The relationships among metacognitive functions, sleep-related thought-control strategies and sleep quality: A mediation analysis.

In the context of sleep disturbances, increasing evidence suggests a critical role of sleep-related dysfunctional metacognitive activity, including metacognitive control of intrusive thoughts in the pre-sleep period. Although the relationship between sleep-related thought-control strategies and poor sleep quality is well recognized, the possible contribution of general metacognitive functioning within this relation is still unclear. In this study, we performed a mediation analysis to examine the role of thought-control strategies on the relationship between metacognitive abilities and sleep quality in individuals with different self-reported sleep characteristics. Two-hundred and forty-five individuals participated in the study. Participants completed the Pittsburgh Sleep Quality Index, the Thought Control Questionnaire Insomnia-Revised, and the Metacognition Self-Assessment Scale to evaluate sleep quality, thought-control strategies and metacognitive functions, respectively. The results showed that worry strategy in the pre-sleep period mediates the relationship between metacognitive functions and sleep quality. Particularly, the ability to understand one's mental states and mastery functions could be the two metacognitive domains primarily involved in the dysfunctional metacognitive thought-control activity responsible for reduced sleep quality. The observed effect suggests that inadequate metacognitive functioning is associated with poor sleep quality in healthy subjects via the mediation of dysfunctional worry strategy. These findings suggest the potential relevance of clinical interventions to enhance specific metacognitive abilities, with the aim to promote more functional strategies for managing cognitive and emotional processes during the pre-sleep period.

Impaired Metacognitive Differentiation, High Difficulty in Controlling Impulses and Non-acceptance of Emotions are Associated With the Severity of Gambling Disorder.

The role of metacognition in gambling disorder (GD) is underexplored. To date, only two studies have investigated the role of metacognitive functioning, but among the adolescent population. The first aim of the current research was to assess and compare adult male gamblers with healthy controls (HCs) in relation to metacognition, impulsivity and emotional dysregulation. The second aim was to identify the variables among metacognition, impulsivity and emotional dysregulation associated with the severity of GD by means of linear regression.A total of 116 adult males (58 with GD and 58 HCs) completed self-report questionnaires on gambling severity, metacognition, emotional dysregulation and impulsivity. A linear regression analysis was run to assess the variables associated with gambling severity.Patients with GD exhibited more impaired scores than HCs in all the psychopathological dimensions investigated. More interestingly, gambling severity was significantly associated with metacognitive differentiation/decentration, difficulty in controlling impulses and non-acceptance of negative emotions.According to our results, the severity of gambling is associated with impaired metacognitive differentiation, high difficulty in controlling impulses and non-acceptance of negative emotions, and these findings can lead to new treatment implications. Interventions focused on metacognition and emotion regulation could help patients with GD to avoid maladaptive strategies such as behavioural addictions and, more specifically, to manage their own emotions. This type of treatment could help gamblers to become more aware of their internal state and learn strategies for adaptively managing emotions through functional metacognitive differentiation.

Validation of the Italian version of the 25-item Hikikomori Questionnaire (HQ-25-I).

INTRODUCTION: The present study aimed to adapt the 25-item Hikikomori Questionnaire to the Italian context (HQ-25-I) and to test its psychometric properties in two samples, particularly a sample of residents with psychiatric conditions (n = 117) and a sample of individuals from the community (n = 209). METHODS: We tested the fit of the original three-factor structure (Socialization, Isolation, and Emotional Support) and measurement invariance across the two groups, and the reliability, convergent, and criterion (concurrent) validity of the HQ-25-I. RESULTS: The results showed that the original measurement model fitted the data well and that it was invariant across the two groups. The measure was reliable and positively correlated with some maladaptive personality trait domains (PID-5-BF), Depression (BDI-II), and Hopelessness (BHS) in both groups, with higher scores observed in the clinical sample. However, low correlations were found between the HQ-25-I and the PID-5-BF Detachment and Negative Affectivity. CONCLUSIONS: The results from the study showed that the HQ-25-I is reliable, but further examination of its validity is warranted. Implications for theory and future research are discussed.

Psychometric properties of the Italian version of the Interpersonal Needs Questionnaire-15 (INQ-15-I).

