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Tijdschrift voor Psychiatrie 43 (2001) 10, 705 - 714

Review article

Attachment and psychopathology: reflective functioning

N.J. Nicolai

background In the theory of the British researcher Fonagy disturbances in reflective functioning or mentalisation play a pivotal role in the development of personality disorders. Especially childhood sexual and physical abuse has a negative impact on the development of reflective functioning.
aims In this article an overview is given of recent research on the relationship between attachment, metacognition and reflective functioning in relation tot pathogenesies of personality disorders.
methods Recent research on attachment and reflective functioning was compiled on the basis of recent publications, handbooks, and an internetsearch on Fonagy's researchproject in the United States and United Kingdom.
results Reflective functioning is a reliable measure of secure attachment and mentalisation. Mentalisation means that the individual is able to experience others as having a mind of their own. Reflective functioning can be measured with a nine-point scale (the Reflective Functioning Scale) based on the Adult Attachment Interview. Reflective functioning is significantly lowered in persons with personality disorders. Patients with a history of childhood sexual abuse, physical abuse, early losses and separation have also significantly lowered reflective functioning.
conclusions Psychotherapy with patients with a history of childhood trauma or personality disorder has to take into account the lowered reflective functioning and the underlying disorganised attachment style. Changes in reflective functioning can be the result of developmental and psychodynamic psychotherapy. The Reflective Functioning Scale can also be used as a measure of the efficacy of psychodynamic psychotherapy of personality disorders, posttraumatic stressdisorders and dissociative disorders.

keywords attachment, metacognition, psychopathology, reflective functioning, trauma