Impaired decentration in personality disorder: A ... - Wiley Online Library

Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 16, 450–462 (2009) Published online 28 May 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.619

Practitioner Impaired Decentration in Personality Report Disorder: A Series of Single Cases Analysed with the Metacognition Assessment Scale Giancarlo Dimaggio,1 Antonino Carcione,1 Giuseppe Nicolò,1* Laura Conti,1 Donatella Fiore,1 Roberto Pedone,2 Raffaele Popolo,1 Michele Procacci1 and Antonio Semerari1 1 2

Third Center of Cognitive Psychotherapy—Rome, Italy Departement of Psychology, University of Naples II, Naples, 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. Copyright © 2009 John Wiley & Sons, Ltd. 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. Keywords: Personality Disorder, Decentration, Metacognition, Theory of Mind, Egocentrism

* Correspondence to: Giuseppe Nicolò, c/o Terzo Centro di Psicoterapia Cognitiva, via Ravenna 9/c 00161, Rome, Italy. E-mail: [email protected] This paper has been supported with a grant received by Fondazione Anna Villa e Felice Rusconi.

Copyright © 2009 John Wiley & Sons, Ltd.

Impaired Decentration in Personality Disorder

INTRODUCTION Working with patients suffering from personality disorders (PDs) is hampered by the difficulties these persons find in forming reasonable, rich and realistic representations of the others with which they interact, including their therapists. These patients often stick to their own ideas about what is passing through the other’s mind without questioning their beliefs. They neither imagine that they can not be in the limelight of the other’s thoughts, nor that the other’s perspective might differ from their own. This problem is almost a defining characteristic of PD, often described as egocentric or non-empathic (Krueger, Skodol, Livesley, Shrout, & Huang, 2007; Livesley, 2006). Some maintain that PDs have a limited ability to adopt others’ perspectives and use them to improve the quality of their relationships (Dimaggio, Semerari, Carcione, Nicolò, & Procacci, 2007), and encounter difficulties understanding that what others think about the self is different from what they think. Both are aspects of what is described as a mentalization or metacognitive deficit (Bateman & Fonagy, 2004; Clarkin, 2005; Dimaggio, Procacci, et al., 2007; Livesley, 2008). A lack of concern for others’ ideas and emotions, and a deficit in the ability to perceive the similarity between the self and the other and to stand in the other’s shoes—i.e., empathy (Preston & de Waal, 2002)—have been described in PD patients (Krueger et al., 2007) and also their relatives (Guttman & Laporte, 2002). The question is more than academic. An ‘understanding the others’ dysfunction could be one likely cause for the problems these persons find in living an adapted social life; they may, for example, be unable to find consistent explanations for others’ contradictory and ever-changing behaviours or to solve conflicts because of their poor understanding of others’ perspective. The dysfunction, together with other aspects of the metacognitive or mentalizing system for making sense out of own and others’ mental states, could, therefore, be a significant therapeutic target, as in the cases of mentalization-based therapy (Bateman & Fonagy, 2004) or metacognitive interpersonal therapy (Dimaggio, et al., 2007). Initial evidence (Levy et al., 2006) shows that at least some effective treatments for borderline PD (BPD), such as transference-focused therapy (Clarkin, Yeomans, & Kernberg, 2006), promote a greater capacity in these persons to reflect on their own and others’ states of mind. Many elements can prevent PDs from forming realistic, reasonable and nuanced representations Copyright © 2009 John Wiley & Sons, Ltd.

451 of others’ minds. First, intense emotions such as loneliness or anger can disrupt their ability to question problematic beliefs. BPD patients tend, at times of intense arousal, to construct extreme and unrealistic representations of the other’s mind (Bateman & Fonagy, 2004), convinced, for example, that their partner is not answering a phone call because he or she is being unfaithful to them, without considering the idea that he or she might simply be involved in a work meeting. Rigid schemas for representing others (Clarkin et al., 2006; Young, Klosko, & Weishaar, 2003) may also constrict mental state understanding. Wired with easy-to-apply interpersonal constructions, PD patients quickly find ambiguous and subtle reasons for the idea that the other is hurting or deceiving them. This focus on threat can prevent them from engaging in the reasoning effort necessary to arrive at evidence that their beliefs might be false or ungrounded (‘I think he wants to attack me but I can see that his face looks sad’) (Dimaggio, et al., 2007). Finally, a mentalizing of metacognitive deficit can itself be a pathological element. PDs may simply be poor in forming representations of the others and adopting a perspective different from their own, even when not influenced by disturbing emotions or rigid schemas. In spite of the plausibility of these ideas, the topic has not been investigated at large so far. There is only minor and mixed evidence of difficulties in forming the basic elements of a theory of others’ mind or to deducing emotions from eyes in both psychopathic and non-psychopathic individuals with antisocial PD (Blair et al., 1996, 2002; Dolan & Fullam, 2004; Glass & Newman, 2006). Minor difficulties in identifying others’ emotions via facial expression and prosody were found in BPD (Bland, Williams, Scharer, & Manning, 2004), with a bias towards perceiving anger when cues were ambiguous (Domes et al., 2008). BPD patients also displayed impaired recognition of emotions in integrated facial/prosodic stimuli, as well as impaired discrimination of non-emotional facial features associated with interpersonal antagonism, particularly suspiciousness and assaultiveness (Minzenberg, Poole, & Vinogradov, 2006). An indirect marker of poor understanding of the others’ mental states comes from studies in which a PD population (BPD and cluster C) were shown film clips concentrating on the abandonment, rejection and abuse themes. PDs were less capable than non-clinical controls of providing psychological motivations for the actors’ actions and ascribed less personality traits to them (Arntz Clin. Psychol. Psychother. 16, 450–462 (2009) DOI: 10.1002/cpp

