6/ -53.47 Wingenfeld, and 0.44]
42 23.3 [− Roepke (2018)
62.09, Lysaker et al. (2015) PTSD 48 51 85/ 41.7/ -0.33 [−
− 88 48.3 0.72,
44.85] 0.07]
López-del-Hoyo et al. OCD 31 30 65/ 40.2/ -2.45 [− Mazza et al. (2012) PTSD 20 15 -/- 41.1/ -1.60 [−
(2019) 23 46.4 3.12, − 36.8 2.38, −
1.77] 0.82]
Mısır, Bora, and OCD 34 30 38/ 32.4/ -0.57 [− Nazarov et al. (2014) PTSD 31 20 0/0 42.1/ -0.18 [−
Akdede (2018) 57 34.4 1.07, − 35.8 0.74,
0.07] 0.38]
Pertusa et al. (2012) HD 52 55 23/ 49.4/ 0.19 [− Nietlisbach, PTSD 16 16 50/ 43.7/ 0.37 [−
51 37.4 0.19, Maercker, Rössler, 50 42.3 0.33,
0.57] and Haker (2010) 1.07]
Pertusa et al. (2012) OCD 31 55 39/ 39.0/ -0.15 [− Schmidt and PTSD 16 66 50/ 44.1/ -2.11 [−
51 37.4 0.59, Zachariae (2009) 50 40.4 2.74, −
0.29] 1.47]
Pino et al. (2016) OCD 24 23 50/ 39.1/ -0.32 [−
Note. PT = patients; C = controls, SMD = standardized mean difference, CI =
57 38.7 0.89,
0.26] confidence interval, BDD = Body Dysmorphic disorder, HD = hoarding disorder,
Sayın et al. (2010) OCD 30 30 33/ 34.3/ -0.42 [− OCD = obsessive compulsive disorder, PTSD = posttraumatic stress disorder;
33 33.0 0.93, SAD = social anxiety disorder.
0.09]
Tulacı et al. (2018) OCD 80 80 35/- 30.0/- -0.59 [−
− 0.28], p < .001). Significant substantial heterogeneity was observed
0.91, −
0.28] (T2 = 0.59, χ2(27) = 284.50, p < .001; I2 = 91%). There was no signif­
Yazici and Yazici OCD 50 50 56/ 13.9/ -0.77 [− icant difference between subgroups (χ2(2) = 2.077, p = .25, I2
(2019) 60 13.4 1.18, − = 27.8%).
0.37]
Anxiety disorders
Buhlmann et al. SAD 35 35 40/ 32.2/ -1.05 [−
3.3.2. Obsessive-compulsive and related disorders
(2015) 40 32.7 1.55, − Eleven of the 26 studies compared mentalization between patients
0.55] with an obsessive- compulsive and related disorder versus controls
Hendriks et al. (2020) Anxiety 39 39 62/ 0.56 (Ayribas et al., 2020; Bozikas et al., 2009; Buhlmann et al., 2015; Liu
disorders 54 [0.10,
et al., 2017; López-del-Hoyo et al., 2019; Mısır et al., 2018; Pertusa et al.,
1.01]
Hezel and McNally SAD 40 40 33/ 26.5/ -0.39 [− 2012; Pino et al., 2016; Sayın et al., 2010; Tulacı et al., 2018; Yazici &
(2014) 15 20.1 0.83, Yazici, 2019). Mentalization was significantly and moderately impaired
0.05] in the patient group relative to controls (SMD = − 0.78, 95% CI [− 1.35,
Jacobs et al. (2008) SAD 28 21 54/ 32.4/ -0.39 [− − 0.21], p = .01). Significant substantial heterogeneity was observed (T2
52 36.0 0.96,
0.19]
= 0.96, χ2(12) = 203.85, p < .001; I2 = 94%).
Janssen et al. (2014) SAD 13 14 31/ 38.1/ -0.55 [− A sensitivity analysis was performed in which two study outliers (Liu
36 33.7 1.32, et al., 2017; López-del-Hoyo et al., 2019) were removed as CIs of these
0.23] two studies and the overall estimate did not overlap. The remaining
Kücukparlak et al. SAD 47 50 60/ 31.2/ -0.61 [−
between-group estimate of mentalization was significant (SMD = − 0.40,
(2021) 52 31.3 1.02, −
0.20] 95% CI [− 0.62, − 0.19], p < .001). Significant substantial heterogeneity
Maleki, Zabihzadeh, SAD 35 35 45/ 27.5/ -0.44 [− was found (T2 = 0.08, χ2(10) = 24.94, p = .005; I2 = 60%).
Richman, 57 28.4 0.92, An additional sensitivity analysis was performed excluding Yazici
Demetrovics, and 0.03] and Yazici (2019), as this study was not performed with an adult pop­
Mohammadnejad
(2020)
ulation. Mentalization was significantly and moderately impaired in the
Özturk et al. (2020) SAD 42 42 12/ 14.3/ -0.92 [− patient group relative to controls (SMD = − 0.81, 95% CI [− 1.44,
14 14.4 1.37, − − 0.18], p = .01). Significant substantial heterogeneity was observed (T2
0.47] = 1.08, χ2(11) = 201.89, p < .001; I2 = 95%).
Pertusa et al. (2012) SAD 19 55

