Unpacking the p-factor. Associations Between Maladaptive Personality Traits and General Psychopathology in Female and Male Adolescents.

Adolescence is a period of rapid physical, psychological, and neural maturation that makes youth vulnerable to emerging psychopathology, highlighting the need for improved identification of psychopathology risk indicators. Recently, a higher-order latent psychopathology factor (p-factor) was identified that explains latent liability for psychopathology beyond internalizing and externalizing difficulties. However, recent proposals suggest reconceptualizing the p-factor model in terms of impairments in personality encompassing difficulties in both self-regulation (borderline features) and self-esteem (narcissistic features), but this remains untested. To address this, this study examined the p-factor structure and the contribution of borderline and narcissistic features using two cross-sectional data collections. In Study 1, 974 cisgender adolescents (63% assigned females at birth; age range: 13-19; Mage = 16.68, SD = 1.40) reported on internalizing and externalizing problems (YSR) to test via structural equation models (SEM) different theoretical models for adolescent psychopathology. In Study 2, 725 cisgender adolescents (64.5% assigned females at birth; age range: 13-19; Mage = 16.22, SD = 1.32) reported internalizing and externalizing problems (YSR), borderline personality features (BPFSC-11), and narcissistic personality traits (PNI), to explore, via SEM, the contribution of borderline and narcissistic traits to the p-factor and accounting for gender differences. Results confirmed the utility of a bi-factor model in adolescence. Furthermore, findings highlighted the contribution of borderline features and narcissistic vulnerability to general psychopathology. The study provides the first evidence supporting a p-factor model reconceptualized in terms of personality impairments encompassing difficulties in self-regulation and self-esteem in adolescents.

Different epistemic stances for different traumatic experiences: implications for mentalization.

Traumatic experiences may impair reflective functioning (RF), making it difficult for individuals to understand their own and others' mental states. Epistemic trust (ET), which enables evaluating social information as reliable and relevant, may vary in association with RF. In this study, we explored the implications of different ET stances (i.e., trust, mistrust, and credulity) in the relation between different childhood traumatic experiences (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) and different types of RF impairments (uncertainty and certainty about mental states). A non-clinical community sample of 496 cisgender emerging adults (mage = 24.91, standard deviation = 2.66, 71.85% assigned female at birth, 63.63% heterosexual) reported on their childhood traumatic experiences, ET, and RF. We used structural equation models to examine direct and indirect associations. The results showed significant indirect effects between emotional abuse and uncertainty about mental states through credibility. We also observed significant indirect effects between emotional abuse and certainty about mental states through mistrust and credibility. The findings suggest that a lack of discrimination when evaluating knowledge from others (i.e., credulity) might promote increased uncertainty in RF when emerging adults have experienced emotional abuse in their childhood. Conversely, a tendency to view all information sources as unreliable or ill-intentioned (i.e., mistrust) may foster greater certainty in RF as a protective mechanism against an unreliable and potentially harmful world when combined with childhood emotional abuse. The implications for clinical practice and intervention are discussed.

Problematic internet use in emerging adulthood to escape from maternal helicopter parenting: defensive functioning as a mediating mechanism.

The increasing use of the Internet has raised concerns about its problematic use, particularly among emerging adults who grew up in a highly digitalized world. Helicopter parenting, characterized by excessive involvement, overcontrol, and developmentally inappropriate behavior, has been identified as a potential factor contributing to problematic Internet use (PIU). Under these circumstances, considering that emerging adults navigate their adult lives and strive to reduce their sense of being in-between, implicit emotion regulation strategies, such as defense mechanisms, may help comprehend PIU. The present questionnaire-based study investigated the associations between maternal and paternal helicopter parenting and PIU through defensive functioning among a community sample of 401 cisgender emerging adults (71.82% females; 82.04% heterosexuals; Mage=24.85, SD=2.52) living in Italy. About one-fourth (25.19%) reported PIU. Greater maternal, B=0.904, SE=0.235, p<.001, but not paternal, B=0.343, SE=0.188, p=.068, helicopter parenting was significantly associated with PIU through a less mature defensive functioning. Conversely, neither maternal, B=1.158, SE=0.722, p=.109, nor paternal, B=0.355, SE=0.731, p=.628, helicopter parenting had a direct association with PIU. The results suggest the importance for psychotherapists to incorporate individuals' defense mechanisms and parent-child relationship history when designing tailored interventions for effective treatment of PIU. This emphasis is crucial because, in the context of a developmentally appropriate parenting style, relying on more mature defenses after psychotherapeutic intervention can lead to healthier adjustment among emerging adults.

