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

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

The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders.

BACKGROUND AND AIMS: Some individuals with Personality Disorders (PD), particularly of a non-Borderline type, present with difficulties relating to over-control of cognitions, emotion and behavior, perfectionistic traits, and impaired social interactions. The current study sought to evaluate the strength of association, and interactions of both emotional inhibition and perfectionism in PD's, after controlling for symptoms and interpersonal problems. METHOD: We recruited a sample of 578 treatment seeking outpatients. Diagnosis of PD was made with the SCID-II. Individual's completed measures of perfectionism (Frost-MPS), Emotional Inhibition (EIS), Depression (BDI-II), Anxiety (STAI-Y), Global symptoms (SCL-90-R), and interpersonal problems (IIP-32). RESULTS: Perfectionism was related to interpersonal problems, to the majority of PD symptomatology and to PD severity via number of SCID-II criteria met. Emotional inhibition was linked to symptoms and interpersonal problems as well as with avoidant, dependent, depressive and paranoid PDs; and with overall PD Severity. Inhibition and perfectionism were correlated with each other. Both variables predicted PD above and beyond other variables assessed. Mediation modeling demonstrated that the effect of emotional inhibition on PD severity was fully mediated by perfectionism and interpersonal problems. CONCLUSIONS: Psychological mechanisms of overcontrol are a maintaining factor in many PDs. Both perfectionism and emotional inhibition impact on a broad range of PDs and there is an urgent need for research into these processes, and to adapt psychological interventions to consider these factors.

Metacognitive Interpersonal Therapy for Treating Persecutory Delusions in Schizophrenia.

MIT aims at progressively fostering metacognition until patients are able to understand what kind of interpersonal events or ideas about self and interpersonal interactions trigger their persecutory delusions and to question the delusional meaning they attribute to events.

Mindfulness moderates the relationship between aggression and Antisocial Personality Disorder traits: Preliminary investigation with an offender sample.

INTRODUCTION: Poor mentalizing has been described as a characteristic of Antisocial Personality Disorder (ASPD), along with the well-established role of aggressiveness. In the current study, we tested this hypothesis focusing on a specific aspect of mentalization (i.e., mindfulness). METHOD: We explored the unique and joint contribution of aggression dimensions and mindfulness facets to ASPD traits in an offender sample (N=83). RESULTS: Mindfulness deficits were associated with ASPD traits, and a significant unique association emerged between difficulties in acting with awareness and ASPD traits. Likewise, physical aggression confirmed its association with ASPD traits. Moderation analyses revealed that mindfulness interacted with aggression in predicting ASPD. Specifically, at low levels of mindfulness, the association between aggression and ASPD dropped to nonsignificance. CONCLUSIONS: Results suggest that fostering self-mentalizing is a relevant treatment target when treating offenders with ASPD.

Theory of Mind in Schizophrenia: Associations With Clinical and Cognitive Insight Controlling for Levels of Psychopathology.

Poor insight in schizophrenia is a risk factor for both poor outcomes and treatment adherence. Accordingly, interest in identifying causes of poor insight has increased. This study explored whether theory of mind (ToM) impairments are linked to poor clinical and cognitive insight independent of psychopathology. Participants with schizophrenia (n = 37) and control subjects (n = 40) completed assessments of ToM with the Hinting Task and the Brüne Picture Sequencing Task, clinical insight and psychopathology with the Positive and Negative Syndrome Scale, and cognitive insight with the Beck Cognitive Insight Scale. Results indicated that the schizophrenia group had greater impairments in ToM relative to control subjects. In the schizophrenia group, the Hinting Task performance was related to both cognitive and clinical insight, with only the relationship with cognitive insight persisting after controlling for psychopathology. Picture Sequencing Task performance was related to cognitive insight only. Future research directions and clinical implications are discussed.

Metacognitive interpersonal therapy for co-occurrent avoidant personality disorder and substance abuse.

Many patients with substance abuse problems present with co-occurrent cluster C personality disorders. Focusing on both disorders disrupts the maintenance mechanisms and the vicious cycle between the 2 conditions; however, treatment teams often neglect this issue. In this work, we describe the features of metacognitive interpersonal therapy as applied to a man with avoidant and depressive personality disorders and heroin, cocaine, and alcohol abuse. Psychotherapy proceeded through the following steps: (a) conducting drug therapy to deal with symptoms of abstinence from heroin; (b) forming a therapeutic bond to overcome the patient's severe emotional withdrawal; (c) fostering basic metacognitive capacities such as awareness of emotions and their triggers; (d) sharing formulations of maladaptive interpersonal schemas and descriptions of the associated states of mind; (e) conveying an understanding of the link between interpersonal events (recent ones and traumatic memories) and substance abuse; (f) facilitating the acquisition of critical distance from maladaptive schemas; and (g) promoting the use of adaptive coping skills instead of resorting to substance abuse. Implications for generalizing these procedures to the treatment of other patients with co-occurrent personality disorders and substance abuse are described.

