Abstract
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.
Similar content being viewed by others
Notes
We included PD NOS as MIT was manualized for individuals presenting with a combination of maladaptive interpersonal schemas and reduced metacognition. These include individuals not meeting criteria for a specific PD but suffering from a combination of traits from different PD. For example, an individual with three criteria for Avoidant PD, two for Dependent PD, three for Obsessive–Compulsive PD and two for Paranoid PD is classified as having PD NOS and its dysfunctions are the ones targeted by MIT (Dimaggio et al. 2015). In this example the individual could be characterized by schemas of avoidance and overcontrol.
References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders. Fourth edition. Text revision. DSM-IV-TR. Washington, DC: APA.
Arnevik, E., Wilberg, T., Urnes, O., Johansen, M., Monsen, J., & Karterud, S. (2009). Psychotherapy for personality disorders: Short term day hospital psychotherapy versus outpatient individual therapy—A randomized controlled study. European Psychiatry, 24, 71–78.
Arntz, A., & Jacob, G. (2012). Schema therapy in practice: An introductory guide to the schema mode approach. Chichester, UK: Wiley.
Bamelis, L. L. M., Evers, S. M. A. A., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry, 171, 305–322. doi:10.1176/appi.ajp.2013.12040518.
Bamelis, L. L. M., Renner, F., Heidkamp, D., & Arntz, A. (2011). Extended Schema mode conceptualizations for specific personality disorders: An empirical study. Journal of Personality Disorders, 25, 41–58.
Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization based treatment. Oxford: Oxford University Press.
Bateman, A. W., & Fonagy, P. (2009). Randomly controlled trial of outpatient mentalizing-based therapy versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166, 1355–1364.
Bateman, A., & Fonagy, P. (2013). Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder. British Journal of Psychiatry, 203, 221–227. doi:10.1192/bjp.bp.112.121129.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory-II (p. b9). San Antonio, TX: Psychological Corporation.
Benjamin, L. S. (2003). Interpersonal reconstructive therapy. New York: Guilford Press.
Budge, S. L., Moore, J. T., Del Re, A. C., Wampold, B. E., Baardseth, T. P., & Nienhaus, J. B. (2013). The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments. Clinical Psychology Review, 33(8), 1057–1066. doi:10.1016/j.cpr.2013.08.003.
Carcione, A., Nicolò, G., Pedone, R., Popolo, R., Conti, L., Fiore, D., et al. (2011). Metacognitive mastery dysfunctions in personality disorder psychotherapy. Psychiatry Research, 190, 60–71.
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. (1999). Psychotherapy for borderline personality disorder. New York: Wiley.
Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient personality and therapist responses: An empirical investigation. American Journal of Psychiatry, 171, 102–108. doi:10.1176/appi.ajp.2013.13020224.
Crawford, J., Cayley, C., Lovibond, P. F., Wilson, P. H., & Hartley, C. (2011). Percentile norms and accompanying interval estimates from an Australian general adult population sample for self-report mood scales (BAI, BDI, CRSD, CES-D, DASS, DASS-21, STAI-X, STAI-Y, SRDS, and SRAS). Australian Psychologist, 46, 3–14.
Derogatis, L. R. (1992). SCL-90-R: Administration, scoring of procedures manual-II for the R (evised) version and other instruments of the psychopathology rating scale series: Clinical Psychometric Research Incorporated.
Diedrich, A., & Voderholzer, U. (2015). Obsessive-compulsive personality disorder: A current review. Current Psychiatry Reports, 17, 2. doi:10.1007/s11920-014-0547-8.
Dimaggio, G. (2014). Hitting the bull’s eye in personality disorders psychotherapy. Journal of Contemporary Psychotherapy, 44(2), 65–70.
Dimaggio, G., & Attinà, G. (2012). Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. Journal of Clinical Psychology: In-Session, 68(8), 922–934.
Dimaggio, G., Attinà, G., Popolo, R., & Salvatore, G. (2012a). Personality disorders with over-regulation of emotions and poor self-reflectivity-The case of a man with avoidant and not-otherwise specified personality disorder and social phobia treated with metacognitive interpersonal therapy. Personality and Mental Health, 6(2), 156–162. doi:10.1002/pmh.1193.
