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Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

Paranoid personality disorder (PPD) is a severe condition, lacking specialized and empirically supported treatment. To provide the clinician with insights into how to treat this condition, we present a case study of a 61-year-old man with severe PPD who presented with ideas of persecution, emotionally charged hostility, and comorbid antisocial personality disorder. The client was treated with 6 months of Metacognitive Interpersonal Therapy, which included: creating a shared formulation of his paranoid attitudes; trying to change his inner self-image of self-as-inadequate and his interpersonal schemas where he saw the others as threatening. Guided imagery and rescripting techniques, coupled with behavioral experiments, were used to promote a change. At the end of the therapy the client reported a reliable change in general symptomatology and, specifically, in interpersonal sensitivity, hostility, and paranoid ideation; he could no longer be diagnosed as PPD and only some paranoid and antisocial characteristics remained.

Individuals experiencing avoidant personality disorder (AvPD) tend to make sense of social interactions via maladaptive self-and other attributions. They also experience difficulties in recognizing emotions. A further feature of AvPD psychopathology is the tendency to resort to maladaptive coping strategies, such as behavioral avoidance and perfectionism. Despite its impact, psychological treatments for AvPD remains poorly investigated. Herein, we describe the first five sessions of Metacognitive Interpersonal Therapy with a 28-year-old woman, whose treatment goal was to reduce social avoidance. We describe how this goal was achieved through a combination of working through the therapeutic relationship, alongside experiential techniques such as guided imagery, rescripting, and bodily work. Through this treatment configuration, the patient was able to increase self-awareness of her own emotions, enabling her to realize that she was guided by rigid schemas; specifically seeing herself as inadequate and others as judgmental. Finally, implications for the treatment of AvPD are discussed.

La ricerca empirica mostra un'associazione stretta tra buon funzionamento della relazione terapeutica e buon esito del trattamento. L'attenzione alla relazione terapeutica è uno dei fulcri della terapia metacognitiva interpersonale (TMI). In questo articolo, dopo aver sintetizzato gli aspetti fondamentali del modello, descriveremo come in TMI il lavoro sulla relazione si intrecci con l'utilizzo di tecniche esperienziali quali immaginazione guidata e role playing, finalizzate a promuovere nel paziente la comprensione del suo mondo interno e il cambiamento clinico. Forniremo una serie di esemplificazioni cliniche al fine di descrivere come la relazione sia nel contempo: 1) strumento per favorire l'accesso ai contenuti psicologici rilevanti; 2) strumento per favorire un'esperienza emozionale correttiva; per esempio, in molti casi l'utilizzo di una tecnica esperienziale mette il paziente in condizione di contattare parti di sé libere dalla patologia, e di sperimentare la relazione terapeutica come fonte di speranza e sostegno all'autonomia; 3) oggetto di intervento in caso di rotture della relazione, anche nei casi in cui tali rotture sono la conseguenza dell'utilizzo di tecniche esperienziali. Nel complesso, mostreremo come il processo terapeutico in TMI sia mosso dalla capacità del terapeuta di muoversi agilmente tra l'utilizzo di tecniche volte a esplorazione e cambiamento, e focus sulla relazione

Young adults presenting with personality disorders (PDs) featuring overcontrol and social inhibition urgently require effective psychological interventions to help them navigate important life transitions. metacognitive interpersonal therapy-group (MIT-G) is a time-limited group program designed to enable individuals to find adaptive solutions to their social difficulties. A small randomized clinical trial (RCT) of MIT-G versus treatment as usual (TAU) was conducted with the primary outcomes of improvements in social and interpersonal functioning and global psychological symptoms. Secondary outcomes were specific symptoms of anxiety and depression and changes in alexithymia and emotion dysregulation. From 40 participants, 20 were randomized to 16 weekly sessions of MIT-G, plus 3 individual sessions and 20 to TAU + waiting list. All 20 patients allocated to MIT-G completed treatments, while 2 dropped-out in the TAU arm. Patients in the MIT-G arm reported significant improvements on primary outcomes of functioning, interpersonal problems and global symptoms of medium magnitude, medium effect sizes for changes in depression and anxiety, and large magnitude changes for alexithymia. However, other than alexithymia no significant differences were observed between groups at treatment end. A Time × Condition interaction, indicated that MIT-G was associated with more rapid and larger magnitude improvements in functioning and alexithymia. MIT-G is a well-tolerated treatment option for young adults with overcontrolled PD. Further effectiveness studies in larger samples are underway. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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

