Publications by authors named "Antonino Carcione"

47 Publications

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

J Gambl Stud 2022 Jan 8. Epub 2022 Jan 8.

Department of Health Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.

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.
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http://dx.doi.org/10.1007/s10899-021-10099-yDOI Listing
January 2022

Esoteric power, useless, useful: considerations about dreams in cognitive-behavioural therapy.

Res Psychother 2021 Aug 30;24(2):543. Epub 2021 Aug 30.

Third Centre of Cognitive Therapy, Rome.

For a long time dreamwork in cognitive-behavioural therapy (CBT) was considered useless and as a technique specific to psychodynamic approaches, consequently overlooked in the treatment course. In the last twenty years, thanks to the contribution of neuroscience studies on sleep and dreams, dreams joined the attention and interest of authors belonging to the CBT field. The central feature of dreamwork in CBT is the abandonment of the exploration of latent meaning, which is instead considered in continuity with the waking life. Dreams reflect a patient's view of self, world, and future, and are subject to the same cognitive biases as the waking state. Consequently, the dreamwork can be used to get information about the patient, overcome impasses in therapy, restructure self and interpersonal schemas, and stimulate reflective functioning. Therefore, guidelines have been defined and models of well-articulated intervention in terms of process and content, replicable and teachable through specific training structured. This paper aims to provide an overview of theories regarding the use of dreams in CBT, from a clinical perspective, from Beck to more recent proposals.
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http://dx.doi.org/10.4081/ripppo.2021.543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451210PMC
August 2021

Metacognition and emotion regulation as treatment targets in binge eating disorder: a network analysis study.

J Eat Disord 2021 Feb 15;9(1):22. Epub 2021 Feb 15.

Outpatient Unit for Clinical Research and Treatment of Eating Disorders, University Hospital "Mater Domini", Catanzaro, Italy.

Background: This study aims to examine the underlying associations between eating, affective and metacognitive symptoms in patients with binge eating disorder (BED) through network analysis (NA) in order to identify key variables that may be considered the target for psychotherapeutic interventions.

Methods: A total of 155 patients with BED completed measures of eating psychopathology, affective symptoms, emotion regulation and metacognition. A cross-sectional network was inferred by means of Gaussian Markov random field estimation using graphical LASSO and the extended Bayesian information criterion (EBIC-LASSO), and central symptoms of BED were identified by means of the strength centrality index.

Results: Impaired self-monitoring metacognition and difficulties in impulse control emerged as the symptoms with the highest centrality. Conversely, eating and affective features were less central. The centrality stability coefficient of strength was above the recommended cut-off, thus indicating the stability of the network.

Conclusions: According to the present NA findings, impaired self-monitoring metacognition and difficulties in impulse control are the central nodes in the psychopathological network of BED whereas eating symptoms appear marginal. If further studies with larger samples replicate these results, metacognition and impulse control could represent new targets of psychotherapeutic interventions in the treatment of BED. In light of this, metacognitive interpersonal therapy could be a promising aid in clinical practice to develop an effective treatment for BED.
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http://dx.doi.org/10.1186/s40337-021-00376-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885411PMC
February 2021

Metacognition and emotion regulation as treatment targets in binge eating disorder: a network analysis study.

J Eat Disord 2021 Feb 15;9(1):22. Epub 2021 Feb 15.

Outpatient Unit for Clinical Research and Treatment of Eating Disorders, University Hospital "Mater Domini", Catanzaro, Italy.

Background: This study aims to examine the underlying associations between eating, affective and metacognitive symptoms in patients with binge eating disorder (BED) through network analysis (NA) in order to identify key variables that may be considered the target for psychotherapeutic interventions.

Methods: A total of 155 patients with BED completed measures of eating psychopathology, affective symptoms, emotion regulation and metacognition. A cross-sectional network was inferred by means of Gaussian Markov random field estimation using graphical LASSO and the extended Bayesian information criterion (EBIC-LASSO), and central symptoms of BED were identified by means of the strength centrality index.

Results: Impaired self-monitoring metacognition and difficulties in impulse control emerged as the symptoms with the highest centrality. Conversely, eating and affective features were less central. The centrality stability coefficient of strength was above the recommended cut-off, thus indicating the stability of the network.

