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.

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.

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.

Effect of metacognitive interpersonal therapy on brain structural connectivity in borderline personality disorder: Results from the CLIMAMITHE randomized clinical trial.

BACKGROUND: Recently, we showed that Metacognitive Interpersonal Therapy (MIT) is effective in improving clinical symptoms in borderline personality disorder (BPD). Here, we investigated whether the effect of MIT on clinical features is associated to microstructural changes in brain circuits supporting core BPD symptoms. METHODS: Forty-seven BPD were randomized to MIT or structured clinical management, and underwent a clinical assessment and diffusion-weighted imaging before and after the intervention. Fractional anisotropy (FA), mean, radial, and axial diffusivities maps were computed using FSL toolbox. Microstructural changes were assessed (i) voxel-wise, with tract based spatial statistics (TBSS) and (ii) ROI-wise, in the triple network system (default mode, salience, and executive control networks). The effect of MIT on brain microstructure was assessed with paired tests using FSL PALM (voxel-wise), Linear Mixed-Effect Models or Generalized Linear Mixed Models (ROI-wise). Associations between microstructural and clinical changes were explored with linear regression (voxel-wise) and correlations (ROI-wise). RESULTS: The voxel-wise analysis showed that MIT was associated with increased FA in the bilateral thalamic radiation and left associative tracts (p < .050, family-wise error rate corrected). At network system level, MIT increased FA and both interventions reduced AD in the executive control network (p = .05, uncorrected). LIMITATIONS: The DTI metrics can't clarify the nature of axonal changes. CONCLUSIONS: Our results indicate that MIT modulates brain structural connectivity in circuits related to associative and executive control functions. These microstructural changes may denote activity-dependent plasticity, possibly representing a neurobiological mechanism underlying MIT effects. TRIAL REGISTRATION: ClinicalTrials.govNCT02370316 (https://clinicaltrials.gov/study/NCT02370316).

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.

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.

Exploring Guilt Differences in Grandiose Narcissism, Vulnerable Narcissism, and Malignant Self-Regard.

Narcissistic personality disorder is a heterogeneous and complex pathology which manifests itself very differently in individuals. The aim of the present study was to analyze differences and similarities in morality and sensitivity to feelings of guilt among grandiose narcissism (GN), vulnerable narcissism (VN), and malignant self-regard (MSR). We expected that MSR and VN would be most sensitive to deontological and altruistic guilt, and that MSR and VN would have higher levels of moral standards than GN. A nonclinical sample of 752 participants was evaluated. Results showed a significant association among MSR, VN, and GN. According to our hypothesis, GN turned out to be the one with the lowest association values to guilt measures. Our results demonstrated that MSR is strongly associated with all types of guilt, GN is associated with a substantial lack of guilt, and VN is associated with deontological guilt and self-hate, but not altruistic guilt. Results confirm the relevance of considering and understanding guilt when differentiating GN, VN, and MSR.

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).

Alexithymia in personality disorders: correlations with symptoms and interpersonal functioning.

Impairment in the ability to recognize and make sense of emotions has been hypothesized to be present in a sub-sample of people suffering from personality disorder (PD). In particular it is possible that difficulty recognizing and expressing feelings, or alexithymia, is related to many of the symptoms and problems in making sense of social interactions which are hallmarks of PD. In this study we measured levels of alexithymia with the Toronto Alexithymia Scale-20 and explored its correlations with the overall presence of PD and different PD diagnoses, symptoms, and interpersonal difficulties. Results were largely consistent with the hypothesis. Higher levels of alexithymia were related to high levels of global psychopathology and with dysfunctional representation of interpersonal relations. A sub-sample of patients, mostly suffering from avoidant, dependent, passive-aggressive and depressive PD, had alexithymic features and, in particular reported difficulties describing their feelings to others. A patient with cluster B PD featured no alexithymia. Implications of this study for future research and treatment are discussed.

Metacognitive mastery dysfunctions in personality disorder psychotherapy.

