In recent years, clinicians in the fields of mental health have been increasingly interested in how persons with psychiatric conditions experience a range of difficulties related to how they think about themselves and others (Dimaggio, Salvatore, Popolo, & Lysaker, 2012). In this field of study, researchers have commonly and indistinctly used metacognition and mentalization (i.e. the capacity to conceive of one's own and others' mental states (Allen & Fonagy, 2006).
Metacognition (dis)abilities are strongly associated with many forms of adult psychopathology (Lysaker et al., 2005). Importantly, in schizophrenic patients (similar to what happens in BPD), heterogeneous results have been obtained by studies exploring the functional impact of cognitive deficits, suggesting that there is no direct relationship between these two aspects.One proposed explanation is that metacognition may play an intermediate role in moderating the link between cognitive deficits and functional impairment (Quiles, Prouteau, & Verdoux, 2013). In this line, several studies have reported that metacognitive difficulties strongly interfere with social functioning and have predicted more community functioning in persons with schizophrenia than cognitive deficits (Tas, Brown, Esen-Danaci, Lysaker, & Brüne, 2012). Metacognitive skills may hence be viewed as a key factor in translating cognitive performance skills in daily life.
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From a psychological perspective, biases in self-information processing are a source of suffering (Beck et al., 2006; Clark & Beck, 2010). For this reason, dysfunctional beliefs about cognition (which constitute metacognition), are the basis for the development and maintenance of clinical problems (Matthews & Wells, 2000; Wells & Matthews, 1996), due to, as mentioned previously, this guide’s information processing. For instance, in a study about ruminative thinking in depression (Papageorgiou & Wells, 2003), which has been found to be linked to distorted interpretations of live events (augmenting pessimism about positive events in the future and poor solutions to interpersonal problems) (Lyubomirsky & Nolen-Hoeksema, 1995), authors showed that perseverative negative thinking has multiple effects on low- level and strategic cognitive operations required for restructuring self-knowledge and developing effective coping strategies. Thus, negative beliefs and appraisals of coping (i.e., negative “on-line processing”) contribute most proximally to emotional disturbance.
Metacognition and BPD. The term metacognition has been little used in BPD research [see for instance: (Judd & McGlashan, 2008; Semerari et al., 2005]. In line with the above reasoning, BPD patients are highly vigilant for negative stimuli, especially when stimulus are associated with negative self-appraisals (e.g. using the emotional stroop task) (Sieswerda, Arntz, Mertens, & Vertommen, 2007). Importantly, they also experienced attenuated inhibition of negative emotional stimuli shown by a poor performance during negative priming, directed forgetting, and a linguistic go/no- go task (Domes, Winter, Schnell, & Vohs, 2006; Silbersweig et al., 2007). Furthermore, BPD patients have difficulties engaging brain prefrontal areas when employing psychological distancing to regulate negative emotions (Koenigsberg et al., 2009). In addition, in an interesting study (Schulze et al., 2011), researchers used a reappraisal
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paradigm in which, first, BPD participants viewed a picture (aversive) on the screen and, after this emotional induction, a single word instruction was presented asking participants to ‘maintain’, ‘increase’, or ‘decrease’ their initial emotion. Importantly, BPD patients showed difficulties in the cognitive reappraisal of aversive stimuli (i.e., negative pictures), which are associated with attenuated orbitofrontal activity along with enhanced bilateral insula activity. Therefore, they showed deficits in being capable of voluntarily decreasing aversive emotions by means of cognitive reappraisal. This result, importantly for the present dissertation, suggests impairment in metacognition, in particular in those metacognitive control skills (see Figure 13A).
Complementarily, it has been demonstrated that mindfulness training can facilitate the reappraisal of stressful events and distressing thoughts (Chiesa, Serretti, & Jakobsen, 2013; Garland, Gaylord, & Park, 2009). This training promotes the awareness of all emotional and cognitive events as they occur in the present, a concept clearly related to metacognition. Therefore, as can be seen in Figure 13B, it allows one to “decenter” (i.e. ‘step outside of one’s immediate experience, thereby changing the very nature of that experience’) from the primary, or initial, stress appraisal. As well as this, it facilitates reappraisal with a different perspective that can promote more positive attributes. Thus, this metacognitive approach to mindfulness promotes a shift in mental processes (second order) rather than a direct change of the mental content or behaviours (first order). This shift in perspective (stance) enhances self-regulation and promotes an adaptive response (action), rather than maladaptive stress reactivity (reaction). Importantly, mindfulness has been a useful intervention with BPD patients, suggesting that their problems in self-regulation are, at least in part, related with metacognitive impairment (Linehan, 1993; Soler et al., 2012; Stoffers et al., 2012).
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Another focus of study has been the autobiographical memory (see also section 1.5.2.). It refers to memories of one’s personal life and plays a major role in identity and emotion regulation (Dimaggio et al., 2012). Importantly, autobiographical memory (that is self-referential information) and metacognition are closely related due to having shared brain regions (Rabin & Rosenbaum, 2012; Spreng & Grady, 2010). Interestingly, several studies have shown alterations in the autobiographical memory of BPD patients. Thus, for example, in a fMRI study (Schnell, Dietrich, Schnitker, Daumann, & Herpertz, 2007), during the recall of autobiographical memories, BPD subjects showed a deficit of selective activation of areas involved in autobiographical memory retrieval (they activated the same brain areas both in aversive and neutral memories) suggesting a general tendency towards a self-referential mode of information processing in BPD, or a failure to switch between emotionally salient and neutral stimuli.
Figure 13. (A) The left OFC demonstrated enhanced activity during the decrease of the initial emotional response for the healthy control (HC) compared with the BPD group, accompanied by dampened activation of the bilateral insula in the healthy control group but not for borderline personality disorder patients. A = anterior; L = left;
P = posterior; R = right. Reproduced
from: (Schulze et al., 2011). (B) Mindfulness process. Reproduced from: (Garland et al., 2009)
A
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These findinsg, in addition, fit well with the mentalization-based approach to BPD(see section 1.2.). Briefly, this perspective proposes that self-awareness is built in the context of social attachment. BPD patients show insecure attachment style, leading to mentalization failures. During the mentalization-based treatment, a core aspect is to help patients to narrate specific autobiographical memories, suggesting that its enrichment may promote improvements in metacognitive capacity (Bateman & Fonagy, 2004).
In this context, finally, BPD patients usually present a lack of insight or unawareness of illness, experience difficulties describing their own emotions, and in seeing their own thought processes in a detached and reflective way (Semerari et al., 2005); all these could be conceived of as a failure in metacognition.