Personality Disorders

C. Robert Cloninger, MD, PhD (Corresponding author)

Wallace Renard Professor of Psychiatry
Washington University School of Medicine,
660 South Euclid, Campus Box 8134
St. Louis, MO 63110
Phone: +1 314 362-7005
Fax: +1 314 362-5594
Email [email protected]

Dragan M. Svrakic, MD, PhD.

Professor of Psychiatry
Washington University School of Medicine,

660 South Euclid, Campus Box 8134

St. Louis, MO 63110
Phone: +1 314 362-3903
Fax: +1 314 362-6501
Email: [email protected]

Nigel C Lester, MD
Washington University School of Medicine,
660 South Euclid, Campus Box 8134
St. Louis, MO 63110
Phone: +1 314 362-7005
Fax: +1 314 362-5594
Email [email protected]

Dusica Lecic-Tosevski, MD, PhD

Professor of Psychiatry and Director, Institute of Mental Health, University of Belgrade, Serbia.
E-Mail: [email protected], [email protected]

Nestor Koldobsky, MD.

Professor of Psychiatry, Universidad de la Plata, La Plata, Argentina
E-mail: [email protected]

Michel Botbol, MD
Professor of Child and Adolescent Psychiatry
University Western Brittany, Brest, France
E-mail : [email protected]

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Abstract: 223 words
Text: 6610
Figures: 1
Tabes: 4

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Abstract

The assessment of personality and its disorders is a core feature of Person-centered

Medicine (PCM) because it allows the promotion of health by stimulating greater self-awareness

and thereby promoting the integration of all aspects of a person's life. Growth in self-awareness

leads to greater flexibility and resilience in the individual and thus is at the root of sustainable

well-being. Personality disorder (PD) is the primary psychiatric illness observed in most patients

with psychosocial complaints, and such patients constitute the majority of patients seeking

treatment in primary care. Reliable diagnosis of PD can be made in routine clinical practice by

brief assessment of two essential features of a person’s character -- low self-directedness and low

cooperativeness -- that indicate reduced ability to work and to get along with other people.

Subtypes can be distinguished in terms of configurations of temperament traits measuring a

person’s emotional drives for immediate gratification. Improved self-regulation through

development of character strengths, virtues, and greater plasticity can promote greater physical,

mental, social, and spiritual well-being even in cases of severe PD. The strengths and

weaknesses of both DSM and ICD classifications are discussed in relation to a scientifically

grounded psychobiological model that allows a coherent systematic approach to rating the level

of a person's healthy character strengths and the qualitative diagnostic features of their styles of

emotional expression and mental self-government.

Key Words: Personality, Personality Disorders, Temperament, Character, Pharmacotherapy,

Psychotherapy, Meditation, Contemplation, Self-awareness, Well-Being

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Why are personality disorders important?

The assessment and treatment of personality and its disorders is a core feature of person-

centered medicine for several interrelated reasons (Cloninger and Cloninger 2011). First,

recognition of the personality of another person helps to establish an effective working alliance

because everyone likes to be known as a person with unique interests, motivation, and values,

rather than being reduced to a categorical diagnosis or a chief complaint about a particular organ

or function. Put in a broader historical and cultural context, we see that medicine has more often

adopted a whole person approach (from the Ancients to the Renaissance) and that the fragmented

view of the individual is a more a recent interlude paralleling the modern industrial era.

Second, assessment of personality stimulates greater self-awareness so that people can

begin to better recognize the connections between their lifestyle and their health status, thereby

promoting greater capacity for self-regulation that will help to reduce their suffering and

improve their well-being. Self-regulation, as opposed to external regulation, is the driver of

sustained positive change. In order to understand and appreciate another person's health status, it

is essential to know as much as possible about their personality and lifestyle behavior. Third,

greater self-awareness of the impact of personality and related lifestyle activities is crucial for

health promotion to prevent acute and chronic diseases from emerging before a person becomes

symptomatic. Clinicians are today aware that modern medicine, so often limited to end-stage

symptoms management, is increasingly recognized as an unsustainable approach to human

suffering. The actual causes of most morbidity and mortality are directly related to personality

and lifestyle, so greater self-regulation is essential for reducing the burden of disease and

improving well-being (Mokdad, Marks et al. 2004, Balluz, Okoro et al. 2008). Personality

disorder (PD) is the primary psychiatric illness observed in most patients with psychosocial

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complaints. PD is present in about one-sixth of people in the general population and in most

primary care or psychiatric patients (Cloninger and Svrakic 2009). People with personality

disorders have poor self-esteem, reduced ability to work and to love, and frequent stress

responses that lead them to seek medical treatment.

In addition to generating chronic personal suffering and/or substantial social or

professional consequences, personality disorders predispose an individual to other mental

disorders, including substance abuse, mood and anxiety disorders, eating disorders, somatoform

and dissociative disorders, and psychoses (Cloninger, Zohar et al. 2010). The complex dynamic

interactions of personality are often at the root of this comorbidity that is observed across the full

spectrum of psychiatric illness. Unless the underlying personality features are assessed and

treated, little improvement in the comorbid disorders is likely, certainly not in a sustained way.

Furthermore, personality disorders or extreme personality traits interfere with cooperation with

prescribed treatments and outcome. Without an informed awareness of personality, the therapist

runs the risk as being perceived by the patient as lacking authenticity. Consequently,

effectiveness of any medical treatment is greatly impaired unless their is thorough assessment

and treatment of personality and its disorders in clinical practice, as is amply demonstrated by

the marked burden of chronic disease in Western societies (Cloninger 2013).

Consequently, a solid conceptual understanding and classification are critical to deal with

these prevalent and chronic disorders with sensitivity and efficiency. Yet, current systems for

classification of personality disorders have serious practical and theoretical limitations (Widiger,

Simonsen et al. 2006, Cloninger 2015). The concept of personality disorders as sharply

delineated categories, as described in the current classifications of the American Psychiatric

Association and the World Health Organization, is both imprecise and clinically impractical.

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The categorical criteria for these disorders overlap and many individuals usually meet criteria for

more than one diagnosis. In fact the most common personality disorder diagnosis in DSM-IV

was the residual category of personality disorder “not otherwise specified”, which is used to

designate cases that do not fit any one category well. Such findings raised serious questions

about the validity and utility of categorical personality diagnoses.

In DSM-5 an effort was made to develop a system that could combine aspects of both

dimensional and categorical features. Research has consistently shown that the boundaries

between mental disorders are not sharply defined, and yet DSM persists in delineating many

overlapping disorders while warning clinicians not to reify these diagnoses.

The criteria proposed by the DSM-5 working group on personality disorder were not

accepted because the APA’s Scientific Review Board regarded the scientific evidence as

insufficient for the major changes proposed and the APA’s Clinical and Public Health Review

Board regarded the criteria as too unwieldy for routine clinical use. As a result, the DSM-IV

criteria for personality disorders were retained for official use in DSM-5, but the criteria

proposed by the working group were listed as “alternative criteria” for research and clinical

consideration. Reference to DSM criteria for personality disorders in this chapter indicates the

current official criteria, which are the same in DSM-IV and DSM-5. The alternative DSM-5

criteria will also be briefly described so that the reader can appreciate the shortcomings of

current criteria that the alternative criteria attempt to address, as well as how the alternative

criteria are related to the more coherent approach described herein. Fortunately, scientific

research allows a coherent and clinically practical approach to the assessment and treatment of

personality and its disorders that transcends the limitations of current official classifications in its

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utility for understanding etiology, development, and treatment (Cloninger 2000, Cloninger 2004,

Cloninger 2013, Cloninger 2015)

What is personality?