Conclusions: According to the present NA findings, impaired self-monitoring metacognition and difficulties in impulse control are the central nodes in the psychopathological network of BED whereas eating symptoms appear marginal. If further studies with larger samples replicate these results, metacognition and impulse control could represent new targets of psychotherapeutic interventions in the treatment of BED. In light of this, metacognitive interpersonal therapy could be a promising aid in clinical practice to develop an effective treatment for BED.
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http://dx.doi.org/10.1186/s40337-021-00376-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885411PMC
February 2021

Do Competitive Contexts Affect Mindreading Performance?

Front Psychol 2020 23;11:1284. Epub 2020 Jun 23.

Istituto Universitario Salesiano Torino Rebaudengo (IUSTO), Turin, Italy.

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.
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http://dx.doi.org/10.3389/fpsyg.2020.01284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7324785PMC
June 2020

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

Ann Gen Psychiatry 2020 3;19:36. Epub 2020 Jun 3.

Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio, Fatebenefratelli, Via Pilastroni 4, Brescia, Italy.

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.
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http://dx.doi.org/10.1186/s12991-020-00286-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7271462PMC
June 2020

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

Eur Eat Disord Rev 2020 09 17;28(5):580-586. Epub 2020 May 17.

Outpatient Unit for Clinical Research and Treatment of Eating Disorders, University Hospital "Mater Domini", Catanzaro, Italy.

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 (χ = 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.
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http://dx.doi.org/10.1002/erv.2742DOI Listing
September 2020

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

BMC Psychiatry 2019 06 24;19(1):195. Epub 2019 Jun 24.

Unit of Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy.

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.
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http://dx.doi.org/10.1186/s12888-019-2127-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591903PMC
June 2019

Metacognition as a Predictor of Improvements in Personality Disorders.

Front Psychol 2019 8;10:170. Epub 2019 Feb 8.

Third Centre of Cognitive Psychotherapy - Italian School of Cognitive Psychotherapy (SICC), Rome, Italy.

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.
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http://dx.doi.org/10.3389/fpsyg.2019.00170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375846PMC
February 2019

Cooperation in psychotherapy increases metacognitive abilities: a single-case study.

Riv Psichiatr 2018 Nov-Dec;53(6):336-340

De Sanctis Clinical Centre, Rome, Italy - Department of Human Sciences, Università Europea di Roma, Rome, Italy.

Introduction: Both clinical observations and empirical data suggest that the ability to think about the mental states of themselves and others (i.e., metacognition) is a crucial factor strongly associated to the outcome of individual psychotherapies. Although it has been hypothesized that the activation of cooperation between patient and psychotherapist within psychotherapy sessions may increase metacognitive abilities, few data is still available to support this hypothesis.

Methods: We explore the association between cooperation of patient and psychotherapist and the modifications of metacognition abilities along five sessions of a patient with a personality disorder using the Assessing Interpersonal Motivations in Transcripts method (AIMIT) and the Metacognition Assessment Scale (MAS).

Results: Our data showed that the activation of cooperation was positively associated with both the MAS total scores and all MAS sub-scales.

Discussion And Conclusion: Our results demonstrate that the activation of the cooperation within therapeutic relationship can increase patient's metacognition and its subsystem (e.g. self-monitoring).
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http://dx.doi.org/10.1708/3084.30768DOI Listing
August 2019

Expanding the validity of the malignant self-regard construct in an Italian general population sample.

Psychiatry Res 2018 12 25;270:688-697. Epub 2018 Oct 25.

Department of Psychology, University of Turin, Italy.

