Mentalization, attachment, and defense mechanisms: a Psychodynamic Diagnostic Manual-2-oriented empirical investigation

Submitted: March 2, 2021
Accepted: March 17, 2021
Published: March 29, 2021
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Mentalizing capacities depends on the quality of primary attachment interactions with caregivers who thinks of the child as a subject with mental states. Operationalized as reflective functioning, mentalization is crucial for regulating emotions and developing of a coherent sense of identity, for interacting with individuals making sense to own and others mental states, and for distinguishing internal and external realities without distortions. Although the clinical literature on interplay between mentalization, attachment, and emotional regulation is rich, the empirical research is limited. This study sought to explore connections between reflective functioning, attachment styles, and implicit emotion regulation, operationalized as defense mechanisms, in a group of depressive patients. Twenty-eight patients were interviewed using the adult attachment interview (AAI) and diagnosed using the Psychodynamic Chart-2 of the Psychodynamic Diagnostic Manual, Second Edition. The reflective functioning scale and the defense mechanisms rating scale Q-sort were applied to AAI transcriptions to assess reflective functioning and defensive profile. Patients with secure attachment showed significantly higher levels in reflective functioning and overall defensive functioning as compared to those with insecure attachment. Good reflective functioning and secure attachment correlated with mature defenses and specific defensive mechanisms that serve in better regulating affective states. Overall, the relationship between mentalization, attachment and emotion regulation lay the foundations for the delineation of defensive profiles associated with attachment patterns and reflective functioning in depressive patients. The systematic assessment of these psychological dimensions with gold-standard tools may help in tailoring personalized therapeutic interventions and promoting more effective treatments.



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American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author. doi:
Antonsen, B. T., Johansen, M. S., Rø, F. G., Kvarstein, E. H., & Wilberg, T. (2016). Is reflective functioning associated with clinical symptoms and long-term course in patients with personality disorders?. Comprehensive Psychiatry, 64, 46-58. doi:
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226-244. doi:
Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford, UK: Oxford University Press. doi:
Besharat, M. A., & Khajavi, Z. (2013). The relationship between attachment styles and alexithymia: mediating role of defense mechanisms. Asian Journal of Psychiatry, 6(6), 571-576. doi:
Boldrini, T., Lo Buglio, G., Giovanardi, G., Lingiardi, V., & Salcuni, S. (2020). Defense mechanisms in adolescents at high risk of developing psychosis: An empirical investigation. Research in Psychotherapy: Psychopathology, Process and Outcome, 23(1). doi:
Bouchard, M., Target, M., Lecours, S., Fonagy, P., Tremblay, L., Schachter, A., & Stein, H. (2008). Mentalization in adult attachment narratives: reflective functioning, mental states, and affect elaboration compared. Psychoanalytic Psychology, 25 (1), 47-66. doi:
Bowlby, J. (1969). Attachment and Loss: vol. I. Attachment. New York, NY: Basic Books.
Bowlby, J. (1973). Attachment and loss: vol. II Separation, anxiety and anger. New York, NY: Basic Books.
Bowlby, J. (1980). Attachment and Loss. Vol. 3: Loss, Sadness and Depression. New York, NY: Basic Books.
