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Complex cases and comorbidities between personality and eating disorders

Complex cases and comorbidities between personality and eating disorders are tricky challanges for the clinician. Indeed, patients live their experience and (rightly!) have little interest in psychiatry, psychopathology and psychotherapy manuals. The condition of a single disorder is rare. And even in the case of complex symptoms such as eating disorders it is important to consider the functioning of the personality as a whole.

Journal of Clinical Psychology has recently accepted a paper I worked on together with an amazing international team: Veronica Cavalletti (Tages Charity, Florence), Francesco Gazzillo (University of La Sapienza, Rome), Martin Brüne (Bochum University, Bochum), and Paul Hewitt (University of British Columbia, Vancouver). Here we present a clear-cut example of complex cases and comorbidities between personality and eating disorders.

In this case study we present the course of the psychotherapy of Myriam, a 19-year old female with a severe personality disorder and comorbid eating disorder. During the initial assessment she reported high levels of neuroticism that parallel the diagnosis of obsessive-compulsive personality disorder, borderline personality disorder, and anorexia nervosa. Myriam showed a severely impaired personality functioning defined by perfectionism, self-criticism, interpersonal guilt and overcontrol. Her daily experience was shaped by a self-recriminative inner dialogue associated with maladaptive patterns in the form of food, water and sleep restrictions, self-harm behaviors, and suicidal ideation. She accessed an integrative treatment based on individual (Evolutionary Systems Therapy) and group psychotherapy (Mindful Compassion for Perfectionism). At the end of 14-month intervention she remitted from all the categorical diagnoses and showed reliable changes in several measures. These outcomes were maintained at 3-month follow-up. We describe the integrative conceptualization based on Myriam’s perfectionistic self-recrimination patterns, and the consequent treatment that targeted these patterns rather than focusing on symptom reduction exclusively.

The picture presents the conceptualization of the client based on the Evolutionary Systems Therapy.

For those interested in, the preprint of the paper is freely available and and the published version will have only minimal differences due to production process:

Cheli, S., Cavalletti, V., Gazzillo, F., Brüne, M., & Hewitt P.L. (2024). I don’t deserve anything good: Perfectionistic self-recrimination in a case of comorbid personality and eating disorder. Journal of Clinical Psychology. Preprint available on Authorea, July 16, 2024. https://doi.org/10.22541/au.172114929.99232229/v1 (DOI: 10.1002/jclp.23753).

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Two new studies registered

Evolutionary Systems Therapy, Evolution and Personality Lab

Two new studies registered at our lab! The main goal of Evolution & Personality Lab is to investigare personality and its pathology through the lens of evolutionary psychology and psychopathology. Consistently with this goal and ongoing studies, we registered two research protocols.

The first study is aimed to validate cross-culturally the evolutionarily informed conceptualization model we have worked on in the last few years. The protocol has been registered on ClinicalTrials.gov and comprises three studies involving teams from USA, Italy, Spain, Poland, China: (i) to explore the inter-rater reliability of the model in therapists; (ii) to explore the acceptability by therapists and patients; (iii) to explore the cross-cultural and cross-theoretical validity of training and application of the model. We hope this project will confirm that our model can be used within different cultural contexts and by clinicians with different therapeutic backgrounds.

The second study is aimed to explore the clinical utility of the three interpersonal styles and dynamics we have tested in a previous trial. In a recently concluded study we found that patients with personality pathology may show three prominent interpersonal styles that would correspond to the three main spectra of psychopathology: perfectionistic style and internalizing spectrum; antagonistic style and externalizing spectrum; schizotypal style and reality impairing/psychosis spectrum. The methodology used was potentially biased (patients were forced to chose only one style through a dummy variable). In this new study (registered on OSF) we used de-sitgmatizing labels for the three styles and offer a continuous Likert-type scale.

These two new studies registered on ClinicalTrials and OSF will better describe the clinical utility of our protocol for conceptualizing and treating personality pathology: namely, Evolutionary Systems Therapy. This protocol may be hopefully useful not only as and independent treatment. We are not that interested in proving what we do is good! It would be more important to show how an evolutionarily informed conceptualization may support different kinds of treatments (we are involving colleagues from a variety of background: psychodynamic, integrative, humanistic, cognitive, etc.) and may be reliable in spite of the different cultural background and interpersonal style of the patient.

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Interpersonal dynamics and styles in personality pathology

We have finally presented our work on interpersonal dynamics and styles in personality pathology. During a symposium a was chairing on this topic at the 7° Congress of the European Society of Personality Disorders I summarized our pre-registered trial on the feasibility of our Evolutionary Systems Therapy for personality pathology at large.