Individuals with personality disorders (PDs) have difficulties in modulating mental states and in coping with interpersonal problems according to a mentalistic formulation of the problem. In this article we analyzed the first 16 psychotherapy sessions of 14 PD patients in order to explore whether their abilities to master distress and interpersonal problems were actually impaired and how they changed during the early therapy phase. We used the Mastery Section of the Metacognition Assessment Scale, which assesses the use of mentalistic knowledge to solve problems and promote adaptation. We explored the hypotheses that a) PD patients had problems in using their mentalistic knowledge to master distress and solve social problems; b) the impairments were partially stable and only a minimal improvement could be observed during the analyzed period; c) patients' mastery preferences differed from one another; d) at the beginning of treatment the more effective strategies were those involving minimal knowledge about mental states. Results seemed to support the hypotheses; the patients examined had significant difficulties in mastery abilities, and these difficulties persisted after 16 sessions. Moreover, the attitudes towards problem-solving were not homogenous across the patients. Lastly, we discuss implications for assessment and treatment of metacognitive disorders in psychotherapy.

Metacognition in schizophrenia: the relationship of mastery to coping, insight, self-esteem, social anxiety, and various facets of neurocognition.

OBJECTIVES. Deficits in metacognition, or the ability to think about thinking, are common in schizophrenia and associated with functional impairment. Unknown are what elements of function are affected by what aspects of metacognition. DESIGN. This study explored whether participants with differing capacities for Mastery, a domain of metacognition that reflects the ability to use knowledge about mental states to respond to psychological challenges, had difficulties in different elements of daily function. METHODS. Participants were 98 adults with schizophrenia or schizoaffective disorder in a non-acute phase, classified into three groups on the basis of ratings of their capacity for metacognitive Mastery using the Metacognitive Assessment Scale: low Mastery (those unable to plausibly represent psychological challenges), Intermediate Mastery (those able to plausibly represent psychological problems but cope primarily through passive measures or avoidance), and high Mastery (those able to cope with plausible problems through cognitive means). Participants completed assessments of coping preference, insight, self-esteem, and anxiety. RESULTS. Multivariate Analysis of Variance (MANOVA) and Analysis of Variance (ANOVA) revealed that the high-Mastery group had a greater preference for coping with stressors by thinking and talking about them, and greater insight than all other groups, and higher levels of feeling accepted by peers than the intermediate-Mastery group. The intermediate-Mastery group reported higher levels of resignation when facing stressors and more social phobia than the other two groups. These findings of Mastery group differences in self-esteem and anxiety persisted when neurocognition was controlled for in an Analysis of Covariance (ANCOVA). CONCLUSIONS. Mastery appears linked to coping preference, insight, self-esteem, and anxiety in a generally non-linear manner.

Do Competitive Contexts Affect Mindreading Performance?

Mindreading is contingent upon interpersonal context. Little is known about how competitive contexts influence mindreading skills. The idea was that the capacity to think about mental states would decline when individuals experiencing failure in competition. This study aims to assess effects of a competitive experience (a computer competitive PC game) on a sample of healthy subjects (119 participants). The sample was divided into two sub-samples. The experimental group underwent an experience of failure, consisting in a PC game of logic against a hypothetical opponent. The control group was required instead only to discuss past personal experiences of competitive interactions. The Metacognitive Assessment Interview was administered to each sub-sample for evaluating mindreading capacities. Self-report tests were additionally provided for evaluation of trait-based dispositions: self-esteem, perfectionism, narcissism. Results supported our hypothesis: induction of sense of failure compromises ability to describe one's own mental states and mental states of others. This effect was more pronounced in the domain of self-reflection. Results remained significant after controlling for self-esteem, perfectionism, and narcissism. We discuss possible clinical implications of these findings and the importance of evaluating mindreading capacities under the pressure of social rank as well as of other social motive.

Impaired decentration in personality disorder: a series of single cases analysed with the Metacognition Assessment Scale.

BACKGROUND: There is growing support for the idea that an impaired understanding of others' mental states is an underlying feature of personality disorder (PD). Only recently has there begun to be evidence of impairments to subjects' ability to infer and reason about others' intentions and emotions, and detach from their own perspective when doing so. METHOD: We analysed the transcripts from the first 16 psychotherapy sessions of 14 PD patients. Scales for understanding others' minds from the Metacognition Assessment Scale were used. RESULTS: Patients were generally able to describe others' mental states, although, at times, they had problems. There was, on the other hand, an inability to decentre while reasoning about others, and this was common to all the patients. CONCLUSIONS: PDs indeed feature a poor decentration, which is not easily identified with the usual lab tasks. Implications for further research and treatment are discussed. KEY PRACTITIONER MESSAGE: *Patients with personality disorders have substantial difficulties in adopting others' point of view and standing back from their own, and grasping that they are not the center of other peoples' thoughts.