452 & Veen, 2001; Veen & Arntz, 2000). Both indicators point to an impoverished construction of others. However, data could be interpreted in terms of poor mental state understanding. Impoverished construction would depend on a poor ability to reason in mentalistic terms and find other explanations for others’ actions than those dictated by one’s schemas. PD sufferers are not the only ones with this problem. Sure, some adult psychiatric disorders, such as schizophrenia, involve severe deficits in recognizing and understanding what others think and feel (Brüne, 2005; Harrington, Seigert, & McClure, 2005; Lysaker, Dimaggio, Buck, Carcione, & Nicolò, 2007). But understanding others’ minds is a complex challenge humans never fully solve. Children of around 2 years old grasp when others are pretending—for example, their mother impersonating the ‘Lion King’ without really intending to bite them—but only at 3 years or 4 years do they begin to understand that the beliefs driving others’ actions do not always correspond to how things really are (Wellman, Cross, & Watson, 2001), and it is not before they are 7 years that they become capable of inferring the personality traits behind others’ emotional responses (Gnepp & Gould, 1985; Taylor, Carlson, Maring, Gerow, & Charley, 2004; Yuill & Pearson, 1998). As adults, humans arrive at a sophisticated understanding of the motivations causing others to act or of why someone has lied or given unreliable information. Despite such successes, normal adults experience problems that hamper sensitive understanding of others’ minds (UOM). They tend to overestimate the extent to which others share their point of view (Nickerson, 1991), to forecast others’ behaviour without taking account of the fact that they are not in possession of the same knowledge as themselves (Royzman, Cassidy, & Baron, 2003) or to use stereotypes for explaining intentions and expressions of others perceived as out-group members (Ames, 2004). That individuals are likely to fail at understanding the other’s mind is explained both by the subject of their evaluation—the other’s mental state—being covert and ambiguous, and by mental state understanding being a complex skill requiring numerous processes to be intact to work correctly (Dimaggio & Lysaker, in press; Dimaggio, Lysaker, Carcione, Nicolò, & Semerari, 2008). For example, we need to correctly decode facial expressions and to fully consider the story of a target and contextual factors in order to explain others’ actions and adopt a different perspective to our own, i.e., decentre. Copyright © 2009 John Wiley & Sons, Ltd.

G. Dimaggio et al. To summarize, although PD patients seem to be impaired in the ability to understand others’ mental states and egocentricity, the hypothesis has been rarely investigated, and almost only in persons with antisocial or borderline PD. There has been no research, as far as we know, into understanding others’ mental states in therapeutic dialogue, where the problem ought to appear to its greatest extent. In fact, during psychotherapy, unlike in lab tasks, patients discuss topics and circumstances in which they are deeply involved, so that difficulties in understanding others ought to surface. In this article, therefore, we analyse PD patients’ session transcripts to discover how impaired their ability to read others’ minds and adopt their perspective was. The sample includes patients with PDs such as BPD, narcissistic (NPD) and paranoid (PPD) in which the ability to understand others is supposed to be highly impaired. We also include patients who ought to be more inclined to think about others’ thoughts and emotions, like dependent PD (DPD), which is particularly specialized in understanding others and trying to take care of them (Dimaggio, et al., 2007). We therefore expected an overall impairment, with some PDs displaying greater problems and others milder ones. Given the above, a research design based on a series of single case studies (Stiles, 2005) appears appropriate. Studies like these are not aimed at theory testing, unlike large sample ones, but are theory-building heuristics. Analyses of a series of cases allow for thick descriptions, although of a quantitative kind, of a phenomenon still requiring fine-grained knowledge. We will, therefore, only provide descriptions on a patient-by-patient basis, and describe similarities and differences between persons at a descriptive level. Such a strategy makes it possible to gather information from a number of intensively analysed cases and formulate inferences on which processes are likely to be common among them (Osatuke & Stiles, in press). Collecting information with studies like ours is suitable in a phase in which there is still the need for deeper descriptions of a phenomenon and its nuances. With the data, it is then possible to formulate rigid hypotheses in a few sentences suitable for a statistical hypothesis testing strategy for scrutinizing larger samples.