Calati, R., Oasi, O., De Ronchi, D., & Serretti, A. (2010). The use of the defense style questionnaire in major depressive and panic disorders: A comprehensive meta-analysis. Psychology and Psychotherapy, 83, 1-13. doi:
Carrère, S., & Bowie, B. H. (2012). Like parent, like child: Parent and child emotion dysregulation. Archives of Psychiatric Nursing, 26(3), e23-e30. doi:
Ciocca, G., Rossi, R., Collazzoni, A., Gorea, F., Vallaj, B., Stratta, P., Longo, L., Limoncin, E., Mollaioli, D., Gibertoni, D., Santarnecchi, E., Pacitti, F., Niolu, C., Siracusano, A., Jannini, E. A., & Di Lorenzo, G. (2020). The impact of attachment styles and defense mechanisms on psychological distress in a non-clinical young adult sample: A path analysis. Journal of Affective Disorders, 273, 384-390. doi:
Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychology, 58(4), 644-663. doi:
Conversano, C., & Di Giuseppe, M. (2021). Psychological factors as determinants of chronic conditions: Clinical and psychodynamic advances. Frontiers in Psychology, 12, 635708. doi:
Cramer, P., & Kelly, F. D. (2010). Attachment style and defense mechanisms in parents who abuse their children. The Journal of Nervous and Mental Disease, 198(9), 619-627. doi:
Di Giuseppe, M., Ciacchini. R., Piarulli, A., Nepa, G., & Conversano, C. (2019). Mindfulness disposition and defense style as positive responses to psychology distress in oncology professionals. European Journal of Oncology Nursing, 40, 104-110. doi:
Di Giuseppe, M., Gennaro, A., Lingiardi, V., & Perry, J.C. (2019). The role of defense mechanisms in emerging personality disorders in clinical adolescents. Psychiatry, 82, 128-142. doi:
Di Giuseppe, M., Perry, J. C., Lucchesi, M., Michelini, M., Vitiello, S., Piantanida, A., Fabiani, M., Maffei, S., & Conversano, C. (2020). Preliminary reliability and validity of the DMRS-SR-30, a novel self-report based on the Defense Mechanisms Rating Scales. Frontiers in Psychiatry, 11, 870. doi:
Di Giuseppe, M., Perry, J.C., Petraglia, J., Janzen, J., & Lingiardi, V. (2014). Development of a Q-sort version of the defense mechanisms rating scales (DMRS-Q) for clinical use. Journal of Clinical Psychology, 70, 452-465. doi:
Di Giuseppe, M., Prout, T. A., Fabiani, M., & Kui, T. (2020). Defensive profile of parents of children with externalizing problems receiving Regulation-Focused Psychotherapy for Children (RFP-C): A pilot study. Mediterranean Journal of Clinical Psychology, 8(2). doi:
Eagle, M. N. (2013). Intersections: Psychoanalysis and psychological science.Attachment and psychoanalysis: Theory, research, and clinical implications. New York, NY: Guilford Press.
Fischer-Kern, M., Buchheim, A., Hörz, S., Schuster, P., Doering, S., Kapusta, N. D., Taubner, S., Tmej, A., Rentrop, M., Buchheim, P., & Fonagy, P. (2010). The relationship between personality organization, reflective functioning, and psychiatric classification in borderline personality disorder. Psychoanalytic Psychology, 27(4), 395-409. doi:
Fonagy, P., & Target, M. (1997). Attachment and reflective function: their role in self-organization. Development and psychopathology, 9(4), 679-700. doi:
Fonagy, P., Gergely, G., Jurist, E., Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. Other Press, New York.
Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2019). Mentalizing, epistemic trust and the phenomenology of psychotherapy. Psychopathology, 52(2), 94-103. doi:
Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child Development, 62(5), 891-905. doi:
Fonagy, P., Steele, M., Steele, H., Higgitt, A., & Target, M. (1994). The Emanuel Miller Memorial Lecture 1992. The theory and practice of resilience. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 35(2), 231-257. doi:
Fonagy, P., & Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues, 8(1), 87-114. doi:
Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning manual: version 5 for application to adult attachment interviews. (Unpublished manual) University College London.
George, C., Kaplan, N., & Main, M. (1996). Adult Attachment Interview (3rd ed.). Unpublished manuscript, Department of Psychology, University of California, Berkley.
Gordon, R. M., & Bornstein, R. F. (2015). Brief manual for the Psychodiagnostic Chart-2 (PDC-2). Retrieved from:
Gross, J. J., & Thompson, R. A. (2007). Emotion Regulation: Conceptual Foundations. In J. J. Gross (Ed.), Handbook of Emotion Regulation (pp. 3-24). New York, NY: Guilford Press.