Depression in personality disorders come from multiple sources, ranging from poor metacognition to maladaptive interpersonal schemas and dysfunctional coping strategies, such as avoidance or perfectionism. A modular treatment is needed in order to tackle with the different path leading to low mood in this population. Metacognition Interpersonal Therapy (MIT) adopts such a modular strategy. Five modules are adopted: Module 1 aims at forming a shared understanding of intrapersonal and interpersonal functioning that leads to depression. Module 2 aims at reducing interpersonal repetitive thinking (rumination and worry). Module 3 tackles with behavioural coping, such as avoidance or perfectionism. Therapists and patients negotiate behavioural tasks, such as behavioural activation or trying to counteract perfectionistic strategies. Module 4 aims at helping clients to realize their maladaptive schemas about self, and others are mostly ideas and do not necessarily correspond to the truth. Here, therapists try to help them contact alternative and more benevolent views of human relationships they already might have had but did not notice. Module 5 aims at giving room to healthy, positive, and benevolent views of the self and giving them more room in the stream of consciousness and let the person’s actions be guided by them. During all modules, therapists use a wide array of experiential techniques ranging from guided imagery and rescripting, bodily work, role-play, two chairs and attention training. In order to illustrate how this modular treatment works, we describe the case of a 62-year-old woman with major depression comorbid with paranoid PD with passive-aggressive and avoidant personality traits.

Borderline personality disorder (BPD) is a severe disease, characterized by severe instabilities in identity, affect and relationships. Clinical improvement of BPD can be facilitated by psychotherapy aimed at tackling multiple specific cross-modality impairments and their patterns of interaction: impaired sense of self, maladaptive interpersonal schemas, impaired metacognition, emotion dysregulation and impulsivity. Herein, we describe the steps in the treatment of a young woman meeting the criteria for with BPD with paranoid traits, successfully treated with Metacognitive Interpersonal Therapy, a treatment based on comprehensive assessment of domains. In the initial phase, treatment focused on promoting emotion regulation, integrating opposing patient representations of the therapist, enhancing metacognition, and increasing focus on the maladaptive schema that elicited dysregulated behaviors. Later in therapy, treatment focused on supporting the patient to realize her ideas about self and others were schema-driven; and improving metacognitive capacity to understand others’ minds. General implications for psychotherapy of BPD are discussed.

The resistance of negative symptoms to pharmacologic treatment has spurred interest in understanding the psychological factors that contribute to their formation and persistence. However, little is understood about the psychological processes that reinforce and sustain the negative symptoms domain of diminished expression. Prior research has shown that higher levels of diminished expression relate to deficits in metacognitive capacity. We propose a more complex model in which diminished expression occurs when impairments in metacognitive self-reflectivity, alterations in higher-order language structure, and cognitive symptoms interact and thus interfere with persons' ability to understand and express emotions in ways others can recognize. Individuals with schizophrenia-spectrum disorders (N = 201) provided personal narratives detailing their life story and reflections about their mental illness. Self-reflectivity was measured with the Metacognition Assessment Scale-Abbreviated, and situation models were extracted from participants’ personal narratives via Coh-Metrix 3.0, an automated program that calculates language indices. Diminished expression and cognitive symptoms were measured with the Positive and Negative Syndrome Scale. Structural equation models (SEM) examined whether self-reflectivity mediated the impact of cognitive symptoms and situation models on diminished expression. Results of the SEM revealed that self-reflectivity partially mediated the impact of situation models on diminished expression (β = −.073, p = .008, ±95% CI [-0.126, −0.019]). and fully mediated the influence of cognitive symptoms in diminished expression (β = 0.099, p = .001, ±95% CI [0.038, 0.160]). In conclusion, results suggest that self-reflectivity, linguistic cohesion, and cognitive symptoms may be useful targets for intervention in efforts to treat diminished expression in psychosis.