METHOD Participants The participants were 14 Caucasian adults (3 male and 11 female) all diagnosed as having a PD with Clin. Psychol. Psychother. 16, 450–462 (2009) DOI: 10.1002/cpp

Impaired Decentration in Personality Disorder the Structured Clinical Interview for DSM IV Axis II Disorders (SCID II) (First, Spitzer, Gibbon, & Williams, 1997). Patients had received metacognitive interpersonal therapy (Dimaggio & Semerari, 2003; Dimaggio, et al., 2007) from clinicians with at least 5 years of experience in a private outpatient centre. Patients generally had a high school diploma and about half a university degree. The mean age and education of the sample were, respectively, 29.4 (standard deviation [SD] = 7.2) and 14.9 (SD = 3.8). Patients with mental retardation or active substance abuse were excluded from the study. There were diagnoses in all DSM-IV clusters: four BPD, three NPD, two avoidant (APD), two DPD, two obsessive–compulsive (OCPD) and one PPD. Three raters were involved in the process. Rater A was a male psychotherapist with 15 years experience. Rater B was a female psychotherapist with 10 years experience. Rater C was a male psychotherapist with 25 years experience.

Tool Understanding Others’ Minds Scale from the Metacognition Assessment Scale The Metacognition Assessment Scale (MAS) (Semerari et al., 2003) is a rating scale assessing metacognition, as manifest in individuals’ verbalizations. It is designed to detect changes in the ability of persons to think about thinking in psychotherapy transcripts. The MAS considers metacognition as the set of abilities with which persons understand mental phenomena and use that understanding to tackle sources of distress. Although the MAS contains three scales, here we used only the subscales focusing on a person’s effort to reason

453 about others’ mental states (as opposed to selfreflection). Based on the idea that the basic ability to describe thoughts and feelings and their likely causes should not be as severely affected in PDs as in other pathologies such as schizophrenia (Semerari, Carcione, Dimaggio, Nicolò & Procacci, 2007), while the ability to adopt others’ perspectives or decentre ought to be poor, we decided to calculate the results by unpackaging the subscale items. UOM consists of three items measuring the ability to understand and detail others’ mental states (Figure 1). For example, raters have to evaluate whether patients describe the people with whom they interact with as beings capable of thinking, planning, remembering, imagining and so on. Features of this scale are the descriptions of the emotions others experience and the ability to make hypotheses about the causes thereof and about the motivations—formulated in terms of personality traits or responses to circumstances—behind others’ actions. Decentration (D) is here used as a single-item subscale. It focuses on the perspective from which mind-reading is performed. It evaluates whether patients can perceive that others have lives, interests and motivations separate from their own and act or feel emotions without the patient being at the centre of their thoughts. Patients decentre when they can grasp that others see things differently from themselves and that many variables affect others’ functioning, even if the patients are not among these variables. For example, a patient decentres when he or she demonstrates an understanding that a partner is sad about the loss of a friend, even if the patient did not like the latter.

IDENTIFICATION UOM1 The subject is able to distinguish the other's cognitive operations (such as remembering, imagining, having fantasies, dreaming, awaiting, foreseeing, meditating). UOM2 The subject is able to distinguish the other' s emotional states.

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RELATING VARIABLES UOM3 The subject makes plausible inferences about the other’s mental state recognizing the communicative value of attitudes or behaviours.

DECENTRATION D

The subject is capable of describing the others mental state forming hypothesis which are independent from ones’ own perspective and mental functioning and from ones’ involvement in the relationship.

Figure 1.

Understanding of others’ mind (UOM) scale of the Metacognition Assessment Scale


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MAS Assessment and Rating The MAS assessment is implemented using a series of scoring units. Each unit is defined as a patient speech turn bounded by two therapist utterances. The rater has to identify any attempt to exercise metacognition and, if this is the case, whether it has been used congruously or not. When a patient tries to reason about the other’s mind and is successful at this, the raters register a success (marked with a yes = 1) and, if not, a failure (marked with a no = 0). If there is no clear attempt at using metacognition, then a ‘nothing-to-score’ code is assigned. For instance, if a patient demonstrates an ability to report other’s thoughts, a rater marks a ‘yes’ for the first item of the UOM scale, and if he or she fails in describing the other as a person having ideas or goals, the rater marks the same item as a ‘no’. Successes and failures are evaluated separately for each item; the MAS does not evaluate the definitive presence or absence of a skill, but only the effective or ineffective use of a skill at a particular moment in conversation. Two raters (A and C) were MAS founders; rater B was trained for 80 hours with patients with various PDs. The scoring was blinded and tested over a subset (10%) of randomly selected sessions. Agreement was 92% and kappa (Fleiss, 1971; Siegel & Castellan, 1988) 0.81, which is highly acceptable, considering the complexity of the coded material. Where there were divergent codes, a joint rating was assigned by mutual agreement after a group discussion. As regards convergent validity, the MAS subscales considered here, when applied to persons with schizophrenia, have been linked to impoverished psychosocial function, deficits in neurocognition (Lysaker et al., 2005), aspects of executive function measurement (Lysaker et al., 2008) and performance in tests of affect recognition (Lysaker et al., 2007). As regards executive function, decentration was linked with poorer performance in two of three tests involving the ability to inhibit a response and then make an alternate one. Scores in the test of the ability to inhibit verbal categories correctly classified 71% of the sample as having high versus low capacities in the D domain. These correlations suggest that seeing the others as independent from ourselves involves the ability to inhibit spontaneous responses, based plausibly on one’s own egocentric perspective.

