Metarepresentative functions in borderline personality disorder

Many authors consider that patients suffering from Borderline Personality Disorder (BPD) are hampered in their ability to metarepresent, which is the correct ascribing of states of mind to oneself and to others and the reflecting thereon. Although the ability to mentalize is generally described as being uniform, various authors pinpoint problems which appear to be of a diverse psychological nature. Some describe difficulties in identifying emotions or a shortfall in their regulation, others identify a lack of integration between representations of self and those of others, and yet others focus on the failure to distinguish between fantasy and reality. In the present research all sessions during the first year of therapy of four patients suffering from BPD were tape-recorded and transcribed, and then analyzed using the Metacognition Assessment Scale (MAS), which is designed for the evaluation of the ability to metarepresent in clinical reports. The results support the hypothesis that there is a metarepresentation impairment in BPD but that it is more selective than was thought until now. In particular, such patients maintain their ability to identify internal states, whereas they are impaired in the integration of representations of self and others and in the differentiation between fantasy and reality.     

Introduction to the special feature on the integrated treatment of personality disorder

The solid evidence that personality disorders can be treated effectively goes side by side with, on the one hand, sparse evidence for disorders other than borderline and for personality disorders co-occurrent with one another, and, on the other hand, with a relative lack of knowledge about the actual effective mechanisms of change that underpin successful psychotherapies. In this introduction we present the rationale for this special feature, advocating for an integrated treatment of personality pathology in which empirically-supported strategies and techniques are selected from different traditions on the basis of the pragmatic principle of what works.     

Religious Beliefs or Physicians’ Behavior: What Makes a Patient More Prone to Accept a Physician to Address His/Her Spiritual Issues?

The present study aims to understand the relation between religious beliefs, physicians’ behavior and patients’ opinions regarding “Spirituality, religiosity and health (S/R)” issues, and what makes a patient more prone to accept a physician to address his/her spiritual issues. A cross-sectional study was carried out in outpatients from a tertiary hospital, and a path analysis was used to examine the direct and indirect relationships between the variables. For the final analysis, 300 outpatients were evaluated. Most patients would like their doctors to address S/R issues but did not feel comfortable to ask them. In contrast, they reported most doctors have never addressed S/R issues, and they believe doctors are not prepared to address these issues. The path analysis revealed that patients’ previous experiences with their doctors may be as important as their religious/spiritual beliefs in proneness to accept a physician to address his/her spiritual issues.     

Short-Term Inpatient DBT Combined with Metacognitive Interventions for Personality Disorders: A Pilot Acceptability and Effectiveness Study

This study aims at evaluating the effectiveness of an intensive 1-month residential treatment course in an Italian psychiatric unit for patients meeting criteria for personality disorders (PD). This study involved 189 patients consecutively admitted to the unit and assessed at admission and discharge. The inpatient program was based on Dialectical Behavior Therapy (DBT) combined with Metacognitive interventions. Primary outcome was a reduction of general symptom severity (as measured by SCL-90-R). Secondary outcomes were reduction in depression (BDI), interpersonal problems (IIP-47). Other outcomes were impulsivity (BIS-11), aggressiveness (AQ), and dissociation (DES). We found a significant reduction in symptom severity, as well as in depression, interpersonal problems, dissociation, impulsivity and aggressiveness. The size of this benefit was predicted mostly by number of criteria met at SCID-II and intake scores mostly for impulsiveness and dissociation. In conclusion, intensive 1-month residential DBT combined with metacognitive interventions can be effective in treating patients with any PD presenting with severe global suffering, prominent self-harm and suicidal risk.

     

Impaired self-reflection in psychiatric disorders among adults: A proposal for the existence of a network of semi independent functions

Self-reflection plays a key role in healthy human adaptation. Self-reflection might involve different capacities which may be impaired to different degrees relatively independently of one another. Variation in abilities for different forms of self-reflection are commonly seen as key aspects of many adult mental disorders. Yet little has been written about whether there are different kinds of deficits in self-reflection found in mental illness, how those deficits should be distinguished from one another and how to characterize the extent to which they are interrelated. We review clinical and experimental literature and suggest four different forms of deficits in self-reflection: (a) sense of ownership of one’s own thoughts and actions, (b) emotional awareness, (c) distinction between fantasy and reality and (d) the integration of a range of different views of oneself and others. We propose how these different impairments in self-reflection are linked with one another.     

Metacognitive Interpersonal Therapy for Treating Auditory Verbal Hallucinations in First-onset Schizophrenia

Auditory verbal hallucinations (AVHs) are perceptive-like experiences happening without appropriate stimuli, occurring in two thirds of schizophrenia patients, where they often cause emotional suffering and dangerous behaviors, and interfere with social relationships. Patients with schizophrenia involving AVHs can also be drug-resistant or they may discontinue medications. The most well-known psychotherapeutic intervention for voice-hearing is cognitive behavioral therapy (CBT), which focuses on reducing distress by modifying hearers’ beliefs about their voices. We hypothesize that it is possible to reinforce the clinical approach to AVHs by taking into consideration (a) that patients generally hear voices in particular interpersonal contexts where they experience negative emotions; (b) the relationship between AVHs and metacognition, namely the ability to make sense of mental states. On this basis, AVHs can be seen not just as a cause of emotional distress as CBT postulates, but the outcome of difficulties in meta-cognitively making sense of interpersonal exchanges. In this paper, we describe the treatment of a young man at the onset of schizophrenia with pervasive negative AVHs. The patient was treated with metacognitive interpersonal therapy (MIT), aimed to promote the patient’s metacognition. With this aim, in the first part of the treatment, each time AVHs emerged, the patient’s level of arousal was high and his metacognitive ability very low, the therapist treated AVHs helping the patient to understand and cope with the emotional suffering connected with AVHs. At a more advanced stage of therapy, the therapist helped the patient reach the point of understanding the social triggers which, together with the patient’s self-schemas, ignited his auditory hallucinations; this created the conditions for a significant reduction of the pervasiveness of AVHs.     

When REBT Goes Difficult: Applying ABC-DEF to Personality Disorders

ABC-DEF framework is at the core of rational emotive behavior therapy. It is a highly flexible framework and has proven to be applicable to many emotional disorders. We cannot take for granted, however, that this framework can be used successfully with all clients, particularly with those suffering from severe disorders or personality disorders. In fact, the difficulties of these clients in recognizing, naming and reflecting upon states of mind, their dysregulated emotions and self-defeating behavior, and their difficulty in establishing a strong working alliance with a therapist may hamper the correct implementation of the ABC-DEF framework and the disputing of their irrational beliefs. This paper aims to describe in detail the challenges that clients with personality disorders may pose during treatment and offer possible technical suggestions, derived from either REBT or non-REBT literature, that can help REBT and CBT practitioners adapting their interventions to resistant clients.