This study is part of the activities of our Evolution and Personality Lab and showed promising results. The paper about interpersonal dynamics and styles in personality pathology is under submission….so figers crossed!

The objective of this study was to evaluate the feasibility and rationale of a six-month Evolutionary Systems Therapy for personality pathology. In doing so, we employed a conceptualization that is supposed to be consistent with dimensional models of personality disorders and evolutionary psychopathology. Twenty-one patients were recruited and stratified into three homogeneous subgroups in accordance with spectra of psychopathology (internalizing, externalizing, schizotypy). An evolutionarily informed conceptualization was shared with patients based on three interpersonal styles that we consider to be prominent in the three spectra. Feasibility indicators were evaluated monthly, while changes in clinical measures were assessed by three procedures: ecological momentary assessment, monthly self-report measures, pre-post self-reports and interviews.

Eighteen out of 21 patients remitted from diagnosis, all indicators suggested a high feasibility. Individually, all patients showed reliable changes in measures of symptomatology and personality pathology. A repeated-measures ANOVA reported large effect sizes (η2 ranging between .892 to .979) for the whole sample. Ecological momentary assessment suggests that the three interpersonal styles are prominent in the corresponding spectra both before and after the treatment. This study supports the need for a confirmatory randomized controlled trial on the clinical utility of Evolutionary Systems Therapy. Despite the limited sample size, the findings are consistent with the importance of a dimensional approach to psychopathology and of an evolutionarily informed conceptualization of personality disorders.

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An RCT on Mindful Compassion for Perfectionism

Mindful Compassion for Perfectionism

An RCT on Mindful Compassion for Perfectionism has been published. Mindful Compassion for Perfectionism is a recently developed group format for those struggling with perfectionism. We previously tested its feasibility in two cases series and then designed a randomized controlled trial (RCT).

Mindful Compassion for Perfectionism (MCP) is an 8-week group intervention that integrates Compassion Focused Therapy and Dynamic Relational Therapy. During the sessions, a specific psychoeducation on perfectionism is presented and numerous experiential practices are conducted.

Seventy-two post-graduate students with clinically high perfectionistic traits were randomly assigned either to a control group (wait-list) or two different formats of MCP (online or in-person). Primary outcomes were feasibility (safety, completion, adherence) of MCP and change in perfectionistic cognitions between active treatments and control group. Secondary analyses explored pre-post changes and differences between the two active groups in perfectionistic cognitions, psychosocial distress, group functioning and self-soothing. The picture shows the flow diagram of the RCT design.

No drop-outs or unwanted adverse events were reported, 6.25% of participants missed a single session and 8.33% were excluded from the study for having missed more than one. MCP treatments – both individually and as a unique group – showed a greater reduction of perfectionistic cognitions and psychosocial distress than wait-list (partial η2 ranging between .565 and .591). In-person MCP indicated a greater reduction of perfectionistic cognitions and psychosocial distress and a greater increase of group functioning and self-soothing than online MCP (partial η2 ranging between .157 and .394).

These findings suggest the feasibility and efficacy of MCP in reducing perfectionistic cognitions and psychosocial distress. The in-person format is seemingly more effective than the online format. A new RCT on Mindful Compassion for Perfectionism is an important step.

Further research should explore the efficacy of MCP in respect to other evidence-based treatments. Moreover, the brief format of MCP and its specific focus on experiential practices may support the possibility of including it in modular or stepped-care protocols for those struggling with perfectionism.

Cheli, S., Cavalletti, V., Goldzweig, G., Bui, S., Petrocchi. N., Flett, G., & Hewitt, P. (2024). A three-arm randomized controlled trial to evaluate the efficacy and feasibility of mindful compassion for perfectionism in reducing perfectionistic cognitions. Journal of Psychotherapy Integration. https://doi.org/10.1037/int0000349

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Cross-cultural invariance of perfectionism

Cross-cultural invariance of perfectionism has been tested in a study of Canadian and Italian samples. In this study we got interesting findings.

Perfectionism measures developed in English-speaking populations have become frequently used in many non-English contexts, including in Italy. Establishing structural and measurement equivalence of instruments between Canadian and Italian samples is therefore important in establishing the validity of these concepts and instruments in Italian contexts, and to allow for direct cross-cultural comparisons.