Procedure For each patient, the first 16 sessions were recorded, transcribed and analysed. The main goal of the Copyright © 2009 John Wiley & Sons, Ltd.

G. Dimaggio et al. analysis procedure was to (a) obtain a homogeneous observation period for all the patients; and (b) keep the therapy effects to a minimum. To check the latter, we performed a data comparison of the first half (eight) and the second half (eight) of the sessions in order to see whether therapist interventions might have reduced the dysfunctional aspects, which we expected to be clearly evident early in the therapy. In line with the idea that PD patients’ symptoms diminish but certain basic dysfunctions are more enduring (Morey et al., 2007), we expected that any problem that the patients had in understanding and reasoning about others’ minds would not disappear in 16 sessions. In particular, the picture obtained in the first eight sessions ought to represent a patient’s actual psychological functioning, whatever his/ her therapist’s skill in modifying it.

RESULTS The first analysis involved calculating, for each patient, the total of times in which he or she managed to reason successfully about others’ mental states and suffering or attempted to define others’ thoughts, but failed to produce ideas or proposed implausible hypotheses (Figure 2). Patients proved successful the majority of times in which they tried to describe others’ mind. Only certain patients, in particular NPD2, PPD, BPD2 and DPD2, had a higher failure rate, between a third and a half. In general, therefore, all the patients seemed capable of reading others’ minds, although this does not necessarily indicate that the skill was intact. In the absence of a normative criterion, the failures of some patients may, plausibly, have a clinical value; they may, for example, have occurred in situations of particular emotional activation or problematical interpersonal contexts, with the successes involving less dysfunctional relationships or moments of lower arousal. Things are rather different for D (Figure 3). The ability to reason in non-egocentric terms was more often impaired than functioning in the large majority of the patients (13 out of 14). To sum up, almost all the patients did not decentre in the majority of situations in which they tried to reason by detaching themselves from their own involvement in a relationship or by trying to see the world with others’ eyes. This is particularly true of DDP2, with a 2/30 (6.6%) success/failure ratio. PPD had 11/52 (21.1%); BPD1 had 12/55 (21.8%). DPD1 had 9/38 (23.7%) and NPD1 had 9/37 (24.3%). APD1 was the Clin. Psychol. Psychother. 16, 450–462 (2009) DOI: 10.1002/cpp


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Figure 2. Understanding of others’ mind: sessions 1–16. Note: White lines indicate the raw number of successes and black lines indicate the raw number of failures in understanding of others’ minds for each patient. OCPD = obsessive– compulsive personality disorder. DPD = dependent personality disorder. PPD = paranoid personality disorder. BPD = borderline personality disorder. APD = avoidant personality disorder. NPD = narcissistic personality disorder

patient who engaged least in D, with four occurrences in which he always failed. The next analysis involved a comparison of the first eight and second eight sessions. Both UOM, even if already relatively intact, and D improved in numerous cases in the latter period (Figures 4 and 5). The change was more marked in D, which was the more impaired. When using a cutoff of failures ≥10, eight patients were above the threshold during the first eight sessions while six remained above the threshold in the second period. With a cut-off of failures ≥20, we had five patients above the threshold in the first period and only three in the second period (Figure 5). For example, BPD2 passed from 14/53 (26.4%) to an 18/6 success/failure ratio, BPD1 from 1/32 (3%) to 11/23 (47.8%) and NPD 3 from 7/16 (43.7%) to 10/6. In sum, as regards D, the majority of the patients failed less frequently in the second period and their success/failure ratios improved, with an increase in the proportion of success occurrences. However, in only 4 of the 14 patients did successes become more numerous than failures (see Figure 5). In some cases—OCPD1, OCPD2 and BPD4—D Copyright © 2009 John Wiley & Sons, Ltd.

deteriorated in the second period or remained completely unchanged, e.g., DPD2—1/15 (6.6%) in both periods—or PPD.

