Publications by authors named "Antonio Semerari"

35 Publications

Metacognition Mediates the Relationship Between Maladaptive Personality Traits and Levels of Personality Functioning: A General Investigation on a Nonclinical Sample.

J Nerv Ment Dis 2021 05;209(5):353-361

Psicometrica.it-Ars Psico Clinical Center, Caserta.

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.
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http://dx.doi.org/10.1097/NMD.0000000000001304DOI Listing
May 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

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

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

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

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

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

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

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

Metacognitive mastery dysfunctions in personality disorder psychotherapy.

Psychiatry Res 2011 Nov 17;190(1):60-71. Epub 2011 Feb 17.

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

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.
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http://dx.doi.org/10.1016/j.psychres.2010.12.032DOI Listing
November 2011

A rational model for maximizing the effects of therapeutic relationship regulation in personality disorders with poor metacognition and over-regulation of affects.

Psychol Psychother 2010 Nov;83(4):363-84

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

Background: The therapeutic relationship plays a key role in personality disorder (PD) psychotherapy. Some aspects of therapeutic relationship regulation appear important for treatment of PD clients, including those with constricted relational schemas, poor metacognition, and over-regulation of affects described here. AIM.: To propose a rational model for how and when to work on the therapeutic relationship by treating the underlying personality pathology.

Method: Formalize a step-by-step procedure for performing operations such as validation of clients' experiences, creating a sense of sharedness, assessing the quality of the therapeutic relationship in order to prevent and repair ruptures in the alliance, self-disclosing by the therapist, and metacommunication on the basis of clients' responses to treatment.

Conclusion: We discuss the implications of this model for further research into the PD therapy process.
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http://dx.doi.org/10.1348/147608310X485256DOI Listing
November 2010

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

Psychiatry Res 2011 Nov 25;190(1):37-42. Epub 2010 Aug 25.

SPC Training School of Cognitive Therapy, Terzocentro Psicoterapia Cognitiva, Rome, Italy.

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.
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http://dx.doi.org/10.1016/j.psychres.2010.07.046DOI Listing
November 2011

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

Clin Psychol Psychother 2009 Sep-Oct;16(5):450-62

Third Center of Cognitive Psychotherapy-Rome, Italy.

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.
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http://dx.doi.org/10.1002/cpp.619DOI Listing
January 2010

States of minds in narcissistic personality disorder: three psychotherapies analyzed using the grid of problematic states.

Psychother Res 2008 Jul;18(4):466-80

Terzo Centro di Psicoterapia Cognitiva, Rome, Italy.

The subjective experience of patients suffering from narcissistic personality disorder (NPD) has been studied using various methods. However, there has not been an analysis of psychotherapy session transcripts. It is much more likely that the facets of experience surface in this context than during a single interview or in a self-administered questionnaire. Using the Grid of Problematic States, designed to assess contents emerging in patients' transcripts, the authors analyzed the first 18 psychotherapy sessions with three female patients suffering from NPD and treated by therapists of the cognitive-constructivist school specializing in personality disorders. The three patients' dominant states of mind were characterized by anger, feeling excluded from groups, feelings of being harmed, and distrust toward others. The authors discuss the results and their implications for future research and for the definition of NPD in future editions of the Diagnostic and Statistical Manual of Mental Disorders.
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http://dx.doi.org/10.1080/10503300701881877DOI Listing
July 2008

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

Psychother Res 2008 Nov;18(6):667-76

Terzo Centro di Psicoterapia Cognitiva, Rome, Italy 00161.

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.
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http://dx.doi.org/10.1080/10503300802220132DOI Listing
November 2008

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

Psychother Res 2008 Nov;18(6):645-56

SPC Training School of Cognitive Therapy, Terzo Centro Psicoterapia Cognitiva, Rome, Italy.

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.
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http://dx.doi.org/10.1080/10503300802183686DOI Listing
November 2008

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

Conscious Cogn 2008 Sep 3;17(3):778-89. Epub 2008 Apr 3.

