Symptom severity and mindreading in narcissistic personality disorder

Preliminary Development and Psychometric Evaluation of the Metacognition Brief Rating Scale: An Informant form of the Metacognition Self-Assessment Scale

Objective

Metacognition has been conceptualized as the ability to reflect on self and others' mental states and representations, including affects, beliefs, and intentions. The Metacognition Self-Assessment Scale (MSAS) was developed to assess various aspects of metacognition, aiming to leverage its potential applications in fields like clinical psychology and psychotherapy. However, a concern associated with MSAS is whether individuals can accurately self-report difficulties in identifying and describing mental states, both their own and others', when they lack these abilities. In response to this challenge, we aimed to develop and validate an alternative reporting tool, the Metacognition Brief Rating Scale (MBRS), which serves as an informant form of MSAS.

Method

The MBRS was administered to 384 individuals randomly recruited from the general population. We employed a methodological strategy based on three successive steps. In the preliminary step, items from the MSAS were rewritten into a third-person version by the authors. In the second step, we examined whether the four-factor structure was congruent between the informant-report (MBRS) and the self-report (MSAS) using exploratory and confirmatory factor analysis. In the last step, we examined and compared the psychometric properties of the MBRS and MSAS items, including item characteristics and internal reliability analyses.

Results

The psychometric properties (items and scales) of both versions were found to be adequate, and the four-factor structure of the MBRS was supported. The correlation between the two versions was statistically significant, and the factor structures were similar.

Conclusions

The results support the psychometric properties of the MBRS. However, further research is needed, especially in larger non-clinical and clinical samples, to replicate and extend these findings.

Measuring dysfunctional interpersonal beliefs: validation of the Interpersonal Cognitive Distortions Scale among a heterogeneous German-speaking sample

BACKROUND

Dysfunctional interpersonal beliefs (DIBs) are a key symptom domain in numerous mental disorders. Because DIBs exert a strong influence on social experience and behavior, they play an important role in a mental disorder's development and progression. To date, only the Interpersonal Cognitive Distortions Scale (ICDS) captures DIBs independently of specific disorders, populations, or contexts. The present study's aim was to psychometrically evaluate and validate a German translation of the ICDS.

METHODS

The ICDS was administered along with indicators of convergent (rejection sensitivity, depressive expectations, interpersonal trust, interpersonal problems, perceived social support), discriminant (self-efficacy, perseverative negative thinking, optimism), and clinical validity (psychopathology, perceived stress, well-being) to a pooled sample incorporating non-clinical (N = 114) and clinical (N = 94) participants.

RESULTS

An exploratory factor analysis (EFA) suggested a five-factor solution (factor loadings: .44 to .85). Correlational analyses demonstrated acceptable convergent (ρ = -.29 to -.35, ρ = .27 to .59), suboptimal discriminant (ρ = -.27 to -.38, ρ = .52), and acceptable clinical validity (ρ = -.21, ρ = .36 to .44) at the total-scale level. However, results at the subscale level were mixed and required nuanced interpretation. Likewise, internal consistency was acceptable at the total-scale level (α = .76), but ranged from good to poor at the subscale level (α = .61 to .80). DIBs mediated the negative relationship between mental disorder onset and psychopathology levels.

DISCUSSION

Our results imply DIBs' relevance to mental health and related outcomes. When working with the ICDS's German version, we recommend employing only the "insecurity" subscale, as this was the only scale revealing acceptable psychometric properties. Future studies should improve the construct validity of the ICDS (and its subscales), e.g., by adding more items to the respective subscales and further classes of DIBs.

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.