DISCUSSION Considered together, these data suggest that the PD patients in our sample had a substantial difficulty in adopting the other’s point of view and standing back from their own, and in grasping that others were driven by motivations independent from the relationship they had with themselves. The more basic ability to identify what others think and feel and what drives them to act was only occasionally impaired. Across the sample, functioning varied significantly, with some cases almost always able to correctly infer the intentions underlying in others’ minds and others with numerous occurrences of failed attempts to reason about others (Figure 2). Our study, therefore, seems to support the idea that PDs do indeed have the hypothesized difficulty in reasoning about others’ minds, but in particular, found them egocentric, i.e., with Clin. Psychol. Psychother. 16, 450–462 (2009) DOI: 10.1002/cpp

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Figure 3. Decentration: sessions 1–8. Note: White lines indicate the raw number of successes and black lines indicate the raw number of failures in decentration for each patient. OCPD = obsessive–compulsive personality disorder. DPD = dependent personality disorder. PPD = paranoid personality disorder. BPD = borderline personality disorder. APD = avoidant personality disorder. NPD = narcissistic personality disorder

difficulties in detaching themselves from their own viewpoints in order to understand others and in reasoning without considering their own involvement in a relationship. We find the results consistent both with recent research observing that PD patients—especially antisocial PD—are able to make inferences about others’ thoughts, and with others finding only marginal dysfunctions in the identifying of emotions from eyes, facial expressions and prosody in BPD (Domes et al., 2008; Minzenberg et al., 2006). The UOM scale items evaluate precisely both the ability to ascribe thoughts and intentions to others (Figure 1, items UOM 1 and UOM2) and the ability to describe other’s emotions. The more pronounced impairment we found in D is, in our opinion, due instead to the fact that the lab tasks used hitherto have not been capable of identifying higher level problems, deriving from egocentrism. In fact, detaching from oneself when thinking about others is a complex skill, arrived at later in development and, in part, difficult to Copyright © 2009 John Wiley & Sons, Ltd.

achieve even in non-clinical populations (Royzman et al., 2003). We also consider our data consistent with other experiments, in particular, those pinpointing problems with empathy (Guttman & Laporte, 2002), i.e., the cognitive ability to stand in the other’s shoes. That there were moments when patients failed even in basic construction of the other’s mind could be correlated to the slight bias of BPD towards identifying angry or surprised emotions (Domes et al., 2008; Minzenberg et al., 2006). We can, therefore, hypothesize that PD difficulties in understanding others is state dependent, and probably because of a state of arousal or activation of rigid self–other schemas at the moments in sessions in which patients attempt to depict the others’ mind (Bateman & Fonagy, 2004; Semerari et al., 2007). We are not surprised by the apparent discrepancy between an intact basic UOM and poor D, and do not believe that this represents an inconsistency between ours and other studies. The measurement of the human ability to understand others’ minds Clin. Psychol. Psychother. 16, 450–462 (2009) DOI: 10.1002/cpp


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Figure 4. Understanding of others’ minds: sessions 1–8 versus sessions 9–16. Note: The graph above indicates the raw number of successes and failures in understanding of others’ minds in sessions 1–8 for each patient. The graph below indicates the raw number of successes and failure in understanding of others’ minds in sessions 9–16 for each patient. OCPD = obsessive–compulsive personality disorder. DPD = dependent personality disorder. PPD = paranoid personality disorder. BPD = borderline personality disorder. APD = avoidant personality disorder. NPD = narcissistic personality disorder



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Figure 5. Decentration: sessions 1–8 versus sessions 9–16. Note: The graph above indicates the raw number of successes and failures in decentration in sessions 1–8 for each patient. The graph below indicates the raw number of successes and failure in decentration in sessions 9–16 for each patient. OCPD = obsessive–compulsive personality disorder. DPD = dependent personality disorder. PPD = paranoid personality disorder. BPD = borderline personality disorder. APD = avoidant personality disorder. NPD = narcissistic personality disorder



Impaired Decentration in Personality Disorder is at an embryonic stage (Bell, Siegert, Langdon, & Ellis, in press; Brüne, 2005; Harrington et al., 2005; Lysaker et al., 2008). The evidence collected hitherto about both understanding others’ minds and thinking about thinking overall—including self-reflection—points to metacognition being made up of numerous processes, both independent of each other and correlated (Semerari et al., 2007). Hence, the perceived need for multiple tasks and an analysis of these skills in different observational contexts, ranging from classic lab tasks (e.g., Domes et al., 2008; Minzenberg et al., 2006) to neuroimaging research (Mitchell, Macrae, & Banaji, 2006; Moriguchi et al., 2006; Saxe, Moran, Scholz, & Gabrieli, 2006) and interview analysis. With this, it should be possible to evaluate how individuals reason when involved in events regarding them directly and under the influence of self-relevant emotions, as compared with their performance in abstract tasks (Lysaker et al., 2005, 2007, 2008; Semerari et al., 2003, 2007). The convergent validity of the tools needs to be studied in order to evaluate which measure the same aspects of the ability to understand others’ minds and which tap different aspects. Our tool ought to produce results consistent with other instruments when measuring serious failures in certain populations, and display the unique ability to identify problems in higher mental skills in less dysfunctional populations. For example, there could be a correlation between D and measurements of conceptually distinct skills like empathy, which embraces not only the perspective from which a subject observes—tapped by our scale—but also the ability—not assessed by our scale—to identify oneself with and participate in what the other feels. There could also be a correlation with at least one measurement of perspective taking, i.e., that involving epistemic egocentrism, a bias consisting of a difficulty in setting aside privileged information that one knows to be unavailable to the other, which results in a skewing of one’s prediction of the latter’s perspective towards one’s own privileged viewpoint (Royzman et al., 2003). Finally, it is possible that poor D corresponds to a part of the mentalization dysfunction found when using the Reflective Function Scale (RFS) (Levy et al., 2006). Part of the mentalization deficit found with the RFS probably involved the ability to understand others, even if this is not certain because the RFS does not distinguish between selfreflection and mind-reading. Although we were not studying the therapeutic process, we would, when comparing the first eight Copyright © 2009 John Wiley & Sons, Ltd.