OBJECTIVE: The Interpersonal Needs Questionnaire (INQ-15) is a self-report measure of thwarted belongingness and perceived burdensomeness, two constructs associated with suicidal ideation. The objective of the current study was to translate the INQ-15 from English to Italian (INQ-15-I) and to test its factor structure, reliability, and validity in Italian samples. METHOD: We examined (a) whether the components of the hypothesized two-factor measurement model are invariant across a community sample (N = 510) and a clinical sample (N = 259); (b) the relations between the INQ-15-I factors and measures of depression (Beck Depression Inventory-II), hopelessness (Beck Hopelessness Scale), and suicidal ideation (Beck Scale for Suicide Ideation); (c) the reliability and psychometric properties of the INQ-15-I. RESULTS: Results from multigroup confirmatory factor analyses supported the adequacy of the two-factor model to represent thwarted belongingness and perceived burdensomeness. The model is invariant across community and clinical groups, showing excellent fit. The two INQ-15-I scales measure highly intercorrelated constructs. Both significantly correlate with depression, hopelessness, and suicidal ideation, and correlations are high in the clinical sample. CONCLUSION: The INQ-15-I is a valid and reliable measure of thwarted belongingness and perceived burdensomeness. Implications for research, assessment, and intervention in suicidal ideation are discussed.

Aggressive behavior and metacognitive functions: a longitudinal study on patients with mental disorders.

BACKGROUND: Metacognitive functions play a key role in understanding which psychological variables underlying the personality might lead a person with a severe mental disorder to commit violent acts against others. The aims of this study were to: (a) investigate the differences between patients with poor metacognitive functioning (PM group) and patients with good metacognitive functioning (GM group) in relation to a history of violence; (b) investigate the differences between the two groups in relation to aggressive behavior during a 1-year follow-up; and (c) analyze the predictors of aggressive behavior. METHODS: In a prospective cohort study, patients with severe mental disorders with and without a lifetime history of serious violence were assessed with a large set of standardized instruments and were evaluated bi-monthly with MOAS in order to monitor any aggressive behavior. The total sample included 180 patients: 56% outpatients and 44% inpatients, and the majority were male (75%) with a mean age of 44 (± 9.8) years, and half of them had a history of violence. The sample was split into two groups: poor metacognition (PM) group and good metacognition (GM) group, according to MAI evaluation scores. RESULTS: The PM patients reported a history of violence more frequently than GM patients, during the 1-year follow-up, but no differences between groups in aggressive and violent behavior were found. The strongest predictors of aggressive behavior were: borderline and passive-aggressive personality traits and a history of violence, anger, and hostility. The metacognitive functions alone did not predict aggressive behavior, but metacognitive functions interacted with hostility and angry reactions in predicting aggressive behavior. CONCLUSIONS: This study led to some important conclusions: (a) some aspects closely related to violence are predictive of aggressive behavior only in patients with poor metacognition, thus good metacognition is a protective factor; (b) poor metacognition is associated with a history of violence, which in turn increases the risk of committing aggressive behavior.

The role of self-monitoring metacognition sub-function and negative urgency related to binge severity.

OBJECTIVE: This study aims to test a model where low self-monitoring (a sub-function of first-person domain of metacognition) and high negative urgency lead to a worsening of binge severity through the mediation of emotional dysregulation in patients with binge eating disorder (BED). METHOD: Forty non-BED-obese and 46 BED-obese patients completed a battery of tests assessing metacognition and psychopathology. To test our hypothesized model, a structural equation model (SEM) using maximum likelihood estimation was conducted. RESULTS: BED-obese patients had significantly higher scores in BES, UPPS-P Negative urgency, and DERS total score, and lower MSAS self-monitoring than non-BED-obese, while no differences emerged in the MSAS others-monitoring subscale. The structural model demonstrated very good fit indexes (χ2 = 1.377, df = 2; p = .502, CMIN/DF = 0.688, CFI = 1.000, RMSEA = 0.000, TLI = 1.047) and all paths were significant in the predicted directions. CONCLUSIONS: These preliminary findings show that, low self-monitoring and high negative urgency lead BED-obese patients to express the worsening of binge severity through the mediation of emotional dysregulation. This knowledge may be helpful in the clinical practice to develop a tailor-made treatment. Accordingly, an approach through Metacognitive Interpersonal Therapy could be attempted in BED-obese patients with these characteristics. Highlights Patients with BED exhibited low self-monitoring and high negative urgency. Binge severity was mediated by high level of emotional dysregulation. Metacognitive Interpersonal Therapy may be useful for BED patients.