5
M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

Table 2
Risk of Bias Assessment of Included Studies.
Studies Selection Performance Detection Attrition Reporting

Obsessive compulsive related disorders

Ayribas et al. (2020) Good Good Fair Good Fair

Bozikas et al. (2009) Fair Fair Fair Good Fair
Buhlmann et al. (2015) Good Good Good Good Fair
Liu et al. (2017) Good Good Good Good Good
López-del-Hoyo et al. (2019) Fair Good Good Good Good
Mısır et al. (2018) Fair Fair Fair Good Fair
Pertusa et al. (2012) Fair Good Fair Fair Good
Pino et al. (2016) Fair Good Good Good Good
Sayın et al. (2010) Fair Fair Good Good Fair
Tulacı et al. (2018) Poor Good Good Good Good
Yazici and Yazici (2019) Fair Good Good Good Good
Anxiety disorders
Buhlmann et al. (2015) Good Good Good Good Fair
Hendriks et al. (2020) Fair Good Good Good Fair
Hezel and McNally (2014) Fair Good Good Good Good
Jacobs et al. (2008) Good Good Good Good Fair
Janssen et al. (2014) Fair Good Fair Good Fair
Kücukparlak et al. (2021) Good Good Good Good Good
Maleki et al. (2020) Good Good Good Good Good
Özturk et al. (2020) Good Good Good Good Good
Pertusa et al. (2012) Fair Good Fair Fair Good
Washburn et al. (2016) Good Fair Fair Good Fair
Zainal and Newman (2018) Fair Good Fair Good Fair
Trauma and stressor related disorders
Janke et al. (2018) Good Good Good Good Good
Lysaker et al. (2015) Fair Good Good Good Fair
Mazza et al. (2012) Good Good Fair Good Poor
Nazarov et al. (2014) Good Good Good Good Fair
Nietlisbach et al. (2010) Poor Good Fair Good Fair
Schmidt & Zacharia (2009) Fair Fair Fair Good Fair