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

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

Metacognition deficits are a putative cause of reduced motivation in people with schizophrenia spectrum disorders. However, it is unclear whether certain levels of metacognition are necessary for motivation to emerge. This study used a Necessary Condition Analysis to test whether metacognition was necessary for the presence of motivation and to identify the minimum level of metacognition necessary for high motivation to be possible in people with schizophrenia spectrum disorders (N = 175). Participants completed clinician-rated measures of metacognition and motivation. Necessary Condition Analysis revealed that metacognition is a necessary condition for motivation and that high levels of motivation were only possible, although not guaranteed, when at least a basic level of metacognition was present. The findings suggest that metacognition is a necessary building block for the development of motivation. Results suggest that targeting metacognition may be essential for improving motivation among people with schizophrenia spectrum disorders who do not meet this metacognition threshold.

While deficits in metacognition, or the ability to notice and reflect upon mental states has been observed in schizophrenia and linked with poorer concurrent and future function, it is unknown whether these deficits are unique to schizophrenia. Accordingly, this study assessed metacognition using the Metacognitive Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire- 30 (MCQ-30) among 26 adults with schizophrenia, 23 with bipolar disorder and 23 healthy controls. Symptom levels of the psychiatric groups were assessed with the Brief Psychiatric Rating Scale. ANCOVA controlling for age and education revealed that the schizophrenia group had lower scores on the MAS-A total and its subscales compared to the bipolar group and healthy controls. The bipolar disorder group also had lower MAS-A scores than the healthy control group. No group differences were found for the MCQ-30. Examination of symptom correlates revealed MAS-A scores were most commonly related to negative symptoms in both clinical groups. The total score and need for control subscale of MCQ-30 was related to total symptomatology and positive symptoms in patients with bipolar disorder. Correlations between the two measures of metacognition revealed that higher MAS-A scores were significantly related to lower scores on the Need to Control Thoughts MCQ-30 subscale.

Background and objectives Despite the apparent relevance of persecutory delusions to social relationships, evidence linking these beliefs to social functioning has been inconsistent. In this study, we examined the hypothesis that theory of mind moderates the relationship between persecutory delusions and social functioning. Methods 88 adults with schizophrenia or schizoaffective disorder were assessed concurrently for social functioning, severity of persecutory delusions, and two components of theory of mind: mental state decoding and mental state reasoning. Mental state decoding was assessed using the Eyes Test, mental state reasoning using the Hinting Task, and social functioning assessed with the Social Functioning Scale. Moderation effects were evaluated using linear models and the Johnson-Neyman procedure. Results Mental state reasoning was found to moderate the relationship between persecutory delusions and social functioning, controlling for overall psychopathology. For participants with reasoning scores in the bottom 78th percentile, persecutory delusions showed a significant negative relationship with social functioning. However, for those participants with mental state reasoning scores in the top 22nd percentile, more severe persecutory delusions were not significantly associated with worse social functioning. Mental state decoding was not a statistically significant moderator. Limitations Generalizability is limited as participants were generally men in later phases of illness. Conclusions Mental state reasoning abilities may buffer the impact of persecutory delusions on social functioning, possibly by helping individuals avoid applying global beliefs of persecution to specific individuals or by allowing for the correction of paranoid inferences.