People differ markedly from one another in their outlook on life, in the way they interpret

their experiences, and in their emotional and behavioral responses to those experiences. These

differences in outlook, thoughts, emotions, and actions are what characterize an individual’s

personality. More generally, personality can be defined as the dynamic organization within the

individual of the psychobiological systems that modulate his or her unique adaptations to a

changing internal and external environment (Cloninger, Svrakic et al. 1993). Each part of this

definition is important for a clinician to appreciate. Personality is “dynamic”, meaning that it is

constantly changing and adapting in response to experience, rather than being a set of fixed

traits. Inflexibility of personality is actually an indicator of personality disorder. Personality is

regulated by “psychobiological” systems, meaning that personality is influenced by both

biological and psychological variables. Consequently treatment of personality disorders requires

growth in psychological self-understanding and not just treatment with medications, although

these can be helpful adjuncts to therapy (Oldham, Gabbard et al. 2001). These systems involve

interactions among many internal and processes, so each person’s pattern of adjustment is

“unique” to them, even though they follow general rules and principles of development as

complex adaptive systems (Cloninger 2004) Finally, to understand personality and its

development we must pay attention to both the “internal” and “external” processes by which an

individual interacts with and adapts to their own internal milieu and external situation. For

example, when a person is under stress, they are likely to think and feel differently about

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themselves and other people. On the other hand, when they are calm and encouraged, they may

act more maturely and happily. Everyone has personal sensitivities or “rough spots” that surface

when they are under stress. Everyone has “good days” and “bad days”, and this pattern of

variability over time is what characterizes a person’s personality. As the stressors faced in

modern life grow in complexity and intensity, clinicians increasingly observe the emergence of

unhealthy and mal-adaptive patterns in their patients.

What is a personality disorder?

The diagnosis of personality disorder (PD) requires that the patients have a maladaptive

pattern of responses to personal and social stress that is stable and enduring since early

adulthood, inflexible, and pervasive. These response patterns lead to chronic and pervasive

impairments in their ability to work and to cooperate with others. For example, they may have

problems with perfectionism or underachievement, and excessive dependency or social

detachment. In addition, most patients with PD consistently have low self-esteem and handle

stress poorly. The resulting subjective distress often leads them to complain about anxiety,

depression, and worries about physical health. Many patients with personality disorders have

problems with impulse control, such as being too impulsive or too rigid. They also have

problems in the way they perceive and interpret themselves, other people, and events, such as

cognitive deficits in empathy, tendencies to blame others, and tendencies to be suspicious of

others’ intentions. Lastly, these patients have difficulty in maintaining healthy lifestyle choices

about their diet and personal activities, such as drinking, smoking, and exercise. Consequently,

personality and its disorders influence both objective and subjective aspects of physical health.

In summary, the abnormal outlook on life that is characteristic of personality disorder leads to

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impairment in emotional regulation, impulse control, human relationships, cognition, and

physical health.

Individuals with PD typically blame other people or external circumstances for their

own physical, psychological, or social problems. Their externalizing of responsibility is a result

of two characteristics of PDs to which all clinicians must be alert. First, these patients provoke

strong emotional reactions from others but do not recognize the abnormality of their own

attitudes, thoughts, and feelings. Second, they try to change others, instead of changing

themselves. Both these features reflect an effort to reduce their distress and improve their

perceived quality of life, but unfortunately in ways that actually impair their health in the long-

run (Cloninger 2004, Cloninger and Svrakic 2009).

The diagnosis of PD can be made accurately with little time or expense once their

essential features are learned so that they can be recognized and understood. Recognizing the

personality issues underlying somatic and psychosomatic complaints improves treatment

efficiency and outcomes. Both the physician and patient need to understand that personality

predisposes to objective diseases in all organ systems, and not only to functional psychosomatic

complaints (Rosenstrom, Jokela et al. 2012). The impact of personality is observed at the root of

many illnesses, operating through more-or less direct and indirect mechanisms.

Clinical Features of Personality Disorders: Current descriptive criteria that are diagnostic

of a PD according to the American Psychiatric Association are summarized in Table 1.

INSERT TABLE 1 HERE

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 As shown in Table 1, the maladaptive behavior patterns must be “stable and enduring”,

that is, very long term if not lifelong characteristics. The DSM criteria require that the

maladaptive pattern be "of long duration and its onset can be traced back at least to adolescence

or early adulthood". In practice it can be difficult to distinguish long-term maladaptation typical

of PD and chronic personality changes caused by other mental disorders (such as chronic

depression) or long-term situational factors (such as financial dependency on one’s spouse).

Second, the maladaptive pattern must be inflexible and pervasive, that is, manifest in a wide

range of personal and social contexts (i.e., at home, at work, with family, and friends), not only

in isolated aspects of the person's life. Finally, there must be substantial evidence of subjective

distress, impaired social and occupational function, or both. Subjective distress refers to low

self-esteem and limited problem-solving skills, which often lead to anxiety, depression, and

somatic complaints. The social and occupational impairments in people with PD result from

their immature perspective on life, which is manifest as deficits in self-awareness and character

development. More simply, individuals with personality disorders lack mature goals and values.

In addition to these consistent features of all PDs, there is much variation in specific

styles of thinking, feeling, and relating. The Diagnostic and Statistical Manual of Mental

Disorders (DSM), published by the American Psychiatric Association, distinguishes three

clusters of PD (odd, dramatic, and anxious), but features of more than one cluster frequently

occur in the same patient. Furthermore, each cluster is subdivided into discrete subtypes of PD

(see Table 2), but most patients with PD have features of more than one subtype (e.g.,

narcissistic, histrionic, and antisocial symptoms usually occur together).

INSERT TABLE 2 HERE

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 In contrast to the current official criteria for diagnosis of personality disorders in DSM-

IV and DSM-5, DSM-5 also allows consideration of alternative criteria for assessment of

personality functioning and pathological personality traits. The alternative assessment is

comprised of 3 components that were developed separately and are not really coherently related

to one another. The 3 components of the alternative assessment approach are a reduced list of

specific categories, a description of healthy personality, and a list of five pathological traits like

those derived by factor analysis (APA 2013), as summarized in Table 3.

TABLE 3 ABOUT HERE

The alternative criteria for personality disorder in DSM-5 only consider the diagnosis of

a reduced set of categories: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive,

and schizotypal personality disorders, even though there is extensive scientific support for other

disorders, such as histrionic personality disorder. Any system of profiles emerging from 3 to 7

underlying dimensions would require recognition of other syndromes, as illustrated in Figure 1.