Malignant self-regard (MSR) was proposed as a particular type of self-structure that may account for similarities among a set of clinically relevant Personality Disorders (PDs) such as masochistic/self-defeating and depressive PDs that yet have failed to be adequately represented in the diagnostic manuals. The investigation on the MSR may provide a better framework upon which to understand the nature of these personality types and their discrimination from related constructs. The present study examines the psychometric properties of the Italian adaptation of the Malignant Self-Regard Questionnaire (MSRQ). Reliability and validity indicators are determined in a large sample of adults from general population (n = 2574). The measure was found to be reliable and valid, given its correlations with measures of depressive personality, negative affectivity, self-defeating, and vulnerably narcissistic personalities. MSR also can be meaningfully differentiated from a nomological network of related constructs, including sadness rumination, depression, neuroticism, extraversion, and grandiose narcissism. These findings suggest that MSR may be a personality component which includes a negativistic self-representation, vulnerability and hypersensitivity to judgment, sometimes compensated by perfectionistic tendencies. As a whole, results seem to support the reliability and the validity of the Italian adaptation of the MSRQ as a measure of the MSR.
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http://dx.doi.org/10.1016/j.psychres.2018.10.059DOI Listing
December 2018

Symptom severity and mindreading in narcissistic personality disorder.

PLoS One 2018 15;13(8):e0201216. Epub 2018 Aug 15.

Third Center of Cognitive Psychotherapy, Rome, Italy.

Background: Grandiose narcissism has been associated with poor ability to understand one's own mental states and the mental states of others. In particular, two manifestations of Narcissistic Personality Disorder (NPD) can be explained by poor mindreading abilities: absence of symptomatic subjective distress and lack of empathy.

Methods: We conducted two studies to investigate the relationships between mindreading capacity, symptomatic subjective distress and narcissistic personality. In the first study (N = 246), we compared mindreading capacities and symptomatic distress in three outpatient samples: narcissistic patients (NPD); patients with other Personality Disorders (PD); patients without PD. In the second study (N = 1357), we explored the relationships between symptomatic distress, mindreading and specific NPD criteria.

Results: In the first study, the NPD patients showed poorer mindreading than the patients without PD and comparable to patients with other PDs. Symptomatic subjective distress in the narcissistic group was less severe than in the other PDs group and comparable to the group without PDs. However, no relationship emerged between mindreading and symptomatic subjective distress. In the second study, taking the clinical sample as a whole, symptomatic distress appeared negatively linked to grandiosity traits, while mindreading scores were negatively linked to empathy.

Conclusions: NPD showed specific mindreading impairments. However, mindreading capacity did not appear to be directly connected with subjective distress, but did appear to be connected with specific aspects of narcissistic pathology.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201216PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6093639PMC
January 2019

Levels of Social Sharing and Clinical Implications for Severe Social Withdrawal in Patients with Personality Disorders.

Front Psychiatry 2017 4;8:263. Epub 2017 Dec 4.

Third Centre of Cognitive Psychotherapy, Rome, Italy.

Social sharing capacities have attracted attention from a number of fields of social cognition and have been variously defined and analyzed in numerous studies. Social sharing consists in the subjective awareness that aspects of the self's experience are held in common with other individuals. The definition of social sharing must take a variety of elements into consideration: the motivational element, the contents of the social sharing experience, the emotional responses it evokes, the behavioral outcomes, and finally, the circumstances and the skills which enable social sharing. The primary objective of this study is to explore some of the diverse forms of human social sharing and to classify them according to levels of complexity. We identify four different types of social sharing, categorized according to the nature of the content being shared and the complexity of the mindreading skills required. The second objective of this study is to consider possible applications of this graded model of social sharing experience in clinical settings. Specifically, this model may support the development of graded, focused clinical interventions for patients with personality disorders characterized by severe social withdrawal.
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http://dx.doi.org/10.3389/fpsyt.2017.00263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5722791PMC
December 2017

Avoidant personality disorder and social phobia: Does mindreading make the difference?

Compr Psychiatry 2018 01 28;80:163-169. Epub 2017 Sep 28.

Third Center of Cognitive Psychotherapy, Rome, Italy; SPC School of Cognitive Psychotherapy, Rome, Italy.

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.
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http://dx.doi.org/10.1016/j.comppsych.2017.09.011DOI Listing
January 2018

Mindreading Dysfunction in Avoidant Personality Disorder Compared With Other Personality Disorders.

J Nerv Ment Dis 2016 Oct;204(10):752-757

*Terzo Centro di Psicoterapia Cognitiva, Rome; †Department of Psychology, Second University of Naples, Caserta; and ‡Department of Psychology, Center of Cognitive Science, University of Turin, Italy.