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

Background Healthy metacognition involves several capacities, including the ability to integrate information about the self and others in order to formulate ways of coping with social challenges and psychological distress. Multiple studies have demonstrated that reduced general metacognitive capacity is predictive of the development and persistence of overall negative symptom burden. However, there have been no published analyses investigating how specific sub-components of metacognition influence the expression of individual negative symptoms. We aggregated individual participant data from studies reporting measures of subtypes of metacognitive functioning and examined the strength of association with specific negative symptoms. Methods PsycINFO, EMBASE, MEDLINE, Cochrane Library and grey literature databases were searched for eligible studies. Forwards and backwards citation searching and contacting of study authors revealed additional datasets not identified in the original search. Included studies assessed negative symptoms and metacognition using interview-based measures in participants aged 16 years or older. Selection was restricted to quantitative research, excluding case studies, and only English language publications were screened. Experimental and observational studies were screened sequentially at title, abstract and full-text level to determine whether they met search criteria. A second reviewer independently screened a proportion of records to check the reliability of inclusion/exclusion judgements (Cohen’s Kappa = 0.74). Participant data and metadata of included studies were extracted and compiled combining original author and report information for all pre-specified outcomes where available. The proposed plan for the systematic review and meta-analyses was also pre-registered on PROPSERO (CRD42019130678). Results 97 unique reports were identified, of which 30 included negative symptom specific hypotheses. Samples overlapped substantially across publications with these 97 reports corresponding to 30 unique datasets. The raw individual participant level data for 23 of the 30 unique datasets was obtained. Preliminary analyses investigated the relationship between components of metacognition measured with the MAS-A (Lysaker et al., 2005), and the original negative symptoms subscale score of the PANSS (Kay et al., 1987) to maximise available data. We will discuss the results, which suggest that there are distinct relationships between subscales of metacognition and negative symptoms. We will also discuss the limitations of these results including a limited scope for analysing covariates due to the computational complexity of the models used, and difficulties in handling the diversity of data present in the meta-analysis. We will also discuss why high heterogeneity might be present, and provide further support for analysis investigating the relationship between individual negative symptoms and components of metacognition. Discussion The data suggest there is complexity in the relationship between components of metacognition and individual negative symptoms. It is for subsequent analyses to determine whether individual negative symptoms have distinct relationships with each metacognitive capacity, and whether the variation in the strength of these associations could explain the high heterogeneity observed.

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

Avoidant Personality Disorder (AvPD) is one of the most severe and disabling conditions among all personality disorders. To perform a sensitive case formulation aimed at treating AvPD, clinicians need to assess: (1) maladaptive schemas for self and others, mostly based on fear of criticism and disturbed attachment; (2) Impaired metacognition, that is ability to recognize and reflect on mental states, both of oneself and of the others; (3) maladaptive emotional regulation and coping; (4) impoverished autobiographical memory. After having described these problems in AvPD, we illustrate the case of a client treated with Metacognitive Interpersonal Therapy, where a case formulation based on assessment of these domains, was the ground for the therapy.

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

Psychological health and adaptation depend on the capacity to be open and flexible, and see the world from multiple perspectives. Humans need a series of self-narratives to deal with social challenges and scripts that guide them in adaptive decisions in the relational world. These scripts need to include how to deal with a conflict, how to court a potential romantic partner, how to respond to a colleague who is pressing with requests we would prefer to avoid, and so forth. According to proponents of Dialogical Self Theory (DST; Hermans & Dimaggio, 2004; Hermans & Hermans-Konopka, 2010; Hermans & Gieser, 2011; Hermans et al., 1992; Lysaker & Lysaker, 2002), the self is made up of a series of I-positions, as a society of mind (Mead, 1934), which interact and continuously negotiate the course of action to be undertaken and the meaning to ascribe to events.

While poor therapeutic alliance is a robust predictor of poor outcome in substance abuse treatment, less is known about the barriers to therapeutic alliances in this group. To explore this issue, this study examined whether the severity of cluster B personality disorders predicted therapeutic alliances concurrently and prospectively in a residential substance treatment program for homeless veterans. Participants were 48 adults with a substance abuse disorder. Personality disorder traits were assessed using the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Personality Disorders, whereas therapeutic alliance was assessed at baseline using the Working Alliance Inventory. Partial correlations controlling for overall symptom severity measured with the Symptom Checklist 90 and education, revealed cluster B traits at baseline predicted all 4 assessments of therapeutic alliance even after controlling for initial levels of therapeutic alliance. Results suggest that higher levels of cluster B traits are a barrier to the formation of working alliances in residential substance treatment.