3.3.3. Anxiety disorders mentalization was marginally significant (SMD = − 0.50, 95% CI
Eleven of the 26 studies compared mentalization between patients [− 1.02, 0.01], p = .06). Significant substantial heterogeneity was found
with an anxiety disorder versus controls (Buhlmann et al., 2015; Hen­ (T2 = 0.26, χ2(4) = 18.34, p < .001; I2 = 78%). Studies on trauma- and
driks et al., 2020; Hezel & McNally, 2014; Jacobs et al., 2008; Janssen stressor related disorders did not include child or adolescent samples,
et al., 2014; Kücükparlak et al., 2021; Maleki et al., 2020; Özturk et al., hence no additional sensitivity analysis was performed.
2020; Pertusa et al., 2012; Washburn et al., 2016; Zainal & Newman,
2018). Mentalization was significantly and moderately impaired in the 4. Discussion
patient group relative to controls (SMD = − 0.39, 95% CI [− 0.68,
− 0.11], p = .007). Significant substantial heterogeneity was observed The current meta-analysis aimed to sum up existing evidence
(T2 = 0.17, χ2(10) = 39.87, p < .001; I2 = 75%). regarding the ability to mentalize across anxiety and related disorders (i.
In a sensitivity analysis, two study outliers (Hendriks et al., 2020; e., anxiety disorders, obsessive-compulsive and related disorders, and
Zainal & Newman, 2018) were removed as CIs of these two studies and trauma and stressor related disorders) compared to healthy controls by
the overall estimate did not overlap. The remaining between-group es­ means of a meta-analysis. Findings indicate impaired mentalization in
timate of mentalization was significant (SMD = − 0.59, 95% CI [− 0.76, patient groups with anxiety and related disorders as compared to
− 0.42], p < .001). No significant heterogeneity was found (T2 = 0.00, healthy controls. More specifically, mentalization deficits were found in
χ2(8) = 7.84, p = .45; I2 = 0%). all patient groups: Patients with anxiety disorders, patients with
In an additional sensitivity analysis, the study including child and obsessive-compulsive and related disorders, and patients with trauma
adolescent samples was excluded (Özturk et al., 2020). Mentalization and stressor related disorders show impaired mentalization as compared
was significantly and moderately impaired in the patient group relative to healthy controls. In sum, there are clear indications of mentalization
to controls (SMD = − 0.34, 95% CI [− 0.63, − 0.05], p = .02). Significant deficits in patients with anxiety and related disorders.
substantial heterogeneity was observed (T2 = 0.15, χ2(9) = 32.66, As the results of the current study indicate, impaired mentalization
p < .001; I2 = 72%). may represent a key clinical factor across anxiety and related disorders.
Specifically, improving aspects of mentalization, such as the processing
3.3.4. Trauma and stressor related disorders of thoughts and feelings and perspective taking, may improve human
Six of the 26 studies compared mentalization between patients with a relationships and interpersonal functioning in these patient groups.
trauma and stressor related disorder versus controls (Janke et al., 2018; Additionally, the ability to mentalize might be crucial in perceiving and
Lysaker et al., 2015; Mazza et al., 2012; Nazarov et al., 2014; Nietlisbach making use of offered social support – a robust predictor for mental
et al., 2010; Schmidt & Zachariae, 2009). Mentalization was signifi­ health. Indeed, previous research finds that the absence or suboptimal
cantly and moderately impaired in the patient group relative to controls utilization of social support is related to psychopathology (e.g., Hoef­
(SMD = − 0.77, 95% CI [− 1.40, − 0.13], p = .02). Significant substantial nagels et al., 2007; Ozer et al., 2003). Thus, the ability to mentalize
heterogeneity was observed (T2 = 0.53, χ2(5) = 39.89, p < .001; I2 might be a crucial ability to build relationships. These relationships can
= 87%). particularly be of support, if individuals perceive the received social
A sensitivity analysis excluding one study outlier (Schmidt & support as helpful (Wang et al., 2021). Hence, problems with mental­
Zachariae, 2009) was performed as CIs of this study and the overall izing might be considered a transdiagnostic factor contributing to
estimate did not overlap. The remaining between-group estimate of interpersonal functioning and the ability to build supportive

6
M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

Fig. 2. Results of the Meta-Analysis: Mentalization in Different Disorders as Compared to Healthy Controls.

