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A meta-analysis of treatments for Cluster A

Cluster A Personality Disorders

Our Evolution and Personality Lab just published a meta-analysis of treatments for Cluster A of personality disorders. The paper has been published by the APA journal Personality Disorders: Theory, Research and Treatment. Here, we disprove the hypothesis that patients with Cluster A personality disorders are poorly adherent to treatments and that these are not effective. Our data suggest that with respect to these outcomes, Cluster A is not dissimilar from other clusters.

Despite an overall prevalence of about 4% and a possible association with well-studied conditions such as schizotypy, little is known about effective treatments for Cluster A personality disorders (PDs), that is, para- noid, schizoid, and schizotypal PD. The aim of this systematic review and meta-analysis was to conduct a narrative synthesis of existing randomized controlled trials and explore the effectiveness of psychosocial and pharmacological treatments for these disorders. Nineteen studies including 468 participants diagnosed with any one of the three Cluster A PDs were included in the systematic review. Data from 291 (k = 5) and 213 (k = 5) participants were included in two different meta-analyses evaluating the reduction of distinctive clin- ical features and the increase of general functioning following treatment, respectively. All the treatments in meta-analyses reported a low overall attrition rate (0.23). The two meta-analyses showed medium-to-large effect sizes (g = .60–.91), but were limited by small sample sizes and large heterogeneity. Collected findings suggest that treatments for paranoid, schizoid, and schizotypal PD may be feasible and effective. We discuss implications for further research.

This systematic review and meta-analysis aimed to explore the feasibility and effectiveness of existing psychosocial and pharmaco- logical treatments for all the Cluster A PDs, that is, PPD, SZPD, and SPD. Despite the heterogeneity of the studies and the limited sample sizes, important findings emerge. Both the narrative synthesis and the two meta-analyses invalidated the hypothesis that patients with these disorders are unlikely to complete treatments and that treat- ments are not safe. Our results suggest that the level of feasibility and safety of treatments for Cluster A PDs are similar to those for all other PDs. Existing treatments also appear to be sufficiently effective in reducing distinctive clinical features and increasing general functioning. Numerous constraints of generality urge the development of new research to identify robust mechanisms of change and effective treatments.

Cheli, S., Wisepape, C. N., Witten, C. D. Y., Floridi, M., Cavalletti, V., Hasson-Ohayon, I., Brüne, M., & Ottaviani, C. (2025). Psychosocial and pharmacological interventions for cluster a personality disorders: A systematic review and two exploratory meta-analyses. Personality Disorders: Theory, Research, and Treatment. Advance online publication. https://doi.org/10.1037/per0000732

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New therapy for obsessive-compulsive personality disorder

Evolutionary Systems Therapy, Evolution and Personality Lab

Journal of Personality Disorders published our paper on a new therapy for obsessive-compulsive personality disorder. In this study we extend what we knew about the clinical utility of our treatment model, namely Evolutionary Systems Therapy.

Obsessive-compulsive personality disorder is the most common personality disorder, with a prevalence of approximately 6.5% in the general population. However, little is known about the effective psychotherapy for this disorder. In this case series, we employed evolutionary systems therapy to support five adults diagnosed with obsessive-compulsive personality disorder. Evolutionary systems therapy is a novel form of psychotherapy that integrates evolutionary psychopathology, compassion-focused therapy, and metacognitively oriented treatments. Primary outcome (personality pathology) was assessed monthly from baseline to follow-up. Secondary outcomes (anxiety, depression, perfectionism, self-criticism, overcontrol) were assessed at initial and final sessions. Moreover, we evaluated the feasibility of intervention (completion, attendance, adverse events). At the end of 6 months of treatment, all the participants reported reliable changes and remitted from diagnosis. These outcomes were maintained at 1-month and 3-month follow-ups. Further research is needed to provide evidence about the acceptability of evolutionary systems therapy in the treatment of obsessive-compulsive personality disorder.

In this five cases series we preliminarily explored the acceptability and feasibility of EST for OCPD. Despite the limitations of a cases series design – which is an important constraint on the generality of the collected outcomes – we reported promising findings. All the patients remitted from diagnosis and showed a significant downward trend in personality pathology. These changes were maintained at the 3-month follow-up. Moreover, we found reliable changes in symptoms such as anxiety and depression and in possible therapeutic targets such as perfectionism, self-criticism and overcontrol. Our study seemingly supports the importance of evolutionarily informed approaches to conceptualization and treatment, which allow distinguishing maladaptive strategies from distinctive personality features. In conclusion, we hope that there will be an increase in studies aimed at developing empirically validated treatments for a highly prevalent disorder with elevated suicidal risk such as OCPD.

This new therapy for obsessive-compulsive personality disorder confirms that Evolutionary Systems Therapy may be effective across the whole spectrum of personality disorders.

Cheli, S. Goldzweig, G. Hewitt, P., Bui, S., & Cavalletti, V. (2025). Evolutionary Systems Therapy for Obsessive-Compulsive Personality Disorder: A Five Case Series. Journal of Personality Disorders, 39(1), 61–76. https://doi.org/10.1521/pedi.2025.39.1.61

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The Savant Syndrome

Savant Syndrome, Autism

The Savant Syndrome is a very rare condition that has been extensively debated in fiction and non-fiction. Sara Bui and I wrote a chapter for the new Palgrave Encyclopedia of Disability on this very topic.

Savant Syndrome is a rare condition in which individuals display exceptional skills in one or more areas of functioning. Historically, the presence of these skills is reputed to be associ- ated with some disability, the most frequent (50%) of which is autism spectrum disorder. The prevalence in the general population is estimated at about 1%, with the majority of studies suggesting that nine out of ten cases are congenital and eight out of ten cases are males.

The exceptional skills that are distinctive of this syndrome typically range from music, art, calendar calculating, mathematics, or mechanical/visual-spatial skills. Little is known about the mechanisms involved in Savant Syndrome, and there are no guidelines for the assessment and treatment of associated impairment or distress. Recent advances suggest considering the exceptional skills and possible disabilities along a continuum. This new perspective may lead to a greater understanding about the relationship between this syndrome and wider and better studied conditions such as autism, neurodiversity, and giftedness.

In the final section about treatments we also refer to one of the few existing examples of psychosocial treatment for this condition, that is our evolutionarily informed protocol.

Cheli, S., Bui, S. (2025). Savant Syndrome. In: Bennett, G., Goodall, E. (eds) The Palgrave Encyclopedia of Disability. Palgrave Macmillan, Springer. https://doi.org/10.1007/978-3-031-40858-8_216-1

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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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