PsyCARE study: assessing impact, cost-effectiveness, and transdiagnostic factors of the Italian ministry of health's "psychological bonus" policy.

BACKGROUND: The prevalence of anxiety and depression disorders is surging worldwide, prompting a pressing demand for psychological interventions, especially in less severe cases. Responding to this need, the Italian government implemented the "Psychological Bonus" (PB) policy, allotting 25 million euros for mental health support. This policy entitles individuals to a minimum of four to twelve psychological sessions. In collaboration with the National Board of Italian Psychologists, our study assesses this policy's effectiveness. Indeed, the PsyCARE study aims to examine the utilization of the Psychological Bonus, evaluate its impact on adult and adolescent participants' psychological well-being through pre- and post-intervention assessments and six-month follow-up, and conduct a longitudinal cost-effectiveness analysis of this policy. A secondary aim is to investigate the influence of these interventions on transdiagnostic factors, including emotion regulation and epistemic trust. METHODS: The study involves licensed psychotherapists and their patients, both adults and adolescents, benefiting from the Psychological Bonus. Data collection is underway and set to conclude in December 2023. Psychotherapists will provide diagnostic information and assess patient functioning. In addition, patients will be evaluated on mental health aspects such as clinical symptoms, emotion regulation, epistemic trust, and quality of life. We will employ linear mixed-effects models to analyze the outcomes, accounting for both fixed and random effects to capture the hierarchical structure of the data. DISCUSSION: We anticipate the study's findings will highlight reduced psychological distress and improved quality of life for participants and demonstrate the Psychological Bonus policy's cost-effectiveness. The study will gather data on the role of specific versus nonspecific therapeutic factors in psychotherapy while adopting a patient-tailored approach to identify effective therapeutic elements and examine transdiagnostic factors. Overall, this study's findings will guide future measures within the Italian healthcare system, fostering a psychological health culture and providing valuable insights to the broader public. STUDY REGISTRATION: https://osf.io/6zk2j.

Associations of mentalization and epistemic trust with internalizing and externalizing problems in adolescence: A gender-sensitive structural equation modeling approach.

INTRODUCTION: Mentalization, operationalized as reflective functioning (RF), allows individuals to interpret actions as caused by intentional mental states. Previous research highlighted the gender-specific associations between adolescents' internalizing and externalizing difficulties and mentalizing impairments. In addition, research suggested that mentalizing facilitates the creation of epistemic trust (ET) to evaluate social information as accurate, reliable, and relevant. However, few investigations explored the concurrent associations between RF, ET, and adolescent psychopathology. METHODS: A sample of 447 Italian cisgender adolescents (57% assigned females at birth; age range 12-19 years old; Mage = 15.54, SD = 1.98) self-reported RF (RFQY-5), ET towards mother, father, and peers (IPPA) and mental health problems (YSR-112). Gender-specific structural equation modeling explored the associations between RF, ET, and internalizing/externalizing problems. RESULTS: Results suggested an excellent fit for the theoretical model and revealed gender-related associations. In females, findings suggest that ET mediates the association between RF and psychopathology, with indirect associations from RF through ET to lower internalizing and externalizing problems. However, in males, RF and ET display independent associations with psychopathology. CONCLUSION: Overall, findings suggest that ET might be a transdiagnostic factor playing different roles associated with adolescent psychopathology. Indeed, links between RF and ET might help to explore gender differences in mental health problems in this developmental phase.