However, the categories in the alternative DSM-5 approach were not systematically derived from

the set of five pathological traits delineated in DSM-5, as is done in the psychobiological model

of personality. Likewise, healthy personality functioning did not represent the healthy poles of

the pathological personality traits. In fact, the description of healthy personality included

descriptors closely related to Self-directedness and Cooperativeness. Self-directedness is not the

healthy pole of Negative Affectivity because Negative Affectivity includes low Self-directedness

combined with high Harm Avoidance.

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 As a result of these limitations and internal inconsistencies, the alternative criteria

provide an approach to diagnosis that was judged by the APA to be inadequately supported by

scientific data and too unwieldy for clinical practice.

Deconstructing the components of personality and its disorders

Qualitative terms like "inflexible" and "enduring" require subjective judgments and

produce little precision in the diagnosis of PD in general. Fortunately, quantifiable components

of personality have been identified that allow the differential diagnosis of personality disorders

(Cloninger 1987, Cloninger 2000, Cloninger 2013). The features that distinguish people with

any PD from those with no PD are called character traits. The features that differentiate among

subtypes of PD are called temperament traits. More generally, temperament is defined as the

emotional core of personality. Character is defined in terms of a person’s goals, values, and

human relationships. A person’s character is based on their outlook on life, which allows them

to regulate conflicts among the temperament dimensions. The regulation of emotional drives

allows a person to accomplish meaningful goals and to maintain human relationships in

accordance with his or her values and needs. Hence the harmonious integration of personality

depends on the coherence of character, not on the temperament configuration.///

Three dimensions of character have been distinguished: self-directedness,

cooperativeness, and self-transcendence. Self-directed people are responsible, purposeful,

resourceful, self-accepting, and dutiful, whereas others are blaming, aimless, helpless, vain, and

insecure. Cooperative people are tolerant, empathic, helpful, compassionate, and principled,

whereas uncooperative people are prejudiced, uncaring, selfish, revengeful, and opportunistic.

Self-transcendent people are intuitive, idealistic, contemplative, faithful, and spiritual, whereas

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others are self-conscious, pragmatic, judgmental, cynical, and skeptical. Each of these aspects of

character are crucial for healthy adaptation to life under current world conditions in which ego-

centric behavior is threatening to produce mass extinction (Cloninger 2013).

It has been repeatedly demonstrated that poorly developed character traits, especially self-

directedness, increase the risk for PD substantially (Cloninger 2000). Indeed, most individuals

with PD have difficulty accepting responsibility, setting long-term goals, accepting their own

limitations, and/or overcoming obstacles they encounter in life. Usually, but not always, they are

also uncooperative, i.e., they tend to be intolerant of others, insensitive to other people's feelings,

selfish, have difficulty trusting and confiding in other people, and are often hostile and

revengeful when others disappoint them, but are quick to take advantage of others in an

unprincipled manner when the opportunity arises.

High self-directedness is not always protective against PD. Some narcissistic and

antisocial persons may appear to be highly self-directed, i.e., quite resourceful and purposeful

and thus successful in pursuing their narcissistic or antisocial goals. Recent genetic research

indicates that their reports of self-directedness are an expression of their egotism so their low

self-acceptance serves to distinguish it from health-promoting forms of Self-directedness. Their

very low cooperativeness (e.g., intolerance of others, low empathy) and low self-transcendence

(e.g., lack of generosity and other virtues) may so interfere with social relations that they have a

PD.

While low character traits represent the core features determining the presence or absence

of PD, other quantifiable traits are used for differential diagnosis of the DSM clusters (eccentric,

dramatic, anxious) and discrete subtypes of PD. The different clusters of PD are distinguished

by differences in basic emotions regulated by the temperament dimensions. Four dimensions of

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temperament have been identified, and are labeled novelty seeking, harm avoidance, reward

dependence, and persistence. Individuals high in novelty seeking are impulsive, quick-tempered,

extravagant, and dislike rules, as is characteristic of antisocial, histrionic and other erratic PDs.

Individuals high in harm avoidance are anxious, fearful, shy, and fatigable, as is characteristic of

avoidant and other anxious PDs. Individuals low in reward dependence are socially indifferent,

aloof, cold, and independent, as is characteristic of schizoid and other odd PDs. Individuals who

are high in persistence, such as some mature and some obsessional patients, are industrious and

persevering, whereas those who are low in persistence are easily discouraged. Factor analyses

have repeatedly supported the validity of the above three DSM clusters of PD (i.e., eccentric/odd,

anxious/fearful, erratic/dramatic) except that symptoms for compulsive PD tend to load

separately from other PDs thus forming a fourth cluster (Mulder and Joyce 1997). The fourth

temperament dimension, Persistence, has been shown to correlate with symptoms for obsessive-

compulsive PD.

In ICD-11 four groups of patients that correspond closely to individuals extreme in these

four temperaments are being considered for simpler categorization of personality difficulties and

disorders (Tyrer, Crawford et al. 2014). In the ICD-11 classification of personality variation, the

main distinction is a severity rating of personality dysfunction ranging from no personality

disorder to personality difficulty and mild, moderate, and severe personality disorder (Tyrer

2014). Personality difficulty is not a disorder but its use would allow recognition of such

dysfunction as a target for intervention. The severity rating of personality dysfunction is then

further qualified by description of four domain traits that describe what personality features are

most prominent in the person. These four domain traits correspond to the four temperaments:

negative affective traits (i.e., anxiety-prone as in high Harm Avoidance), dissocial (i.e.,

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impulsive as in high Novelty Seeking), detached (i.e., aloof as in low Reward Dependence), and

anankastic (i.e., obsessional as in high Persistence). Peter Tyrer, the head of the ICD-11

committee on personality disorders, has argued that the DSM-IV criteria were unrealistic

scientifically because they tried to specify sharp boundaries between categories that are better

described on a continuum of severity. He has pointed out that DSM-IV criteria were also

unpopular in practice for clinicians for the essentially the same reason -- they had too many

categories that frequently overlapped. Tyrer noted that DSM-5 has failed to address effectively

either the scientific or the practical problem of many categories for personality disorder. In fact,

DSM-5 alternative criteria were rejected by the leadership of DSM-5 itself and the alternative

criteria were listed for possible consideration by clinicians, but made the criteria even more

unwieldly and impractical for use. He has called on psychiatrists worldwide to adopt the ICD-11

criteria in place of DSM-5 because he feels the ICD-11 approach will destigmatize the diagnosis

and encourage clinical intervention by emphasizing severity of dysfunction over falsely reified

categorical distinctions (Tyrer 2014). Fortunately the psychobiological model of personality and

its disorders is scientifically well-grounded and provides practical ways to rate the severity of

personality disorder in terms of its character dimensions and also allows specification of

prominent features of personality profiles in terms of its temperament dimensions (Cloninger

2015). Multidimensional profiles of temperament and character have the diagnostic power that

clinicians like about a categorical diagnosis and do not falsely reify the diagnosis as representing

a homogeneous disease entity.

It is important to recognize that both DSM and ICD approaches to classification have

serious deficiencies because they fail to describe the multidimensional structure of the normal

and abnormal aspects of a person's personality in a systematic way. ICD rates severity and

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describes prominent traits, which is simple and practical but does not capture the information

needed to guide treatment optimally. DSM-5 alternative criteria are a hybrid approach to

categories and dimensions that are not really coherent because the categories cannot be derived

from profiles of the dimensions.