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.
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http://dx.doi.org/10.1097/NMD.0000000000000536DOI Listing
October 2016

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

Am J Psychother 2015 ;69(3):317-30

Centro di Terapia Metacognitiva Interpersonale, Roma, Italy.

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.
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http://dx.doi.org/10.1176/appi.psychotherapy.2015.69.3.317DOI Listing
December 2015

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

J Nerv Ment Dis 2015 Aug;203(8):626-31

*Terzo Centro di Psicoterapia Cognitiva & SPC School of Cognitive Psychotherapy, Rome; †Department of Psychology, Center of Cognitive Science, University of Turin, Turin; and ‡Department of Psychology, Second University of Naples, Salerno, Italy.

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.
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http://dx.doi.org/10.1097/NMD.0000000000000339DOI Listing
August 2015

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

Clin Psychol Psychother 2016 Jul 12;23(4):329-39. Epub 2015 May 12.

Centre for Metacognitive Interpersonal Therapy, Rome, Italy.

Unlabelled: 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.
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http://dx.doi.org/10.1002/cpp.1959DOI Listing
July 2016

Metacognitive dysfunctions in personality disorders: correlations with disorder severity and personality styles.

J Pers Disord 2014 Dec;28(6):751-66

Metacognitive impairment is crucial to explaining difficulties in life tasks of patients with personality disorders (PDs). However, several issues remain open. There is a lack of evidence that metacognitive impairments are more severe in patients with PDs. The relationship between severity of PD pathology and the extent of metacognitive impairment has not been explored, and there has not been any finding to support the linking of different PDs with specific metacognitive profiles. The authors administered the Metacognitive Assessment Interview to 198 outpatients with PDs and 108 outpatients with no PDs, differentiating overall severity from stylistic elements of personality pathology. Results showed that metacognitive impairments were more severe in the group with PDs than in the control group, and that metacognitive dysfunctions and the severity of the PD were highly associated. Positive correlations were found between specific metacognitive dysfunctions and specific personality styles. Results suggest that metacognitive impairments could be considered a common pathogenic factor for PDs.
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http://dx.doi.org/10.1521/pedi_2014_28_137DOI Listing
December 2014

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

Compr Psychiatry 2014 Feb 22;55(2):268-73. Epub 2013 Oct 22.

Centre for Metacognitive Interpersonal Therapy, Rome, Italy.

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.
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http://dx.doi.org/10.1016/j.comppsych.2013.08.027DOI Listing
February 2014

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

Psychother Res 2013 ;23(6):624-32

a Centro Di Terapia Metacognitiva Interpersonale , Rome , Italy.

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.
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http://dx.doi.org/10.1080/10503307.2013.845921DOI Listing
August 2014

Differences between axes depend on where you set the bar: associations among symptoms, interpersonal relationship and alexithymia with number of personality disorder criteria.

J Pers Disord 2013 Jun 6;27(3):371-82. Epub 2012 Nov 6.

Third Center of Cognitive Psychotherapy, Rome, Italy.

Personality disorders are better understood as entities that vary according to severity along specific domains rather than a phenomenon separate from and unrelated to Axis I disorders. This study explores whether patients who were rated as having greater numbers of personality disorder traits reported greater levels of interpersonal problems, psychiatric symptoms, and alexithymia. The sample was composed of 506 consecutive patients assessed in a private outpatient center who were administered the SCID-II Symptom-Checklist (SCL-90-R), Inventory of Interpersonal Problems (IIP-47), and Toronto Alexithymia-Scale (TAS-.20). Based upon the number of personality disorder traits identified in the SCID, participants were classified into five groups: 0-4, 5-9, 10-14, 15-19, and 20 or more personality disorder traits met. Comparisons between groups revealed that symptom severity and levels of interpersonal problems increased between groups as the number of personality disorder traits increased. After covarying for symptom severity, there were no significant between-groups differences for levels of alexithymia. Findings are consistent with the claims that the simple Axis I-Axis II distinction is not an optimal strategy to understand personality pathology. It instead may be more fruitful to consider group differences in terms of numbers of personality disorder traits met.
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http://dx.doi.org/10.1521/pedi_2012_26_043DOI Listing
June 2013

The development of the Metacognition Assessment interview: instrument description, factor structure and reliability in a non-clinical sample.