Metacognitive reflective and insight therapy for people in early phase of a schizophrenia spectrum disorder.

Schizophrenia often involves a loss of metacognitive capacity, the ability to form complex and integrated representations of self and others. Independent of symptoms and neurocognition, deficits in synthetic metacognition are related to difficulties of engaging in goal-directed activities in social and vocational settings. Within this backdrop, we provide a case report of the effects of Metacognitive Reflective Insight Therapy (MERIT) that assisted a patient suffering from first episode schizophrenia during 2 years of individual psychotherapy. A total of 8 elements of MERIT that stimulate and promote metacognitive capacity are presented. As illustrated in this report, these procedures helped the patient move from a state in which he had virtually no complex ideas about himself or others to one in which he had developed integrated and realistic ideas about his own identity and the identity of others. He then could use these representations to understand and effectively respond to life challenges.

Metacognition-oriented social skills training for individuals with long-term schizophrenia: methodology and clinical illustration.

PURPOSE: There is much evidence indicating the presence of social deficits in schizophrenia and the detrimental effect of these deficits on global functioning in this population. As a result, social skills training (SST) has emerged as a legitimate psychosocial treatment, although effectiveness research has revealed small effect sizes and limited generalizability regarding the benefits of this treatment. METHODS: In light of the strong evidence of metacognitive deficits in schizophrenia and the importance of metacognition to successful social functioning, we propose a novel therapeutic intervention wherein metacognitive remediation is integrated into SST: metacognition-oriented social skills training (MOSST). In the current paper, we present MOSST, an adapted SST programme wherein clients are also encouraged to have mindful contact with their own thoughts and to better consider and understand the mental states of others as well as the connection between mental states and behaviour. RESULTS: We present a case wherein an individual with schizophrenia successfully completed the MOSST programme. CONCLUSION: We outline directions for future research, starting with the logical next step of empirically testing the efficacy of MOSST. KEY PRACTITIONER MESSAGE: Currently social skills training is considered to be the elected psychosocial treatment for people affected by schizophrenia, although evidence indicates limited benefits. People with schizophrenia have metacognitive deficits, which interfere with proper social functioning. A metacognitive-oriented social skills training (MOSST) intervention has been developed by the authors.A treatment such as MOSST, which integrates social skills training and metacognitive training, promises to improve social skills through improving the metacognition.

The affective grounds of the mind. The Affective Pertinentization (APER) model.

The paper presents the Affective Pertinentization model (APER), a theory of the affect and its role it plays in meaning-making. APER views the affect as the basic form of making sense of reality. It consists of a global, bipolar pattern of neurophysiological activity through which the organism maps the instant-by-instant variation of its environment. Such a pattern of neuropsychological activity is constituted by a plurality of bipolar affective dimensions, each of which maps a component of the environmental variability. The affect has a pluri-componential structure defining a multidimensional affective landscape that foregrounds (i.e., makes pertinent) a certain pattern of facets of the environment (e.g., its pleasantness/unpleasantness) relevant to survival, while backgrounding the others. Doing so, the affect grounds the following cognitive processes. Accordingly, meaning-making can be modeled as a function of the dimensionality of the affective landscape. The greater the dimensionality of the affective landscape, the more differentiated the system of meaning is. Following a brief review of current theories pertaining to the affect, the paper proceeds discussing the APER's core tenets - the multidimensional view of the affect, its semiotic function, and the concepts of Affective Landscape and Phase Space of Meaning. The paper then proceeds deepening the relationship between the APER model and other theories, highlighting how the APER succeeds in framing original conceptualizations of several challenging issues - the intertwinement between affect and sensory modalities, the manner in which the mind constitutes the content of the experience, the determinants of psychopathology, the intertwinement of mind and culture, and the spreading of affective forms of thinking and behaving in society. Finally, the unsolved issues and future developments of the model are briefly envisaged.

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.

Out of illness experience: metacognition-oriented therapy for promoting self-awareness in individuals with psychosis.