Unpacking trust: The Italian validation of the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ).

The construct of epistemic trust has received much consideration in recent psychological literature, even though mainly from a theoretical perspective. The overall aim of this study was to validate the first self-report measure of epistemic trust-the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ)-in an Italian sample. Our primary goal was to test the factorial validity of the instrument, also exploring the influence of age, gender, and level of education on epistemic trust (Study 1, n = 843). Secondarily, we investigated the associations between epistemic trust, mistrust, credulity, and other aspects of psychological functioning, as well as with the presence of adverse childhood experiences in a smaller number of participants (Study 2, n = 445). Besides the ETMCQ, the survey included an ad hoc questionnaire investigating socio-demographic characteristics and self-report measures of reflective functioning, mentalized affectivity, traumatic experiences, attachment, and psychological symptoms. Statistical analysis showed a three-factor hierarchical structure similar to the model proposed in the original validation, with some differences that suggest an influence of cultural factors in determining individuals' epistemic stance. Our results corroborate previous theoretical contributions regarding the association between epistemic trust and psychological wellbeing, and between epistemic disruptions and higher levels of psychological suffering. Both Mistrust and Credulity were significantly related to the presence of childhood traumatic experiences, attachment avoidance and anxiety, lower levels of mentalization, lower abilities in emotional regulation, and higher levels of psychopathological symptoms. The ETMCQ represents an easily administered and time-effective tool. Its use could pave the way for interesting clinical and theoretical findings.

Emerging personality in adolescence: developmental trajectories, internalizing and externalizing problems, and the role of mentalizing abilities.

INTRODUCTION: Identifying longitudinal trajectories of emerging personality (EP) is crucial to highlight developmental patterns that might foster personality pathology in adolescence and early adulthood. Research on the exacerbation of personality pathology in adolescence identifies the significant contribution of internalizing and externalizing problems and suggests the importance of considering aspects such as mentalization, while accounting for gender differences. METHODS: In our study, we adopted a mixed-model approach to (1) explore longitudinally EP (Adolescent Personality Structure Questionnaire; APS-Q) over 12 months in a sample of adolescents (N = 178, 62% females, mAGE = 15.04, SD = 1.27), accounting for gender effects. Moreover, (2) we assessed the longitudinal effect of internalizing and externalizing problems (Youth Self-Report; YSR-112) on EP. Finally, (3) we addressed the moderating role of mentalization (Movie Assessment for Social Cognition; MASC) in this developmental pathway. RESULTS: Results highlighted a two-way pattern of EP. No changes were found in the level of difficulties in Self-acceptance, Investments and Goals, and Relationships with family dimensions. However, significant changes were found in personality functioning in the dimensions of Sense of Self, Aggression, and Relationships with friends. More, changes in difficulties in Sexuality emerged only in females. Also, gender differences emerged in the level of severity of EP. In addition, Internalizing and Externalizing problems differentially predicted difficulties in personality dimensions. Finally, mentalizing features moderated the relationship between Internalizing problems and Sense of Self and Internalizing problems and Self-acceptance, respectively. CONCLUSIONS: Our contribution aligns with recent developmental models of personality pathology, suggesting that different personality dimensions develop at different paces. More, it highlights the predictive power of externalizing and internalizing problems on difficulties in personality dimensions. Finally, it advances the discussion on the contribution of mentalizing abilities to EP.

Adolescence in lockdown: The protective role of mentalizing and epistemic trust.