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.

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.

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.

Metacognition in First Episode Psychosis: Item Level Analysis of Associations with Symptoms and Engagement.

Significant metacognitive impairments are observed in first episode psychosis (FEP) and chronic psychosis samples. There is evidence of associations between metacognition and presentation in FEP, but the relative contribution of metacognitive understanding of the self and the other is as yet unclear. The current study is a secondary analysis of date on metacognition, symptoms and engagement with treatment (help-seeking) in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology and help-seeking within treatment (clinician-rated service engagement) were also measured. An item level analysis of the MAS-R was conducted exploring associations between symptoms and cognitive, emotional, differentiation, integration and decentration aspects of metacognition. We report that associations between negative symptoms and deficits in the understanding of other's mental states extend across cognitive, emotional, integrative and decentration aspects of metacognition. We also report associations between negative symptoms and understanding one's own mind. We also note that cognitive and decentration aspects of metacognition were significantly associated with help-seeking once in treatment. Our findings suggest that an appreciation of metacognitive processes may inform treatment frameworks for FEP. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: Individual components of metacognition including the capacity to relate cognitive and emotional variables are important in first episode phychosis. Impaired metacognitive understanding of both one's own and others' mental states is associated with increased negative symptoms. Metacognitive variables may be important in understanding how different individuals seek help or engage with services after the initiation of treatment.

Personality Disorders and Mindreading: Specific Impairments in Patients With Borderline Personality Disorder Compared to Other PDs.

The capacity of understanding mental states is a complex function which involves several components. Single components can be selectively impaired in specific clinical populations. It has been suggested that impairments in mindreading are central for borderline personality disorder (BPD). However, empirical findings are inconsistent, and it is debatable whether BPD presents a specific profile of mindreading impairments. The aim of this study is to compare BPD and other PDs in mindreading. Seventy-two patients with BPD and 125 patients with other PD diagnoses were assessed using the Metacognition Assessment Interview. BPD showed difficulties in two mindreading functions, differentiation and integration, even when the severity of psychopathology was controlled. These results suggest a specific mindreading impairment in BPD and a strong relationship between these impairments and the severity of psychopathology.

Perfectionism and Personality Disorders as Predictors of Symptoms and Interpersonal Problems.

Maladaptive perfectionism is a common factor in many disorders and is correlated with some personality dysfunctions. Less clear is how dimensions, such as concern over mistakes, doubts about actions, and parental criticism, are linked to overall suffering. Additionally, correlations between perfectionism and personality disorders are poorly explored in clinical samples. In this study we compared a treatment seeking individuals (n=93) and a community sample (n=100) on dimensions of maladaptive perfectionism, personality disorders, symptoms, and interpersonal problems. Results in both samples revealed maladaptive perfectionism was strongly associated with general suffering, interpersonal problems, and a broad range of personality disordered traits. Excessive concern over one's errors, and to some extent doubts about actions, predicted unique additional variance beyond the presence of personality pathology in explaining symptoms and interpersonal problems.

Metacognition, symptoms and premorbid functioning in a first episode psychosis sample.

Significant metacognitive impairments are observed in chronic psychosis samples but metacognition is less understood in first episode psychosis (FEP). The current study explored correlations between metacognition, symptoms and premorbid functioning in an FEP sample. In a cross-sectional cohort study, individuals in the first 12 months of treatment metacognition were assessed with the Metacognition Assessment Scale-Revised version (MAS-R). Psychotic symptomatology, premorbid adjustment, and clinician rated service engagement were also measured. Lower scores for metacognitive understanding of other's minds were significantly correlated with greater negative symptoms, poorer early adolescent social adjustment and poorer clinician rated help-seeking. Our findings suggest that FEP individuals with difficulties in understanding other's minds have more social deficits and may be less able to make effective use of treatment.

Exploring the outcomes of psychotherapy sessions: how do therapists' responsiveness and emotional responses to patients with personality disorders affect the depth of elaboration?

