Poor metacognition in Narcissistic and Avoidant Personality Disorders: four psychotherapy patients analysed using the Metacognition Assessment Scale

Psychometric properties and validation of the metacognitive self-assessment scale (MSAS) in a Turkish sample

Objective

Metacognition, a multifaceted psychological construct, encompasses recognising and explaining one's cognitive processes and those of others. Notably, deficits in metacognitive abilities are linked with diminished social performance, reduced quality of life, and increased severity of Personality Disorders (PD). While there are other assessment tools available in Turkish for evaluating metacognition, none offer the same combination of speed, simplicity, flexibility, and multidimensionality for screening metacognitive abilities as the Metacognition Self-Assessment Scale (MSAS).The Metacognitive Self-Assessment Scale (MSAS) was designed to evaluate various metacognitive functions-namely, Monitoring, Integration, Differentiation, and Disintegration-as described by the Metacognitive Multifunction Model. This study aims to translate and validate the MSAS for Turkish culture.

Method

To check the factor structure's suitability for the Turkish population, 467 non-clinical participants (67.7% female, ranged from 18 to 31, mean 24.18; ±3.25) were included.

Results

Initial analyses confirm that the scale is a valid and dependable instrument for Turkish culture. Construct validity, represented by the 18 items and four subscales, was confirmed through Confirmatory Factor Analysis (CFA) and criterion validity assessments. As well as the test-retest reliability of the scale was confirmed. Based on these findings, it was concluded that the scale is valid and reliable for use in Turkey. The model aligns well with empirical data, highlighting its strong construct validity and indicating good reliability of the scale.

Conclusion

The Turkish version of the MSAS, developed to measure metacognition and its associated components, has proven to be a credible and reliable tool, especially in non-clinical settings.

Agency in avoidant personality disorder: a narrative review

Objectives

Avoidant personality disorder (AvPD) is a highly prevalent personality disorder, especially in clinical settings, yet scarcely researched. People diagnosed with AvPD have severe impairments in functioning and suffer greatly, yet we still lack meta-analytic evidence for therapy and only a few RCTs are conducted. Patient factors are the most important for outcome in therapy, in general. Lack of agency might be a core deficit in people diagnosed with AvPD. Their conditions might be improved if we understand their agency better. We review previous research regarding psychological mechanisms and interpersonal relationships that facilitate or hinder agency in AvPD in daily life and psychotherapy.

Methods

Summarizing original literature in a narrative review with reflexive thematic analysis.

Results

People diagnosed with AvPD seem to have significant impairments in their sense of agency due to a lack of emotional awareness, an overweight of inhibiting vs. activating emotions, and difficulties regulating emotions. Difficulties also seem related to high levels of attachment avoidance and fear, creating strong ambivalence in social needs, in addition to a strong tendency to subordinate to others. A weak sense of self with a poor narrative, self-doubt, and harsh self-critique makes a reflexive and intentional stand increasingly difficult for these people.

Conclusion

This review gives a clinically meaningful understanding of core strengths and deficits in the personality functioning of AvPD that can help clinicians map out important therapeutic work, identify barriers to client-agency in therapy, and work through relational difficulties in the therapeutic alliance.

Metacognition and insight dynamics exploration in borderline personality disorder: Exploring the underlying dynamics

Metacognition and Insight are related to hard-to-treat disorders and among them is Borderline Personality Disorder (BPD). We recruited 190 BPD patients and measured Insight, Metacognition, Impulsivity, and BPD traits. Results showed BPD's significant links with Insight and Metacognition. Metacognition significantly correlated with two Impulsivity dimensions, whereas Insight significantly correlated with most of them. Regressions analysis revealed a significant relationship between Insight and Metacognition on Impulsivity and Borderline traits. Mediation analysis proved the indirect effect of Metacognition/Insight on Borderline traits through Impulsivity at a significative level. Both seem relevant for research and therapeutic application in BPD following different dynamics even if the limitation of our study stands in its gender ratio and possible comorbidity issues. Urgency appears as a critical factor to assess, notably with Positive emotion-based impulsivity.

The dark side of empathy in narcissistic personality disorder

Narcissistic personality disorder is characterized by self-absorption, grandiosity, exploitation of others and lack of empathy. People with that disorder may switch from an overt form, mainly with grandiosity, to a covert presentation, with fears, hypersensitivity and dependence from others. Empathy represents a key point in detecting people affected by narcissistic personality disorder because, even if it is described as reduced, it plays a fundamental role in exploitation and manipulation. A systematic search of Literature without any language or time restriction, was performed combining thesaurus and free-search indexing terms related to Narcissistic personality disorder and empathy and produced 531 results. Fifty-two papers that analyzed possible issues in the empathic attitude of people with narcissistic personality disorder were included in this narrative review. Empathy is the capability of understating and feeling others emotions. It is not a unitary construct and can be distinguished in cognitive and affective. It might be channeled into prosocial and antisocial behaviors. A crucial trait identified in narcissistic empathy is affective dissonance that is closely related to rivalry as part of the dark tetrad (narcissism, machiavellianism, psychopathy, and sadism). Subjects affected by narcissistic personality disorder show greater impairment in affective aspects while their cognitive part of empathy appears preserved. Saving at least the cognitive aspects of empathy may contribute to therapeutic improvement of affective aspects.

Personality and mentalization: A latent profile analysis of mentalizing problematics in adult patients

BACKGROUND

The aim of this study was to investigate the relationship between patients' mentalizing problematics and their personality; specifically, it aimed to identify clusters of individuals characterized by specific patterns of mentalizing imbalances and to analyze the relationship between these and diagnosis of personality disorder (PD), nonmentalizing modes, emotion dysregulation, and interpersonal reactivity.