OBJECTIVE: Mentalizing is the ability to interpret one's own and others' behavior as driven by intentional mental states. Epistemic trust (openness to interpersonally transmitted information) has been associated with mentalizing. Balanced mentalizing abilities allow people to cope with external and internal stressors. Studies show that social isolation imposed by the COVID-19 pandemic was highly stressful for most people, especially for adolescents. Here we examine whether mentalizing and epistemic trust were protective factors in relation to emotional distress during the lockdown. METHOD: A total of 131 nonclinical adolescents, aged between 12 and 18 years, were evaluated during the lockdown using the Reflective Functioning Questionnaire for Youth, Inventory of Parent and Peer Attachment, Perceived Stress Scale, and Difficulties in Emotion Regulation Scale. RESULTS: Results from network analysis showed that epistemic trust and mentalizing were negatively associated with perceived stress and emotion dysregulation. Epistemic trust in fathers was associated with level of perceived stress, and epistemic trust in mothers with emotion dysregulation. CONCLUSION: These findings suggest that epistemic trust and the capacity to mentalize were low in adolescents during lockdown, and this was associated with high levels of stress. However, robust levels of epistemic trust and mentalizing may have acted as protective factors that buffered individuals from the risk of emotional dysregulation during the lockdown.

The interplay of mentalization and epistemic trust: a protective mechanism against emotional dysregulation in adolescent internalizing symptoms.

Mentalization is the ability to interpret actions as caused by intentional mental states. Moreover, mentalization facilitates the development of epistemic trust (ET), namely, the ability to evaluate social information as accurate, reliable, and relevant. Recent theoretical literature identifies mentalization as a protective factor, contrasting psychopathology and emotional dysregulation. However, few investigations have explored the concurrent associations between mentalization, ET and emotion dysregulation in the context of internalizing problems in adolescence. In the present study, 482 adolescents from the general population aged between 12 and 19 were assessed with the epistemic trust mistrust credulity questionnaire, the reflective functioning questionnaire- youth, the difficulties in emotion regulation scale, and the youth self-report. We tested the relationship between the variables through serial mediation models. Results showed that mentalization reduces internalizing problems via emotional dysregulation; ET is positively associated with mentalization but not symptomatology. Finally, both epistemic mistrust and epistemic credulity are significantly associated with internalizing symptomatology; those effects are mediated differently by difficulties in emotional regulation. In conclusion, the present study confirms mentalization's role as a protective factor in developmental psychopathology. Nevertheless, exploring the role of the different epistemic stances guarantees a better understanding of psychopathological pathways in adolescence.

Parenting Stress, Maternal Self-Efficacy and Confidence in Caretaking in a Sample of Mothers with Newborns (0-1 Month).

A mother's responses to her newborn and her confidence in the child's caretaking depend on her attachment security, general parental stress, and perceived self-efficacy. However, few studies have analyzed maternal confidence in caretaking and how it is influenced by some mothers' characteristics. We aimed to examine the association between maternal adult attachment and confidence in a child's caretaking and to understand whether this relationship was mediated by parenting stress and maternal self-efficacy. The sample consisted of 96 mothers with a mean age of 33 years with newborn children aged between 3 and 30 days. The instruments used were the Experiences in Close Relationships-Revised (ECR-R), the Mother and Baby Scale (MABS), the Parenting Stress Index Short Form (PSI-SF), and the Maternal Self-Efficacy Questionnaire (MEQ). The results showed a positive association between attachment avoidance and lack of confidence in caretaking, and this association was mediated by parenting stress. Conversely, attachment anxiety appeared not to influence confidence in caretaking, and maternal self-efficacy did not appear to mediate the relationship between attachment and confidence in the caretaking of infants. Our results could guide new research in studying confidence in caretaking and enable healthcare professionals to recognize at-risk situations early from the first month after childbirth.

Behind the Scenes of COVID-19 Vaccine Hesitancy: Psychological Predictors in an Italian Community Sample.