relationships across common psychiatric disorders. they also found that mentalization was clearly and significantly more
Moreover, the findings of the current study suggest that the degree of impaired in patients with PTSD compared to other anxiety disorders
impairment in mentalization might be disorder-specific. Although de­ (including OCD) and healthy controls. However, the difference in
ficiencies are noted in all patient groups, the between-group difference mentalization between the trauma and stressor related disorders group
was not found in the specific subgroup of patients with trauma- and and the control group became marginally significant (p = .06) in the
stressor related disorders when study outliers were removed. The pa­ current study after the removal of one outlier. This outlier (Schmidt &
tients in the OCD and related disorders group and the anxiety disorders Zachariae, 2009) thus seems to be highly influential on the results. The
condition did demonstrate such a deficit in mentalization even after significant between-group effect for patients with trauma and stressor
removal of outliers. Hence, the observed mentalization deficit may be related disorders versus controls should therefore be interpreted with
more robust in patients with anxiety disorders or OCD and related dis­ caution. An explanation for the lack of a significant difference after the
orders. Moreover, it must be noted that the group with anxiety disorders removal of the outlier may lie in the limited number of studies that were
mostly consisted of patients diagnosed with a social anxiety disorder. included in the current meta-analysis. Only six articles focused on
Thus, mentalization deficits in the anxiety disorder group seem to be mentalization in patient groups with trauma- and stressor related dis­
present in patients with social anxiety, but less is known about men­ orders, of which one was removed as an outlier in the sensitivity anal­
talization deficits in individuals with other anxiety disorders. ysis, while patient groups with anxiety disorders and OCD and related
The finding of a significant disorder-specific deficit with mentaliza­ disorders were compared to healthy controls in eleven studies each. The
tion in PTSD diagnosed patients is consistent with Plana et al. (2014), as limited number of studies could account for a lack of power to detect

