PERSONALITY DISORDERS – DIAGNOSTIC ACTUALITIES
Personality disorders always reassert themselves as a field of controversies. Nowadays, the psychiatric and social complications of the patients' behavior with personality disorders are of a particular diversity and severity. They may be favored, masked or shaped by the social and cultural environment. Therefore, the earliness and accuracy of the diagnosis become especially important. This must be a n e l a b o r a t e d p r o c e s s , c l i n i c a l l y a n d psychometrically well-founded, but culturally and morally conditioned.
The human person has a structural complexity that explains the perspectives diversity from which it can be approached. The hypercomplex structure, biologically, psychologically, socially and spiritually conditioned, integrates a hierarchy of needs and existential values, as well as of inclinations and abilities to satisfy them and follow them. Personal traits are inherited, respectively acquired by education, socialization and by cultural and spiritual acquisitions during the different stages of personogenesis (1).
The personality structure is reflected in the individual behaviour that is appropriate to the diversity of life’s roles and in interpersonal relations. In this respect, the traits which confer persistence and stability to the behaviour of the person and make him/her thus predictable, are the dominantly inherited ones – a classic example would be shyness regarded as a predictive element of social phobias. These types of traits they accompany and feed on childhood experiences, and are the ones that mostly correspond to social rules and expectations allowing – since the end of the first decade of life – inter-individual differentiations. The latter ones are subsequently emphasized also by the contribution of the acquired traits, so that at the personological maturity age from the end of the third decade of life – the individual behaviour becomes stable and reflects both the dominantly inherited intimate Self and biologically conditioned, and the social Self socially and culturally and spiritually conditioned (2).
At maturity the human person is aware of “who he is” and “what he is” and has common motivations and existential values with those around him. This means a way of thinking, of feeling, of acting and of being, consequently, of seeking the meaning of his own life and a happiness formula as durable as possible. Self- image and self-esteem are mutually inter-conditioning and ensuring adaptation and efficiency in the roles of life and in the relationships with the people around.
When harmony between the structural components of a person is missing or is only partial – due to a deviant personogenesis – we found ourselves on the territory of pathological personalities or personality disorders. Overall, they are characterized by a quasi- permanent adaptation deficit in the existential roles which represent a source of individual and collective suffering – unaware or partially aware of.
Pathological personalities incorporate a diversity of maladaptive traits, which may be conjuncturally shaded away or masked by significant intellectual or creative abilities, by tolerance or indifference to entourage and by the particularities of the professional role. As the harmoniously structured personalities, they are ego-syntonic, but they transfer the entire responsibility of the personal intentions and actions on those around them and create themselves gradually a system of norms and rules of conduct, but also of egocentric values. From this perspective disharmonic behaviour emphasizes in its turn the inter-individual differences (2).
Self-image and self-esteem become thereby fragile and inauthentic, contradictory or they are in a paradox relationship. All pathological personalities seek – through the mentioned methods – access to a version of selfish happiness, solitary and lacking depth and authenticity.
For the reasons thus outlined the diagnosis of the personality disorders becomes a complex process of which accuracy depends of a multitude of variables. Among these, the ego-syntonic character of psycho- behavioral manifestations and the congruence between maladaptive traits and biographical experiences which condition and favour each other, have a prevailing role. In the same context, the diagnostic approach is influenced by demographic factors, the mentality and preconceptions of the entourage, by the frequent association with episodes and disease of Axis I, as well as by the relativity of rules, conduct patterns and contemporary community values.
Any diagnostic approach in the given context means simultaneously also a moral approach appropriate to its stigmatizing character favoured by the ignorance of the medical sphere and profane world, by negative semantic conditioning, by self-perception and poor self-control of the maladaptive traits, by the negative impact of biographical narrative descriptions and of course by the always unpleasant consequences of the disharmonic behaviour on the entourage.
Currently, in diagnosing personality disorders, important are the maladaptive manifestations and their effects on the entourage, next to the development of the intentionality of personal attitudes and acts. These are to the disadvantage of the current condition and the biographic moment lived. Starting from the premise that patients’ narrations have an egocentric, unstable and manipulative character, the diagnosis has a particular complexity integrating clinical interviews and structured ones, a great variety of scales and questionnaires that aim towards – among other various references – both biographic memory and subjective well-being. Heteroanamnesis and autobiographical narration contents have a particular role.