To put these deficiencies in perspective, it is important to consider what temperament and

character traits reveal about a person. Temperament traits regulate the primary emotions of fear

(harm avoidance), anger (novelty seeking), and attachment/disgust (reward dependence). Often

people with PD impress others as irrational and/or excessively emotional because their behavior

and interactions are dominated by extreme temperament traits that are only weakly modulated by

character traits. These patients have a rather limited spectrum of the elementary emotions to

respond everything going on inside and around them. In contrast, mature people have a more

complex emotional life including a broad spectrum of so-called secondary emotions, such as

humility, compassion, empathy, equanimity, and patience. The likelihood of a well-adapted

temperament and mature character is high when these complex emotions are prominent.

Character traits describe the maturity of a person's goals and values in ways that can be

specified both in terms of severity and in terms of profiles that describe a person's style of mental

self-government. Additional personality subtypes can each be distinguished by a unique

combination of values on the temperament dimensions. These can all be assessed by mental

status examination or by psychometric testing, as described elsewhere for the interested

(http://psychobiology.wustl.edu). For example, borderline PD is characterized by high novelty

seeking, high harm avoidance, and low reward dependence. Antisocial personality has the same

temperament profile except that harm avoidance is low. It is easy to remember the

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discriminating features of most personality disorders as the extremes of a cube with three

dimensions defined by novelty seeking, harm avoidance, and reward dependence (see Figure 1).

INSERT FIGURE 1 HERE

Stages in the Development of Self-awareness and Well-Being

A full assessment of personality requires consideration of a person’s level of self-

awareness and well-being, not just their impairments. Health and well-being are more than the

absence of deviant traits. Well-being depends on a person’s level of self-awareness and leads to

the expression of human virtues and positive emotions that go beyond what is average in

contemporary society (Cloninger 2004).

There are three major stages of self-awareness along the path to well-being, as

summarized in Table 4, based on extensive work by many people (Cloninger 2004). The

absence of self-awareness occurs in severe personality disorders and psychoses in which there is

little or no insightful awareness of the preverbal outlook or beliefs and interpretations that

automatically lead to emotional drives and actions. Lacking self-awareness, people act on their

immediate likes and dislikes, which is usually described as an immature or “child-like” ego state.

The first stage of self-awareness is typical of most adults most of the time. Ordinary

adult cognition involves a capacity to delay gratification in order to attain personal goals, but

remains egocentric and defensive. Ordinary adult cognition is associated with frequent distress

when attachments and desires are frustrated. Hence the average person can function well under

good conditions, but may frequently experience problems under stress. At this stage of self-

awareness, a person is able to make a choice to relax and let go of their negative emotions,

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thereby setting the stage for acceptance of reality and movement to higher stages of coherent

understanding.

INSERT TABLE 4 HERE

The second stage of self-aware consciousness is typical of adults when they operate like a

“good parent”. Good parents are allocentric in perspective – that is, they are “other-centered”

and capable of calmly considering the perspective and needs of their children and other people in

a balanced way that leads to satisfaction and harmony. This state is experienced when a person

is able to observe his or her own subconscious thoughts and consider the thought processes of

others in a similar way to observing his or her own thoughts. Hence the second stage is

described as “meta-cognitive” awareness, mindfulness, or “mentalizing”. The ability of the mind

to observe itself allows for more flexibility in action by reducing dichotomous thinking and

excessive emotional reactivity (Teasdale, Moore et al. 2002, Kuyken, Hayes et al. 2015, van der

Velden, Kuyken et al. 2015). At this stage, a person is able to observe himself and others for

understanding, without judging or blaming. However, in a mindful state people still experience

the emotions that emerge from a dualistic perspective, so mindfulness is only moderately

effective in improving well-being (Cloninger 2004)

The third stage of self-awareness is called contemplation because it is direct perception of

one’s outlook – that is, the preverbal assumptions and schemas that direct one’s attention and

provide the frame that organize and bias our expectations, attitudes, and interpretation of events.

Contemplation, which brings into consciousness what was unconscious, can be thought of as the

opposite process as repression, which puts memories out of consciousness. Direct awareness of

our outlook allows the enlarging of consciousness by accessing previously unconscious material,

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thereby letting go of wishful thinking, prejudicial biases, and the impartial questioning of basic

assumptions and core beliefs about life, such as “I am helpless”, “I am unlovable”, or “faith is an

illusion”. For example, many modern psychiatrists are skeptical materialists who are not aware

that their reductionist outlook is an extreme metaphysical assumption for which they have no test

or adequate evidence, but which leads them to ignore considerations that are essential for well-

being in themselves and their patients (Moreira-Almeida and Santos 2011, Cloninger 2013). In

the third stage of self-awareness people begin to become aware of such assumptions and biases

of which they had previously been unconscious. The third stage of self-awareness can be

described as “soulful” contemplation because in this state a person becomes aware of deep pre-

verbal feelings that emerge spontaneously from a unitive and holistic perspective, such as hope,

compassion, and reverence (Cloninger 2004)Contemplation is much more powerful in

transforming personality than is mindfulness, which often fails to transform a person’s

unconscious outlook on life or to reduce feelings of hopelessness (Linehan 1993)

Extensive empirical work has shown that movement through these stages of development

can be described and quantified in terms of steps in character development or psychosocial

development, as in the work of Vaillant on Erikson’s stages of ego development (Vaillant and

Milofsky 1980). Such development can be visualized as a spiral of expanding height, width, and

depth as a person matures or increases in coherence of personality. Likewise, the movement of

thought from week to week or month to month has the same spiral form regardless of the time

scale. Such “self-similarity” in form regardless of time scale is a property characteristic of

complex adaptive systems, which are typical of psychosocial processes in general (Cloninger

2004). The clinical utility of this property is that therapists can teach people to exercise their

capacity for self-awareness, moving through each of the stages of awareness just described.

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Their ability to do so, and the difficulties they have, reveals the way they are able to face

challenges in life over longer periods of time. Cloninger has developed an exercise, called the

“Silence of the Mind” meditation, with explicit instructions to take people thorough each of the

stages of awareness as well as they can (Cloninger 2004). The first phase of this meditation

results in a relaxed state in the first stage of self-awareness. The second phase facilitates entry

into the second stage of self-awareness, and the third phase into the third stage of self-awareness,

if the person is able to do so. Using this and a way of observing thought during mental status

examination, mental health professionals can assess a person’s thought and its level of coherence

in a way that is constructive, easy, and precise without being judgmental (Cloninger, Zohar et al.

2010, Cloninger and Cloninger 2011). As the patient moves from ordinary self-awareness,

through mindfulness and then contemplation, the therapist and patient can calmly discover

together particular blockages in the patients’ path toward well-being, and develop creative

solutions to individual challenges.