459 and second eight sessions, point to the trend in the majority of the patients towards improvement in both UOM and in D, a finding consistent with the idea that psychotherapy promotes reasoning about mental states. It is to be noted that the improvement observed may depend on the type of treatment. All the patients in our sample were, in fact, undergoing a form of therapy with the improvement of metacognition among its specific objectives (Dimaggio, Semerari, et al., 2007). It is, for now, impossible, therefore, to maintain that our result can be generalized to the therapeutic process in all PD patients treated with other approaches. As forecast, however, the impairments did not disappear completely except in a few cases; almost all the patients who continued in the second eight sessions have problems seeing others as distinct from the self, thus suggesting that the problem might have trait-like characteristics. The results we expected were only partially obtained. We expected that different PDs would display different degrees of problem and, in particular, that impairments of D would be more marked in disorders like paranoid or narcissistic (Semerari et al., 2007). Even if it is not possible to draw conclusions with this sample, all the patients studied were egocentric. The worst failure/success ratio was found in the paranoid PD patient, but further research is needed to understand if this finding was not coincidental.

Limits Our research, albeit pioneering in its studying of a field—psychotherapy transcripts—in which the ability to understand others had never been investigated, has various limitations. To start with, the PD sample was small (14), although it was almost of the same size as in former lab studies and our analysis was much more intensive and detailed than in occasional lab tests. It is, however, impossible to evaluate what effect the diagnoses had on the dysfunction with such small numbers; moreover, some PDs were not even represented in the sample. Correlations with psychopathology or social functioning are missing. It is, therefore, impossible to evaluate whether the problem found was: (a) clinically important and not a feature of a normal population; and (b) correlated with symptoms or social functioning. Even if there was no standardized outcome measurement, the clinicians’ reports described the majority of the cases as good outcome ones, so that an improvement in understanding the others was Clin. Psychol. Psychother. 16, 450–462 (2009) DOI: 10.1002/cpp

460 to be expected. However, the lack of formalized outcome measurement and the limited size of the sample make it impossible to reply with certainty to the question whether therapeutic improvement is accompanied by better metacognition. To overcome these limitations, we have designed a semi-structured interview to measure metacognition, correlating it with outcome measurements (psychopathology and interpersonal and social functioning). Similarly, to assess convergent and divergent validity of the MAS in PD, we are administering it in combination with measures of facial recognition and theory of mind. Another problem is the limited sensitivity of the D measurement. We consider the evidence found of a homogeneous D dysfunction in the PDs to be provisional. There needs to be an analysis of whether this gets triggered in—disorder-specific— interpersonal contexts or depends on a patient’s affective state, or whether more sensitive measuring would distinguish between the PDs. Finally, PD patients treated with other techniques need to be analysed. In fact, throughout the study, we did not consider the therapeutic intervention variable, whereas patients can display better or worse mental state understanding—or not even try to understand what others think and feel—in line with how much their therapist encourages them to do it or puts them in a suitable relational context. The therapists in this study made an effort to stimulate mentalistic descriptions of others. This probably put them in a position to pinpoint the dysfunction and probably also facilitated the improvement. Lastly, the role of other variables needs to be considered, to evaluate how much mind-reading difficulties depend on the patients, therapists, technique or therapeutic alliance.

CONCLUSIONS PD patients display problems with decentreing, i.e., standing in the other’s shoes notwithstanding one’s own point of view and involvement in the relationship. This impairment was found in the majority of the 14 patients analysed. Unlike in schizophrenia, our patients’ ability to describe others as thinking beings, driven by intentions and emotions, was not seriously impaired. In spite of this, the PD patients frequently had difficulties describing others’ mental states and the causes behind their feelings or actions, and it is possible that these occurrences were clinically significant. How egocentrism responds to treatment and is Copyright © 2009 John Wiley & Sons, Ltd.

G. Dimaggio et al. associated with outcome also needs to be evaluated. If the data were positive, this dysfunction could be included among the target variables to be measured for a better understanding of the therapeutic process in PDs, and clinicians could take account of it in treatment planning.