METHODS

Four hundred therapeutic dyads were recruited. A part of these (n = 183) only completed clinician-report measures, Mentalization Imbalances Scale, and Modes of Mentalization Scale, while others (n = 217) also completed patients' self-report measures, which were Reflective Functioning Questionnaire, Difficulties in Emotion Regulation Scale, and Interpersonal Reactivity Index.

RESULTS

A latent profile analysis enlightened the presence of four clusters with problematics in the dimensions of mentalization, indicated by cluster names: (1) Affective-self-automatic profile (ASA-P) (with higher percentage of PDs); (2) External profile (E-P) (with lower percentage of PDs); (3) Others-automatic-affective profile (OAA-P); (4) Cognitive-self-automatic profile (CSA-P). Multivariate analysis of variances confirmed that the four clusters differed in relation to the quality of mentalization, emotional dysregulation and interpersonal reactivity, with higher levels of nonmentalization modes, uncertainty about mental states and emotion dysregulation in ASA-P, higher levels of good mentalization in E-P, lower impulsivity in CSA-P, and greater empathic concern in OAA-P.

"It's not you, it's me": identity disturbance as the main contributor to interpersonal problems in pathological narcissism

BACKGROUND

Core impairments in self and other functioning typify individuals with personality disorder. While interpersonal dysfunction is a known element of narcissistic disorders, empirical research investigating intrapersonal elements is lacking. The aim of this study was to investigate the internal representations of individuals with grandiose and vulnerable features, as manifested through their attachment styles, and the specific role of identity disturbance in explaining the relationship between pathological narcissism and maladaptive interpersonal functioning.

METHODS

A sample of 270 university students completed the Brief Pathological Narcissism Inventory (B-PNI), the Severity Indices of Personality Problems (SIPP), the Relationship Questionnaire (RQ), and the Inventory of Interpersonal Problems (IIP-32).

RESULTS

Both vulnerable and grandiose narcissism were positively associated with both fearful and preoccupied attachment, and negatively associated with secure attachment, whilst grandiose narcissism was also positively associated with dismissive attachment. Furthermore, unstable representations of self, poor self-reflective functioning, and low sense of purpose fully mediated the relationship between interpersonal problems and grandiose narcissism while partially mediating the relationship between interpersonal problems and vulnerable narcissism.

CONCLUSIONS

Overall, our findings suggest that for individuals presenting with narcissistic features, capacity for adaptive interpersonal functioning is grounded by deficits in identity integration. Implications of these findings are discussed.

Conceptualisation and Measurement of Reflective Process in Psychotherapy: A Systematic Scoping Review

Psychological therapies use talk as a means to produce change for individuals who are experiencing distress. Despite a significant body of research comparing approaches, there is little evidence for the superiority of one model over another. The process of reflection has been suggested as a common factor across modalities, and research aiming to measure this phenomenon is emerging. This scoping review is focussed on the conceptualisations, measurement and process outcomes of reflective talk as it occurs during therapy. Twenty-two studies were selected from a total of 3712 papers identified following a systematic search of SCOPUS, MEDLINE, PsychINFO and Web of Science databases. A variety of descriptors emerged: intrapersonal constructs such as mentalization and metacognition tended to view reflectivity as an individually acquired skill or trait, where other descriptors adopted an interpersonal understanding of reflection as co-constructed through dialogue. Our findings suggest a shift from individual to intersubjective understandings of reflecting processes in therapy may be a valuable area for future research.

Treating Avoidant Personality Disorder With Combined Individual Metacognitive Interpersonal Therapy and Group Mentalization-Based Treatment: A Pilot Study

ABSTRACT

Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

The Functional Psychotherapy Approach: A Process-Outcome Multiple Case Study

Objective: The present work aims to conduct the first naturalistic empirical investigation of the process and outcome assessment of functional psychotherapy (FP) treatment. The FP model of psychotherapy is rooted in psychoanalysis and integrates the verbal communication approach founded on transference and countertransference dynamics with the analysis of bodily processes.

Method: The study sample included ten patients recruited on a voluntary basis and treated by clinicians in their private practices. Each patient received FP with an average duration of 40 h (min 35 and max 42). Therapies had weekly sessions, were audio-recorded with the patient’s written consent, and lasted for an average of 10 months (min 9 and max 12). Outcome and process tools included the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and the Luborsky’s the Core Conflictual Relationship Theme (CCRT), used to assess therapeutic benefit, and the Metacognition Assessment Scale (MAS) and the Italian Discourse Attributes Analysis Program (IDAAP) system, used to evaluate therapeutic benefit and process. The MMPI-2 was used also in the follow-up assessment.

Results: Results show that FP had a positive therapeutic outcome on the patients assessed in this study, and that the therapeutic benefits were maintained over time. Some specific features of the FP approach were found to contribute more than others to the observed therapeutic benefits.

Conclusion: The current investigation constitutes a first step toward assessment of the therapeutic effectiveness of FP. Future developments should apply the methodology to a larger sample, possibly introducing different methodologies to enable detection of specific bodily oriented processes and techniques.

When less is more: The perception of psychotherapy techniques as a function of patient personality disorder

OBJECTIVE

Psychopathology research suggests that individuals with higher levels of personality disorder (PD) traits, especially those with a comorbid major depressive disorder (MDD), tend to be highly aroused in interpersonal contexts, manifested by an intensified perception of interpersonal interactions. Little is known about the way this tendency manifests in the process of psychotherapy. The current study explored the patient's perception of techniques in psychotherapy among patients with higher vs. lower levels of PD, as well as the patient-therapist agreement on techniques used.