Psychological variables may be crucial in favoring or discouraging health-related behaviors, including vaccine acceptance. This study aimed to extend the previous literature by outlining the psychological profile associated with COVID-19 vaccine hesitancy in a sample of Italian citizens. Between April and May 2021, 1122 Italian volunteers completed a web survey on COVID-19 vaccine acceptance, also including several self-reported psychological measures. A multiple hierarchical logistic regression analysis was performed to identify the psychological variables associated with vaccine hesitancy. Low confidence in COVID-19 vaccine efficacy and safety, low collective responsibility, high complacency, and high calculation (i.e., extensive information searching, and costs-benefit estimates) predicted higher hesitancy. Our results suggest that to be effective, vaccine-related communications should be as clear, understandable, and sound as possible, preventing the spreading of misunderstandings, or even fake information, that may foster people's insecurities and distrust. Furthermore, the advantages and necessity of vaccination, both at the individual and community-level, should be clearly emphasized. Efficacious vaccine-related communications may be crucial, not only to maintain an adequate immunity rate for COVID-19, but also to inform policymakers and public authorities in the case of possible future infectious outbreaks.

Anxiety in Attachment and Sexual Relationships in Adolescence: A Moderated Mediation Model.

Adolescence is characterized by several transformations, such as identity construction, progressive estrangement from parents, relational interest in peers, and body changes that also involve sexuality issues. In this process, attachment patterns play a fundamental role in relationships, and when these are dysfunctional, they can result in internalizing and externalizing problems. Often, females show their relational difficulties through internalizing expressions and males through externalizing expressions. Additionally, given the sexual progress involved in this life moment, psychological symptomatology may influence adolescents' perception of sex and performance. Our purpose is to study the mediating role of internalizing and externalizing symptomatology in the relationship between attachment patterns and sexual and psychological dimensions. In addition, we investigated the moderating effect of the sex assigned at birth on this mediation model. n = 493 adolescents (38.3% males; Mage = 16.51; SD = 1.17) participated in the study. The results show a significant mediation effect of internalizing symptomatology on the relationship between attachment and sexual anxiety. Additionally, this effect is moderated significantly by assigned-at-birth sex. These results confirm that in adolescence, attachment patterns can influence adolescents' perception of sex. The connection between these two psychological dimensions is influenced by symptomatologic expression. Further investigations are needed.

Advancement in the child attachment interview and the child and adolescent reflective functioning scale using a PDM-2 framework: case reports.

The Child Attachment Interview (CAI) is a well-established semi-structured interview, widely used to identify attachment representations in middle childhood and adolescence. The application of the Child and Adolescent Reflective Functioning Scale (CRFS) to CAI narratives allows for an assessment of child mentalization, considered a strong predictor of attachment security. The 2nd edition of the Psychodynamic Diagnostic Manual (PDM-2) includes CAI and CRFS as valid and reliable assessment measures in order to assess the dominion of the Mental Functioning axis. The aim of the present paper is to investigate the informative power of CAI and CRFS for the overall understanding of mental functioning and personality in a PDM-2 framework. The present report includes the discussion of two clinical cases of school-aged children in applying the Psychodiagnostic Chart-Second Edition (PDC-2) to the CAI transcript. The first case concerns a young male, aged 10, suffering from Oppositional-Provocative Disorder (externalizing disorder), while the second case concerns a young female, aged 15, suffering from Somatic Symptoms Disorder (internalizing disorder). PDC-2 for children and adolescents was used. Data from the scoring of CAI and CRFS were combined with a systematic evaluation of the qualitative contents emerging from CAI transcripts. A detailed analysis suggests that both the CAI and CRFS are useful attachment-oriented measures, able to explore child's mental states, and together with the application of PDC-2 they provide an essential contribution in the understanding of developmental psychopathology. Implications of this innovative approach for clinical assessment, treatment design, and interventions are further discussed.

Binge eating attitudes in community adolescent sample and relationships with interview-assessed attachment representations in girls: a multi-center study from North Italy.