Gyurak, A., Gross, J. J., & Etkin, A. (2011). Explicit and implicit emotion regulation: a dual-process framework. Cognition & Emotion, 25(3), 400-412. doi:
Hayden, M. C., Müllauer, P. K., Beyer, K. J., Gaugeler, R., Senft, B., Dehoust, M. C., & Adreas, S. (2021). Increasing mentalization to reduce maladaptive defense in patients with mental disorders. Frontiers in Psychology, 12, 637915. doi:
Hershenberg, R., Davila, J., Yoneda, A., Starr, L. R., Miller, M. R., Stroud, C. B., & Feinstein, B. A. (2011). What I like about you: The association between adolescent attachment security and emotional behavior in a relationship promoting context. Journal of Adolescence, 34(5), 1017-1024. doi:
Hesse, E. (2008). The Adult Attachment Interview: Protocol, method of analysis, and empirical studies. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed., pp. 552-598). New York, NY: Guilford Press.
Hilsenroth, M. J., Callahan, K. L., & Eudell, E. M. (2003). Further reliability, convergent and discriminant validity of overall defensive functioning. The Journal of Nervous and Mental Disease, 191(11), 730-737. doi:
Hilsenroth, M. J., Katz, M., & Tanzilli, A. (2018). Psychotherapy research and the Psychodynamic Diagnostic Manual (PDM-2). Psychoanalytic Psychology, 35(3), 320-327. doi:
Hoglend, P., & Perry, J. C. (1998). Defensive functioning predicts improvement in treated major depressive episodes. The Journal of Nervous and Mental Disease 186(4), 238-243.
Hörz-Sagstetter, S., Mertens, W., Isphording, S., Buchheim, A., & Taubner, S. (2015). Changes in reflective functioning during psychoanalytic psychotherapies. Journal of the American Psychoanalytic Association, 63(3), 481-509. doi:
Katznelson, H. (2014). Reflective functioning: a review. Clinical Psychology Review, 34 (2), 107-117. doi:
Kobak, R., & Bosmans, G. (2019). Attachment and psychopathology: a dynamic model of the insecure cycle. Current Opinion in Psychology, 25, 76-80. doi:
Laczkovics, C., Fonzo, G., Bendixsen, B., Shpigel, E., Lee, I., Skala, K., Prunas, A., Gross, J., Steiner, A., & Huemer, J. (2018). Defense mechanism is predicted by attachment and mediates the maladaptive influence of insecure attachment on adolescent mental health. Current Psychology 39, 1388-1396. doi:
Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., & Kernberg, O. F. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74(6), 1027-1040. doi:
Lingiardi, V., & Bornstein, R. F. (2017). Profile of mental functioning - M axis. In V. Lingiardi & N. McWilliams (Eds.), Psychodynamic diagnostic manual (2nd ed.). (pp. 75-133). New York, NY: Guilford Press.
Lingiardi, V., Lonati, C., Delucchi, F., Fossati, A., Vanzulli, L., & Maffei, C. (1999). Defense mechanisms and personality disorders. The Journal of Nervous and Mental Disease, 187(4), 224-228. doi:
Lingiardi, V., McWilliams, N., Bornstein, R. F., Gazzillo, F., & Gordon, R. M. (2015). The Psychodynamic Diagnostic Manual Version 2 (PDM-2): Assessing patients for improved clinical practice and research. Psychoanalytic Psychology, 32(1), 94-115. doi:
Maffei, C., Fossati, A., Lingiardi, V., Madeddu, F., Borellini, C., & Petrachi, M. (1995). Personality maladjustment, defenses, and psychopathological symptoms in nonclinical subjects. Journal of Personality Disorders, 9(4), 330-345. doi:
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development, 50, 66-104. doi:
Malik, S., Wells, A., & Wittkowski, A. (2015). Emotion regulation as a mediator in the relationship between attachment and depressive symptomatology: A systematic review. Journal of Affective Disorders, 172, 428-444. doi:
Martino, G., Caputo, A., Schwarz, P., Bellone, F., Fries, W., Quattropani, M. C., & Vicario, C. M. (2020). Alexithymia and inflammatory bowel disease: A systematic review. Frontiers in Psychology, 11, 1763. doi:
