{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T16:26:51Z","timestamp":1792686411575,"version":"4.5.0"},"reference-count":49,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2023,2,19]],"date-time":"2023-02-19T00:00:00Z","timestamp":1676764800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Anorexia nervosa (AN) usually emerges in adolescence when important changes occur in cognitive, emotional, and social processes. Mentalizing, alexithymia, and impulsiveness represent key dimensions for the understanding and interpretation of psychological difficulties in AN. The outbreak of the COVID-19 pandemic has impacted adolescents with AN, showing a worsening of the disease. The main aims of the present paper are (1) to compare adolescents with AN before and during the COVID-19 pandemic and (2) to explore the relationship between mentalizing, alexithymia, impulsiveness, and psychological difficulties related to eating disorders in adolescents with AN during the COVID-19 pandemic. One hundred and ninety-six AN female adolescents (N = 94 before COVID-19; N = 102 during COVID-19) participated in this study. The results show that adolescents with AN during the COVID-19 pandemic had a more impaired functioning profile than the before COVID-19 group. Mentalizing, alexithymia, and impulsiveness had a predictive role on psychological difficulties related to eating disorders in adolescents with AN during the COVID-19 pandemic. In conclusion, our data reveal that the COVID-19 pandemic has likely represented a stress condition that affects mental health; worsening the severity of adolescents with AN clinical condition. Lastly, predictive patterns suggest the existence of a link between difficulties in the ability to face the problems of the present time using effective strategies and the severity of psychological symptoms.<\/jats:p>","DOI":"10.3390\/ijerph20043670","type":"journal-article","created":{"date-parts":[[2023,2,20]],"date-time":"2023-02-20T03:29:06Z","timestamp":1676863746000},"page":"3670","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Investigating Functioning Profile of Adolescents with Anorexia before and during the COVID-19 Pandemic: A Cross-Sectional Study on Mentalizing, Alexithymia, and Impulsiveness"],"prefix":"10.3390","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0141-1218","authenticated-orcid":false,"given":"Fabiola","family":"Bizzi","sequence":"first","affiliation":[{"name":"Department of Educational Sciences, University of Genoa, Corso A. Podest\u00e0 2, 16121 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2898-094X","authenticated-orcid":false,"given":"Anna","family":"Riva","sequence":"additional","affiliation":[{"name":"Child and Adolescent Mental Health Department, Fondazione IRCCS San Gerardo dei Tintori, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1524-9469","authenticated-orcid":false,"given":"Simone","family":"Charpentier Mora","sequence":"additional","affiliation":[{"name":"Department of Educational Sciences, University of Genoa, Corso A. Podest\u00e0 2, 16121 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0610-6650","authenticated-orcid":false,"given":"Marta","family":"Tironi","sequence":"additional","affiliation":[{"name":"Department of Educational Sciences, University of Genoa, Corso A. Podest\u00e0 2, 16121 Genoa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sofia Elena","family":"Sforza","sequence":"additional","affiliation":[{"name":"Child and Adolescent Mental Health Department, Fondazione IRCCS San Gerardo dei Tintori, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy"},{"name":"School of Medicine and Surgery, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorenzo Maria","family":"Milani","sequence":"additional","affiliation":[{"name":"Child and Adolescent Mental Health Department, Fondazione IRCCS San Gerardo dei Tintori, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3832-2860","authenticated-orcid":false,"given":"Renata","family":"Nacinovich","sequence":"additional","affiliation":[{"name":"Child and Adolescent Mental Health Department, Fondazione IRCCS San Gerardo dei Tintori, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy"},{"name":"NeuroMI\u2014Milan Center for Neuroscience, University of Milano-Bicocca, 20126 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,2,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"American Psychiatric Association, DSM-5 Task Force (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5TM, American Psychiatric Publishing, Inc.. [5th ed.].","DOI":"10.1176\/appi.books.9780890425596"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1080\/07351692209348990","article-title":"Early Intervention and the Development of Self-Regulation","volume":"22","author":"Fonagy","year":"2002","journal-title":"Psychoanal. Inq."