DESIGN

The study used an integration of qualitative and quantitative methodology on data from a randomized controlled trial (RCT) for the treatment of depression.

METHOD

Sixty-nine patients with MDD participated in the study and were evaluated for PD symptoms prior to treatment. A set of multilevel analyses were conducted to assess the association between PD and perception of techniques, as well as a zoom-in exploration within a case study.

RESULTS

Patients with higher levels of PD reported more techniques implemented by the therapist than patients with lower levels. In addition, the agreement between patient and therapist on techniques was lower, such that patients with PDs reported more techniques than their therapist. The case study supported these findings and illustrates the potential for patients with PDs to perceive a greater use of techniques as a sign of therapist investment.

CONCLUSION

Consistent with psychopathology research, the findings suggest that patients with PDs tend to experience techniques as more intense than the therapist, in comparison with patients without PD.

PRACTITIONER POINTS

There are indications that patients with higher levels of personality disorder traits will tend to experience the techniques in psychotherapy in a more intense manner than patients with lower level personality disorder traits. It is likely that patients with higher levels of personality disorder traits will experience their therapists as more active than therapists think they are. Therapists of patients with higher levels of personality disorders should be sensitive of each of their patients' experiences. As the case study demonstrated at least in some cases patients with higher levels of personality disorder may experience the techniques in an intense manner as a sign of therapist investment, however, other patients may experience this differently. Therefore, it is crucial for the therapist to be aware of how the patient experienced the encounter - investment or intrusiveness.

Emotional dysfunction in avoidant personality disorder and borderline personality disorder: A cross-sectional comparative study

According to the literature, avoidant personality disorder (APD) is often overlooked in research on personality disorders. In the present study, patients with APD were compared to patients with borderline personality disorder (BPD) with respect to emotional dysfunction. Emotional dysfunction was operationalized through the Affect Integration Inventory. Sixty-one patients receiving treatment at specialized outpatient hospital facilities for either BPD (n = 25) or APD (n = 36) (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) were included in a cross-sectional study. Supporting our expectations of no difference in the global capacity for affect integration between groups, the estimated difference was 0.00 (95% confidence interval [CI] [-0.53, 0.53]). On the other hand, the expected increased dysfunction in APD regarding Expression could not be confirmed. Furthermore, problems with specific affects distinguished the groups; integration of Interest was worse in APD (p = 0.01), whereas integration of Jealousy was worse in BPD (p = 0.04). In terms of prototypical modes of experiencing affects, APD was characterized by decreased access to the motivational properties of Interest (p < 0.01), while BPD was more driven by Interest (p < 0.01), Anger (p < 0.01), and Jealousy (p = 0.01). In conclusion, even though the two disorders are characterized by similar overall levels of emotional dysfunction, they differ systematically and predictably regarding specific affects and modes of experiencing. These findings carry implications for the understanding of emotional dysfunction in APD and BPD, suggesting specific areas of emotional dysfunction that could be targeted in tailored psychotherapeutic interventions.

Pathological Narcissism and Emotional Responses to Rejection: The Impact of Adult Attachment

Background: Aspects of pathological narcissism, such as grandiosity, vulnerability and entitlement, tend be enacted in therapeutic settings, negatively influencing outcome and alliance between the clients and therapist. This research took an experimental approach to understanding the interplay between the emotional reactions of individuals with a pathological narcissistic presentation, and adult attachment style. We predicted that participants reporting narcissistic vulnerability would report greater insecurity in attachment (fearful and preoccupied styles), greater trait emotional reactivity, and also experience more intense and negative responses to simulated rejection

Methods: 269 participants (75.84% female, median age = 21) completed baseline and rejection trials of a virtual ball-tossing game, following the assessment of grandiose and vulnerable pathological narcissism, entitlement, adult attachment, trait emotional reactivity (measured prior to the rejection) and in-situ affective response (measured both before and after the rejection). Change in affect from baseline was calculated to capture affective responses to the manipulation.

Results: Vulnerable narcissism was positively associated with both fearful and preoccupied attachment, and negatively associated with secure and dismissive attachment, whilst grandiose narcissism was significantly related to preoccupied attachment only. Multiple hierarchical regression analyses showed vulnerable narcissism predicted both (1) more negative trait emotional reactivity and (2) a significant increase in negative affect following the rejection trial. Grandiose narcissism was associated with (1) higher positive trait emotional reactivity, and (2) significant reductions in positive affect following rejection.

Conclusion: Results indicated that those high in pathological narcissistic vulnerability reported greater insecurity in attachment, negative trait emotional reactivity and experienced a more negative and intense emotional reaction to rejection. Grandiose narcissism was related to a more deactivated pattern of emotional reactivity, and less positive (rather than more negative) emotional reactions. Findings have important implications for therapy, particularly regarding communication of emotions for individuals high in vulnerable and grandiose narcissism.

Metacognition Mediates the Relationship Between Maladaptive Personality Traits and Levels of Personality Functioning: A General Investigation on a Nonclinical Sample

ABSTRACT

The impaired ability to reflect on one's own state of mind and that of others (called metacognition or mentalization) is a central feature of personality disorders (PDs). Metacognition involves different specific abilities, which can be selectively impaired with different PDs and personality maladaptive traits. Moreover, research in the field of PDs has indicated that personality features and metacognitive abilities are associated with the severity of personality pathologies. In this study, we tested a mediation model of the interactions between these variables on predicting levels of personality functioning in a sample of adults taken from the general population (N = 775). Results showed that the relationship between personality traits and personality functioning is partially mediated by metacognitive abilities. These findings support the hypothesis that metacognition plays a significant role in predicting the levels of impairment in personality functioning. These findings have several clinical implications.