Treatment

General Principles: Individuals with PD seldom think that they have a mental disorder

and so seldom seek help for mental disorder unless other people (such as a spouse, a colleague,

or parents) are insistent. This usually happens when maladaptive behaviors create severe marital,

family, and/or career problems. In addition, individuals with PD often seek medical seek help

when other associated mental symptoms (e.g., anxiety, depression, substance abuse) or somatic

symptoms begin to bother them. Hence person-centered medicine offers the opportunity to help

people with PDs to address problems that they personally care about, which is their own physical

and mental well-being. Medical consultation is an important opportunity to help people with

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PDs to recognize the changes they need to make in order to improve their subjective well-being

and their objective health. In general, patients with PD require a multifaceted treatment plan that

always combines psychotherapy and pharmacotherapy.

There are three major barriers to effective treatment of PD, but, fortunately, all are

preventable errors within the control of the healthcare professional. The first is the frequent loss

of professional objectivity, signaled by the development of strong emotions (positive or

negative) also called positive or negative counter-transference. Such inappropriate personal

involvement is a red flag to reassess the treatment strategy, seek objective supervision of therapy

sessions, and, if persistent, mandate referral to another psychiatrist or therapist. Frequent

discussions and counseling with colleagues are useful because even strong counter-transference

feelings can persist unrecognized.

The second preventable error in PD management is to believe the myth that PDs cannot

be treated effectively. This myth is partly initiated by negative counter-transference of some

professionals, and then sustained by a failure to consider signs showing the effectiveness of

treatment. In other words, belief in the untreatability of a patient sets the stage for a self-

fulfilling prophecy. However, many controlled studies indicate that even severe PDs, such as

borderline or antisocial, can be effectively treated within an appropriate setting, such as a

cooperative therapeutic alliance (Cloninger 2005)

The third preventable error in PD management is to give direct advice on personal and

social problems. This is counterproductive in patients with PD because they usually become

dependent, non-compliant, or resentful. Occasionally, direct advice may be offered to some

antisocial, narcissistic, and schizoid patients who are at low risk of developing dependency and

need precise structure and direction initially. When tempted to give direct advice to patients,

21
remember that change in personality requires more than common sense and logic. If the

relationship leads to frequent advice giving, then referral to a psychiatrist or psychologist may be

indicated. People change if they become self-aware and thus able to self-observe, eventually

leading to recognition of their own role in chronic dissatisfaction with their health status, and

with themselves and their relationships. Personal growth thus arises from new insights about

oneself, the environment, and the connection between one's personality, lifestyle, and health

status. Direct advice robs the patient of the opportunity to develop new insights and to learn from

his or her mistakes. Although supportive psychotherapy is not recommended with PD patients,

supporting their existing coping mechanisms that are mature and adaptive is always useful (e.g.,

joint evaluation of options and encouragement to practice skills in solving problems).

Substantial personality change, which is invariably needed people with PDs, involves an

extensive reorganization of internalized concepts and coping mechanisms and thus requires

precise diagnostic analysis, specific treatment strategies, and expert training. The expert

treatment may include any of the several available psychotherapy approaches and is usually

combined with pharmacotherapy and mind-body therapy, so optimally the treatment of

personality disorder is a prominent example of the utility of person-centered (integrative)

medicine in practice. The major points relevant to integrative therapy of PDs are summarized

below.

As already mentioned, individuals with PD have a peculiar capacity to elicit strong

emotions from other people. They are often described as aggravating, unlikable, difficult, or bad.

Alternatively, they may be seductive or dependent, and elicit inappropriate emotions or actions,

such as sexual interest or the urge to rescue. Even professionals may have difficulty treating

them with respectful objectivity because of a blurring of personal boundaries. Such loss of

22
objectivity occurs because the patient's deeply felt assumptions about other people may often

elicit interpersonal responses that are appropriate to the patient's assumptions. Our assumptions

about ourselves and others often become self-fulfilling prophecies because of automatic

mechanisms of affect transfer. If someone smiles at you, communicating appreciation, it is

natural to experience feelings of social attachment and to smile back automatically. Likewise, if

someone frowns, communicating anger, it is natural to feel defensive in preparation for his or her

angry attack. For example, many patients with PD are suspicious and hostile about others'

motives. This distrustful attitude is communicated in many verbal and non-verbal ways and

often elicits disagreement or frank hostility from others. These uncooperative responses

reinforce the original negative assumptions of the patient, which in turn leads to further

alienation.

This vicious cycle of affect transfer can only be interrupted by professional objectivity

combined with patience and compassionate respect for the patient’s disability. Such objectivity

arises from recognizing the overall meaning and implications of their pattern of interpersonal

signals, so that their verbal and non-verbal communication takes on diagnostic and therapeutic,

rather than personal, significance. In optimal therapeutic relationships, "patients" should be

patiently hopeful and physicians should be compassionately realistic. Whenever professionals

become aware of strong positive or negative emotions toward a patient (so-called "counter-

transference" reactions), this should help to alert them to the possibility that the patient has a PD.

As many patients with PD do not recognize or admit their psychopathology they resist

and resent psychiatric diagnoses and any form of mental health treatment. Accordingly, it is

prudent to steadfast in a person-centered approach to health care: let the patient define his/her

treatment goals and then jointly evaluate the likelihood of successful outcome until treatment

23
goals that both patient and therapist agree upon can be identified. Initially, these goals should be

as simple and concrete as possible (e.g., "to develop social skills", or "to reduce alcohol use",

etc.). In many, but not all cases, successful completion of this initial phase will motivate the

patient to define other, more complex treatment goals and to continue treatment.

Both primary care-takers and mental health experts need to keep in mind that there is a

natural succession of stages in the treatment of patients with personality disorders. The four

stages in the treatment of a patient with personality disorder can be described as (1) crisis

management and stabilization, (2) awakening of a positive perspective and spiritual values in

life, (3) illumination, and (4) integrated intelligence (Cloninger 2006). Each has different goals

and requires different methods. The complete care-taker should be prepared to guide people

along these stages, ever ready to advance to the next stage if a person is interested and prepared

to do so. In this chapter the initial stabilization and awakening phases will be discussed using an

integrative medical approach that combines integrative pharmacotherapy (Cloninger and Svrakic

1997, Svrakic and Cloninger 2012), mind-body therapy (Bertisch, Wee et al. 2009, Chiesa 2010,

Fjorback 2012), and person-centered psychotherapy (Cloninger and Cloninger 2011). The more

advanced phases of treatment will be considered in another chapter on psychotherapy.

Integrative treatment of personality disorders: The initial stage of crisis management and

stabilization deals with the presenting problem and stressors in order to help the patient get into a

calm enough state and a working alliance with the psychiatrist. The second stage involves

elevating a person’s outlook on life so that they can experience things they enjoy and value under

relaxed conditions. This involves a spiritual awakening that has often been neglected in strictly

cognitive-behavioral or psychodynamic approaches but without which there is little capacity for

24
fundamental change in the quality of life. The third stage of illumination involves increases in

self-awareness and capacity for contemplation that elevate a person’s usual thoughts, feelings,

and relationships in a wide range of conditions. The fourth stage of integration of reason and

love in action allows a person to be mature and happy even under conditions that were

previously stressful. Patients with PDs can pass through these stages on their own (i.e., remit

spontaneously) or be guided through these stages in treatment facilitated by a scientifically

designed set of physical, personal, social, cognitive, and spiritual exercises (Cloninger 2006).