Deficits in metacognitive abilities, which enable persons to make sense of their own mental states and those of others, often are observed among persons with schizophrenia. To address these deficits we have sought to develop a metacognition-oriented form of psychotherapy that may foster self-reflectivity leading to the ability to think critically about delusional beliefs and to engage in and sustain healthy social exchanges. To illustrate Metacognition Oriented Therapy, we analyzed its application in an early psychotherapy session with a young woman who had disorganized schizophrenia. In this paper we specifically explore how the therapist followed a sequence of steps aimed at: 1) reconstructing episodes in life-narratives, 2) helping the patient name distressing emotions that appear in the narrative episode, 3) validating and normalizing the patient's experiences, 4) promoting awareness of emotional triggers and the links between affects and social behavior, and 5) validating emerging subjective experiences. We stress how these procedures helped the patient eventually become more able to start questioning her own delusional beliefs. The generalization of these procedures to the psychotherapy of schizophrenia is discussed.

Metacognition in schizophrenia: correlates and stability of deficits in theory of mind and self-reflectivity.

Research suggests that many with schizophrenia experience a range of deficits in metacognition including difficulties recognizing the emotions and intentions of others as well as reflecting upon and questioning their own thinking. Unclear, however, is the extent to which these deficits are stable over time, how closely related they are to one another and whether their associations with core aspects of the disorder such as disorganization symptoms are stable over time. To explore this issue, we administered three assessments of Theory of Mind (ToM), the Beck Cognitive Insight Scale (BCIS), and the Positive and Negative Syndrome Scale at baseline and 6 months to 36 participants with schizophrenia. Correlations revealed the ToM and BCIS scores were stable across the two test administrations and that the ToM tests were closely linked to each other but not to the BCIS. Poorer baseline performance on the ToM tests and the Self-Certainty scale of the BCIS were linked to greater cognitive symptoms at baseline and follow-up, while greater Self-Reflectivity on the BCIS was linked to greater levels of emotional distress at both baseline and 6-month follow-up. Results are consistent with assertions that deficits in metacognition are a stable feature of schizophrenia.

Metacognition and social function in schizophrenia: associations over a period of five months.

INTRODUCTION: Deficits in the ability to think about thinking have been widely observed in persons with schizophrenia and linked with concurrent assessments of various forms of function. Less is known though about their links to outcome over time. To address this issue, the current study explores whether Mastery, a domain of metacognition that reflects the ability to use knowledge about one's own mental states and those of others to respond to psychological challenges, is related to the frequency of social contact and persons' capacity for social relatedness. METHODS: Participants were 72 adults with schizophrenia spectrum disorders enrolled in vocational rehabilitation; these patients completed a baseline assessment as well as a follow-up assessment 5 months later. Mastery was assessed using the Metacognitive Assessment Scale and social functioning by the Quality of Life Scale. RESULTS: Using structural equation modelling, the proposed model demonstrated acceptable fit even when a range of possible confounding variables were entered as covariates. CONCLUSIONS: . Results are consistent with the possibility that certain forms of metacognition affect social function among persons with schizophrenia, both concurrently and over time.

Steps Towards a Unified Theory of Psychopathology: The Phase Space of Meaning Model.

The hypothesis of a general psychopathology factor (p factor) has been advanced in recent years. It is an innovation with breakthrough potential, in the perspective of a unified view of psychopathology; however, what remains a controversial topic is how its nature might be conceptualized. The current paper outlines a semiotic, embodied and psychoanalytic conceptualization of psychopathology - the Phase Space of Meaning (PSM) model - aimed at providing ontological grounds to the p factor hypothesis. Framed within a more general model of how the mind works, the PSM model maintains that the p factor can be conceived as the empirical marker of the degree of rigidity of the meaning-maker's way of interpreting experience, namely of the dimensions of meanings used to map the environment's variability. As to the clinical implications, two main aspects are outlined. First, according PSM model, psychopathology is not an invariant condition, and does not have a set dimensionality, but is able to vary it locally, in order to address the requirement of situated action. Second, psychopathology is conceived as one of the mind's modes of working, rather than the manifestation of its disruption. Finally, the puzzling issue of the interplay between stability and variability in the evolutionary trajectories of patients along with their life events is addressed and discussed.

Cognitive theory of mind in bipolar disorder: Comparisons with healthy controls and associations with function.

Cognitive forms of Theory of Mind (ToM) have been linked to social function in Bipolar Disorder (BD). To explore this social functioning was assessed with the GAF and cognitive ToM was assessed with the Hinting Task and the Picture Sequencing Task (PST) in 45 patients with BP and 45 healthy controls. As predicted, the BD group took longer to complete the PST. The BD group did not offer more incorrect responses to either cognitive ToM task. Greater latency on the PST predicted poorer social function after controlling for symptoms, partially supporting a relationship between ToM and social function in BD.

