Mentalization and Dysfunctional Eating Behaviors: The Mediating Role of Body Uneasiness

Adolescence is a critical developmental period marked by significant biological, psychological, and social transformations. During this time, adolescents often experience heightened vulnerability to developing dysfunctional eating attitudes and behaviors, with body image concerns frequently taking center stage. While body dissatisfaction has long been recognized as a risk factor for eating psychopathology, the intricate mechanisms linking difficulties in understanding one’s own and others’ mental states—a concept known as mentalization—to these eating patterns, specifically through the lens of body uneasiness, remain an area of ongoing research. A recent study published in Frontiers in Psychology sheds light on this complex interplay, suggesting that body uneasiness may serve as a crucial intermediary process.

The Adolescent Crucible: Navigating Body Image and Mental Well-being

The transition through adolescence is a tumultuous phase. Biologically, puberty brings about significant changes in body shape and appearance, naturally drawing adolescents’ attention inward. Psychologically, this period is characterized by a dynamic process of identity formation and the shaping of self-concept, heavily influenced by how individuals perceive their physical selves. Socially, adolescents are increasingly exposed to peer scrutiny, social comparison, and the pervasive influence of idealized beauty standards disseminated through traditional and social media. These external pressures can amplify feelings of inadequacy and body dissatisfaction, which are well-established predictors of dysfunctional eating attitudes and behaviors.

Dysfunctional eating behaviors (DEB) encompass a wide range of maladaptive patterns related to food and body image, including restrictive dieting, binge eating, and excessive preoccupation with weight and shape. While these behaviors do not always meet the diagnostic criteria for clinical eating disorders (EDs) like anorexia nervosa or bulimia nervosa, they represent a significant public health concern. Epidemiological data indicate that lifetime prevalence rates for DSM-5 eating disorders range from 5.5% to 17.9% in young women and 0.6% to 2.4% in young men in Western countries, with notably higher rates among gender and sexual minority individuals. Subthreshold DEB are considerably more common in non-clinical adolescent populations and are recognized as important precursors to full-threshold EDs.

The Role of Mentalization: Understanding the Inner Landscape

In recent years, research has increasingly focused on the sociocognitive processes that underpin the development and persistence of dysfunctional eating behaviors. Central to this understanding is the concept of mentalization, defined as the capacity to understand one’s own and others’ mental states—emotions, thoughts, beliefs, and intentions—that guide behavior. This complex metacognitive ability develops primarily within early attachment relationships and is crucial for effective emotional regulation and interpersonal functioning.

Individuals engaging in DEB often exhibit difficulties in identifying, tolerating, and expressing their emotional states. Their modes of mentalization can be primitive, characterized by an inability to distinguish between physical and emotional states or between their own and others’ experiences. In such cases, dysfunctional eating behaviors can become a means of expressing or managing emotions that cannot be otherwise represented or understood. This phenomenon is sometimes referred to as "embodied mentalization," where the body becomes a container for unprocessed experiences.

Body Uneasiness: A Bridge Between Mentalization and Eating Behavior

The study by Cecere and colleagues (2026) specifically investigated the potential mediating role of body uneasiness in the relationship between mentalization difficulties and dysfunctional eating attitudes and behaviors in Italian adolescents. Body uneasiness is conceptualized as a multidimensional experience of distress related to body image, encompassing cognitive, emotional, and behavioral components such as weight phobia, body image concerns, avoidance behaviors, compulsive self-monitoring, and depersonalization.

The research team hypothesized that adolescents with lower levels of mentalization would report higher levels of body uneasiness. Furthermore, they posited that higher levels of body uneasiness would be associated with more pronounced dysfunctional eating attitudes and behaviors. Crucially, they proposed that body uneasiness would statistically mediate this association, meaning it would help explain how difficulties in mentalization contribute to maladaptive eating patterns.

Methodology: A Glimpse into Adolescent Experiences

The study involved 91 Italian adolescents aged 15 to 20 years, recruited from upper secondary schools in the Rome metropolitan area. Participants completed a digital self-report questionnaire, designed to be anonymous and accessible via smartphones. To ensure a relatively homogeneous sample, participants were screened to exclude those with declared neurodevelopmental, neurological, or psychiatric disorders. The final sample comprised 45 females and 46 males.