7
M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

significant effects, although the sample sizes of the included studies is arguably important (Main, 1991). Colonnesi et al. (2017) found that
were sufficiently large. Another explanation may lie in PTSD related social anxiety seems to be related to mentalization in a non-clinical
difficulties with mentalization, where mentalization deficits are poten­ sample of 4-year olds. Moreover, both studies that were included in
tially linked to an underlying emotion processing deficit in PTSD the current meta-analysis (Özturk et al., 2020; Yazici & Yazici, 2019)
(Fonagy et al., 2012). These emotional processing deficits might be a found a significant mentalization deficit in adolescents diagnosed with
consequence of the core symptoms of PTSD, such as emotional numbing, an anxiety or related disorder as compared to healthy individuals. This
defined as being emotionally unresponsive and detached (APA, 2013). suggests a link between mentalization and anxiety disorders in children.
This underlying emotion processing deficit may be conceptually related However, the number of studies in child or adolescent samples is so
with affective mentalization, which includes the processing of emotions limited that no more than two studies met the inclusion criteria for the
(Fonagy et al., 2012), but is perhaps unrelated to cognitive mentaliza­ current study. This emphasizes the need for more studies on mentali­
tion. However, these types of mentalization are difficult to capture with zation in child or adolescent samples with anxiety and related disorders.
the measurement instruments used in the studies included in this
meta-analysis. These instruments seem to require the participant to
reason about another person’s mental state, which taps into the cogni­ 4.2. Implications
tive dimension of mentalization and not so much affective mentaliza­
tion. Hence, future research should examine mentalization deficits in Despite these limitations, the results of the current study have some
PTSD differentiating between different types of mentalization. important implications. Previously, only one study had focused on
The finding of a disorder-specific mentalization deficit in patients mentalization in anxiety and related disorders differentiating between
with social anxiety is also not in line with Plana et al. (2014), in which patient groups. The current study extended that meta-analysis with
no mentalization deficit was found in this patient group. However, they more recent studies. In addition, the number of studies in each patient
only included one study on social anxiety, whilst the present findings are group was higher in the current study than in previous meta-analyses,
based on multiple studies. Moreover, the literature illustrates that making the current findings more accurate. Theoretically, it seems
problems with social (cognitive) skills are well established in patients plausible that mentalization could be a transdiagnostic factor that con­
with social anxiety (for example, see Pickard et al., 2017). These find­ tributes to interpersonal functioning among common psychiatric disor­
ings suggest that these patients may also portray problems with men­ ders. This also has important clinical implications, as it provides an
talization during social interactions, as the capacity to mentalize can be additional target for treatment. As mentalization seems to be especially
classified as a social (cognitive) skill (Green et al., 2008). Furthermore, affected in PTSD, OCD and SAD, individuals with these disorders could
the mentalization deficit was even found in a non-clinical population, benefit from interventions targeting mentalization. Mentalization
where individuals with higher self-reported social anxiety, perform should be standardly assessed in individuals with PTSD, OCD and SAD,
worse on mentalization tasks (Alvi et al., 2020). Taken together, the so that it can be targeted adequately during treatment. Improving
current study suggests that patients with social anxiety show profound mentalizing may increase experienced social support, which is in turn
difficulties with mentalization, which underscores that addressing important for treatment effect and symptom severity (Santini et al.,
mentalization deficits in these patient groups might be important in 2015). Unfortunately, mentalization-based treatment is not yet avail­
future research and clinical practice. able for anxiety and related disorders, as this is most commonly applied
in personality disorders (Bateman & Fonagy, 2013). As the results of the
4.1. Limitations current study show that mentalization can be seen as a transdiagnostic
factor in anxiety and related disorders, developing mentalization based
A few limitations should be noted. First, a moderate degree of treatment for these patient groups is an important next step.
between-study heterogeneity was found in studies examining certain
study populations, including patients diagnosed with anxiety disorders, 5. Conclusion
obsessive-compulsive and related disorders, and trauma and stressor
related disorders. This might be related to the wide variety of tasks used In conclusion, the current study indicated that mentalization prob­
to measure mentalization. Additionally, potential confounding effects of lems are present across common psychiatric conditions, including anx­
comorbid psychiatric conditions may have led to heterogenetic iety and related disorders (i.e., anxiety disorders, obsessive-compulsive
between-study results, as comorbidity was present in seven of the and related disorders, and trauma and stressor related disorders) with
included studies, while five studies did not assess comorbidity. Second, specific deficiencies noted in PTSD, OCD and SAD. These findings un­
the instruments used in the included studies seemed to tap into the derscore that mentalization might represent a transdiagnostic factor that
cognitive construct of mentalization. Hence, it was not possible to could be a target for clinical interventions. Additionally, disorder-
examine differences between affective and cognitive mentalization. A specific interventions may be needed as mentalization problems might
third study limitation is that the number of studies for each patient be more profound in certain mental conditions and related to specific
population was limited, which might have led to distorted results. This symptoms.
may particularly be the case with respect to the trauma and stressor
related disorders conditions, consisting of six studies. However, the
sample sizes of the included studies themselves seem to be sufficient. Declaration of interest
This also seems to be true for anxiety disorders, as nine out of eleven
studies in this subgroup only included samples with SAD. An additional None.
limitation is the risk of bias in the included studies. The majority of the
included studies scored ‘fair’ or ‘poor’ on one or more criteria. While the Acknowledgment
quality of the those studies was still rated as ‘fair’, it should be noted that
potential biases in these studies may have distorted the results. Finally, None.
the current meta-analysis included only two studies with child/
adolescent samples. While the sensitivity analyses excluding these
studies did not show different results, it is important to differentiate Funding
between these age groups when assessing mentalization. Mentalization
is a social cognitive skill that develops during childhood and examining This research did not receive any specific grant from funding
how this may be affected in children with anxiety and related disorders agencies in the public, commercial, or not-for-profit sectors.

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M. Sloover et al. Journal of Anxiety Disorders 92 (2022) 102641

Appendix A. Supporting information Psychiatry, 11. Article 118 〈https://dx-doi-org.ru.idm.oclc.org/10.3389%2Ffpsyt.2

020.00118〉.
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