Validation of a Chinese version of the short form of Metacognitions Questionnaire (MCQ-30)

BACKGROUND

This study investigated the psychometric properties of a Chinese version of the short form of Metacognitions Questionnaire (MCQ-30), which is an effective tool to assess metacognitive beliefs that have been linked to mental disturbance/disorder. We also tested whether metacognition factors would correlate with Internet gaming disorder (IGD) tendency.

METHODS

Six hundred and eighty Chinese university students (Mean age=19.72, SD=1.38; 31.9% male) voluntarily completed an anonymous online questionnaire. Using standard translation procedures, the MCQ-30 items were translated from English into Chinese language and then back-translated. Depression, anxiety, and IGD tendency were assessed by validated scales.

RESULTS

Confirmatory factor analysis (CFA) results supported the five-factor structure of the MCQ-30, with satisfactory model fit and good reliability. Criterion-related validity was also supported by significant positive correlations between the five factors and depression/anxiety symptoms. All of the five metacognition factors were also significantly correlated with IGD tendency, with positive beliefs about worry and cognitive confidence being the most salient factor after controlling for gender and age.

LIMITATIONS

This study did not examine the test-retest reliability of this scale, and the generalizability of the findings to other age groups remains unclear.

CONCLUSIONS

This study showed satisfactory psychometric properties of a Chinese version of the MCQ-30 and is the first to demonstrate a positive association between specific metacognition factors and IGD tendency among Chinese people. The latter finding supports an application of metacognitive therapy to the treatment of behavioral addictions, including IGD.

Dialogical Integration of Life Experiences and Successful Aging

This article examines the hypothesis that the dialogical integration of life experiences is related to successful aging. Life story interviews with 93 older Czech adults were sorted into categories characterized by specific patterns of life experience integration: (i) without dialogical processes, (ii) with differentiated I-positions, (iii) with dialogical relationships, (iv) partially integrated, and (v) completely integrated. The results indicated that the categories were ordered, yielding low-level correlations with scales of successful aging in predicted directions. A comparison of the categories revealed that they were related to successful aging in a cumulative way, starting with the most essential indicator (lower scores of rumination) in the participants who had developed at least dialogical relationships, continuing to higher well-being linked with partial integration, and ending with an advanced indicator (optimism toward future) linked with complete integration. These relationships were summarized in a hypothetical model that is open to further examination.

The association between metacognitive abilities and outcome measures among people with schizophrenia: A meta-analysis

Background:

Deficits in metacognition are one of the major causes of the difficulties experienced by individuals with schizophrenia. Studies have linked these deficits to symptom exacerbation and deterioration in psychosocial functioning. The aim of the present meta-analysis was to examine the extensive existing literature regarding metacognitive deficits among persons with schizophrenia; a further aim was to assess the extent to which metacognitive abilities are linked to outcome measures of symptoms and psychosocial functioning.

Method:

We conducted a systematic literature search of studies examining the relationship between metacognitive abilities and outcome measures among people with schizophrenia. We then analyzed the data using a random-effects meta-analytic model with Cohen's d standardized mean effect size.

Results:

Heterogeneity analyses (k = 32, Cohen's d = −.12, 95% CI.−1.92 to 1.7) produced a significant Q-statistic (Q = 456.89) and a high amount of heterogeneity, as indicated by the I2 statistic (93.04%), suggesting that moderator analyses were appropriate. As hypothesized, measure type moderated the metacognitive deficit with homogenous effect for psychosocial functioning measures (Q = 9.81, I2 = 19.47%, d = .94. 95% CI .58 to 1.2) and symptoms (Q = 19.87, I2 = 0%, d = −1.07, 95% CI −1.18 to −.75). Further analysis found homogenous effects for MAS-A subscales as well as PANSS factors of symptoms.

Conclusion:

Our meta-analysis results illustrated a significant association between metacognitive deficits and both symptomatic and psychosocial functioning measures. These links suggest that the associations between metacognitive abilities and symptomatic outcomes are different from those between metacognitive abilities and psychosocial functioning measures. Intriguing hypotheses are raised regarding the role that metacognitive abilities play in both symptoms and psychosocial functioning measures of people diagnosed with schizophrenia spectrum disorders.

Processes of Change in Psychotherapy for Narcissistic Personality Disorder

The present study aims at determining the role for outcome of potential processes of change in psychotherapy for narcissistic personality disorder (NPD). They were examined on three levels: the content, the process, and the relationship. A total of 161 patients suffering with NPD were recruited in a naturalistic setting as part of the present study. They underwent a long- term clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video- or audio-recorded and analyzed with an observer-rated instrument that measures the quality of the interaction processes from the patient's and therapist's perspectives. Different self-report measures were used to assess therapy outcomes. In-session improvement was observed in both patient and therapist processes across sessions. Patient improvement in the three levels of processes was systematically related with outcome. Only partial relationships were found between therapist improvement and outcome. The present study represents the first systematic insight into core changes in patients with NPD undergoing psychotherapy.