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1159\/000286529","article-title":"The Prevalence of \u2018Alexithymic\u2019 Characteristics in Psychosomatic Patients","volume":"22","author":"Sifneos","year":"1973","journal-title":"Psychother. Psychosom."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1002\/eat.22473","article-title":"Attachment and mentalization and their association with child and adolescent eating pathology: A systematic review","volume":"49","author":"Jewell","year":"2015","journal-title":"Int. J. Eat. Disord."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1016\/S0165-1781(00)00109-8","article-title":"Alexithymia and depression in eating disorders","volume":"93","author":"Corcos","year":"2000","journal-title":"Psychiatry Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1521\/bumc.2018.82.3.202","article-title":"The mediating role of mentalizing between attachment and eating disorders","volume":"82","author":"Redondo","year":"2018","journal-title":"Bull. Menn. Clin."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1097\/NMD.0b013e3181e526c8","article-title":"Mentalization and Relationships With Parents as Predictors of Eating Disordered Behavior","volume":"198","author":"Gur","year":"2010","journal-title":"J. Nerv. Ment. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1348\/000711201161145","article-title":"Attachment in anorexia nervosa: A transgenerational perspective","volume":"74","author":"Ward","year":"2001","journal-title":"Br. J. Med. Psychol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1176\/appi.ajp.158.4.547","article-title":"Personality Profiles in Eating Disorders: Rethinking the Distinction Between Axis I and Axis II","volume":"158","author":"Westen","year":"2001","journal-title":"Am. J. Psychiatry"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Rothschild-Yakar, L., Stein, D., Goshen, D., Shoval, G., Yacobi, A., Eger, G., Kartin, B., and Gur, E. (2019). Mentalizing Self and Other and Affect Regulation Patterns in Anorexia and Depression. Front. Psychol., 10.","DOI":"10.3389\/fpsyg.2019.02223"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1002\/erv.2158","article-title":"Reflective Functioning in 70 Patients Suffering from Bulimia Nervosa","volume":"20","author":"Pedersen","year":"2012","journal-title":"Eur. Eat. Disord. Rev."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s40519-018-0482-5","article-title":"Emotional intelligence, empathy and alexithymia in anorexia nervosa during adolescence","volume":"25","author":"Peres","year":"2020","journal-title":"Eat. Weight Disord. Stud. Anorexia, Bulim. Obes."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.psychres.2005.04.001","article-title":"Depressive personality dimensions and alexithymia in eating disorders","volume":"135","author":"Speranza","year":"2005","journal-title":"Psychiatry Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"65","DOI":"10.3280\/MAL2018-002005","article-title":"Disregolazione affettiva, disorganizzazione dell\u2019attaccamento e disturbi alimentari: Fattori di rischio individuali e familiari","volume":"20","author":"Guiducci","year":"2018","journal-title":"Maltrattamento E Abus. All\u2019infanzia"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1007\/s40519-014-0101-z","article-title":"Anorexia nervosa and its relation to depression, anxiety, alexithymia and emotional processing deficits","volume":"19","author":"Schulze","year":"2014","journal-title":"Eat. Weight Disord. Stud. Anorex. Bulim. Obes."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"768","DOI":"10.1002\/1097-4679(199511)51:6<768::AID-JCLP2270510607>3.0.CO;2-1","article-title":"Factor Structure of the Barratt Impulsiveness Scale","volume":"51","author":"Patton","year":"1995","journal-title":"J. Clin. Psychol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1016\/j.eatbeh.2004.11.002","article-title":"Subjective self-control and behavioural impulsivity coexist in anorexia nervosa","volume":"6","author":"Butler","year":"2005","journal-title":"Eat. Behav."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1007\/s40519-021-01126-3","article-title":"High levels of physical activity in female adolescents with anorexia nervosa: Medical and psychopathological correlates","volume":"27","author":"Riva","year":"2022","journal-title":"Eat. Weight Disord. Stud. Anorex. Bulim. Obes."