REFERENCES Ames, D.R. (2004). Inside the mind-reader’s toolkit: Projection and stereotyping in mental state inference. Journal of Personality and Social Psychology, 87, 340–353. Arntz, A., & Veen, G. (2001). Evaluations of others by borderline patients. Journal of Nervous and Mental Disease, 189, 513–521. Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization-based treatment. Oxford: Oxford University Press. Bell, E.M., Siegert, R.J., Langdon, R., & Ellis, P.M. (in press). The assessment of ToM in schizophrenia and other severe mental illnesses of adulthood. In G. Dimaggio, & P.H. Lysaker (Eds), Metacognition in severe adult mental disorders: From basic research to treatment. London: Routledge. Blair, R., Mitchell, D., Richell, R., Kelly, S., Leonard, A., Newman, C., & Scott, S. (2002). Turning a deaf ear to fear: Impaired recognition of vocal affect in psychopathic individuals. Journal of Abnormal Psychology, 111, 682–686. Blair, R.J., Sellars, C., Strickland, I., Clark, F., Williams, A., Smith, M., & Jones, L. (1996). Theory of mind in the psychopath. Journal of Forensic Psychiatry, 7, 15–25. Bland, A.R., Williams, C.A., Scharer, K., & Manning, S. (2004). Emotion processing in borderline personality disorders. Issues in Mental Health and Nursing, 25, 655–672. Brüne, M. (2005). Theory of mind in schizophrenia: A review of the literature. Schizophrenia Bulletin, 31, 21–42. Clarkin, J.F. (2005). Conceptualization and treatment of personality disorders. Psychotherapy Research, 16, 1–11. Clarkin, J.F., Yeomans, F., & Kernberg, O.F. (2006). Psychotherapy of borderline personality: Focusing on object relations. Washington, DC: American Psychiatric Publishing, Inc. Dimaggio, G., & Lysaker, P.H. (in press). Metacognition in severe adult mental disorders: From research to treatment. London: Routledge. Dimaggio, G., & Semerari, A. (Eds) (2003). I disturbi di personalità. Modelli e trattamento. Stati mentali, metarappresentazione, cicli interpersonali [Personality disorders: Models and treatment. States of mind, metarepresentation and interpersonal cycles]. Roma-Bari: Laterza. Dimaggio, G., Lysaker, P.H., Carcione, A., Nicolò, G., & Semerari, A. (2008). Know yourself and you shall know the other . . . to a certain extent. Multiple paths of influence of self-reflection on mindreading. Consciousness and Cognition, 17, 778–789.


Impaired Decentration in Personality Disorder Dimaggio, G., Procacci, M., Nicolò, G., Popolo, R., Semerari, A., Carcione, A., & Lysaker, P.H. (2007). Poor metacognition in narcissistic and avoidant personality disorders: Analysis of four psychotherapy patients. Clinical Psychology and Psychotherapy, 14, 386– 401. Dimaggio, G., Semerari, A., Carcione, A., Nicolò, G., & Procacci, M. (2007). Psychotherapy of personality disorder: Metacognition, States of Mind and Interpersonal Cycles. London: Routledge. Dolan, M., & Fullam, R. (2004). Theory of mind and mentalizing ability in antisocial personality disorders with and without psychopathy. Psychological Medicine, 34, 1093–1102. Domes, G., Czieschnek, D., Weidler, F., Berger, C., Fast, K., & Herpertz, S.C. (2008). Recognition of facial affect in borderline personality disorder. Journal of Personality Disorders, 22, 135–147. First, M.B., Gibbon, M., Spitzer, R.L., Williams, J.B.W., & Benjamin, L. (1997). Structured Clinical Interview for DSM IV Axis II Disorders. Washington, DC: American Psychiatric Press. First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J.B.W. (1997). Structured clinical interview for DSM-IV personality disorders, (SCID-II). Washington, DC: American Psychiatric Press. Fleiss, J.L. (1971). Measuring nominal scale agreement among many raters. Psychological Bulletin, 76, 378– 382. Glass, S.J., & Newman, J.P. (2006). Recognition of facial affects in psychopathic offenders. Journal of Abnormal Psychology, 115, 815–820. Gnepp, J., & Gould, M.E. (1985). The development of personalized inferences: Understanding other people’s emotional reactions in light of their prior experiences. Child Development, 56, 1455–1464. Guttman, H.A., & Laporte, L. (2002). Empathy in families of women with borderline personality disorder, anorexia nervosa, and a control group. Family Process, 39, 345–358. Harrington, L., Siegert, R.J., & McClure, J. (2005). Theory of mind in schizophrenia: A critical review. Cognitive Neuropsychiatry, 10, 249–286. Krueger, R.F., Skodol, A.E., Livesley, J.W., Shrout, P.E., & Huang, Y. (2007). Synthesizing dimensional and categorical approaches to personality disorders: Refining the research agenda for DSM-V axis II. International Journal of Methods in Psychiatric Research, 16, 65–73. Levy, K.N., Meehan, K.B., Kelly, K.M., Reynoso, J.S., Weber, M., Clarkin, J.F., & Kernberg, O.F. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027– 1040. Livesley, W.J. (2003). Practical management of personality disorders. New York: Guilford. Livesley, W.J. (2006). The Dimensional Assessment of Personality Pathology (DAPP) approach to personality disorder. In S. Strack (Ed.), Differentiating normal and abnormal personality (2nd ed., pp. 401–425). New York: Springer Publishing Company.