25
 What is done in the first stage of treatment depends greatly on individual patient and his

or her presenting situation. This initial stage may involve stabilization of the patient with

medications if they are indicated and the patient is interested in such treatment. Medications are

often helpful, but not everyone wants such treatment because they always carry some risk of

side-effects and can be costly. The advantages and disadvantages must be carefully weighed to

respect the patient’s wishes and to help them be calm and organized enough for further growth in

self-awareness. On the other hand, integrative mind-body therapy or psychotherapy requires

more motivation for fundamental change than use of medication, so some people prefer to not try

to develop their capacity for self-regulation and prefer to rely on more passive treatments like

medication. Commitment to change requires recognition that change is possible and worthwhile.

A person-centered care-taker must engage the patient by providing a range of alternative

approaches to achieve what the patient values, such as relief of subjective distress (i.e., anxiety,

depression, sleep problems) and enhancement of self-confidence and self-respect by

accomplishing SMART (specific, measurable, achievable/assignable, realistic, time-related)

goals (Cloninger, Salloum et al. 2012).

Providing a wide range of alternative approaches to a problem gives people flexibility

and hope that if one thing is too difficult or not effective, there are other pathways to well-being.

Medications can be targeted to specific symptoms, particularly anxiety and mood dysregulation,

aggression, emotional detachment, and magical thinking/perceptual abberations (Svrakic and

Cloninger 2012). Biofeedback for stress reduction is useful to optimize heart rate variability and

other indicators of psychophysiological coherence (Zohar, Cloninger et al. 2013). Psychosocial

interventions relying on person-centered dialogue can motivate people who were not even

considering change in lifestyle to improve their health related behaviors, including motivating

26
people to improve diet, exercise regularly, and reduce stress (Nigg, Burbank et al. 1999). Many

mind-body and energy therapies, such as acupressure, Tai Chi, and Qi Gong, promote self-

regulation, character development, and enhanced well-being (Bertisch, Wee et al. 2009).

Randomized controlled trials of mindfulness training promote well-being in association with

increased self-directedness, cooperativeness, and self-transcendence (Campanella, Crescentini et

al. 2014). Throughout this process, the clinician will periodically direct the patient to observe

their individual progress and character development, continually building hope and further

motivating the virtuous spiral upwards.

Conclusions

In practice, a flexible person-centered care-taker must be open to what is appealing to the

people they are treating and to what works regardless of their own personal preferences and

theoretical biases. Such flexibility is also what facilitates the maturation and integration of

personality through self-awareness, self-regulation, and beginning to consider and value the

needs of others. As a deeper awareness of connectedness grows, so a sustained change in the

outlook develops. Most fundamentally, a holistic approach that addresses all three aspects of a

person (i.e., body, thoughts, and soul) is essential for the maturation and integration of

personality in the full range of a person's life. People cannot enjoy full health without becoming

aware of the interrelationships among the sexual, physical, emotional, social, cognitive, and

spiritual components of their life. Accordingly, the assessment and treatment of people with

personality disorders must address the person as a whole, rather than reducing them to an organ

or a disease.

27
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Table 1. Qualitative description of personality disorders

DISCRIMINATING FEATURES
A maladaptive pattern of responses to personal and social stress that is
- stable and enduring since teens
- inflexible and pervasive
- causing subjective distress
and/or
impaired work and/or social relations

CONSISTENT FEATURES
Strong emotional reactions elicited from others
(like anger or urge to rescue)
Efforts to blame and change others, rather than oneself

VARIABLE FEATURES
- Odd, eccentric
- Erratic, impulsive
- Anxious, fearful

31
Table 2. Qualitative Clusters and Subtypes of Personality Disorders according to the current
official criteria of the American Psychiatric Association (DSM-IV, 1994 and DSM-5, 2014)

Cluster Subtype Discriminating Features

_________________________________________________________________
ODD/ECCENTRIC
Schizoid socially indifferent
Paranoid suspicious
Schizotypal eccentric

ERRATIC/IMPULSIVE
Antisocial disagreeable
Borderline unstable
Histrionic attention-seeking
Narcissistic self-centered

ANXIOUS/FEARFUL
Avoidant inhibited
Dependent submissive
Obsessive perfectionistic

NOT OTHERWISE
SPECIFIED
Passive-
aggressive negativistic
Depressive pessimistic
_________________________________________________________________

32
 Table 3. Alternative Assessment of Personality Functioning and Pathological Traits

(DSM-5, 2014)

Component of Assessment Elements to be assessed Descriptors

Personality Functioning Functioning of self Identity (self-esteem, sense of

uniqueness with boundaries)

Self-direction (rational goal-

setting)

Interpersonal Functioning Empathy

Intimacy

Pathological Traits Negative Affectivity Negative emotions, like

anxiety, depression, anger

Detachment Avoidance or withdrawal

from intimate relationships

Antagonism Hostility, self-importance

Disinhibition Impulsive self-gratification

Psychoticism Odd or eccentric thoughts and

behavior

33
Table 4. Three stages of self-awareness on the path to well-being (adapted from

Cloninger 2004)

Stage Description Psychological Characteristics

0 unaware immature, seeking immediate gratification

(“child-like” ego-state)

1 average adult purposeful but egocentric

cognition able to delay gratification, but has
frequent negative emotions (anxiety, anger, disgust)
(“adult” ego-state)

2 meta-cognition mature and allocentric

aware of own subconscious thinking
calm and patient,
so able to supervise conflicts and relationships
(“parental” ego-state, “mindfulness”)

3 contemplation effortless calm, impartial awareness

wise, creative, and loving
able to access what was previously unconscious
as needed without effort or distress
(“state of well-being”, “soulfulness”)

34
Figure 1
FF

35
Empapa clínicos e históricos en la humanización del diagnóstico y el tratamiento de los
trastornos de la persona, de la personalidad y de la personalidad

La propuesta de este capítulo es describir sintéticamente el leitmotiv de la

humanización y personalización del diagnóstico y tratamiento de trastornos de la
personalidad.
La personalidad y los conceptos persona son aspectos esenciales de la filosofía, la
sociología, la antropología, la ciencia, la ciencia médica, de salud mental y de la
psicología, todos ellos interesados en la comprensión de la esencia de los seres
humanos.