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1016\/j.adolescence.2019.06.007","article-title":"Roles of age, gender and psychological difficulties in adolescent mentalizing","volume":"74","author":"Poznyak","year":"2019","journal-title":"J. Adolesc."},{"key":"ref_20","unstructured":"Luyten, P., Fonagy, P., Lowyck, B., and Vermote, R. (2012). Handbook of Mentalizing in Mental Health Practice, American Psychiatric Publishing, Inc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1080\/08039488.2019.1707869","article-title":"The mentalization profile in patients with eating disorders: A systematic review and meta-analysis","volume":"74","author":"Simonsen","year":"2020","journal-title":"Nord. J. Psychiatry"},{"key":"ref_22","first-page":"1941","article-title":"Alexithymia in parents and adolescent anorexic daughters: Comparing the responses to TSIA and TAS-20 scales","volume":"10","author":"Balottin","year":"2014","journal-title":"Neuropsychiatr. Dis. Treat."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1007\/s007870200006","article-title":"Do Adolescent Anorexia Nervosa Patients Have Deficits in Emotional Functioning?","volume":"11","year":"2002","journal-title":"Eur. Child Adolesc. Psychiatry"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1080\/21662630.2013.794497","article-title":"Deficits in mentalization: A risk factor for future development of eating disorders among beforeadolescent girls","volume":"1","author":"Cate","year":"2013","journal-title":"Adv. Eat. Disord."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"510","DOI":"10.1097\/NMD.0b013e3182948316","article-title":"Mentalizing in Self vs. Parent Representations and Working Models of Parents as Risk and Protective Factors From Distress and Eating Disorders","volume":"201","author":"Waniel","year":"2013","journal-title":"J. Nerv. Ment. Dis."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1186\/s13034-022-00482-x","article-title":"Increase in admission rates and symptom severity of childhood and adolescent anorexia nervosa in Europe during the COVID-19 pandemic: Data from specialized eating disorder units in different European countries","volume":"16","author":"Gilsbach","year":"2022","journal-title":"Child Adolesc. Psychiatry Ment. Health"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Clemente-Su\u00e1rez, V.J., Mart\u00ednez-Gonz\u00e1lez, M.B., Benitez-Agudelo, J.C., Navarro-Jim\u00e9nez, E., Beltran-Velasco, A.I., Ruisoto, P., Arroyo, E.D., Laborde-C\u00e1rdenas, C.C., and Tornero-Aguilera, J.F. (2021). The Impact of the COVID-19 Pandemic on Mental Disorders. A Critical Review. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph181910041"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Monteleone, P. (2021). Eating Disorders in the Era of the COVID-19 Pandemic: What Have We Learned?. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph182312381"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Charpentier Mora, S., Bastianoni, C., Cavanna, D., and Bizzi, F. (2022). Emerging Adults Facing the Covid-19 Pandemic: Emotion Dysregulation, Mentalizing, and Psychological Symptoms. Curr. Psychol. A J. Divers. Perspect. Divers. Psychol. Issues, 1\u20136.","DOI":"10.1007\/s12144-022-03322-5"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"S38","DOI":"10.1037\/tra0000760","article-title":"Losing and regaining reflective functioning in the times of COVID-19: Clinical risks and opportunities from a mentalizing approach","volume":"12","author":"Lassri","year":"2020","journal-title":"Psychol. Trauma Theory Res. Pr. Policy"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"486","DOI":"10.1016\/j.jad.2021.10.091","article-title":"The association between insecurity and subjective well-being among youth during the COVID-19 outbreak: A moderated mediation model","volume":"297","author":"Wen","year":"2021","journal-title":"J. Affect. Disord."},{"key":"ref_32","unstructured":"Garner David, M. (2008). Eating Disorder Inventory-3, Psychological Assessment Resources, Inc."},{"key":"ref_33","unstructured":"Giannini, M., Pannocchia, L., Dalle Grave, R., Muratori, F., and Viglione, V. (2008). EDI-Eating Disorder Inventory-3, Giunti OS."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Fonagy, P., Luyten, P., Moulton-Perkins, A., Lee, Y.