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

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

Deficits in mindreading in stressful contexts and their relationships to social withdrawal in schizophrenia.

Patients with schizophrenia are commonly observed to socially withdraw and also to have difficulty forming representations of what other people feel, think, and intend. Yet it is unclear whether these two dysfunctions are related to one another. To address this issue, the authors offer two case analyses and hypothesize that difficulties knowing the thoughts and feelings of others are correlated with unpleasant emotional arousal, are more intense during certain interpersonal interactions, and can generate social withdrawal.

Emotion dysregulation, impulsivity and personality disorder traits: A community sample study.

The present study was designed to test an emotion regulation framework to understand individual differences in personality disorder (PD) traits in a non-clinical sample. Specifically, we tested whether: selected dimensions of emotion dysregulation were differentially related to PD traits; and whether emotion dysregulation and impulsivity had independent associations with PD traits. A community sample of 399 individuals (mean age = 37.91; 56.6% males) completed self-report measures of PDs, emotion dysregulation and impulsivity. Emotion dysregulation facets and impulsivity had uniform bivariate associations with PD traits, but also evidenced unique associations in multiple regression analyses. Nonacceptance of emotional responses was the emotion dysregulation dimension underlying a wide array of PD. A limited repertoire of effective emotion regulation strategies was characteristic of cluster C PD, whereas emotional unawareness distinctly predicted schizoid PD. Antisocial PD traits were uniquely related to difficulties controlling impulsive behavior when upset. Finally, histrionic, narcissistic, and obsessive-compulsive PD were related to better self-reported emotion regulation. Impulsivity further explained a significant amount of variance in schizotypal, antisocial, borderline (positively), and obsessive-compulsive PD traits (negatively). If replicated in clinical samples, our findings will support the usefulness of targeting both emotional dysregulation and impulsivity in PDs psychotherapy.

Metacognitive interpersonal therapy in group: a feasibility study.

Patients with personality disorders (PDs) other than borderline, with prominent features of social inhibition and over-regulation of emotions, are in need of specialized treatments. Individuals present with poor metacognition, that is the capacity to understand mental states and use psychological knowledge for the sake of purposeful problem solving; and are guided by maladaptive interpersonal schemas. We developed a short-term group intervention, Metacognitive Interpersonal Therapy in Groups (MIT-G), incorporating psychoeducational and experiential elements, to help these individuals become more aware of their drives when interacting with others; and to help them adopt more flexible behaviors via improvements in metacognition. We present results of an effectiveness study, evaluating whether we could replicate the initial positive results of our first pilot randomized controlled trial. Seventeen young adults outpatients with personality disorders were included in the 16 session program. Effect sizes were calculated for change from baseline to treatment end for the primary outcome, symptoms and functioning (Clinical Outcomes in Routine Evaluation Outcome Measure) and then for one putative mechanism of change - metacognition. Emotional dysregulation and alexithymia were also assessed. Qualitative evaluations of the acceptability and subjective impact of the treatment were also performed. MIT-G was acceptable to participants. There were medium to large magnitude changes from pre- to post- treatment on wellbeing, emotion dysregulation, alexithymia and metacognition. These gains were maintained at follow-up. There was evidence of clinically significant change on key variables. MITG appears acceptable to patients, as evidenced by the absence of drop-out from treatment. In light of the positive outcomes of this study and the expanding evidence base, MIT-G is a candidate for dissemination and investigations in larger trials as a possible effective intervention for PDs characterized by tendencies to overcontrol.

Emotion dysregulation, symptoms, and interpersonal problems as independent predictors of a broad range of personality disorders in an outpatient sample.

Emotion dysregulation (ED) is considered a hallmark of borderline personality disorder and is prominent in other personality disorders (PDs). Its presence and contribution to personality pathology need to be explored in the whole range of PDs. In this study, we investigated the association of ED with the whole range of PD traits, symptoms, and interpersonal problems and then investigated whether ED had a unique contribution in predicting the different PDs. A sample of 478 treatment-seeking outpatients was interviewed with the SCID-II. The patients were then tested for symptoms (SCL-90-R), interpersonal problems (IIP-32), and ED (DERS). RESULTS: ED correlated with the large majority of PDs and with symptoms and interpersonal problems. Regression showed how ED explained a unique part of the variance for many PDs. ED appears to be a relevant feature of pathology in many PDs; with replication, it can be considered a treatment target in this population. PRACTITIONER POINTS: Emotion dysregulation is present in many personality disorders. Emotion dysregulation is not just explained by heightened symptoms and interpersonal problems in personality disorders. Emotion dysregulation could be considered a treatment target in personality disorders other than borderline.