A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode"

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

Can neuroscience help to understand narcissism? A systematic review of an emerging field

Narcissism is a Janusian personality construct, associated with both grandiose self-assuredness and dominance, as well as vulnerable insecurity and reactivity. Central questions of intra- and interpersonal functioning in narcissism are still a matter of debate. Neuroscience could help to understand the paradoxical patterns of experience and behavior beyond the limitations of self-reports. We provide a systematic review of 34 neuroscience studies on grandiose, vulnerable, pathological narcissism, and Narcissistic Personality Disorder (NPD), spanning experimental investigations of intra- and interpersonal mechanisms, research on neurophysiological and neuroendocrine aspects of baseline function, and brain structural correlates. While neuroscience has scarcely directly studied vulnerable narcissism, grandiose narcissism is associated with heightened vigilance to ego threat and stress responses following ego threat, as well as heightened stress indicators in baseline measures. Such responses are not commonly observed in self-reports, highlighting the potential of neuroscience to augment our understanding of self-regulatory dynamics in narcissism. Interpersonal functioning is characterized by deficits in social-affective processes. Both involve altered activity within the salience network, pointing to a double dissociation regarding the expression of narcissism and self/other oriented situational focus. Findings are summarized in an integrative model providing testable hypotheses for future research along with methodological recommendations.

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.

Self-serving social strategies: A systematic review of social cognition in narcissism

Narcissistic Personality Disorder is characterised by inflated self-importance, an excessive need for admiration, and a lack of empathy. The interpersonal difficulties associated with narcissistic personality may be becoming more widespread given its increasing prevalence within the general population. This systematic review investigated the relationship between narcissistic personality traits and social cognition (i.e. theory of mind; emotion recognition; empathy; emotional intelligence) in clinical and non-clinical samples. Cognitive empathy (i.e. perspective taking) appears unlikely to be impaired, while affective empathy (relating to another’s emotion state) may be reduced in association with narcissism. Those with grandiose narcissism rate their empathic skills more highly than those with vulnerable narcissism, but concurrent administration of objective measures is rare, limiting insight into the validity of self-ratings. Rather than deficits in aspects of social cognition, the overall pattern could reflect motivation, or advantageous use of social cognitive skills to serve the self. Indeed, interpersonal strategies associated with narcissism (e.g. deception; manipulation) suggest the application of understanding another’s beliefs or desires in the context of low empathy. Further research should seek to explore performance on a wider range of emotion recognition and theory of mind tasks, and whether characteristics such as excessive jealousy and paranoia could reflect hyper-mentalizing.

Dissociating Profiles of Social Cognitive Disturbances Between Mixed Personality and Anxiety Disorder

BACKGROUND

An emerging body of research has begun to elucidate disturbances to social cognition in specific personality disorders (PDs). No research has been conducted on patients with Mixed Personality Disorder (MPD), however, who meet multiple diagnostic criteria. Further, very few studies have compared social cognition between patients with PD and those presenting with symptomatic diagnoses that co-occur with personality pathologies, such as anxiety disorder (AD). The aim of this study was to provide a detailed characterization of deficits to various aspects of social cognition in MPD and dissociate impairments specific to MPD from those exhibited by patients with AD who differ in the severity of personality pathology.

METHOD

Building on our previous research, we administered a large battery of self-report and performance-based measures of social cognition to age-, sex- and education-matched groups of patients with MPD or AD, and healthy control participants (HCs; n = 29, 23, and 54, respectively). This permitted a detailed profiling of these clinical groups according to impairments in emotion recognition and regulation, imitative control, low-level visual perspective taking, and empathic awareness and expression.

RESULTS

The MPD group demonstrated poorer emotion recognition for negative facial expressions relative to both HCs and AD. Compared with HCs, both clinical groups also performed significantly worse in visual perspective taking and interference resolution, and reported higher personal distress when empathizing and more state-oriented emotion regulation.

CONCLUSION

We interpret our results to reflect dysfunctional cognitive control that is common to patients with both MPD and AD. Given the patterns of affective dispositions that characterize these two diagnostic groups, we suggest that prolonged negative affectivity is associated with inflexible styles of emotion regulation and attribution. This might potentiate the interpersonal dysfunction exhibited in MPD, particularly in negatively valenced and challenging social situations.

