Research Article: To know or not to know? Mentalization as protection from somatic complaints

Date Published: May 2, 2019

Publisher: Public Library of Science

Author(s): Sergi Ballespí, Jaume Vives, Naida Alonso, Carla Sharp, María Salvadora Ramírez, Peter Fonagy, Neus Barrantes-Vidal, André Aleman.


Somatization processes are usually associated with a lack of insight or with emotional unawareness, especially in adolescents where the ability for self-reflection is beginning to mature. However, the extent to which different levels of insight explain variations in somatization remains understudied. This study aimed to evaluate whether high-level emotional awareness (comprehension) but not low-level awareness (only attention) is needed to psychologically cope with suffering, thus leading to lower somatization. Specific predictions were: 1) High attention along with High comprehension will be associated with significantly lower frequency of somatic complaints than other combinations (Low attention and Low comprehension, or High attention but Low comprehension); 2) In absence of comprehension, no attention will be more optimal than attention only, because only-attention might work as an amplificatory of suffering without the possibility of processing it. Self-reports of meta-cognitive processes, somatization, and control variables were obtained from 264 adolescents from a non-clinical population (54.5% female; aged 12–18, M = 14.7, SD = 1.7). In line with expectations, results revealed significant differences in the effects of insight positions on somatization: Attention+Comprehension (M = 4.9, SE = 0.9) < Nothing (M = 7.1, SE = 0.3) < Only attention (M = 8.9, SE = 0.7). Compared to Nothing, Attention+comprehension was associated with significantly reduced somatic complaints (B = -2.2, p = 0.03, 95% CI -4,1 to 0.2). However, Only attention was associated with increased somatic complaints compared to the other two conditions (B = 1.8, p = 0.03, 95% CI 0.2 to 3.4; B = 4, CI 95% 1.6–6.3, p = 0.001, respectively). This highlights the role of higher-order awareness (i.e., comprehension or clarity) in the processing of suffering and stresses its value in the adaptive coping of emotional distress.

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The awareness of one’s own mental states—also referred as insight, metacognition, or self-awareness—is present as a therapeutic aim in most psychological treatments [1–5]. Insight is broadly defined as the ability to reflect upon and manage one’s emotions, and to utilize the information provided by these emotions adaptively [6]. Insight has been associated with therapeutic adherence [7,8], and it constitutes a core active ingredient of most psychodynamic interventions, including, for instance, Mentalization Based Treatment (MBT) [9]. This highlights the importance of insight for mental health and spurs interest in how it works, i.e., how it contributes to healthy psychological functioning.

Table 1 shows descriptive statistics and correlations of the variables involved in the analyses. Sex distribution consisted of 57% males in the group with High attention and High comprehension, 46% in the group with Low attention and Low comprehension, 15% in the group with High attention but Low comprehension, and 70% in the group with Low attention but High comprehension. Among the 264 participants, only 23 participants show the most advantageous position (High attention along with High comprehension). The most frequent MZ position was Low attention and Low comprehension (n = 163), while ‘partial positions’ were present in 41 (High attention but Low comprehension) and 37 (Low attention but High comprehension) participants, respectively. As expected, somatization is positively correlated with attention but negatively with comprehension.

The aim of this study was to analyze the association between different types of emotional awareness and somatization in adolescence–a developmental period characterized by the growth of somatization problems as well as an increased capacity for psychological insight. Specifically, the frequency of somatizations in cases of: a) attention along with comprehension, b) attention only but without comprehension, and c) low general awareness (no attention + no comprehension) were compared.

Despite limitations, this study is the first to our knowledge to analyze the separate contribution of two levels of awareness of one’s own emotional states (attention vs. comprehension or clarity) to the frequency of somatic complaints. Current results confirm predictions and are consistent with previous findings: mentalizing appears to be protective against somatization, and the inability to mentalize is associated with a higher frequency of somatic complaints. Furthermore, our findings support that different degrees of insight explain variations in the frequency of somatic complaints, and highlight that 1) comprehension is needed to achieve a level of insight associated with reduced somatization, probably because it helps to process suffering through psychological skills, and 2) low-level of emotional awareness (simple attention but without comprehension) is not only insufficient to prevent somatization, but it can even be the least optimal option, since it probably works as an amplification system and it is associated with the highest frequency of somatic complaints. These results have been obtained with a sample of adolescents from the general population, which means higher tendency to somatize and more developmental variability in mentalizing capacities than in other stages. Knowing that, age and sex were controlled for in all analyses, results were explained in key of development, and need for replication with new samples (e.g., adults, clinical) has been pointed out. Beyond these considerations, this is the first study to highlight the role of comprehension beyond simple attention in the processing of suffering, and to stress the value of emotional understanding (higher-order awareness) in adaptive coping with emotional distress.




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