Tracing Metacognition in Psychotherapy: Associations With Symptoms of General Distress and Depression

Deficits in metacognition have often been identified as a central feature in various forms of psychopathology. The current study explores changes in metacognition and symptoms during the process of psychodynamic-oriented psychotherapy conducted in a community setting among people with diverse psychological challenges. We examined the associations between metacognition and symptoms at both the within-client and the between-clients level. Nine good-outcome and nine poor-outcome cases of psychodynamic treatment were analyzed. In terms of metacognitive abilities, results showed that clients who were part of the good-outcome group had higher levels of decentration than did clients who were part of the poor-outcome group. In addition, clients' ability to understand the other's mind improved significantly only for clients in the good-outcome group. Furthermore, sessions in which clients' self-reflectivity was higher were followed by increased symptom levels (in the next session) beyond group (poor or good outcome group). Clinical implications regarding the improvement of metacognitive abilities and their associations with outcome measures are discussed.

Metacognitive Interpersonal Mindfulness-Based Training for Worry About Interpersonal Events: A Pilot Feasibility and Acceptability Study

Individuals with personality disorders experience worry and repetitive thoughts regarding interpersonal scenarios. Mainstream mindfulness-based approaches may be insufficient to soothe these individual's distress due to difficulties in letting thoughts go and refocusing attention to the present moment. For this reason, we devised an adapted form of mindfulness-based program called Metacognitive Interpersonal Mindfulness-Based Training (MIMBT) for personality disorders. In this pilot study, 28 individuals attended nine weekly sessions to evaluate the feasibility and acceptability, and to establish preliminary outcomes. All individuals completed the program. Attendance was very high (96%). Significant changes were observed on the primary outcome of reduction in repetitive thinking, measured using the Metacognition Questionnaire-30. We also observed a decrease in depression severity. Despite important limitations, this pilot study suggests that MIMBT has the potential to be a viable and well-accepted option for increasing positive outcomes in the treatment of personality disorders. Clinical considerations and directions for future research are discussed.

Metacognitive Interpersonal Therapy in group (MIT-G) for young adults with personality disorders: A pilot randomized controlled trial

Young adults with personality disorders (PD) other than borderline are in urgent need of validated treatments to help them in managing important life transitions. Therapeutic interventions focused upon social and interpersonal difficulties may facilitate these individuals in maximizing opportunities for employment, forming stable romantic relationships, and belong to social groups. It is also important that they are offered evidence-based, first-line time-limited treatments in order to maximize effectiveness and reduce costs. We developed a 16-session programme of group-based Metacognitive Interpersonal Therapy (MIT-G) including psychoeducation on the main interpersonal motives, an experiential component enabling practice of awareness of mental states; and use of mentalistic knowledge for purposeful problem-solving. We report a feasibility, acceptability, and clinical significance randomized clinical trial. Participants meeting inclusion criteria were randomized to receive MIT-G (n = 10) or waiting list+TAU (n = 10). Dropout rate was low and session attendance high (92.19%). Participants in the MIT-G arm had symptomatic and functional improvements consistent with large effect sizes. In the MIT-G arm similarly large effects were noted for increased capacity to understand mental states and regulate social interactions using mentalistic knowledge. Results were sustained at follow-up. Our findings suggest potential for applying MIT-G in larger samples to further test its effectiveness in reducing PD-related symptoms and problematic social functioning.

A Temperament-Attachment-Mentalization-Based (TAM) Theory of Personality and Its Disorders

Theories of personality and its disorders need, from time to time, to be revised and updated according to new empirical and conceptual developments. Such development has taken place in the realms of affective neuroscience, evolution, and social cognition. In this article, we outline a new personality theory, which claims that phenomena we usually ascribe to the concept personality are best understood by postulating a web consisting of three major constituents: temperament (mainly primary emotions), attachment, and self-consciousness (mentalizing). We describe these constituents, their neurobiological underpinnings, the subjective experiences they evoke, and their behavioral implications. We discuss the relevance of the espoused theory in the field of personality disorders with references to borderline, narcissistic, and avoidant personality disorders as well as the DSM-5 alternative model. Implications for social psychology, psychotherapy, and common sense self-understanding are outlined. The theory aims to bridge previous contradictions between natural sciences and hermeneutics by its propositions of the evolution of self-consciousness.

Facial emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders

Previous studies that aimed to support emotion recognition deficits and alexithymia in B cluster personality disorders have mainly focused on borderline personality disorder (BPD), and resulted in mixed findings. In our study we examine emotion recognition and alexithymia in patients with histrionic (HPD), narcissistic (NPD) and borderline (BPD) personality disorders compared to each other and healthy controls. Furthermore, the possibility is investigated that it is not the type of PD but the severity of psychopathology which predicts the severity of emotion recognition deficits and alexithymia. Patients with HPD, NPD, BPD and healthy controls (N = 20 for each group) were examined by using the Ekman 60 Faces Test (FEEST) and the Toronto Alexithymia Scale (TAS-20). To measure the extent and severity of psychopathology, the Symptom-Checklist-90 Revised (SCL-90-R) was used. Patient groups performed significantly worse compared to healthy controls on the Ekman test and TAS-20, while we found no significant differences among patient groups in emotion recognition and alexithymia. Furthermore, higher scores on the SCL-90-R predicted poorer emotion recognition performance and higher alexithymic features. The empirical data supports the conclusion that the severity of psychopathology plays an important role in predicting emotion recognition deficits and alexithymia in borderline, narcissistic, and histrionic personality disorders.

Mechanisms of Change in Treatments of Personality Disorders: Introduction to the Special Section

The present introduction to the Special Section on Mechanisms of Change in Treatments of Personality Disorders explains the value of research focusing on processes of change in psychotherapy by referring to a variety of methodologies. Whereas outcome for these treatments has been repeatedly demonstrated, it remains an open question what the core psychobiological features of change are. Taking a radically empirical perspective, this introduction focuses on patient and therapeutic relationship variables, such as emotional and socio-cognitive processing. The six empirical articles of the Special Section are introduced, as are the three discussions of the Special Section.