McMahon, C., Barnett, B., Kowalenko, N., & Tennant, C. (2005). Psychological factors associated with persistent postnatal depression: past and current relationships, defense styles and the mediating role of insecure attachment style. Journal of Affective Disorders, 84(1), 15-24. doi:
Mikulincer, M. (1995). Attachment style and the mental representation of the self. Journal of Personality and Social Psychology, 69(6), 1203-1215. doi:
Mikulincer, M., & Horesh, N. (1999). Adult attachment style and the perception of others: The role of projective mechanisms. Journal of Personality and Social Psychology 76, 1022-1034. doi:
Mikulincer, M., & Shaver, P.R. (2018). Attachment theory as a framework for studying relationship dynamics and functioning. In A. L. Vangelisti & D. Perlman (Eds.), The Cambridge handbook of personal relationships (p. 175-185). Cambridge University Press. doi:
Müller, C., Kaufhold, J., Overbeck, G., & Grabhorn, R. (2006). The importance of reflective functioning to the diagnosis of psychic structure. Psychology and Psychotherapy, 79, 485-494. doi:
Nazzaro, M.P., Boldrini, T., Tanzilli, A., Muzi, L., Giovanardi, G., & Lingiardi, V. (2017). Does reflective functioning mediate the relationship between attachment and personality?. Psychiatry Research, 256, 169-175. doi:
Oasi, O., Buonarrivo, L., Codazzi, A., Passalacqua, M., Risso Ricci, G. M., Straccamore, F., & Bezzi, R. (2017). Assessing personality change with Blatt’s anaclitic and introjective configurations and Shedler-Westen Assessment Procedure profiles: Two case studies in psychodynamic treatment. Research in Psychotherapy: Psychopathology, Process and Outcome, 20(1). doi:
Olson, T. R., Perry, J. C., Janzen, J. I., Petraglia, J., & Presniak, M. D. (2011). Addressing and interpreting defense mechanisms in psychotherapy: General considerations. Psychiatry, 74(2), 142-165. doi:
Perry, J. C. (1990). Defense mechanism rating scales (5th ed.). Boston, MA: The Cambridge Hospital.
Perry, J.C. (2014). Anomalies and specific functions in the clinical identification of defense mechanisms, Journal of Clinical Psychology, 70, 406-418. doi:
Perry, J.C., Presniak, M.D., & Olson, T.R. (2013). Defense mechanisms in schizotypal, borderline, antisocial, and narcissistic personality disorders. Psychiatry,76(1), 32-52. doi:
Prunas, A., Di Pierro, R., Huemer, J, & Tagini, A. (2019). Defense mechanisms, remembered parental caregiving, and adult attachment style. Psychoanalytic Psychology, 36, 64-72. doi:
Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal reflective functioning, attachment, and the transmission gap: A preliminary study. Attachment and Human Development, 7(3), 283-298. doi:
Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. L., & Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with childhood mal- treatment histories: links to sensitive parenting and infant attachment security. Attachment and Human Development, 16 (5), 515-533. doi:
Taubner, S., Hörz, S., Fischer-Kern, M., Doering, S., Buchheim, A., & Zimmermann, J. (2013). Internal structure of the Reflective Functioning Scale. Psychological Assessment. 25 (1), 127-135. doi:
Taubner, S., White, L. O., Zimmermann, J., Fonagy, P., & Nolte, T. (2013). Attachment-related mentalization moderates the relationship between psychopathic traits and proactive aggression in adolescence. Journal of Abnormal Child Psychology, 41, 929-938. doi:
Vaillant, G. E. (1992). Ego mechanisms of defense: A guide for clinicians and researchers. Washington: American Psychiatric Press.

How to Cite

Tanzilli, A., Di Giuseppe, M. ., Giovanardi, G., Boldrini, T., Caviglia, G., Conversano, C., & Lingiardi, V. (2021). Mentalization, attachment, and defense mechanisms: a Psychodynamic Diagnostic Manual-2-oriented empirical investigation. Research in Psychotherapy: Psychopathology, Process and Outcome, 24(1).

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