The study aimed to assess the effectiveness of metacognitive interpersonal therapy (MIT) as a psychological treatment for presentations consistent with non-borderline personality disorders (PD). We conducted a single-case series of three patients with personality disorders meeting inclusion criteria. Clients received 2 years of weekly individual MIT. Outcomes were assessed every 3 months for the first year at the end of treatment and at 3-months follow-up. Co-primary outcomes were reduction in the number of SCID-II PD criteria met and reduction in self-reported global distress (SCL-90-R GSI). Secondary outcomes were reduction in self-reported interpersonal problems (IIP-32), anxiety (STAI-Y), depression (BDI-II) and emotional dysregulation (DERS). Reliable Change Indices were calculated for all outcomes. All three patients completed treatment, achieving reliable change at the end of treatment for reduction in total number of personality disorder criteria and in overall symptoms. For secondary outcomes, two patients improved in emotion regulation, one in depression. There was no evidence of reliable change on self-reported anxiety or interpersonal problems. At 3-months post treatment improvements in overall symptoms and emotional regulation were observed for all patients. Plot analyses of the results showed a trend towards reduction for all outcomes. MIT is a new manualized treatment for non-borderline PD’s. We demonstrate preliminary evidence of acceptability and effectiveness in this understudied population. Future studies are required to establish the effectiveness of MIT in larger PD samples, including patients with lower socio-economic status.

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.

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

Objectives Borderline personality disorder traits have been observed to be linked with both insecure attachment styles as well as deficits in mentalizing and metacognition. Less is known, however, about how attachment style does or does not interact with deficits in mentalizing and metacognition to create, sustain, or influence levels of borderline personality disorder traits. In this study, we examined the hypothesis that metacognitive mastery, which is the ability to use knowledge about mental states of self and others to cope with distress and solve social problems, moderates the relationship of anxious attachment style with the severity of borderline personality disorder traits. Methods Concurrent assessments were gathered of metacognitive mastery using the Metacognitive Assessment Scale Abbreviated, anxious attachment style using the Experiences of in Close Relationships Scale, and borderline personality disorder traits using the Structured Clinical Interview for DSM-IV Axis II Disorders. Participants were 59 adults in an early phase of recovery from substance use disorders in a residential setting. Results Multiple regression revealed that metacognitive mastery moderated the relationship of anxious attachment style with the number of borderline personality disorder traits. A median split of the anxious attachment and metacognitive mastery scores was performed yielding 4 groups. An analysis of covariance revealed that participants with higher levels of anxious attachment and poorer metacognitive mastery had more borderline personality disorder traits did than the other groups after controlling for levels of psychopathology. Conclusion Insecure attachment may be associated with higher number of borderline personality disorder traits in the presence of deficits in metacognitive mastery. Patients with substance use and borderline personality disorder traits may benefit from treatment which addresses metacognitive mastery.

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

Auditory verbal hallucinations (AVHs) are perceptive-like experiences happening without appropriate stimuli that in individuals with schizophrenia very often feature distressing contents. AVH frequently interfere with social relationships or result in dangerous behaviours. We hypothesize that in schizophrenia several vulnerability factors, especially when a subject is engaged in real or represented interpersonal transactions, lead to the appearance of AVHs, and favour their self-perpetuation over time. We analyse the different psychological factors that, according to empirical studies and clinical experience with persons with schizophrenia, seem involved in the genesis of AVHs. Several vulnerability factors appear to interact with situational ones to trigger AVHs: a) a facilitation of neural transmission from the premotor regions to the perceptual ones; b) a difficulty attuning with others, c) interpersonal schemas, provoking emotional suffering, intrusive thoughts and rumination; d) metacognitive dysfunctions. Once AVHs have appeared, further factors promote their perpetuation over time: a) cognitive factors like ruminative processing on AVHs, b) metacognitive beliefs about AVHs. An integrated theoretical model of AVHs is described and ideas for its empirical testing are suggested.