Avoidant personality disorder and social phobia: Does mindreading make the difference?

OBJECTIVE

Avoidant personality disorder (AvPD) is closely related to and partially overlaps with social phobia (SP). There is an ongoing debate as to whether AvPD and SP can be classified as separate and distinct disorders or whether these diagnoses rather reflect different degrees of severity of social anxiety. The hypothesis of this study is that in patients with AvPD and in those with AvPD and comorbid SP both interpersonal functioning and metacognitive abilities (the ability to understand mental states) are more severely impaired than they are in patients with SP only. We also hypothesise that the interpersonal and metacognitive functioning of these patients (both AvPD and AvPD+SP) is comparable to that of patients with other PD diagnoses.

METHODS

To test this hypothesis, we compared four groups (22 patients with SP, 32 patients with AvPD, 43 patients with both AvPD and SP and 50 patients with other personality disorders without SP and AvPD criteria) on metacognitive abilities, interpersonal functioning and global symptomatic distress.

RESULTS

Metacognitive ability showed significant variation among the four groups, with the lowest score observed in the AvPD group. As far as the interpersonal functioning is concerned, the lack of sociability was more severe in the AvPD group compared with the SP group. These differences were maintained even after controlling for global symptomatic distress.

CONCLUSION

Results are in line with the alternative model of PD, proposed in the DSM-5, as dysfunction of the self and relationships. They suggest that specific impairments in critical areas of self domains and interpersonal domains of personality functioning may serve as markers distinguishing AvPD from SP.

Levels of Social Sharing and Clinical Implications for Severe Social Withdrawal in Patients with Personality Disorders

Social sharing capacities have attracted attention from a number of fields of social cognition and have been variously defined and analyzed in numerous studies. Social sharing consists in the subjective awareness that aspects of the self's experience are held in common with other individuals. The definition of social sharing must take a variety of elements into consideration: the motivational element, the contents of the social sharing experience, the emotional responses it evokes, the behavioral outcomes, and finally, the circumstances and the skills which enable social sharing. The primary objective of this study is to explore some of the diverse forms of human social sharing and to classify them according to levels of complexity. We identify four different types of social sharing, categorized according to the nature of the content being shared and the complexity of the mindreading skills required. The second objective of this study is to consider possible applications of this graded model of social sharing experience in clinical settings. Specifically, this model may support the development of graded, focused clinical interventions for patients with personality disorders characterized by severe social withdrawal.

Personality, personality disorders, and the process of change

OBJECTIVE

The present paper elaborates a process perspective of change in psychotherapy for personality disorders (PDs). Firstly, the paper reviews the literature of mechanisms of change in treatments of PD, with the main focus on emotional processing and socio-cognitive processing. Secondly, it proposes an illustrative case-series analysis of eight cases, drawn from a mediation analysis conducted within the context of a randomized controlled trial for borderline personality disorder (BPD).

METHOD

As such, cases with good and poor outcomes are compared, as are cases with poor and good intake features and cases with poor and good process markers across treatment.

RESULTS

The results illustrate possible pathways to healthy change over the course of four months of treatment, and possible pathways of the absence of change.

CONCLUSIONS

These results are discussed with regard to three main research perspectives: the combination of qualitative and quantitative methodology in psychotherapy research may be applied to case study research, a neurobehavioral perspective on change may incorporate the individualized experience in the laboratory and therapist responsiveness to patient characteristics may be a core feature of fostering change. Clinical or methodological significance of this article: The present paper illustrates individual pathways to change in personality disorders. It illustrates how coping capacities influence the process of psychotherapy and outcome in personality disorders. It demonstrates the relevance of individualizing treatments for personality disorders. It demonstrates several integrative features of psychotherapy research, in particular the use of neurobehavioral paradigms and the integration of single-case research within randomized controlled trials.

Mindreading Dysfunction in Avoidant Personality Disorder Compared With Other Personality Disorders

The ability to reflect on one's own states of mind and those of others (metacognition or mindreading) is strongly implicated in personality disorders (PDs). Metacognition involves different abilities, and there is evidence that specific abilities can be selectively impaired in different PDs. The purposes of this study were to compare metacognitive competence in avoidant PD (AvPD) with that in other PDs and to investigate whether there is a specific profile for AvPD. Sixty-three patients with AvPD and 224 patients with other PDs were assessed using the Metacognitive Assessment Interview. AvPD patients showed difficulties with two metacognitive functions: monitoring and decentration, even when the severity of psychopathology was controlled for. These results support the hypothesis of specific profiles of metacognitive dysfunction in different PDs and highlight a close link between impaired monitoring and decentration functions and the inhibited and withdrawn personality style typical of AvPD.