Impaired empathy but no theory of mind deficits in adult attention deficit hyperactivity disorder

OBJECTIVE

The cognitive capacity to change perspective is referred to as theory of mind (ToM). ToM deficits are detectable in a variety of psychiatric and neurological disorders. Since executive abilities are closely associated with ToM skills, we suspected that due to a common neuropsychological basis, ToM deficits exist in treatment-naïve adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Performance of treatment-naïve adults with ADHD (N = 30) in tasks assessing executive functions (Trail Making Test, Stroop color-word test, and Test Battery for Attentional Performance), empathy skills (Cambridge Behaviour Scale), and ToM (Movie for Assessment of Social Cognition) was compared with that of a healthy control group (N = 30) matched according to basic demographic variables.

RESULTS

Compared to healthy controls, treatment-naïve adults with ADHD showed deficits in various executive functions and the ability to empathize (all p < .05). However, no performance differences were found with regard to ToM (all n.s.).

CONCLUSIONS

Since studies in juveniles with ADHD often show impaired ToM performance, it is conceivable that ToM deficits may become attenuated due to neuronal development in adolescence. Furthermore, our findings imply that ToM impairments, even when present in adult ADHD, appear to be independent of executive deficits and might be explained by comorbid disorders.

Metacognitively oriented psychotherapy for schizotypal personality disorder: A two-case series

Schizotypal personality disorder represents a broad range of maladaptive behaviour, which has been linked to both personality disorder and schizophrenia spectrum disorders; however, to date, little effort has been devoted to developing psychosocial treatment approaches to address it. In response, we conducted two case studies exploring the effects of two metacognitively oriented forms of psychotherapy: metacognitive interpersonal therapy and metacognitive reflection and insight therapy for patients with schizotypal personality disorder. We chose these two forms of therapy as they have been successfully delivered, respectively, to persons with other personality disorders and schizophrenia spectrum disorders. Both treatments consisted of weekly individual psychotherapy sessions over a period of 6 months. General symptoms were assessed during the first week of treatment, at treatment end and at 1 month following treatment using the Symptom Check List-90-Revised, while schizotypal traits were assessed with the Structured Clinical Interview for DSM-5. Both patients completed all sessions, and there were no reports of any adverse outcomes. Both patients achieved reliable change in symptoms (ranging from 4.98 to 9.81) and a significant reduction in schizotypal features. Results provide preliminary evidence of the feasibility of metacognitively oriented interventions for schizotypal personality disorder. © 2019 John Wiley & Sons, Ltd.

Neurobiological and clinical effect of metacognitive interpersonal therapy vs structured clinical model: study protocol for a randomized controlled trial

BACKGROUND

Borderline Personality Disorder (BPD) is a complex and debilitating disorder, characterized by deficits in metacognition and emotion dysregulation. The "gold standard" treatment for this disorder is psychotherapy with pharmacotherapy as an adjunctive treatment to target state symptoms. The present randomized clinical trial aims to assess the clinical and neurobiological changes following Metacognitive Interpersonal Therapy (MIT) compared with Structured Clinical Management (SCM) derived from specific recommendations in APA (American Psychiatric Association) guidelines for BPD.

METHODS

The study design is a randomized parallel controlled clinical trial and will include 80 BPD outpatients, aged 18-45 enrolled at 2 recruitment centers. Primary outcome will be the clinical change in emotion regulation capacities assessed with the Difficulties in Emotion Regulation Scale (DERS). We will also investigated the effect of psychotherapy on metacognitive abilities and several clinical features such as BPD symptomatology, general psychopathology, depression, personal functioning, and trait dimensions (anger, impulsivity, alexithymia). We will evaluate changes in brain connectivity patterns and during the view of emotional pictures. A multidimensional assessment will be performed at the baseline, at 6, 12, 18 months. We will obtain structural and functional Magnetic Resonance Images (MRIs) in MIT-Treated BPD (N = 30) and SCM-treated BPD (N = 30) at baseline and after treatment, as well as in a group of 30 healthy and unrelated volunteers that will be scanned once for comparison.

DISCUSSION

The present study could contribute to elucidate the neurobiological mechanisms underlying psychotherapy efficacy. The inclusion of a multidisciplinary study protocol will allow to study BPD considering different features that can affect the treatment response and their reciprocal relationships.

TRIAL REGISTRATION

NCT02370316 . Registered 02/24/2015.