Dimaggio, G., Carcione, A., Salvatore, G., Semerari, A., & Nicolò, G. (2010). A rational model for maximizing the effects of therapeutic relationship regulation in personality disorders with poor metacognition and over-regulation of affects. Psychology and Psychotherapy: Theory, Research and Practice, 83(4), 363–384. doi:10.1348/147608310x485256.
Dimaggio, G., & Lysaker, P. H. (2010). Metacognition and severe adult mental disorders: From research to treatment. London: Routledge.
Dimaggio, G., & Lysaker, P. H. (2015). Metacognition and mentalizing in the psychotherapy of patients with psychosis and personality disorders. Journal of Clinical Psychology, 71, 117–124. doi:10.1002/jclp.22147.
Dimaggio, G., Montano, A., Popolo, R., & Salvatore, G. (2015). Metacognitive interpersonal therapy for personality disorders: A treatment manual. London: Routledge.
Dimaggio, G., Nicolò, G., Semerari, A., & Carcione, A. (2013). Investigating the personality disorder psychotherapy process: The roles of symptoms, quality of affects, emotional dysregulation, interpersonal processes, and mentalizing. Psychotherapy Research, 23(6), 624–632.
Dimaggio, G., Procacci, M., Nicolò, G., Popolo, R., Semerari, A., Carcione, A., et al. (2007). Poor metacognition in narcissistic and avoidant personality disorders: Four psychotherapy patients analysed using the metacognition assessment scale. Clinical Psychology and Psychotherapy, 14(5), 386–401. doi:10.1002/cpp.541.
Dimaggio, G., Salvatore, G., Fiore, D., Carcione, A., Nicolò, G., & Semerari, A. (2012b). General principles for treating the overconstricted personality disorder. Toward operationalizing technique. Journal of Personality Disorders, 26, 63–83.
Dimaggio, G., Valeri, S., Salvatore, G., Popolo, R., Montano, A., & Ottavi, P. (2014). Adopting metacognitive interpersonal therapy to treat narcissistic personality disorder with somatization. Journal of Contemporary Psychotherapy, 44(2), 85–95.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1997). User’s guide for the Structured clinical interview for DSM-IV axis I disorders SCID-I: clinician version: American Psychiatric Pub.
Fonagy, P. (1991). Thinking about thinking: Some clinical and theoretical considerations in the treatment of a borderline patient. The International Journal of Psycho-Analysis, 72(4), 639.
Fonagy, P., & Bateman, A. W. (2016). Adversity, attachment, and mentalizing. Comprehensive Psychiatry, 64, 59–66. doi:10.1016/j.comppsych.2015.11.006.
Gask, L., Evans, M., & Kessler, D. (2013). Personality disorder. BMJ, 347, f5276.
Giromini, L., Velotti, P., de Campora, G., Bonalume, L., & Cesare Zavattini, G. (2012). Cultural adaptation of the difficulties in emotion regulation scale: Reliability and validity of an Italian version. Journal of Clinical Psychology, 68(9), 989–1007.
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54.
Holi, M. M., Marttunen, M., & Aalberg, V. (2003). Comparison of the GHQ-36, the GHQ-12 and the SCL-90 as psychiatric screening instruments in the Finnish population. Nordic Journal of Psychiatry, 57(3), 233–238.
Horowitz, L., Alden, L., Wiggins, J., & Pincus, A. (2000). Inventory of interpersonal problems (IIP-32/IIP-64). London: Psychological Corporation.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12.
Kopta, S. M., Howard, K. I., Lowry, J. L., & Beutler, L. (1994). Patterns of symptomatic recovery in psychotherapy. Journal of Consulting and Clinical Psychology, 62, 1009–1016.
Kramer, A., Pascual-Leone, A., Rohde, K. B., & Sachse, R. (2016). Emotional processing, interaction process, and outcome in clarification-oriented psychotherapy for personality disorders: A process-outcome analysis. Journal of Personality Disorders, 30, 373–394.
Livesley, J. W., Dimaggio, G., & Clarkin, J. F. (Eds.). (2016). Integrated treatment for personality disorders: A modular approach. New York: Guilford.
Lo Coco, G., Gullo, S., Scrima, F., & Bruno, V. (2012). Obesity and interpersonal problems: An analysis with the interpersonal circumplex. Clinical Psychology and Psychotherapy, 19(5), 390–398.
Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Inter-rater reliability of the structured clinical interview for DSM-IV Axis I disorders (SCID I) and Axis II disorders (SCID II). Clinical Psychology and Psychotherapy, 18, 75–79.
Lobbestael, J., van Vreeswijk, M. F., & Arntz, A. (2008). An empirical test of schema mode conceptualizations in personality disorders. Behaviour Research and Therapy, 46, 854–860.
Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: The core conflictual relationship theme method. Washington, DC: American Psychological Association.
Lynch, T. R., & Cheavens, Jennifer S. (2008). Dialectical behavior therapy for comorbid personality disorders. Journal of Clinical Psychology, 64(2), 154–167. doi:10.1002/jclp.20449.
Lynch, T. R., Hempel, R. J., & Clark, L. A. (2016). Promoting radical openness and flexible-control. In W. J. Livesley, G. Dimaggio, & J. F. Clarkin (Eds.), Integrated treatment for personality disorders: A modular approach. New York: Guilford.
Lysaker, P. H., Olesek, K., Buck, K., Leonhardt, B. L., Vohs, J., Ringer, J., et al. (2014). Metacognitive mastery moderates the relationship of alexithymia with cluster C personality disorder traits in adults with substance use disorders. Addictive Behaviors, 39(3), 558–561.
Maples, J. L., Miller, J., Wilson, L. F., Seibert, L. A., Few, L. R., & Zeichner, A. (2010). Narcissistic personality disorder and self-esteem: An examination of differential relations with self-report and laboratory-based aggression. Journal of Research in Personality, 44, 559–563. doi:10.1016/j.jrp.2010.05.012.
McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., et al. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166, 1365–1374.
Morley, S., & Dowzer, C. (2014). Manual for the leeds reliable change indicator: Simple Excel (tm) applications for the analysis of individual patient and group data. Leeds, UK: University of Leeds.
Muran, J., Safran, J., Samstag, L., & Winston, A. (2005). Evaluating an alliance-focused treatment for personality disorders. Psychotherapy: Theory Research, Practice, Training, 42, 532–545.
Popolo, R., Lysaker, P. H., Salvatore, G., Montano, A., Sirri, L., Buonocore, L., et al. (2014). Emotional inhibition in personality disorders. Psychotherapy and Psychosomatics, 83, 377–378. doi:10.1159/000365110.
Ronningstam & Weinberg. (2013). Narcissistic personality disorder: Progress in recognition and treatment. Focus, 11, 167–177.
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press.
Semerari, A., Carcione, A., Dimaggio, G., Falcone, M., Nicolo, G., Procacci, M., et al. (2003). How to evaluate metacognitive functioning in psychotherapy? The metacognition assessment scale and its applications. Clinical Psychology and Psychotherapy, 10, 238–261.
Semerari, A., Carcione, A., Dimaggio, G., Nicolò, G., & Procacci, M. (2007). Understanding minds, different functions and different disorders? The contribution of psychotherapeutic research. Psychotherapy Research, 17, 106–119.
Semerari, A., Colle, L., Pellecchia, G., Buccione, I., Carcione, A., Dimaggio, G., et al. (2014). Metacognitive dysfunctions in personality disorders: Correlations with disorder severity and personality styles. Journal of Personality Disorders, 28, 751–766.
Soldz, S., Budman, S., Demby, A., & Merry, J. (1995). A short form of the inventory of interpersonal problems circumples scales. Assessment, 2, 53–63.
Spielberger, C. D. (1989). State-trait anxiety inventory: A comprehensive bibliography. Palo Alto, CA: Consulting Psychologists Press.
Spielberger, C., Gorsuch, R. L., & Lushene, R. V. G. A. (1983). Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press.
Yang, M., Coid, J., & Tyrer, P. (2010). Personality pathology recorded by severity: National survey. British Journal of Psychiatry, 197, 193–199.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Dimaggio, G., Salvatore, G., MacBeth, A. et al. Metacognitive Interpersonal Therapy for Personality Disorders: A Case Study Series. J Contemp Psychother 47, 11–21 (2017). https://doi.org/10.1007/s10879-016-9342-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10879-016-9342-7