[Affective mentalizing in Addictive Borderline Personality: A literature review]

This literature review concerns affective mentalizing in borderline addictive personality. This concept postulates the group between addictions and borderline personalities may correspond to Personality Disorders (PDs). First, we will present conceptualizations and evaluations of affective mentalizing. The latter refers to one dimension of mentalization, a process by which an individual interprets his/her mental states and those of others. Lecours and Bouchard proposed a hierarchic model: the Élaboration verbale de l'affect (EVA). They also developed an empiric methodology: the Grille de l'élaboration verbale de l'affect (GEVA). The methodological approach of Lecours fulfils the requirements made by Cho-Kain, Gunderson and Luyten, involving a narrower operationalization of the mentalization concept through the evaluation of its dimensions. Conceptualizations and evaluations enabled focus on mentalization psychopathology. Fonagy and Bateman studied this latter in the subjects with PDs, particularly in Borderline Personality Disorders (BPD). We describe mentalization failure, its etiology and consequences in the BPD. Several forms of mentalization psychopathology are identified. Its etiology is largely environmental. Fonagy and Bateman developed the optimum developmental model of mentalization and referred to it to explain etiology of mentalization failure in BPD. Consequences of mentalization failure explicate its functioning. Mentalization may be considered as essential in their comprehension and their care. Research about mentalization of PDs does not integrate addiction as one comorbidity factor. However, Allen, Fonagy and Bateman describe a bidirectional interaction between mentalization failure and addiction. We propose to examine the mentalization of Borderline Addictive Personality. This concept groups addictions and borderline personalities in just one clinical entity other than their links of co-morbidities.

An experimental investigation of mentalization ability in borderline personality disorder

OBJECTIVE

Deficits in mentalization ability have been theorized to underlie borderline personality disorder (BPD) and have led to mentalization-based treatments. Yet there has been little empirical investigation into whether mentalization deficits do differentiate the BPD population from healthy controls, and the specific nature of these differences.

METHOD

Five pre-existing Theory of Mind (ToM) tasks that assessed simple to complex mentalization capacity in both the affective and cognitive domains were administered to the same groups of age and gender matched patients with BPD and controls. Self-report measures assessed cognitive and affective empathy and childhood trauma and abuse.

RESULTS

The BPD group did not differ significantly from the healthy control group on basic cognitive false-belief picture-sequencing tasks, or on overall accuracy when discriminating mental states from viewing images of eyes, and attributing emotions based on social events. They were, however, significantly less accurate in identifying positive mental states on the Reading the Mind in the Eyes (RME) task and showed significantly more mentalization errors on affective and cognitive understanding of faux pas (faux pas total score p<.01) and on a Joke Appreciation task (p=.01), that required integration of multiple perspectives. They also self-reported less empathic perspective taking (p<.01). Observation of patterns of performance hinted at specific underlying biases (e.g. a default tendency to use superficial black-and-white attributions to others, such as, "he is mean", when explaining behavior). It was also found that as childhood experiences of punishment increased, adulthood mentalization ability decreased on all affective ToM tasks and on the cognitive and affective components of understanding faux pas.

CONCLUSIONS

The BPD group was as capable as controls in undertaking simple mentalization. However, deficits in mentalization capacity became evident when mentalization tasks became more complex and required the integration of multiple perspectives. Increasing childhood experiences of punishment were related to decreasing mentalization ability in adulthood. Findings support the use of treatments to improve mentalization skills in BPD, however, further research is needed to better specify the nature of underlying mentalizing biases in this population.

Metacognition in persons with substance abuse: Findings and implications for occupational therapists

Background

Addiction is a massive public health problem in which a person’s occupational life is compromised and metacognition is impaired. Occupational therapists may play a critical role in addiction rehabilitation, but more information about patterns of metacognitive deficit co-occurring with addictive behaviour is needed to develop interventions that specifically target these impairments.

Purpose

This study examined whether persons with addiction(s) demonstrated specific patterns of metacognitive deficit on four subscales of metacognition measuring self-reflectivity, understanding others’ thoughts, decentration, and mastery.

Method

Using a mixed-methods design, qualitative data were obtained via the Indiana Psychiatric Illness Interview, which was then rated using a quantitative scale, the Metacognition Assessment Scale–Abbreviated.

Findings

Persons with addiction(s) demonstrated significant impairments in metacognitive mastery but not other areas of metacognition.

Implications

Occupational therapy interventions for addiction should focus on improving metacognitive mastery. Future efficacy studies of interventions to improve mastery and overall outcomes are warranted.

Metacognition in psychosis: comparison of schizophrenia with bipolar disorder

While deficits in metacognition have been observed in schizophrenia (SZ), it is less clear whether these are specific to the disorder. Accordingly, this study compared metacognitive abilities of patients with schizophrenia and bipolar disorder (BD) and examined the degree to which neurocognition contributed to metacognitive deficits in both groups. Participants were 30 patients with SZ and 30 with BD. Metacognitive capacity was measured using the Metacognition Assessment Scale Abbreviated (MAS-A). This scale comprises four domains: self-reflectivity, understanding others' minds, decentration and mastery. Verbal memory, executive functioning and symptoms were concurrently assessed. Group comparisons revealed that SZ patients had greater deficits in metacognitive self-reflectivity, which correctly classified 85.2% of patients with SZ in a logistic regression. Self-reflectivity and understanding others'minds were related to verbal memory and executive functioning in the SZ group, but not in the BD group. Furthermore, greater positive and general psychotic symptoms were associated with poorer metacognition in SZ. Results suggest SZ involves unique deficits in the ability to self-reflect and that these deficits may be uniquely linked with neurocognition.

The Metacognitions about Symptoms Control Scale: Development and Concurrent Validity

OBJECTIVE

This paper presents the development and preliminary validation of a self-report instrument designed to measure metacognitions pertaining to symptoms control in the form of the following: (1) symptoms focusing and (2) symptoms conceptual thinking.

METHODS

A total of 124 patients (95 female and 29 male) presenting with chronic fatigue syndrome (CFS) contributed data to the study to test the structure and psychometric properties of the Metacognitions about Symptoms Control Scale (MaSCS).