Background: The impact of depth of elaboration in individual psychotherapy sessions on overall treatment effectiveness was found in the empirical literature. In the best sessions, relevant content is processed with greater depth; in contrast, in the shallower sessions, the emerging content is more superficial. Evidence suggests that achieving a high level of depth is closely related to specific therapist characteristics and relational dimensions (including clinicians' emotional responses to patients). The present study aimed to (a) compare therapist responsiveness and countertransference patterns in psychotherapy sessions with different levels of depth of elaboration; and (b) examine if the positive countertransference pattern mediated the relationship between therapist responsiveness and depth of elaboration. Methods: Eighty-four clinicians were asked to select one patient with personality disorders in their care and complete the Depth Scale of the Session Evaluation Questionnaire, the Patient's Experience of Attunement and Responsiveness Scale, and the Therapist Response Questionnaire concerning one of their sessions. Results: The results showed that sessions with higher levels of depth of elaboration were characterized by greater therapist responsiveness and more positive countertransference. Conversely, poor therapist responsiveness and hostile/angry, disengaged, and helpless/inadequate countertransference responses were found in shallower sessions. Moreover, positive countertransference mediated the relationship between therapist responsiveness and depth of elaboration. Conclusion: This study sought to shed light on the processes underlying the outcomes of psychotherapeutic sessions, highlighting the strong impact of relational factors. Advancing knowledge of these mechanisms seems crucial to identifying the active ingredients of the therapeutic process and understanding what (does not) promote successful outcomes.

Metacognition as a transdiagnostic factor across eating disorders: a latent profile analysis study.

Background: Metacognition is a crucial aspect of understanding and attributing mental states, playing a key role in the psychopathology of eating disorders (EDs). This study aims to explore the diverse clinical profiles of metacognition among patients with EDs using latent profile analysis (LPA). Method: A total of 395 patients with a DSM-5 diagnosis of ED (116 AN-R, 30 AN/BP, 100 BN, 149 BED) participated in this study. They completed self-report measures assessing metacognition, eating psychopathology, depression, emotional dysregulation, personality traits, and childhood adversities. LPA and Welch ANOVAs were conducted to identify profiles based on metacognition scores and examine psychological differences between them. Logistic regression models were employed to explore associations between personal characteristics and different profiles. Results: A 3-class solution had a good fit to the data, revealing profiles of high functioning (HF), intermediate functioning (IF), and low functioning (LF) based on levels of metacognitive impairments. Participants in the IF group were older and had a higher BMI than those in the HF and LF groups. Individuals with BN were largely categorized into HF and LF profiles, whereas participants with BED were mainly included in the IF profile. Participants in the LF group reported an impaired psychological profile, with high levels of depression, emotional dysregulation, childhood adversity, and personality dysfunction. Multinomial logistic regression analyses showed significant associations between metacognitive profiles and emotional and neglect abuse, emotion dysregulation, and detachment. Conclusion: This exploratory study unveils distinct metacognitive profiles in EDs, providing a foundation for future research and targeted interventions. In this light, metacognitive interpersonal therapy could be a valid and effective treatment for EDs, as suggested by the initial promising results for these patients.

Investigating the personality disorder psychotherapy process: the roles of symptoms, quality of affects, emotional dysregulation, interpersonal processes, and mentalizing.

Personality Disorders (PDs) can reasonably hope to gain benefit from psychotherapy. Nevertheless many patients do not fully respond. Research therefore has to be done into which variables need to be targeted in psychotherapy, in order to tailor treatment to the needs of the majority of PD patients. These have to date been understudied, in particular where patients have PD other than borderline and where they obtain no or limited benefits from available treatments. Many elements of the therapy process, such as therapy alliance, can be investigated. We outline here some personality pathology core issues and then describe how the authors involved in this special issue investigated the roles of symptoms, emotional experience and regulation, interpersonal patterns and mentalizing in PD psychotherapy.

Metacognitive interpersonal therapy in borderline personality disorder: Clinical and neuroimaging outcomes from the CLIMAMITHE study-A randomized clinical trial.