Terzo Centro di Psicoterapia Cognitiva, Associazione di Psicologia Cognitiva, Via Ravenna 9/C, 00161 Rome, Italy.

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.
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http://dx.doi.org/10.1016/j.concog.2008.02.005DOI Listing
September 2008

Metacognitive interpersonal therapy in a case of obsessive-compulsive and avoidant personality disorders.

J Clin Psychol 2008 Feb;64(2):168-80

Terzo Centro di Psicoterapia Cognitiva-Associazione di Psicologia Cognitiva, Rome, Italy.

Metacognitive interpersonal therapy (MIT) for personality disorders is aimed at both improving metacognition--the ability to understand mental statesand modulating problematic interpersonal representations while building new and adaptive ones. Attention to the therapeutic relationship is basic in MIT. Clinicians recognize any dysfunctional relationships with patients and work to achieve attunement to make the latter aware of their problematic interpersonal patterns. The authors illustrate here the case of a man suffering from obsessive-compulsive and avoidant personality disorders with dependent traits. He underwent combined individual and group therapies to (a) modulate his perfectionism, (b) prevent shifts towards avoiding responsibilities to protect himself from feared negative judgments, and (c) help him acknowledge suppressed desires. We show how treatment focused on the various dysfunctional personality aspects.
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http://dx.doi.org/10.1002/jclp.20450DOI Listing
February 2008

Early narcissistic transference patterns: an exploratory single case study from the perspective of dialogical self theory.

Psychol Psychother 2006 Dec;79(Pt 4):495-516

Terzo Centro di Psicoterapia Cognitiva - Training school in psychotherapy, Associazione di Psicologia Cognitiva (APC), Rome, Italy.

Persons exhibiting narcissistic personality traits are difficult to treat in psychotherapy, in particular because of the problems they have in building up a sound therapeutic relationship. We discuss the hypothesis that the threats to a therapeutic alliance emerge both from patients' maladaptive patterns of behaving towards others and from therapists being affected by these patterns and becoming a part of a dysfunctional dialogue. We examine this phenomenon in terms of Dialogical Self Theory and suggest that a patient can be conceptualised as embodying a cast of characters weaving a problematic dialogue both within the self and with other selves. Via the analysis of the transcripts of the first four audiotaped sessions of a psychotherapy involving a woman with narcissistic traits we identified one early dominant dialogical pattern in which a contemptuous and a contemptible character faced each other, shadowing characters in search for help. Such a pattern is consistent with the literature on interpersonal processes in narcissism. The therapist was involved in the pattern from the third session, suggesting that countertransference with individuals displaying narcissistic personality traits is caused more by the pathology than by their therapist's characteristics. Implications for treatment are discussed.
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http://dx.doi.org/10.1348/147608305x63089DOI Listing
December 2006

Toward a model of self pathology underlying personality disorders: narratives, metacognition, interpersonal cycles and decision-making processes.

J Pers Disord 2006 Dec;20(6):597-617

Associazione di Psicologia Cognitiva (APC), Rome, Italy.

If we want to explain the links between the various and heterogeneous elements--symptoms, dysfunctional forms of behavior and poor social functioning--making up personality disorders, we need model a self pathology that portrays dysfunctions, the links among them, and how their interactions maintain disorders over time. In our view, the most likely elements of self pathology are: a. problematic contents (thoughts and emotions)--experienced subjectively as states of mind and organized in the form of narratives; b. shortfalls in the ability, termed meta-cognition, to reflect on mental states, both of oneself and of others; c. pathogenic interpersonal schemas; and d. maladaptive decision-making processes. These elements get altered in the various personality disorders and interact to form typical pathological organizations. This article seeks to describe a model of self pathology in personality disorders and discuss its current scientific status based on a literature review that spans several disciplines. The model is illustrated with an example of how the pathogenic elements can interact to form personality disorder. Lastly, the limitations and advantages of the model are discussed.
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http://dx.doi.org/10.1521/pedi.2006.20.6.597DOI Listing
December 2006
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