Personality Disorders represent a distinct nosologic category that imprint in a specific manner on everyday behaviour, being at the same time quantitative versions of certain essential and general dimensions of the normal personality. This is why the categorical personologic diagnosis must always be followed by a complementary dimensional approach. This double perspective confers to it a dynamic and staged character in which there are integrated demographic, social and economic, cultural, spiritual and moral references. The diagnosis approach thus structured pleads for the fact that the personality dimensions may modify in time and in relation to factors of environment and confer – also by this means – complexity and accuracy to the therapeutic and rehabilitative interventions.
N o w a d a y s , f r o m t h e c a t e g o r i c a l perspective are kept the three clusters – A, B and C, corresponding to bizarre, eccentric and dissocial personalities, respectively to the anxious ones to which are added the personopathies due to a medical condition and that is temporary epilepsy, in which the intercritical behaviour is dominated by affective lability, by impulsivity, by aggressiveness, by paranoidism and apathy. A second large category is represented by mixed personality disorders and unspecified ones – with the criterion of partial diagnoses present.
A l t o g e t h e r, f r o m t h e c a t e g o r i c a l perspective, the level of accuracy of the diagnosis diminishes with age in Cluster B personality disorder, and increase with age in Cluster C personality disorder, and it is not dependant of this demographic reference in Cluster A personality disorder, the accuracy of the diagnosis being for all three clusters higher in the rural environment. Cluster A personality disorders and antisocial PD are encountered predominantly in male gender, and borderline PD, histrionic PD and dependence PD in female gender.
In pathological personalitites diagnosis – according to DSM V – we start from the premise that in the same patient are encountered criteria belonging to other personopathic types. Therefore if a patient does not reunite the complete criteria for one or more personality disorders there is outlined a version of diagnostic framing simultaneously categorical and dimensional, that includes also personopathic entities defined only by traits. Diagnostic criteria common to all personality disorders are the functioning level in roles and the presence of pathological traits. Within this frame are described six p e r s o n a l i t y d i s o r d e r s w h i c h i n t e g r a t e v a r i o u s combinations of maladaptive traits – schizotypal PD, borderline PD, antisocial PD, narcissistic PD, avoidant PD and obsessive-compulsive PD, and four personality disorders defined only by traits – schizoid PD, paranoid PD, histrionic PD and dependence PD – which may be integrated to a significant extent into the first six (3).
The assessment of pathological traits which should allow diagnosis framing, resorts to a dimensional model suggested by the five-factors model Big Five. Thus, there are described binoms – negative affectivity / a ff e c t i v e s t a b i l i t y, d e t a c h m e n t / e x t r o v e r s i o n , antagonism/agreeableness, disinhibition /consciousness and psychoticism / lucidity (4)(5). Each dimension matches five facets – a total of 25 – representing the clinical dominant components. Starting from this model it has been elaborated the personality inventory PID- 5 which is used for the staged assessment of personality dimensions and facets as well as for structuring therapeutic strategy and assessing its efficiency.
The personality functioning in life’s roles is targeting two components, and that is, the Self and the interpersonal sector. The Self integrates identity, consciousness and self-esteem, self-evaluation skills and regulation of emotions and self-direction. To the interpersonal sector corresponds the empathy – even under circumstances of disaccord with those around – but also the ability to understand the consequences of one’s own behaviour and the behaviour of others. They are associated with intimacy, that is the ability to maintain harmonious and stable interpersonal relations. It has been elaborated – within this frame – the Level of Personality Functioning Scale that allows the evaluation of the affectation level of different components of the Self and of the interpersonal sector on a scale from 1 to 4.
Thus there are set out the specific diagnostic criteria for pathological personality and that is – the presence of one or more pathological facets of personality, significant deficiencies in the functioning of the Self and of the interpersonal, predictable behaviour in different life situations next to the presence of a stable adaptive deficit, but independent of the educational level, other medical conditions and abusive consumption of psychotropic substances.
It should be stressed the fact that the dimensional perspective allows nuanced diagnostic formulations linkable to the temporal identity, and also facilitates the understanding of the personological continuum – normality-abnormality – mental illness (6). Thus, neuroticism and extroversion decrease with age, consciousness and agreeableness intensify in time, and openness to experience – from the model of the BIG FIVE factors – increases with age in individualistic type of societies. Additionally a significant level of agreeableness influences positively the self-esteem, life satisfactions, the curiosity and next to an increased consciousness, favours interpersonal communication, openness to experience as well as cultivation of virtues. This way the psychoticism decreases and life quality and longevity are increasing. The increased levels of openness to experience determine – in individualist societies – early development of dominant psychological traits of the two genders, cultivate selfishness and egocentrism – but also they mask them to the same extent – and the adherence to social rules. Nevertheless the dimension of openness is low in all pathological personalities.