PURPOSE: To compare community girls at risk and not at risk for binge eating (BE) in attachment representations through a narrative interview and to test the predictive role of attachment pattern(s) on the risk of binge eating among community girls. METHODS: From 772 community adolescents of both sexes (33% boys) screened through the Binge Eating Scale (BES), 112 girls between 14 and 18 years, 56 placed in a group at risk for binge eating (BEG), and 56 matched peers, not at risk (NBEG), were assessed in attachment representations through the Friends and Family Interview (FFI). RESULTS: (1) Compared to NBEG, girls in the BEG showed more insecure-preoccupied classifications and scores, together with lower narrative coherence, mother's representation as a secure base/safe haven, reflective functioning, adaptive response, and more anger toward mother. (2) Both insecure-dismissing and preoccupied patterns predicted 15% more binge-eating symptoms in the whole sample of community girls. CONCLUSIONS: Insecure attachment representations are confirmed risk factors for more binge eating, affecting emotional regulation and leading to "emotional eating", thus a dimensional assessment of attachment could be helpful for prevention and intervention. Implications and limits are discussed. LEVEL OF EVIDENCE: III. Evidence obtained from cohort or case-control analytic studies.

Italia Ti Ascolto [Italy, I am listening]: an app-based group psychological intervention during the COVID-19 pandemic.

The onset of the coronavirus disease 2019 (COVID-19) pandemic impacted individuals' psychological wellbeing resulting in heightened perceived stress, anxiety, and depression. However, a significant issue in accessing psychological care during a lockdown is the lack of access to in-person interventions. In this regard, research has shown the efficacy and utility of psychological app-based interventions. 'Italia Ti Ascolto' (ITA) has been developed as a population tailored internet-based intervention to offer an online professional solution for psychological support needs. The ITA app is available on iOS and Android systems. Users completed a baseline assessment on emotion regulation strategies (cognitive reappraisal and expressive suppression), psychological stress, anxiety, depression, and perceived social support. Participants could select among several one-hour long clinical groups held by expert psychotherapists. After every session, people were asked to complete a quick users' satisfaction survey. Our contribution presents ITA's intervention protocol and discusses preliminary data on psychological variables collected at baseline. Data showed significant associations between emotion regulation strategies, symptoms of depression and anxiety, and level of stress. Moreover, the role of perceived social support is considered. Future developments and implications for clinical practice and treatment are discussed.

MOG-IgG-associated disorder and systemic lupus erythematosus disease: Systematic review.

INTRODUCTION: Myelin oligodendrocyte glycoprotein (MOG) is a nervous system protein expressed by oligodendrocytes to constitute the myelin sheath. Autoantibodies against MOG have been widely described in neurological and autoimmune diseases such as MOG-IgG-associated disorder (MOGAD).Although underlying mechanisms have not yet been understood, an overlap of MOGAD and Systemic Lupus Erythematosus (SLE) has been shown in the literature. OBJECTIVES: The aim of this systematic review was to assess the possible correlations between MOGAD and SLE based on reported features found in the literature that support the association of the two. METHODS: A keyword-based literature search was conducted, applying a ten-year filter and using the following key-words: "MOG autoantibody-associated disease and Systemic Lupus Erythematosus"; "MOG and Systemic Lupus Erythematosus" "Anti-MOG and Lupus"; "MOG and SLE"; "MOG and LUPUS" on MEDLINE/PUBMED, ScienceDirect, SciELO, LILACS and Cochrane; and "MOG antibody-associated disease and SLE" on Google Scholar. RESULTS: Eleven publications reporting on the MOGAD and SLE correlation were included in qualitative synthesis: animal experiment (1), cross-sectional (3), prospective (2), retrospective (1), non-systematic review (3), and case report (1) studies. CONCLUSION: Not much is known about the connection between MOG-IgG-associated disorder and SLE. Unfortunately, only observational studies have been conducted in humans so far, providing us with limited data. While MOGAD features have been reported to develop in SLE patients, this is not an universal finding. In fact, many different issues impair these results, making it difficult to match the findings of different studies.