Algunas definiciones

Personalidad (P)
En la antigüedad, Hipócrates personalidad definida VAGUADA la teoría humor en la
ciencia médica. La evolución de la ciencia general ofreció una gran trayectoria de los
aspectos conceptuales de la persona y personalidad, muchas veces en relación con la
manifestación persona externa, el comportamiento.
Personalidad se refiere a la regularidad y la consistencia en el comportamiento y para
toda la experiencia individual. La personalidad es lo que nosotros, qué y quién somos y
nos hace diferente a los demás configurar.
La persona
Persona es un arquetipo integrado por el papel que desempeñan los seres humanos
para obtener las demandas `s. La persona también permite misma para manifestar sus
sentimientos en una forma aceptada por los otros.
Personalidad normal.
Personalidad normal se podría describir como las características de todos los rasgos
cognitivos, Emocional Y de comportamiento en la vida cotidiana de una persona. Esta
totalidad habitualmente es estable y predecible. (1)
Desorden de personalidad
La Escuela de Medicina de Pittsburgh, Western Psiquiátrica Inst y Clínica, analiza 4
formas relacionadas pero analíticamente diferentes en las que los trastornos de
personalidad (PDS) se puede conceptualizar. Desde un punto de vista biomédico,
constituyen entidades médicas para las que existe un fundamento neurobiológico y
validación. Desde un punto construccionista de vista cultural, PD se basan en
concepciones de la personalidad y las normas de comportamiento culturalmente

36
 apropiado que se han desarrollado en las sociedades angloamericanas. Desde un
punto de vista histórico-social, las PD ilustran dramáticamente el proceso de
medicalización que ha tenido lugar en las sociedades, especialmente en lo que se
refiere a este comportamiento social. Por último, las PD plantean un dilema filosófico en
tanto que es conceptualmente difícil trazar una línea clara entre el científico y el nivel
cultural. (1).
La Organización Mundial de la Salud y la Asociación Americana de Psiquiatría han
producido las definiciones de las definiciones de personalidad. La Clasificación
Internacional de los Trastornos Mentales y del Comportamiento (CIE-10) (Organización
Mundial de la Salud 1992), define un trastorno de la personalidad como: "una
perturbación grave en la condición caracterológica y tendencias de comportamiento del
individuo, por lo general involucran varias áreas de la personalidad, y casi siempre
asociada con un trastorno considerable personal y social ". La cuarta edición del
Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-IV) (American
Psychiatric Association, 1994) define un trastorno de la personalidad como: 'un patrón
permanente de experiencia interna y de comportamiento que se aparta acusadamente
de las expectativas de la cultura del individuo'. DSM IV introducir la neccessity a la
cultura considerer en la evaluación de los trastornos de personalidad, como un gran
paso para introducir la personalidad y sus trastornos en sus medios de comunicación
(3, 4). La personalidad también según DSM IV es "Un patrón permanente de
experiencia interna y de comportamiento los aparta acusadamente de las expectativas
de la cultura del sujeto. Este patrón se manifiesta en dos (o más) de las siguientes
áreas: 1. Cognición (es decir, formas de percibir e interpretar uno mismo, otras
personas y eventos) 2. Afectividad (es decir, el rango, la intensidad, la responsabilidad,
y la adecuación de emocional respuesta) 3. interpersonal funcionamiento 4. control de
los impulsos "
És permanente patrón ONU de Experiencia interna y de Comportamiento, Que se
aparta acusadamente de las Expectativas de la Cultura del Sujeto, y se Manifiesta en
dos o mas áreas: cognición, afectividad, Actividad interpersonales, y Control de
impulsos. Es persistente e inflexible, y Se presenta en Una Amplia Gama de
Situaciones Personales y Sociales, comporta malestar significativo o Deterioro social, el
laboral o de OTRAS ÁREAS Importantes de la Vida. Es estable y de larga Duración,
Inicia en la adolescencia o al Principio de la Edad adulta, no es atribuible una
Manifestación o Consecuencia de Otro trastorno mental, (2).
El Manual Diagnóstico y Estadístico de los Trastornos Mentales (5 ed .; DSM-5;
American Psychiatric Association, 2013), incluye un nuevo enfoque para el diagnóstico
de trastornos de la personalidad (PDS) sigue en la Sección III, para estimular aún más
la investigación con la posibilidad de que esta propuesta se incluirá más formalmente
en futuras versiones del DSM. Examinar simultáneamente sus 2 componentes
principales: un sistema para el deterioro calificación personalidad y un modelo
tridimensional de nuevo desarrollo de rasgos de personalidad patológicos. Este
importante reconceptualización de la psicopatología de la personalidad, el DSM-5,
identifica deficiencias fundamentales en el funcionamiento de la personalidad, los
rasgos de personalidad patológicos y prominentes tipos de personalidad patológicos.
Una evaluación integral de la personalidad consta de cuatro componentes: los niveles
de funcionamiento de la personalidad, tipos de trastorno de la personalidad, los

37
 dominios de rasgos de personalidad patológicos y facetas, y los criterios generales
para el trastorno de la personalidad. Esta evaluación de cuatro partes se centra la
atención en la identificación de psicopatología de la personalidad con el aumento de
grados de especificidad, con base en un clínico de tiempo disponible, información y
conocimientos. (5).
Los DSM-5 trastornos profundizan en la necesidad de considerar a la persona y su
entorno, cuando en los criterios generales de la personalidad introducir la identidad y su
relación interpersonal como factores de una definición adecuada:. Deficiencias
significativas en el funcionamiento de la personalidad se manifiesta por: 1. Deficiencias
en uno mismo funcionamiento en dos aspectos: a. Identidad, donde es una referencia
excesiva a los demás para la auto-definición y regulación de la autoestima; una auto-
evaluación exagerada puede inflarse o desinflarse o vacila entre los extremos; y la
regulación emocional refleja fluctuaciones en la autoestima. segundo. Autodirección
donde El establecimiento de objetivos se basa en obtener la aprobación de los demás;
los estándares personales son excesivamente alto con el fin de verse a sí mismo como
excepcionales, o demasiado bajo basado en un sentido de derecho; menudo
desconocen propias motivaciones.
2. Deficiencias en el funcionamiento interpersonal se manifiesta por también dos
aspectos: a. la empatía, donde hay un deterioro de la capacidad de reconocer o
identificarse con los sentimientos y necesidades de los demás; un exceso en sintonía
con reacciones de los demás, pero sólo si se percibe como relevante para uno mismo;
y sobre o subestimación del efecto propio en los demás. segundo. La intimidad, donde
las relaciones son en gran parte superficial y existen para servir a la regulación
autoestima; mutualidad limitada por poco interés genuino en otras "experiencias y
predominio de la necesidad de obtener beneficios personales (cita DSM 5).

Cultur
La ciencia y la práctica de la psiquiatría internacionalista contemporáneo encarna y
perpetúa siete pecados culturales y espirituales que están en necesidad de la
absolución: (1) incapacidad para apreciar los orígenes evolutivos de la psicopatología y
las implicaciones que esto tiene sobre su carácter simbólico (2) la promoción de un
secular credo, reduccionista del diagnóstico y la práctica que deja de lado la sabiduría
evolucionada de las grandes tradiciones de la medicina, así como los resultados
empíricos en psiquiatría culturales relacionadas con el carácter integrado de la
psicopatología; (3) la confianza en una filosofía y la nosología del diagnóstico que niega
la importancia de la psicología cultural humana y la importancia de la naturaleza de la
realidad existencial de una persona social, que afecta el carácter de la psicopatología;
(4) el desprecio del mandato social, moral que dio origen a la disciplina y la profesión
de la psiquiatría, que era para ayudar a personas desfavorecidas, explotado, y los
grupos sociales marginados cuya situación requiere abordar las preocupaciones de
base más amplia sobre el significado, la cultura y la espiritualidad, así como la realidad
de la explotación política y económica; (5) una negligencia y devaluación de los
significados culturales, religiosos y espirituales esenciales que son parte integral de la
experiencia y el diagnóstico de psicopatología y que están en necesidad especial de
reafirmación en el mundo contemporáneo; (6) una confianza indebida en un sistema de
tratamiento farmacéutico, la lógica de lo que minimiza si no se excluye el papel de la

38
 psicología cultural; y (7) la aprobación de las formas de psicoterapia que omiten la
importancia de las preocupaciones culturales, religiosos y espirituales en favor de,,
rúbricas objetivas, economicistas preformulados comportamiento. CULTURA,
ESPIRITUALIDAD Y PSIQUIATRÍA

Profesor Horacio Fábrega Jr. de Psiquiatría y Antropología de la Universidad de

Pittsburgh, 3811 0hara Street, Pittsburgh, PA 15213, EE.UU..