Metacognition as a Predictor of Improvements in Personality Disorders.

Personality Disorders (PDs) are particularly hard to treat and treatment drop-out rates are high. Several authors have agreed that psychotherapy is more successful when it focuses on the core of personality pathology. For this reason, therapists dealing with PDs need to understand the psychopathological variables that characterize this pathology and exactly what contributes to maintaining psychopathological processes. Moreover, several authors have noted that one key problem that characterizes all PDs is an impairment in understanding mental states - here termed metacognition - which could also be responsible for therapy failures. Unfortunately, a limited number of studies have investigated the role of mentalization in the process of change during psychotherapy. In this paper, we assume that poor metacognition corresponds to a core element of the general pathology of personality, impacts a series of clinical variables, generates symptoms and interpersonal problems, and causes treatment to be slower and less effective. We explored whether changes in metacognition predicted an improvement among different psychopathological variables characterizing PDs; 193 outpatients were treated at the Third Center of Cognitive Psychotherapy in Rome, Italy, and followed a structured path tailored for the different psychopathological variables that emerged from a comprehensive psychodiagnostic assessment that considered patients' symptoms, metacognitive abilities, interpersonal relationships, personality psychopathology, and global functioning. The measurements were repeated after a year of treatment. The results showed that changes in metacognitive abilities predicted improvements in the analyzed variables.

Know yourself and you shall know the other... to a certain extent: multiple paths of influence of self-reflection on mindreading.

Social and neurocognitive research suggests that thinking about one's own thinking and thinking about the thinking of others-termed 'mindreading', 'metacognition', 'social cognition' or 'mentalizing' are not identical activities. The ability though to think about thinking in the first person is nevertheless related to the ability to think about other's thoughts in the third person. Unclear is how these phenomena influence one another. In this review, we explore how self-reflection and autobiographical memory influence the capacity to think about the thoughts and emotions of others. We review studies suggesting that the more individuals are able to reflect on and retrieve episodes from their life narratives, the more they are likely to grasp others' thoughts and emotions. We discuss evidence supporting this possibility including studies of the neurocognitive bases of empathy and self-awareness and how different aspects of self-reflection may impact on mindreading. We also draw from clinical reports how improved self-reflection may result in a more nuanced mindreading, namely persons suffering from schizophrenia and narcissistic personality disorder. We finally discuss the implications for research and practice and consider whether there are conditions in which the reverse is true, where self-reflection might impair mindreading or in which mindreading may facilitate self-reflection.

How states of mind change in psychotherapy: an intensive case analysis of Lisa's case using the Grid of Problematic States.

This study uses the Grid of Problematic States (GPS) to examine Lisa's case, one of the most successful in the York Psychotherapy Depression Project. This study tried to assess whether the contents of mental experience form stable clusters consistent with a diagnosis of depression. It was possible with the GPS to pinpoint problematic states typical of depression and trace the transitional states occurring in Lisa between two different mental states: depressive and well-being. The GPS analysis suggested that the treatment successfully managed to deal with symptoms and to change the patient's thought themes and emotions. At the end of treatment, Lisa was less sad and displayed some anger, and a state of being nurtured emerged.

An intensive case analysis of client metacognition in a good-outcome psychotherapy: Lisa's case.

The authors analyzed the successful case of Lisa, a client with major depression, using the Metacognitive Assessment Scale (MAS). Consistently with the literature on depression, the authors hypothesize that Lisa's ability to reflect on mental states--here metacognition--is marginally affected. The authors found that Lisa was better at describing her own mind rather than understanding the mind of the others. Furthermore, the most severe impairment was in using metacognition to cope with mental state source of distress and to enact strategies to solve interpersonal problems. During the therapy such difficulties improved progressively. Limitations and implications of these findings are discussed.