The data collection was conducted in the spring of 2025 as part of a university-led initiative, adhering to ethical standards outlined in the Declaration of Helsinki and approved by the Ethics Committee (CERUS) of the International University of Rome (UNINT). The questionnaire, taking approximately 30 minutes to complete, included three validated instruments:

• The Body Uneasiness Test (BUT): This 71-item self-report questionnaire assesses multidimensional body uneasiness. For this study, the BUT-A section was utilized, providing a Global Severity Index (GSI) and five subscales: Weight Phobia (WP), Body Image Concerns (BIC), Avoidance (A), Compulsive Self-Monitoring (CSM), and Depersonalization (D). Internal reliability for the subscales was reported as good, with Cronbach’s alpha values ranging from 0.79 to 0.93 within the study sample.
• The Eating Attitudes Test (EAT): A 26-item screening instrument designed to identify dysfunctional eating attitudes and behaviors, the EAT assesses concerns about body weight, calorie restriction, food control, and compensatory behaviors. Responses are rated on a six-point Likert scale. The total scale demonstrated good reliability (Cronbach’s alpha = 0.85) in the study sample. A cut-off score of 20 is often used to indicate potential eating disorder symptomology.
• The Mentalization Questionnaire (MZQ): This 15-item tool measures self-reported mentalization difficulties across four dimensions: Reflecting (REF), Emotional Awareness (EA), Primitive Experience (PE), and Regulation of Affect (RA). Participants respond on a 5-point Likert scale, with lower scores indicating greater difficulties. The adolescent version of the MZQ was used, demonstrating a total score reliability (MZQ_TOT) of 0.85.

Statistical analyses were performed using JASP software. Spearman correlations were calculated to examine bivariate relationships, and a bootstrap mediation analysis with 1,000 resamples was conducted to test the proposed mediation model. The study acknowledged that the data did not follow a normal distribution, prompting the use of non-parametric methods.

Key Findings: Unpacking the Mediating Role

The results of the study revealed significant associations among the three core variables:

• Mentalization and Body Uneasiness: A strong negative correlation was found between self-reported mentalization difficulties (MZQ) and body uneasiness (GSI). Adolescents who reported greater difficulties in understanding their own and others’ mental and emotional states also exhibited higher levels of body-related distress. This finding aligns with theoretical predictions that challenges in symbolizing internal states may lead to their manifestation through physical concerns.
• Body Uneasiness and Dysfunctional Eating: A substantial positive correlation was observed between body uneasiness (GSI) and dysfunctional eating attitudes and behaviors (EAT). This confirms previous research highlighting the critical link between body image distress and maladaptive eating patterns. Adolescents experiencing greater body uneasiness were more likely to report dysfunctional eating attitudes.
• The Mediating Pathway: The mediation analysis provided compelling evidence for the role of body uneasiness. The total effect of mentalization difficulties on dysfunctional eating attitudes was significant. However, after accounting for body uneasiness, the direct effect of mentalization on eating attitudes became non-significant, indicating that body uneasiness statistically explained the association between the two. The indirect effect through body uneasiness was significant, suggesting that difficulties in mentalization are linked to dysfunctional eating attitudes, at least in part, because they contribute to increased body uneasiness.

The study authors noted that while the indirect effect was significant, the pattern of opposing signs between the total effect (negative) and the direct effect (positive) suggests a complex relationship, possibly involving mediation that suppresses parts of the direct relationship. This warrants cautious interpretation and further investigation.

Implications and Future Directions

The findings of this study carry significant implications for understanding and addressing dysfunctional eating behaviors in adolescents. The research suggests that body uneasiness acts as a bridge, connecting difficulties in mentalization to maladaptive eating patterns. This highlights the importance of considering both the capacity to understand mental states and the experience of body-related distress when intervening with adolescents at risk for or exhibiting DEB.

From a clinical and preventive standpoint, these results suggest that interventions targeting the improvement of mentalization skills—such as fostering emotional awareness, the ability to reflect on one’s own and others’ mental states, and developing more nuanced understanding of emotions—could be beneficial. Simultaneously, addressing body uneasiness directly through strategies aimed at reducing body image concerns, challenging weight phobias, and promoting healthier body acceptance is also crucial.

The authors emphasize that the cross-sectional nature of the study prevents definitive causal conclusions. It is not possible to ascertain whether mentalization difficulties precede body uneasiness and DEB, or if the relationship operates in the reverse direction, or is influenced by other unmeasured factors. Future research should employ longitudinal designs to track these variables over time, allowing for a clearer understanding of the temporal sequence and potential causal pathways.

Furthermore, the study acknowledges several limitations. The reliance on self-report measures, while common in psychological research, can be subject to response biases. The method used to screen for pre-existing disorders, based solely on self-report, may not be fully robust. The EAT, being a screening tool, does not provide a clinical diagnosis. Additionally, the study did not account for factors such as ethnicity or body mass index (BMI), which could influence the observed relationships. The sample size, while adequate for initial exploration, could be expanded for greater generalizability, particularly to more diverse or clinical adolescent populations.

Despite these limitations, the study provides valuable insights into the complex interplay between mentalization, body uneasiness, and dysfunctional eating behaviors during adolescence. It underscores the need for integrated approaches that address both cognitive-emotional processing and body image concerns in the prevention and treatment of eating-related psychopathology. The findings serve as a foundation for future research aimed at developing more targeted and effective interventions for this vulnerable population.