Psychiatry Res 2012 Dec 18;200(2-3):890-5. Epub 2012 Aug 18.

Terzo Centro di Psicoterapia Cognitiva-Scuola di Psicoterapia Cognitiva (SPC), Training School in Cognitive Psychotherapy, via Ravenna 9/c, 00161 Rome, Italy.

Background: Metacognition is a multi-facet psychological construct; deficits in metacognitive abilities are associated to low social functioning, low quality of life, psychopathology, and symptoms. The aim of this study was to describe and develop a valid and reliable interview for assessing metacognition.

Methods: The semi-structured interview, based on the author's theory model of the metacognition construct, is described. The Metacognition Assessment Interview (MAI) is an adaptation of the Metacognition Assessment Scale (MAS) and evaluates how the subject is interviewed used metacognition during his own real life experiences elicited by the interviewer. A user manual was developed to assist the interview and scoring procedure.

Results: Exploratory factor analysis and confirmatory factor analysis revealed preliminary evidence of a two factor-hierarchical structure, with two lower-order scales, representing the two main theoretical domains of the metacognitive function, "the Self" and "the Other", and one single higher-order scale that we labelled metacognition. Contrary to the authors' prediction the existence of the four distinct dimensions under the two domains was not confirmed. The MAI and its two domains demonstrated acceptable levels of inter-rater reliability and internal consistency.

Conclusions: The MAI appears to be a promising instrument for assessing metacognition. Future psychometric validation steps and clinical directions are discussed.
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http://dx.doi.org/10.1016/j.psychres.2012.07.015DOI Listing
December 2012

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

J Nerv Ment Dis 2012 Jul;200(7):644-7

Terzo Centro di Psicoterapia Cognitiva, Rome, Italy.

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.
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http://dx.doi.org/10.1097/NMD.0b013e31825bfb10DOI Listing
July 2012

General principles for treating personality disorder with a prominent inhibitedness trait: towards an operationalizing integrated technique.

J Pers Disord 2012 Feb;26(1):63-83

Centro di Terapia Metacognitiva Interpersonale, Piazza Martiri di Belfiore 4, 00195, Rome, Italy.

Psychotherapists need to perform tasks such as being empathetic, performing an ongoing assessment of cases, self-disclosing, making explicit treatment contracts, validating patients' experiences and promoting awareness of psychological experience, if they are to be effective in treating personality disorder (PD). Successful therapy also requires a systematic accurate PD model. We suggest here that it is still unclear how, when, and according to what session markers therapists need to perform specific operations to maximize therapeutic gains. This article describes and operationalizes a step-by-step procedure for organizing and delivering the interventions necessary for effective outcomes, such as maintaining a good therapeutic relationship, increasing understanding of mental states, reducing symptoms and improving social adaptation. The procedure is illustrated by reference to the treatment of cases of emotionally overly-constricted PDs. We include a theoretical proposal to facilitate the development of measures for evaluating the efficacy of therapist actions.
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http://dx.doi.org/10.1521/pedi.2012.26.1.63DOI Listing
February 2012

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

Br J Clin Psychol 2011 Nov 24;50(4):412-24. Epub 2011 Jan 24.

Roudebush VA Medical Center, Indiana, USA.

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.
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http://dx.doi.org/10.1111/j.2044-8260.2010.02003.xDOI Listing
November 2011

Poor insight in schizophrenia: links between different forms of metacognition with awareness of symptoms, treatment need, and consequences of illness.

Compr Psychiatry 2011 May-Jun;52(3):253-60

Roudebush VA Medical Center (116H), Indianapolis, IN 46202, USA.

Objective: Many persons with schizophrenia experience poor insight or reflexive unawareness of the symptoms and consequences of their illness and, as a result, are at risk for treatment nonadherence and a range of negative outcomes. One recent theory regarding the origins of poor insight in schizophrenia has suggested that it may result, in part, from deficits in metacognitive capacity, or the ability to think about thinking, both one's own and the thinking of others.

