Donatella Fiore

Attachment disorganization and borderline patients’ metacognitive responses to therapists’ expressed understanding of their states of mind: A pilot study

Abstract This study explores the relationship between psychotherapists’ validation interventions and patients’ metacognitive responses at the beginning of treatment of borderline personality disorder (BPD). A model of BPD based on disorganized attachment provides the hypothesis that, before patients’ internal working model of attachment has been corrected within the therapeutic relationship, therapist interventions that are likely to activate patients’ attachment system are also likely to induce temporary disorganization of patients’ metacognitive functions. Any validation intervention implies that therapists openly display an understanding and accepting attitude when they comment on patients’ reported experiences and is, therefore, likely to activate the patients’ attachment system. Linehans (1993) manual of dialectic–behavioral therapy (DBT) was used as a guideline to assess validation interventions adopted by therapists. The transcripts of the second individual session in the psychotherapy of 19 consecutive patients were analyzed. Checklists based on the DBT manual were used to identify therapists’ validating, supportive, and neutral interventions. The Metacognitive Assessment Scale was used to assess changes in specific aspects of patients’ metacognitive processes during therapeutic dialogues. Following validation interventions, patients’ responses revealed significantly higher rates of temporary metacognitive failure in comparison to the responses solicited by neutral intervention.

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

Abstract 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.

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

Abstract 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 Lisas 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.

Differences Between Axes Depend on Where You Set the Bar: Associations Among Symptoms, Interpersonal Relationship and Alexithymia With Number of Personality Disorder Criteria

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.

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

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.

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

Abstract 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.

DISORGANIZED NARRATIVES: PROBLEMS IN TREATMENT AND THERAPIST INTERVENTION HIERARCHY

The way in which patients tell therapists their stories has an impact on treatment. They try to put their emotions and the events generating them, their goals and the behavior they adopt to achieve them, and so on, together in a coherent discourse. But some patients fail in organizing their narratives. They might describe a diffuse arousal without letting the reasons for their discomfort be known, switch from one subject to another without any apparent connection, or pile up one topic after another, thus overwhelming a listener, who is unable to see which is the main one. We call such narratives disorganized. They do not help a patient to make sense of experience or achieve consistency in behavior. A therapist listening has difficulty in planning treatment and often reacts negatively to such patients. Here we propose a series of interventions aimed at improving narrative coherence, creating a sound therapeutic relationship and making treatment effective. We will describe the therapy with a seriously dissociated patient in which this intervention has proven useful.

Dialogical Relationship Patterns in Narcissistic Personalities: Session Analysis and Treatment Implications

Patients with narcissistic features are difficult to treat in psychotherapy, in particular because of problems in building sound therapeutic relationships with them. Therapists can get easily involved in dysfunctional relationship patterns that have a negative impact on the therapeutic alliance. Tracing the typical patterns that can recur in persons with narcissistic features should, therefore, prove useful in helping therapists to recognize their involvement in them at an early treatment stage and to deal with them effectively. A dialogical theory of the self offers a promising perspective from which to recognize and describe these patterns. From this vantage point, we discuss the treatment of a client diagnosed as having a narcissistic personality. What occurred during this therapy lends support to the idea that there are typical dialogical relationship patterns in patients with narcissistic features and that knowing them might help therapists to make treatment effective, avoid early dropouts, and successfully manage the therapeutic relationship. In addition, we put forward the hypothesis that some of the therapeutic techniques described here also can be applied to other patients displaying similar narcissistic features.

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

OBJECTIVE Avoidant personality disorder (AvPD) is closely related to and partially overlaps with social phobia (SP). There is an ongoing debate as to whether AvPD and SP can be classified as separate and distinct disorders or whether these diagnoses rather reflect different degrees of severity of social anxiety. The hypothesis of this study is that in patients with AvPD and in those with AvPD and comorbid SP both interpersonal functioning and metacognitive abilities (the ability to understand mental states) are more severely impaired than they are in patients with SP only. We also hypothesise that the interpersonal and metacognitive functioning of these patients (both AvPD and AvPD+SP) is comparable to that of patients with other PD diagnoses. METHODS To test this hypothesis, we compared four groups (22 patients with SP, 32 patients with AvPD, 43 patients with both AvPD and SP and 50 patients with other personality disorders without SP and AvPD criteria) on metacognitive abilities, interpersonal functioning and global symptomatic distress. RESULTS Metacognitive ability showed significant variation among the four groups, with the lowest score observed in the AvPD group. As far as the interpersonal functioning is concerned, the lack of sociability was more severe in the AvPD group compared with the SP group. These differences were maintained even after controlling for global symptomatic distress. CONCLUSION Results are in line with the alternative model of PD, proposed in the DSM-5, as dysfunction of the self and relationships. They suggest that specific impairments in critical areas of self domains and interpersonal domains of personality functioning may serve as markers distinguishing AvPD from SP.

Definizione e selezione di un gruppo di controllo non clinico per la valutazione degli outcome in soggetti trattati in gruppi di Skills Trainingcondotti secondo la Dialectical Behaviour Therapy (DBT)

I gruppi di skills training condotti secondo la DBT rappresentano un mediatore cruciale del cambiamento. Lo skills training e necessario quando mancano abilita emotive, cognitive, comportamentali integrate per risolvere problemi personali e raggiungere gli obiettivi desiderati. Questo lavoro ha lo scopo di selezionare un gruppo di controllo non clinico confrontabile con i gruppi in trattamento DBT-Skills per valutarne gli esiti. La possibilita di disporre di valori di baseline di soggetti non clinici relativamente alle capacita di regolazione emotiva, abilita sociali e sintomatologia, consente la valutazione statistica degli outcome dei soggetti in trattamento non solo rispetto al miglioramento fra le diverse fasi del training, ma anche in relazione alla potenziale generalizzabilita del risultato alla popolazione normale di riferimento. Sulla base delle caratteristiche sociodemografiche di pazienti inclusi nella DBT e stato selezionato un gruppo di controllo di 100 soggetti non clinici, appaiato per eta, genere, stato civile e titolo di studio equivalenti al campione clinico. Al campione di controllo e stata somministrata la stessa batteria di test utilizzata per la valutazione del gruppo in trattamento. Sono state misurate: efficacia percepita nella regolazione emotiva (APEP/APEN), caratteristiche temperamentali (TCI-R), sintomatologia e disagio psichico (SCL-90R), abilita interpersonali (IIP), alessitimia (TAS-20). I risultati sono stati confrontati con i punteggi ottenuti sia nella valutazione iniziale che a 6 mesi dal trattamento (un intero ciclo di Skills Training DBT) nei soggetti con disturbo borderline di personalita (reperiti presso il Terzocentro di Psicoterapia Cognitiva di Roma). I soggetti in trattamento DBT presentano, dopo un ciclo completo di Skills Training capacita di regolazione emotiva e problem-solving equivalenti a quelle mostrate dai soggetti non clinici.