Different psychotherapeutic approaches demonstrated their efficacy but the possible neurobiological mechanism underlying the effect of psychotherapy in borderline personality disorder (BPD) patients is poorly investigated. We assessed the effects of metacognitive interpersonal therapy (MIT) on BPD features and other dimensions compared to structured clinical management (SCM). We also assessed changes in amygdala activation by viewing emotional pictures after psychotherapy. One hundred forty-one patients were referred and 78 BPD outpatients were included and randomized to MIT or SCM. Primary outcome was emotional dysregulation assessed with the Difficulties in Emotion Regulation Scale (DERS). We also assessed BPD symptomatology, number of PD criteria, metacognitive abilities, state-psychopathology, depression, impulsiveness, interpersonal functioning, and alexithymia. A subset of 60 patients underwent functional magnetic resonance imaging before and after 1 year of psychotherapy to assess amygdala activation by viewing standardized emotional pictures (secondary outcome). DERS scores decreased in both groups (time effect p < .001). The Cohen's d effect size for change (baseline posttreatment) on DERS was very large (d = 0.84) in MIT, and large (d = 0.76) in SCM. Both groups significantly improved in depressive symptoms, state-psychopathology, alexithymia, and interpersonal functioning. MIT showed larger effect on metacognitive functions than SCM (Time × Group p < .001). Both interventions showed a significant effect on BPD symptomatology although SCM group showed a larger decrease. On the contrary, MIT group showed larger decrease in impulsivity and number of PD criteria. Interestingly, both MIT and SCM modulated amygdala activation in BPD patients. MIT is a valid and effective psychotherapy for BPD with an impact on amygdala activation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations of metacognition with symptoms, insight, and neurocognition in clinically stable outpatients with schizophrenia.

Research indicates that many with schizophrenia experience deficits in metacognitive capacity or the ability to form complex representations of themselves and others. Previous work has found that metacognitive capacity in schizophrenia is correlated with symptoms, insight, and neurocognitive deficits. We sought to replicate these results in a sample of Italian participants treated in a community setting. Metacognition was assessed with the abbreviated Metacognition Assessment Scale and correlated with concurrent assessment of symptoms, insight, and neurocognitive abilities, including verbal and visual memory, premorbid intelligence, processing speed, and executive function. Correlations revealed that, consistent with previous work, lesser capacity for self-reflectivity was related to greater levels of negative symptoms, poorer insight, neurocognitive impairment (particularly impairments in verbal and visual memory) premorbid intelligence, and processing speed. Other metacognitive domains were also linked to poorer neurocognition. Results support contentions that deficits in metacognition are linked with negative symptoms, insight, and neurocognitive deficits.

Vulnerable self, poor understanding of others' minds, threat anticipation and cognitive biases as triggers for delusional experience in schizophrenia: a theoretical model.

It remains unclear what processes lead to the establishment of persecutory delusions in acute phases of schizophrenia. Recently, it has been argued that persecutory delusions arise from an interaction among a range of emotional, cognitive and social factors. In this work, we explored this possibility by first discussing the relevant aspects of recent theoretical models of the causes of persecutory delusions. Then, we offered an analysis of the literature, illustrated with clinical observations suggesting that persecutory delusions are triggered during stressful intersubjective transactions by the interactions of (a) an alteration in empathetic perspective taking and in pragmatic understanding of others' minds; (b) a perception/representation of the self as vulnerable or subordinate and of the other as dominant and threatening; and (c) a hyperfunctioning of the threat/self-protection system when faced with perceived danger. Implications for future research and treatment of people suffering from this symptom are discussed.

Aberrant Structural Connectivity of the Triple Network System in Borderline Personality Disorder Is Associated with Behavioral Dysregulation.

BACKGROUND: Core symptoms of Borderline Personality Disorder (BPD) are associated to aberrant connectivity of the triple network system (salience network [SN], default mode network [DMN], executive control network [ECN]). While functional abnormalities are widely reported, structural connectivity (SC) and anatomical changes have not yet been investigated. Here, we explored the triple network's SC, structure, and its association with BPD clinical features. METHODS: A total of 60 BPD and 26 healthy controls (HC) underwent a multidomain neuropsychological and multimodal MRI (diffusion- and T1-weighted imaging) assessment. Metrics (fractional anisotropy [FA], mean diffusivity [MD], cortical thickness) were extracted from SN, DMN, ECN (triple network), and visual network (control network) using established atlases. Multivariate general linear models were conducted to assess group differences in metrics and associations with clinical features. RESULTS: Patients showed increased MD in the anterior SN, dorsal DMN, and right ECN compared to HC. Diffusivity increases were more pronounced in patients with higher behavioral dysregulation, i.e., suicidal attempting, self-harm, and aggressiveness. No differences were detected in network structure. CONCLUSIONS: These results indicate that the triple network system is impaired in BPD at the microstructural level. The preferential involvement of anterior and right-lateralized subsystems and their clinical association suggests that these abnormalities could contribute to behavioral dysregulation.