Cognitive Flexibility as a Mediator Between Mentalization and Symptom Severity in Generalized Anxiety Disorder

Abstract

Objective Mentalization and cognitive flexibility are key constructs in contemporary models of anxiety psychopathology; however, their interrelationship in clinically diagnosed generalized anxiety disorder (GAD) remains insufficiently delineated. This study aimed to examine whether cognitive flexibility mediates the association between mentalization and anxiety severity. Methods In this cross-sectional study, 110 patients with GAD, diagnosed according to DSM-5 criteria, completed the Mentalization Scale, Cognitive Flexibility Inventory, and Generalized Anxiety Disorder-7. Associations were assessed using Pearson correlation analyses, and mediation was examined using bias-corrected bootstrapping (5,000 resamples). Results Cognitive flexibility was moderately negatively associated with GAD severity (r=-0.421, p<0.001), whereas mentalization showed a weaker but significant negative association (r=-0.293, p=0.002). In addition, mentalization and cognitive flexibility were strongly positively correlated (r=0.636, p<0.001). Mediation analysis revealed a significant indirect effect of mentalization on anxiety severity through cognitive flexibility (B=-0.083, 95% confidence interval [-0.132, -0.042], p=0.001), while the direct effect was not statistically significant. Conclusion Cognitive flexibility significantly mediated the association between mentalization and anxiety severity; however, given the cross-sectional design, this finding should be interpreted as statistical mediation rather than evidence of a causal mechanism. Although causal inferences cannot be established due to the cross-sectional design, cognitive flexibility may represent a clinically relevant target for reducing anxiety symptoms. Future longitudinal and interventional studies are warranted to clarify the directionality and clinical implications of these findings.