In individualist type of sociocultures, the particularities of education favour high levels of neuroticism, extroversion and openness to experience. Whereas in cooperative traditional type of sociocultures are favoured agreeableness, consciousness and those facets of extroversion that cultivate empathic closeness.
According to professional options – regarded as first order reference of the psychological maturity – these are congruent with temperamental traits, dominantly inherited in cooperative type of societies and with character traits, socially and culturally conditioned in individualist type of societies.
In the same context, the stable traits of personality have an adaptive role in traditional societies of cooperative type, and character traits, socially and culturally conditioned fulfill a similar role in individualist type of societies. Antisocial type traits are rare in cooperative type of societies in both genders and there are more frequent in individualist type of societies – having a preponderant extension currently in female gender.
In the diagnostic formulation of the personality disorder must be also taken into account the fact that in both genders maladaptive traits of adults vitiate the personogenesis in childhood age, the behaviour models and adulterate existential values favoring the formation of certain unstable-impulsive and anxious type of traits. Also, adult maladaptive traits disrupt the functioning in roles of those around, affect quasi-constantly interpersonal relationships and favour the development in a close human environment of certain selfish adaptive strategies. There are frequently enough assortative associations – including marriages – between persons with similar maladaptive traits who have separately, but also together, similar biographical experiences.
The spiritual dimensions – including those assignable to various religions – of personality may mask, shape or shade away maladaptive conducts. Thus, although the need of sacred is appropriate to each human being, the abilities of self-transcendence derived from it are diminished in all pathological personalities (7). Religious practices may favour – except the fundamentalist ones – extroversion, agreeableness, consciousness and openness to intellectual and spiritual experiences. They promote virtues – dominantly the Christian ones, but also the ones ensuring communication and closeness primarily humanist between people and communities. Psychoticism decreases and latent personal aptitudes and resources are mobilized. Overall, longevity and life quality are favoured (8).
It should be stressed also the importance – in the base diagnostic approach – of the temporal dimension of the identity. Therefore, in the age interval 16-21 years old, the personality disorder diagnosis is formulated only if the adaptive deficit lasts over 12 months in persons of male gender from environments with low social an economical level. On the other hand – in young people – the unstable, d e p e n d e n t t y p e o f t r a i t s , t h e o r i g i n a l i t y a n d nonconformism may be attributed to age. Introversion and consciousness have the same significance in third age.
The personality disorder diagnosis at an adult age is relativized by the multiple comorbidities with the Axis I diseases, by overestimation of the economic and social environment influences, as well as the hospitalization or detention conditions in which often are performed the personological evaluations. Often behaviour disorders are masked by the roles of life or ignored by the community mentality. In third age, the intervention of cognitive factors, the more fragile somatic condition, the rarefaction of the social support network and of the existential roles, influence negatively the accuracy of pathological personalities diagnosis.
The psychiatrist’s responsibility in formulating the personality disorder diagnosis is a most particular one because of the diversity of prejudices and expectations of the profane world, but also of the medical one, the particularities of contemporary social and cultural dynamics and of gravity stigmatization – ethically similar
– with the one in the psychoses field.
And maybe – in the last resort – it is often difficult to know if an ugly image or an adored one is inside us or outside.
1.Nirestean A sub.red. Personalitate si deschidere spirituala. Tg.Mures: University Press, 2009
2.Lazarescu M, Nirestean A. Tulburarile de personalitate. Iasi: Ed.Polirom, 2007
3.Diagnostic and Statistical Manual of Mental Disorders, 5th ed., American Psychiatric Association, 2013
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5.Costa PT, Mc Crae RR. Revised NEO – Personality Inventory and the NEO-Five-Factor Inventory professional manual. Psychological Assesment Resources, Odessa FL, 1992
6.Widiger TA, Simonsen E. Alternative Dimensional Models of Personality Disorders: Finding a Common Groand. Journals of Personality Disorders 2005, 2, 110-130
7.Trimble MR. The soul in the brain. Baltimore: John Hopkins University Press, 2007
8.Joseph R. The transmitter to God. University Press of California, Berkeley, 2001