Urinary tract infection in patients with multiple sclerosis: An overview.

INTRODUCTION: Multiple sclerosis (MS) is a demyelinating, chronic, inflammatory, and autoimmune disease of the central nervous system (CNS) with axonal degeneration, presenting a progressive and variable course. MS patients usually have complications, such as bladder dysfunction, presence of urinary symptoms, and Urinary Tract infection (UTI), which is one of the three most common non-neurological complications in MS patients. OBJECTIVE: Analyze the most diverse aspects of UTI in MS patients, focusing on risk factors, prevalence, hospitalization, mortality rates, diagnosis, and treatment of UTIs in this group. METHODS: A non-systematic review of articles published on PubMed in the last 10 years with the search terms "Urinary Tract Infection" AND "Multiple Sclerosis". DISCUSSION: MS patients have a high UTI prevalence, mainly due to the occurrence of urinary disorders in these patients. The most common symptoms of UTI in MS patients are urinary urgency, polyuria, nocturia, urinary retention, and incontinence. Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most found organisms and treatment is based on antibiotic therapy. Moreover, UTIs can precipitate outbreaks, worsen the disease, causing more damage and a severe neurological condition deterioration. In addition, UTIs in this group are associated with a high hospitalizations rate and a high mortality rate. Therefore, patients in MS outbreaks with urinary symptoms or positive urinalysis must keep corticosteroid therapy and Disease-Modifying Treatments (DMTs). Whether clinically stable or MS relapse patients, the urinalysis and the presence of symptoms must guide the treatment in each group. Moreover, the pharmacological treatment of asymptomatic bacteriuria has no evidence of clinical efficacy. As the treatment of asymptomatic bacteriuria induces a significant increase in more resistant bacterial strains, it is recommended exceptionally in cases of recurrent acute UTIs, prior to handling of the UTI, pregnancy or patients in need of immunosuppression. CONCLUSION: UTI represents a great risk and concern in MS patients. The high prevalence, hospitalization rate, and mortality rate of UTI in MS is worrying, such as the cause-consequence relationship between UTIs and the use of corticosteroids in outbreaks. Therefore, it is important to be aware of a UTI in this group to make early diagnoses, adequate management, and new infections prevention. Thus, further studies are needed to thoroughly analyze each nuance of this important comorbidity for MS patients.

In-session interactive dynamics of the psychotherapy process between therapeutic alliance, therapist expertise, therapist technical intervention, patient metacognition and functioning.

Empirical research has explored different dimensions of the therapy process and their associations, often showing bidirectional links: for example, metacognition may be favoured by a positive alliance with the clinician; on the other hand, metacognitive difficulties may be an obstacle for the alliance. However, little is still known about the overall relationship between multiple dimensions during the psychotherapy process. The aim of this study is to further explore the in-session interaction of therapeutic process variables, focusing on patient metacognition, therapeutic alliance, technical intervention, therapist expertise, and patient functioning. Participants included 45 patients involved in a psychodynamic weekly treatment in two clinical centres. Therapists were both in-training and experienced clinicians. Four instruments were applied on four psychotherapy sessions (178 verbatim transcripts): Metacognition Assessment Scale-Revised (MAS-R) assessing metacognition, Collaborative Interaction Scale (CIS) assessing therapeutic alliance, Psychodynamic Intervention Rating Scale (PIRS) assessing therapist technical interventions, and Shedler-Westen Assessment Procedure (SWAP)-200 assessing patient functioning. Sequential analyses revealed that specific therapist interventions co-occurred with three different levels of therapeutic alliance: a first one characterized by positive collaboration, the second one by neutral collaboration, and the third one by ruptures. Moreover, and critically, the patient metacognition, patient functioning, and therapist expertise were found to exert different effects in the three alliance levels. These findings suggest the existence of a specific interdependence between the variables involved in the research. These results further indicate that the therapist expertise is a key element in the therapeutic process, as it can drastically affect the in-session interactive dynamic.