The current study investigated the measurement equivalence between a Canadian and an Italian sample for the commonly used measures of perfectionism constructs based on the Comprehensive Model of Perfectionistic Behavior. The Hewitt & Flett Multidimensional Perfectionism Scale, the Perfectionistic Self-Presentation Scale, and the Perfectionism Cognitions Inventory were examined for configural, metric, and scalar invariance via equivalence testing of multigroup confirmatory factor analysis models.

The results showed some evidence for configural and metric equivalence for the three measures, thus facilitating cross-cultural interpretation of pattern of associations. However, there was no consistent evidence for scalar invariance, thus suggesting that direct comparisons of perfectionism levels between the two contexts cannot be meaningfully interpreted. This highlights the need for research in both Canadian and Italian contexts to understand cross-cultural invariance of perfectionism.

These findings further highlight the complexity of translating instruments developed in one culture into another, even in two industrialized, “Western” countries. Further research, particularly collaboration by Canadian and Italian researchers using multi-method approaches, would be useful for elucidating the similarities and differences between these two cultures in how perfectionism manifests, how participants respond on perfectionism questionnaires, and the implications of such for understanding psychological difficulties and their treatment.

Cai, N., Dang, S. S., Cheli, S., Cavalletti, V., Flett, G. L., & Hewit, P. L. (2024). Examination of Measures of Perfectionism for Structural and Measurement Invariance in an Italian and a Canadian Sample. Journal of Psychoeducational Assessment, 0(0). https://doi.org/10.1177/07342829241273166

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New advancements in Evolutionary Systems Therapy

EST Advancements

We are collecting new advancements in Evolutionary Systems Therapy. This is a new form of psychotherapy that integrates evolutionary psychopathology, compassion focused therapy and metacognitively oriented treatments.

To date, Evolutionary Systems Therapy (EST) has shown promising results in the treatment of personality disorders with traits primarily related to psychoticism and detachment: one randomized controlled trial (RCT) suggested that EST without medication is at least as effective as CBT with medication for patients diagnosed with schizotypal personality disorder (Cheli et al, 2023); some case series have shown the feasibility of EST for paranoid and schizoid personality disorders and for autistic traits (Cheli et al., 2024; Cheli, Chiarello & Cavalletti, 2023; Cheli & Cavalletti, 2023); moreover, we suggest how it can work with adolescents with schizotypal traits (Cheli et al., 2023).

Now we are working on new advancements in Evolutionary Systems Therapy. First, a new RCT is closed to end and – fingers crossed – it should confirm and extend previous findings. Second, an open trial currently underway is investigating the clinical utility of EST for all personality disorders. Third, a single case on comorbid eating and personality disorder, plus a 5 case series on obsessive compulsive personality disorder have been submitted. The single case is accessible as preprint. It investigates the role of self-recriminatory dialogue in a young female diagnosed with anorexia nervosa, borderline and obsessive-compulsive personality disorder.

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Psychotherapy on an Acute Psychiatric Ward

 Psychotherapy on an acute psychiatric ward is not that easy. In this study the team led by Ilanit Hasson-Ohayon – plus some external scholars such as myself – shows how Metacognitive Reflection and Insight Therapy is a feasible and reliable option.

This study investigated the efficacy of psychotherapy during hospitalization on an acute psychiatric ward. A controlled trial was conducted to assess the effects of Metacognitive Reflection and Insight Therapy (MERIT) upon metacognition and psychiatric symptoms. Data from 40 inpatient women were analysed.

Findings included significant interaction effects between group (intervention or control group) and time (preintervention and postintervention) in regard to the metacognitive abilities and general psychiatric symptoms. Participating in MERIT seems to improve one’s ability to use reflective knowledge to cope with psychological challenges and to improve symptomatology level.

This study confirms the importance of targeting general psychopathologycal factors – such as metacognition – in those struggling with severe mental disorders.

Cohen-Chazani, Y., Igra, L., Hamm, J., Leonhardt, B., Klion, R., Cheli, S. and Hasson-Ohayon, I. (2024), Psychotherapy on an Acute Psychiatric Ward: Preliminary Findings From a Controlled Study. Clinical Psychology & Psychotherapy, 31: e3002. https://doi.org/10.1002/cpp.3002

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The State of the Art of The HiTOP Model

HiTOP

The State of the Art of The HiTOP Model is the title of a new review on the Hiearchical Taxonomy of Psychopathology (HiTOP). The paper is part of a special issue published by Behavior Therapy on new trends and approaches in psychotherapy. I am happy to have been part of the team led by David Cicero.