RESULTS

A principal components factor analysis indicated that a two-factor solution best fitted the data. The factors were labelled positive and negative metacognitions about symptoms control. Further analyses revealed that both factors had good internal consistency. Correlation analyses established preliminary concurrent validity, indicating that both positive and negative metacognitions about symptoms control were significantly associated with levels of fatigue in CFS. Regression analysis revealed that positive and negative metacognitions about symptoms control significantly predicted fatigue severity when controlling for anxiety and depression.

CONCLUSIONS

The newly developed instrument may help future research that examines the role of metacognitions in CFS, as well as aiding clinical assessment and case formulation.

KEY PRACTITIONER MESSAGE

The MaSCS is a useful first instrument to assess metacognitions in CFS. The MaSCS may help to deepen our understanding of symptoms control (symptoms focusing and conceptual thinking about symptoms) in the experience of CFS symptoms. Assessing and conceptualizing symptoms control through the MaSCS may aid treatment of CFS.

Metacognition, social cognition, and symptoms in patients with first episode and prolonged psychoses

While it has been documented that persons with prolonged schizophrenia have deficits in metacognition and social cognition, it is less clear whether these difficulties are already present during a first episode. To explore this issue we assessed and compared metacognition using the Metacognition Assessment Scale-Abbreviated (MAS-A) and social cognition using the Eyes, Hinting and Bell-Lysaker Emotional Recognition Tests (BLERT) in participants with first episode psychosis (FEP; n=26), participants with a prolonged psychosis (n=72), and a psychiatric control group consisting of persons with a substance use disorder and no history of psychosis (n=14). Analyses revealed that both psychosis cohorts scored lower than controls on the MAS-A total and all subscales except metacognitive mastery. Compared to the FEP group, the persons with prolonged psychosis demonstrated greater metacognitive capacities only in those MAS-A domains reflective of the ability to understand the mental state of others and to see that others may have motivations and desires separate from their own. Other domains of metacognition did not differ between psychosis groups. The Eyes, Hinting and BLERT scores of the two psychosis groups did not differ but were poorer than those produced by the control group. Exploratory correlations in the FEP group showed a pattern similar to that previously observed in prolonged psychosis. Taken together, these findings suggest that while certain domains of metacognition could improve with prolonged psychosis, difficulties with global metacognition and social cognition may be stable features of the disorder and perhaps unique to psychosis.

Metacognitive mastery moderates the relationship of alexithymia with cluster C personality disorder traits in adults with substance use disorders

Cluster C personality disorder traits have been observed in substance use disorders and linked with poorer outcome. One potential factor which may cause these disturbances in personality function is alexithymia, or the inability to name and express emotion. There may be other proximate factors which moderate the impact of alexithymia on the expression of cluster C traits, such as metacognitive mastery, which is the ability to use knowledge about mental states of self and others to cope with distress and solve social problems. To examine the possibility that mastery mediated the effects of alexithymia on cluster C traits, we assessed each of these constructs using the Metacognitive Assessment Scale Abbreviated, Toronto Alexithymia Scale and SCID II among 58 adults in an early phase of recovery from substance misuse disorders in a residential setting. Results of a multiple regression revealed that, after controlling for symptom severity and severity of substance misuse history, metacognitive mastery moderated the effect of alexithymia on number of cluster C traits. A median split and subsequent ANCOVA revealed that participants with higher levels of alexithymia and poorer metacognitive mastery had more cluster C traits than the other groups. These findings may have clinical implications, suggesting that patients with substance use disorders may benefit from treatment which addresses metacognitive mastery.

Three-week inpatient Cognitive Evolutionary Therapy (CET) for patients with personality disorders: evidence of effectiveness in symptoms reduction and improved treatment adherence

OBJECTIVES

The aim of this study was to evaluate the efficacy of Cognitive Evolutionary Therapy (CET) in an intensive short residential treatment of a wide range of severe personality disorders (PDs) that resulted in a reduction of social functioning and significant personal distress.

DESIGN

Each patient was assessed at admission, discharge, and 3 months later in order to determine if there was a reduction in symptoms and an improved adherence to former outpatient programs and to check if patients were undergoing new treatment after discharge.

METHOD

Fifty-one patients participated in this study. The 20-hr weekly program consisted of two individual sessions and various group modules. Outcome measures included: self-reported measures of depression, anxiety, general symptoms, number and duration of inpatient admissions after the programme, and continuation in an outpatient treatment programme.

RESULTS

The results show an overall improvement in general psychopathology after the release and in follow-up sessions, a decrease in the number of further hospital admissions, and an increased level of attendance of outpatient therapy.

CONCLUSIONS

This study shows that intensive short residential treatment is an effective treatment for patients with a wide range of PDs.

General principles for treating personality disorder with a prominent inhibitedness trait: towards an operationalizing integrated technique

Psychotherapists need to perform tasks such as being empathetic, performing an ongoing assessment of cases, self-disclosing, making explicit treatment contracts, validating patients' experiences and promoting awareness of psychological experience, if they are to be effective in treating personality disorder (PD). Successful therapy also requires a systematic accurate PD model. We suggest here that it is still unclear how, when, and according to what session markers therapists need to perform specific operations to maximize therapeutic gains. This article describes and operationalizes a step-by-step procedure for organizing and delivering the interventions necessary for effective outcomes, such as maintaining a good therapeutic relationship, increasing understanding of mental states, reducing symptoms and improving social adaptation. The procedure is illustrated by reference to the treatment of cases of emotionally overly-constricted PDs. We include a theoretical proposal to facilitate the development of measures for evaluating the efficacy of therapist actions.