-W., Warren, F., Howard, S., Ghinai, R., Fearon, P., and Lowyck, B. (2016). Development and Validation of a Self-Report Measure of Mentalizing: The Reflective Functioning Questionnaire. PLoS ONE, 11.","DOI":"10.1037\/t67295-000"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1002\/jclp.23218","article-title":"The Italian version of the Reflective Functioning Questionnaire: Validity within a sample of adolescents and associations with psychological problems and alexithymia","volume":"78","author":"Bizzi","year":"2022","journal-title":"J. Clin. Psychol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1177\/070674379003500402","article-title":"Validation of the Alexithymia Construct: A Measurement-Based Approach","volume":"35","author":"Taylor","year":"1990","journal-title":"Can. J. Psychiatry"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"551","DOI":"10.1016\/S0022-3999(96)00228-0","article-title":"Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: An Italian multicenter study","volume":"41","author":"Bressi","year":"1996","journal-title":"J. Psychosom. Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"815","DOI":"10.1002\/jclp.1051","article-title":"Psychometric properties of an Italian version of the Barratt Impulsiveness Scale-11 (BIS-11) in nonclinical subjects","volume":"57","author":"Fossati","year":"2001","journal-title":"J. Clin. Psychol."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Locati, F., Milesi, A., Conte, F., Campbell, C., Fonagy, P., Ensink, K., and Parolin, L. (2022). Adolescence in lockdown: The protective role of mentalizing and epistemic trust. J. Clin. Psychol., ahead of print.","DOI":"10.1002\/jclp.23453"},{"key":"ref_40","first-page":"16","article-title":"Exploring mentalizing in adolescents with anorexia nervosa and borderline personality disorder: A comparative study of psychiatric inpatients and healthy controls","volume":"9","author":"Wall","year":"2021","journal-title":"Scand. J. Child Adolesc. Psychiatry Psychol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"104438","DOI":"10.1016\/j.appet.2019.104438","article-title":"Emotion regulation across eating pathology: A meta-analysis","volume":"143","author":"Prefit","year":"2019","journal-title":"Appetite"},{"key":"ref_42","first-page":"24","article-title":"The relationship between alexithymia, defense mechanisms, eating disorders, anxiety and depression","volume":"55","author":"Lenzo","year":"2020","journal-title":"Riv. Di Psichiatr."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"991","DOI":"10.3389\/fpsyt.2019.00991","article-title":"Alexithymia and Treatment Outcome in Anorexia Nervosa: A Scoping Review of the Literature","volume":"10","author":"Gramaglia","year":"2020","journal-title":"Front. Psychiatry"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1002\/erv.817","article-title":"Eating one\u2019s words: Part III. Mentalisation-based psychotherapy for anorexia nervosa\u2014An outline for a treatment and training manual","volume":"15","year":"2007","journal-title":"Eur. Eat. Disord. Rev."},{"key":"ref_45","unstructured":"Bateman, A., and Fonagy, P. (2012). Handbook of Mentalizing in Mental Health Practice, American Psychiatric Publishing."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Robinson, P., Hellier, J., Murphy, C., Barrett, B., Rutterford, C., Lemonsky, F., and Fonagy, P. (2015, January 23\u201325). A Randomized Controlled Trial of Mentalization-Based Therapy (ED) against Specialist Supportive Clinical Management (ED) in Patients with both Eating Disorders and Symptoms of Borderline Personality Disorder: The Nourished Study. Proceedings of the Poster Session Presented at the International Eating Disorder Conference, Boston, MA, USA.","DOI":"10.1186\/1471-244X-14-51"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Jones, E., Mitra, A., and Bhuiyan, A. (2021). Impact of COVID-19 on Mental Health in Adolescents: A Systematic Review. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18052470"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1016\/j.chc.2019.05.001","article-title":"Updates on Treatments for Adolescent Anorexia Nervosa","volume":"28","author":"Lock","year":"2019","journal-title":"Child Adolesc. Psychiatr. Clin. North Am."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1266","DOI":"10.1111\/jcpp.12449","article-title":"Practitioner Review: Borderline personality disorder in adolescence-recent conceptualization, intervention, and implications for clinical practice","volume":"56","author":"Sharp","year":"2015","journal-title":"J. Child Psychol. Psychiatry"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/4\/3670\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:36:20Z","timestamp":1760121380000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/4\/3670"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,19]]},"references-count":49,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2023,2]]}},"alternative-id":["ijerph20043670"],"URL":"https:\/\/doi.org\/10.3390\/ijerph20043670","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,19]]}}}