La heterogeneidad de la persona, la personalidad y el trastorno de la personalidad en

aspectos como la etiología, clínicas, pronóstico, evolución y tratamiento ha obligarnos a
analizar varios aspectos de diagnóstico y tratamiento, la genética, el temperamento, el
trauma, resilencia, la familia, la evolución, chilhood y adolescency, cognitivo y
desarrollo metacognitivo, valores, medio ambiente y sociedad, una serie de aspectos
que se han ido de la biología al ambiente social.
Esta complejidad en el análisis de los factores etiológicos y de riesgo había sido
introducido en las últimas décadas en varios tratamientos manualizados, así, muchos
de ellos ha tomado uno de estos factores como central para el desarrollo de técnicas
especiales de tratamiento. Frente a esto y con el sentido de poner atención en la
persona Dimaggio y Livesley explica que "el tratamiento no debe estrellas desde un
enfoque estrecho manual de tratamiento-trastorno específico, sino de un análisis
detallado o deconstrucción de la enfermedad del paciente y que los métodos de
tratamiento debe ser seleccionados sobre la base de lo que funciona para los
problemas específicos y la patología, que son el foco de preocupación "(6). A partir de
estas consideraciones, se introduce el concepto de tratamiento integrado como una
forma de acercarse a toda la complejidad de un paciente. No para adaptarse al
paciente a una teoría, si no adaptar las teorías para la especificidad de la paciente.
Cuando se toma en los principios generales de tratamiento, es posible ver un paso más
en la humanización del enfoque, ya que se requiere para identificar principios eficaces
de cambio terapéutico. El mecanismo genérico son una también una fuerte alianza de
trabajo, con el terapeuta en un enfoque enfático y flexible, una actitud terapéutica de
cuidado, cálido, la empatía, la consideración positiva, congruencia y autenticidad y un
nivel relativamente alto de actividad, y la relación terapeuta-paciente con un acuerdo
sobre los objetivos del tratamiento, la fuerte colaboración y trabajar hacia las metas (7).
Gunderson introducir Buena Gestión de Psiquiatría (GPM) por un corto plazo, la terapia
intermitente y normativo que por lo general son "lo suficientemente bueno". El enfoque
de tratamiento podría ser realizado por "nivel de entrada entrenado" inicial, permitiendo
que más possibilies de tratamiento para una población más grande. En caso de que
GPM no funciona o necesita ser completado es posible utilizar terapias basadas en la
evidencia como terapia dialéctica conductual (DBT), Linehan 1993), Tratamiento de
mentalización-Based (MBT, Bateman y Fonagy 2012), Transferencia centró
Psicoterapia (PTF, Yeomans et al., 2002), la terapia integrativa (IT, Livesley, 2007).
A partir de este mecanismo genérico se desarrollan los principios de tratamiento común
que también profundizan la consideración del enfoque para el individuo. Un uso
específico de la teoría del apego a refinar e individualizar el tratamiento PD (8). A esto
se añade mecanismo de tratamiento común o específica como la consideración de la
cognición social y los valores. La presencia de una buena carga de los valores permite

39
 el diagnóstico diferencial y el pronóstico de PD. También el desarrollo de los valores
durante el proceso de la terapia a mejorar los medios de comunicación y la
comprensión de los demás y la valorización. La cognición social permite al niño la
comprensión de las personas y de la realidad física que se basa en las experiencias de
signos mediada compartidos, transmitidos culturalmente JPD 2 2014 Ryley

La psicoeducación con el paciente y la familia contribuyen a la atención sanitaria y la

promoción solo se trata de la comunicación coactivo respetuosa "con la persona" (9).
Psichoeducation ayuda a diluir la estigmatización y los falsos conceptos de la familia o
de las personas acerca de los trastornos de personalidad del paciente como es un
ocioso, un ausente, una prostituta y así sucesivamente. Los pacientes cuando
entienden lo que está pasando con ellos también abandonar falsa el pronóstico de los
conceptos sobre sí mismos y su trastorno, que les permiten aceptar e integrar mejor a
un trato más humanizado y personal. Mecanismo otros, muchos de los que están en la
práctica y muchos que se presentó como nuevo mecanismo de diagnóstico, abordaje y
tratamiento incrementar el enfoque humanización y personalización en los trastornos
de la personalidad y de la personalidad. Conceptos de psicoeducación básicos, en
particular para los pacientes límite, son que el trastorno es significativamente haritable,
que es muy sensible a la tensión ambiental, que tienen una amígdala cerebral
hiperreactivas, muchos pacientes tienen remisiones de síntomas, tener múltiples
formas de tratamiento empíricamente validado, y mejorar significativamente sin recibir
estas terapias.

Lista de referencia
(1) Trastornos Fábrega H. personalidad como entidades médicas: Una interpretación
cultural. Revista de Trastornos de la Personalidad 8 [2], 149-167. 1994.
(2) Kaplan Harold, Sadock Benjamín J. Compendio de Psiquiatría. Salvat Editores SA,
editor. 2da., 1-979. 19987. Barcelona-Madrid.
(3) DSM - IV Manual diagnóstico y estadístico de los trastornos mentales. American
Psychiatric Association, editor. Cuarto, 1-886. 1999. Washington.
(4) OMS. CIE 10. Trastornos mentales y del Comportamiento. Organización Mundial de
la Salud, editor. 7-424. 1992. Madrid, FORMA S.A.
(5) Miller JD, Lynam DR. Las oportunidades perdidas en el DSM-5 Sección III trastorno
de personalidad nnnmodel: Comentario sobre "trastornos de personalidad son la
vanguardia de la era post-DSM-5.0". Personal.Disord. 4 [4], 365-366. 2.013.
(6) Dimaggio G, Livesley J. Introducción a la función especial en el tratamiento integral
de los trastornos de la personalidad. J.Pers.Disord. 26 [1], 1-6. 2012.
(7) Livesley WJ. Tratamiento integrado: un marco conceptual para un enfoque basado
en la evidencia para el tratamiento del trastorno de la personalidad. J.Pers.Disord. 26
[1], 17-42. 2012.
(8) Critchfield KL. Adaptación de los principios comunes de tratamiento para adaptarse
a las personalidades individuales. J.Pers.Disord. 26 [1], 108-125. 2012.
(9) Cloninger R, Cloninger K. Las personas crean la salud: promoción de la salud
eficaz. Revista Internacional de persona centrada Medicina [3], 114-122. 2.013.
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