461 Livesley, W.J. (2008). Towards a genetically-informed model of borderline personality disorder. Journal of Personality Disorders, 22, 42–71. Lysaker, P.H., Carcione, A., Dimaggio, G., Johannesen, J.K., Nicolò, G., Procacci, M., & Semerari, A. (2005). Metacognition amidst narratives of self and illness in schizophrenia: Associations with insight, neurocognition, symptom and function. Acta Psychiatrica Scandinavica, 112, 64–71. Lysaker, P.H., Dimaggio, G., Buck, K.D., Carcione, A., & Nicolò, G. (2007). Metacognition and the sense of self within narratives of schizophrenia: Associations with multiple domains of neurocognition. Schizophrenia Research, 93, 278–287. Lysaker, P.H., Warman, D.M., Dimaggio, G., Procacci, M., LaRocco, V., Clark, L., Dike, C., & Nicolò, G. (2008). Metacognition in schizophrenia: Associations with multiple assessments of executive function. Journal of Nervous and Mental Disease, 196, 384–389. Mitchell, J.P., Macrae, C.N., & Banaji, M.R. (2006). Dissociable medial prefrontal contributions to judgments of similar and dissimilar others. Neuron, 50, 655–663. Morey, L.C., Hopwood, C.J., Gunderson, J.G., Skodol, A.E., Shea, M.T., Yen, S., Stout, R.L., Zanarini, M.C., Grilo, C.M., Sanislow, C.A., & McGlashan, T.H. (2007). Comparison of alternative models for personality disorders. Psychological Medicine, 37, 983–994. Moriguchi, Y., Ohnishi, T., Lane, R.D., Maeda, M., Mori, T., Nemoto, K., Matsuda, H., & Komaki, G. (2006). Impaired self-awareness and theory of mind: An fMRI study of mentalizing in alexithymia. Neuroimage, 32, 1472–1482. Nickerson, R.S. (1991). How we know—and sometimes misjudge—what others know: Imputing one’s own knowledge to others. Psychological Bulletin, 126, 747– 753. Osatuke, K., & Stiles, W.B. (in press). Numbers in assimilation research. Theory and Psychology. Preston, S.D., & deWaal, F.B.M. (2002). Empathy: Its ultimate and proximate bases. Behavioral and Brain Sciences, 25, 1–20. Royzman, E.B., Cassidy, K.W., & Baron, J. (2003). “I know, you know”: Epistemic egocentrism in children and adults. Review of General Psychology, 7, 38–65. Saxe, R., Moran, J.M., Scholz, J., & Gabrieli, J. (2006). Overlapping and non-overlapping brain regions for theory of mind and self reflection in individual subjects. Scan, 1, 229–234. Semerari, A., Carcione, A., Dimaggio, G., Falcone, M., Nicolò, G., Procacci, M., & Alleva, G. (2003). How to evaluate metacognitive functioning in psychotherapy? The Metacognition Assessment Scale and its applications. Clinical Psychology and Psychotherapy, 10, 238–261. Semerari, A., Dimaggio, G., Nicolò, G., Procacci, M., & Carcione, A. (2007). Understanding minds, different functions and different disorders? The contribution of psychotherapeutic research. Psychotherapy Research, 17, 106–119. Siegel, S., & Castellan, N.J. (1988). Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill. Stiles, W.B. (2005). Case studies. In J.C. Norcross, L.E. Beutler, & R.F. Levant (Eds), Evidence-based practices


462 in mental health: Debate and dialogue on the fundamental questions (pp. 57–64). Washington, DC: American Psychological Association. Taylor, M., Carlson, S.M., Maring, B.L., Gerow, L., & Charley, C.M. (2004). The characteristics and correlates of fantasy in school-age children: Imaginary companions, impersonation, and social understanding. Developmental Psychology, 40, 1173–1187. Veen, G., & Arntz, A. (2000). Multidimensional dichotomous thinking characterizes borderline personality disorder. Cognitive Therapy and Research, 24, 23–45.


G. Dimaggio et al. Wellman, H.M., Cross, D., & Watson, J. (2001). Metaanalysis of theory of mind development: The truth about false belief. Child Development, 72, 655– 684. Young, J.E., Klosko, J.S., & Weishaar, M.E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford. Yuill, N.J., & Pearson, A. (1998). The developmental bases for trait attribution: Children’s understanding of traits as causal mechanisms based on desire. Developmental Psychology, 34, 574–586.