Methods: Participants were 65 adults with a schizophrenia spectrum disorder in a postacute phase of illness living in the community. For all participants, we obtained measures of three domains of metacognition, including self-reflectivity, mastery, and perspective taking, using the Metacognitive Assessment Scale and the hinting test and three domains of insight, which were awareness of symptoms, treatment need, and consequences of illness, using the Scale to Assess Unawareness of Mental Disorder. Measures of neurocognition were also collected for potential use as covariates.

Results: Univariate correlations followed by stepwise multiple regressions, which controlled for neurocognition, indicated that self-reflectivity was significantly linked with awareness of symptoms, mastery with treatment need, and mastery and perspective taking were linked with awareness of consequences of illness.

Conclusions: Results suggest that metacognition may be linked to insight in persons with schizophrenia independent of concurrent impairments in neurocognition.
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http://dx.doi.org/10.1016/j.comppsych.2010.07.007DOI Listing
August 2011

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

Clin Psychol Psychother 2012 May-Jun;19(3):247-59. Epub 2011 Mar 4.

Third Center of Cognitive Psychotherapy-Associazione di Psicologia Cognitiva-APC, Rome, Italy.

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.
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http://dx.doi.org/10.1002/cpp.746DOI Listing
September 2012

Progressively promoting metacognition in a case of obsessive-compulsive personality disorder treated with metacognitive interpersonal therapy.

Psychol Psychother 2011 Mar;84(1):70-83; 98-110

Third Center of Cognitive Psychotherapy - Training School in Cognitive Psychotherapy Associazione di Psicologia Cognitiva (APC), Rome, Italy.

Background: Many persons with personality disorders (PD) have problems contemplating mental states and using psychological knowledge to cope with their suffering and solve social problems, the skill termed metacognition in this article. Therapists can focus on metacognitive dysfunctions in order to tailor PD treatment to clients' metacognitive skills.

Aims: To briefly summarize procedures for promoting clients' abilities to define problems in mentalistic terms and use this knowledge to develop new paths towards living an adapted social life, within the context of a continuous regulation of the therapy relationship.

Method: Qualitative analysis of session transcript excerpts from a good-outcome case treated with metacognitive interpersonal therapy.

Conclusion: A therapeutic focus on metacognitive dysfunctions and a regulation of the therapy relationship can lead to improvements in symptoms and interpersonal functioning. The possibility of generalizing the procedure and testing it empirically is discussed.
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http://dx.doi.org/10.1348/147608310X527240DOI Listing
March 2011

Addressing metacognitive capacity for self reflection in the psychotherapy for schizophrenia: a conceptual model of the key tasks and processes.

Psychol Psychother 2011 Mar;84(1):58-69; discussion 98-110

Roudebush VA Medical Center, Indianapolis, Indiana, USA.

Purpose: Recognition that recovery from schizophrenia may involve a deepening of the experience of being in the world has led to the possibility that psychotherapy may play a key role in treatment by enhancing metacognition, or the capacity to think about thinking. While the potential of psychotherapy to enhance metacognition in non-psychotic disorders has been discussed in depth, little has been written about how psychotherapy may systematically address metacognition in schizophrenia. Accordingly, the current paper formulates a model of how psychotherapy might address one specific element of metacognition, namely self-reflectivity.

Methods: Procedures are outlined for assessing clients' capacity for self-reflectivity within narrative contexts during psychotherapy.

Results: Targeted interventions are identified which are tailored to clients' capacities in the moment and which assist clients to think about their own thinking at the level of which they are capable. This may lead clients over time to develop a greater ability to engage in acts of increasingly complex self-reflectivity.

Conclusions: Individual psychotherapy can be modified and utilized to assist persons with schizophrenia to move towards recovery by assisting them to develop the capacity for self-reflectivity. This may lead to clients having a fuller experience of themselves as a being in the world with a richer and more coherent personal narrative.
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http://dx.doi.org/10.1348/147608310X520436DOI Listing
March 2011
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