Introduction

Healthcare workers, particularly physicians, are continuously exposed to a substantial psychological burden due to the specific demands of their profession. These demands include high levels of responsibility, time pressure, and decision-making under conditions of uncertainty. Physicians are often emotionally involved in the care of seriously ill patients. They are exposed to organizational problems such as shift work, administrative burden, and very limited resources. Long-term exposure to such working conditions can lead to chronic exhaustion and the development of burnout syndrome [1, 2].

Burnout at work is conceptualized as a prolonged response to chronic emotional and interpersonal stressors in the workplace [3]. According to the model proposed by Maslach, burnout encompasses three basic dimensions: emotional exhaustion, depersonalization, characterized by a cynical and distant attitude towards patients and work; and reduced personal achievement [4]. Emotional exhaustion reflects a state of excessive strain and depletion of emotional resources [4, 5]. Depersonalization represents emotional distancing and indifference towards patients, while reduced personal achievement involves negative self-evaluation and reduced professional efficacy [4, 5].

Burnout among physicians is a significant global public health problem. In the United States, during the COVID-19 pandemic, the prevalence of burnout among physicians increased from 38.2% in 2020 to 62.8% in 2021, significantly higher than that observed in many other professions [6]. Key factors contributing to burnout include workload, work-life balance, organizational support, and sociodemographic characteristics such as age, gender, and years of professional experience [6]. Given that burnout has important consequences for both physician mental health and the quality and safety of patient care [7, 8], increasing attention has been directed at examining individual psychological factors that may influence susceptibility to burnout.

Alexithymia, also known as "emotional blindness" or emotional illiteracy, is a disorder characterized by difficulty recognizing emotions and a tendency toward external focus rather than introspective thinking [9-11]. Severe alexithymia may be associated with increased anxiety, depression, and impaired emotional regulation, which may predispose individuals to burnout at work [12]. Large population-based studies, such as the Finnish Health Study of 2000, have shown that alexithymia and its subdimensions are significantly associated with burnout, independent of depression and sociodemographic variables [13].

Mentalizing capacity, also referred to as reflective functioning, denotes the ability to understand one’s own and others’ mental states, including emotions, intentions, and desires [14]. Two maladaptive forms of mentalizing capacity can be distinguished: hypermentalizing and hypomentalizing. Hypermentalizing involves excessive and overconfident attribution of mental states to others, whereas hypomentalizing reflects a reduced capacity to recognize and interpret mental states, leading to uncertainty in understanding others’ behavior [14]. However, the interpretation of certainty about mental states, particularly when assessed using the Reflective Functioning Questionnaire (RFQ-8), remains a matter of ongoing debate. In non-clinical populations, higher RFQ-C scores may reflect greater certainty in understanding mental states rather than pathological hypermentalizing. Since alexithymia involves deficits in emotional awareness and expression, it may impair mentalizing capacity and reduce the ability to process emotional information adaptively [15, 16]. In contrast, adequate mentalizing capacity supports emotional regulation, professional functioning, and interpersonal relationships, thereby acting as a protective factor against burnout [15, 16].

Within the Job Demands-Resources (JD-R) framework, burnout is understood as a consequence of a chronic imbalance between job demands and available psychological resources. Previous studies on burnout syndrome have more frequently examined age as a sociodemographic factor. Therefore, following the approach used in previous research, the authors decided to include age as a variable in the present study. From this perspective, individual factors such as emotional processing and interpersonal functioning may represent important personal resources that influence adaptation to occupational stress. Accordingly, burnout can also be conceptualized as being associated with impairments in emotional processing and interpersonal functioning. The JD-R model emphasizes that burnout develops as a result of the imbalance between job demands and available job resources. According to this framework, high occupational demands contribute to emotional exhaustion, whereas adequate job resources may reduce the risk of burnout and promote employee well-being [17].

Alexithymia reflects deficits in emotional awareness and expression, which may hinder the ability to accurately identify and regulate internal states [18, 19]. These deficits may, in turn, be associated with reduced mentalizing capacity, particularly in the form of hypomentalizing, characterized by difficulties in understanding one’s own and others’ mental states [20]. Impaired mentalizing capacity may be linked to maladaptive responses to occupational stress, which may be associated with higher levels of emotional exhaustion and depersonalization [21]. In contrast, more adaptive mentalizing capacity may be related to more effective emotional regulation, resilience, and interpersonal functioning. However, this should be interpreted with caution, as certain forms of mentalizing capacity, such as hypermentalizing, are generally conceptualized as biased or maladaptive [20, 21].

Taken together, alexithymia and mentalizing capacity represent key psychological constructs involved in emotional processing and adaptation to stress. Although both have been individually associated with burnout, their combined effects and interrelationship remain insufficiently explored, particularly among physicians exposed to high occupational demands. A clearer understanding of these mechanisms may support the development of targeted interventions aimed at improving emotional functioning and reducing burnout in clinical settings. The relevance of examining these relationships is particularly pronounced in the context of the Montenegrin healthcare system, which is characterized by limited resources, chronic workforce shortages, high administrative burden, and frequent shift work. These factors represent substantial occupational stressors and may contribute to an increased risk of burnout among physicians [22].

The present study aimed to examine the relationships among sociodemographic characteristics, alexithymia, mentalizing capacity, and different dimensions of burnout in a sample of physicians in Montenegro. To the best of our knowledge, no previous studies have investigated this issue among physicians in Montenegro. The study sought to assess the independent contributions of alexithymia and mentalizing capacity to burnout after controlling for relevant sociodemographic factors.

Based on the theoretical framework and previous empirical findings, it was hypothesized that higher levels of hypomentalizing would be positively associated with emotional exhaustion and depersonalization, whereas higher levels of hypermentalizing would be negatively associated with these burnout dimensions. Alexithymia was expected to be associated with burnout, particularly emotional exhaustion, and to be positively associated with hypomentalizing while being negatively associated with hypermentalizing. Furthermore, it was hypothesized that mentalizing capacity dimensions and alexithymia would significantly contribute to the prediction of burnout dimensions after controlling for sociodemographic and work-related variables.