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a dimensional framework for psychopathology advanced by a consortium of nosologists. In the HiTOP system, psychopathology is grouped hierarchically from super-spectra, spectra, and subfactors at the upper levels to homogeneous symptom components and maladaptive traits and their constituent symptoms, and maladaptive behaviors at the lower levels.

HiTOP has the potential to improve clinical outcomes by planning treatment based on symptom severity rather than heterogeneous diagnoses, targeting treatment across different levels of the hierarchy, and assessing distress and impairment separately from the observed symptom profile.

Assessments can be performed according to this framework with the recently developed HiTOP-Self-Report (HiTOP-SR). Examples of how to use HiTOP in clinical practice are provided for the internalizing spectrum, including the use of the Unified Protocol and other modularized treatments, measurement-based care, psychopharmacology, and in traditionally underserved populations.

Future directions are discussed in this State of the Science review including HiTOP’s use in further developing transdiagnostic treatments, extending the model to include other information such as environmental factors, establishing the treatment utility of clinical assessment for the HiTOP-SR, developing new treatments, and disseminating the model.

The State of the Art of The HiTOP Model presents the potential of this new approach in promoting a dimensionally oriented conceptualization. At the same time, it highlights the need for further research about how to apply it in clinical practice. In previous works both David Cicero and I discussed the HiTOP potential in the field – for example – in the conceptualization and treatment of schizotypy.

Cicero, D. C., Ruggero, C., Balling, C., Bottera, A. R., Cheli, S., Elkrief, L., … Thomeczek, M. L. (2024, February 1). State of the Science: The Hierarchical Taxonomy of Psychopathology (HiTOP). Behavior Therapy, Online publication. https://doi.org/10.1016/j.beth.2024.05.001

Preprint on OSF: https://osf.io/preprints/psyarxiv/qjm2t

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Psychotherapy for Paranoid Personality Disorder

Paranoid Personality

Just released a new paper we wrote on psychotherapy for Paranoid Personality Disorder. The research is a 7-cases series on the feasibility and efficacy of Evolutionary Systems Therapy for those struggling with paranoid traits.

Little is known about effective psychosocial treatments for paranoid personality disorder. This study explores the feasibility of a novel treatment, namely Evolutionary Systems Therapy, in supporting individuals diagnosed with paranoid personality disorder.

Seven patients attended 10 months of individual therapy without receiving any psychopharmacological treatment. The primary outcome was the feasibility of the intervention, while the secondary outcomes were remission from the diagnosis and reliable changes in personality pathology and paranoid ideation.

All the patients completed the treatment, and none of them reported adverse events or missed more than three sessions (less than 10%). Six out of seven patients (85.7%) achieved remission from paranoid personality disorder. diagnosis, which was maintained at the one-month follow-up. Only in the case of Case 7 was the diagnosis of paranoid personality disorder confirmed at both the final assessment and the one-month follow-up. The dimensional scores indicate a clinically significant reduction in maladaptive personality features for all the patients.

Kendall’s Tau and Spearman’s Rho analysis confirmed a significant downward trend in the means of personality pathology and paranoid ideation across the 12 measurements (p< .05). Likewise, Reliable Change Index values were reported (≥ 1.96) for both measures when comparing the initial and final assessments. Table 3 presents these reliable values for all seven participants. No differences were found in Reliable Change Index between the final assessment and the follow-up assessment. Finally, we explored measurements for an optimal treatment dose. Reliable changes (RCI ≥ 1.96) were reported for personality pathology and paranoid ideation by the sixth month of intervention.

This study suggests the feasibility and safety of psychotherapy as an option for individuals diagnosed with paranoid personality disorder. Specifically, Evolutionary Systems Therapy has shown promising, albeit preliminary, results in assisting individuals with paranoid personality disorder. We propose that the potential clinical effectiveness of Evolutionary Systems Therapy may be attributed to its early focus on the interpersonal schemas and cycles originating from paranoid ideation, where individuals perceive themselves as vulnerable and others as threatening, repeatedly perpetuating a self-fulfilling prophecy. The integrated utilization of relational and experiential techniques appears to be effective in reducing personality pathology and paranoid ideation. Further research is necessary to address the limitations inherent in the case series design employed in the present study.

Cheli, S., Goldzweig, G., Chiarello, F., & Cavalletti, V. (2024). Evolutionary systems therapy for paranoid personality disorder: A seven cases series. Bulletin of the Menninger Clinic, 88, 1, 61-80. https://doi.org/10.1521/bumc.2024.88.1.61

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