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SEMIOLOGY OF PERSONALITY DISORDERS M. Dehelean MD PhD Pompilia Dehelean MD PhD Liana Dehelean MD PhD Timisoara University of Medicine and Pharmacy

I. GENERAL CONSIDERATIONS 1. General Medicine consists in several particular disciplines (as parts of a whole) 2. Each particular medical discipline (psychiatry included) has: a) Common characteristics (shared with all other ones) b) Specific differences ( by comparison with all other ones)

GENERAL CONSIDERATIONS 3. Medicine studies the general pathology of the human being 4. The human being is a living system which integrates two indissociable subsystems a) the human psyche (mind) b) the human body as a consequence: 5. The general pathology of the human being includes: a) the psycho- pathology b) the somatic (organic, physical) pathology

GENERAL CONSIDERATIONS 6. The general medicine includes: a) the mental medicine (psychiatry) b) the somatic (organic, physical) medicine with several disciplines 7. Psychiatry and somatic medicine (as a whole) have: a) common characteristics b) specific differences between them

GENERAL CONSIDERATIONS 8. The COMMON CHARACTERSITICS are based on the indissociable unity of the human being The dissociation is only artificial, didactical, heuristical

9. The SPECIFIC DIFFERENCES are based on the different “nature” of the two integrated subsystems

CORPUSCULARITY spatial extension

HUMAN BODY SUBSYSTEM: From body as a whole to cell organites

HUMAN PSYCHE SUBSYSTEM: Personality Character Temperament Instincts, Emotions, Cognition, Volition and so on

QUANTITATIVE MEASUREMENT with standardized instruments with unique and undisputable units of measure

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II. GENERAL MEDICAL SEMIOLOGY 1.

THE GENERAL MEDICAL MODEL of understanding and presentation of any medical condition (disease, illness, disorder) is one of the common characteristics of general medicine and includes: a) etiology b) pathogenesis (hypothetical in psychiatry) c) nosological substratum (morphopatology for somatic medicine, hypothetical for psychiatry) d) symptomogenesis (physiopathology for somatic medicine, hypothetical for psychiatry) e) clinical picture (clinical expressivity of the nosological substratum): symptoms and syndromes = semiology f) course, prognosis g) responsivity (of the substratum and/or of symptoms) to therapy h) prevention

GENERAL MEDICAL SEMIOLOGY 2. THE IMPORTANCE OF SEMIOLOGY WITHIN GENERAL MEDICINE nosological substratum (is strictly specific for each disease/disorder) ↓ clinical expressivity (symptoms) ← SEMIOLOGY ↓ clinical diagnostic criteria (symptoms with higher diagnostic significance) ↓ Specific diagnostic elaboration ↓ Specific, efficient curative therapy (the ultimate scope of medicine)

GENERAL MEDICAL SEMIOLOGY 3. SEMIOLOGICAL AND NOSOLOGICAL levels and entities are separate, parallel but intercorrelate - deterministic (effect - cause) - structural – functional (expressivity – substratum) 4. SYMPTOMS and syndromes, as semiological entities are parts of a whole (the nosological entity). They exist only within their “whole”

GENERAL MEDICAL SEMIOLOGY 5. A CLINICAL DIAGNOSTIC exclusively syndromatic (non-nosologic), if it is not provisional, is a nonsense 6. A SYNDROMOLOGICAL-NONNOSOLOGICAL autonomous medical discipline without a nosological level and nosological entities is a fiction or, it has to be included as a syndrome within another medical discipline.

GENERAL MEDICAL SEMIOLOGY 7. THE MEANINGS OF THE TERM SYMPTOM a) a subjective manifestation of an illness (narrower sense), the objective one being named sign b) any manifestation of an illness (broader sense), signs being also symptoms of an illness and symptoms are signs of this illness c) any clinical data with diagnostic significance (subjective, objective or of other kind: e.g. abnormal traits of personality) – the broadest sense of the term

III. GENERAL PSYCHIATRIC SEMIOLOGY 1. General psychiatric semiology differs from general somatic medicine semiology by a strictly specific semiology with different kinds of symptoms: a) autoplastic symptoms: subjective, intrapsychic caused and resented, e.g. anxiety b) somatoplastic symptoms: subjective, intrapsychic caused but bodily resented, e.g. psychogenic pain

III. GENERAL PSYCHIATRIC SEMIOLOGY c) alloplastic symptoms: objective, observable, with two subtypes: - episodic: present only during an illness episode, e.g. psychomotor agitation - habitual: misbehavior with a permanent potential of manifestation, e.g. inappropriate seductiveness in behavior d) Abnormal traits of personality: deducible from a long time closely observed habitual misbehavior, e.g. impulsivity

III. GENERAL PSYCHIATRIC SEMIOLOGY 2. frequently, the psychiatric semiology is presented in psychiatric literature (books, chapters): a) inappropriate, as clinical description of mental disorders (Cavenar and Brodie) b) much extensively, as a descriptive psychopathology (Sims) c) as a simply glossary in which symptomatologic and nonsymptomatologic terms are mixed (Sadock)

GENERAL PSYCHIATRIC SEMIOLOGY 3. In our opinion a psychiatric semiology must: a) bring together all psychiatric symptoms without any nonsymptomatical mixtures b) classify psychiatric symptoms according to a appropriate taxonomical criterion, e.g. instincts, emotions, cognition, volition and so on c) present each symptom in a same and appropriate manner: designation, definition, description, subtypes, cause (if possible), diagnostic significance

IV. SEMIOLOGY OF PERSONALITY DISORDERS 1. DOES IT EXISTS? many psychiatrists consider that personality disorders as trait pathology, don’t have a real semiology according to the narrow sense of the term symptom In accordance with the broadest sense of the term symptom, personality disorders as any mental disorders must have their semiology

IV. SEMIOLOGY OF PERSONALITY DISORDERS 2. ITS UNICITY The semiology of the personality disorders is unique in psychiatry and in entire medicine because of their strictly specific type of symptoms i.e. abnormal traits of character and their consecutive habitual misbehaviors

IV. SEMIOLOGY OF PERSONALITY DISORDERS 3. THE SELECTION OF THE SYMPTOMS - from ICD 10 Diagnostic Criteria for Research and DSM IV TR Diagnostic criteria for all types of personality disorders → a nuclear semiology From the items of these two sources of data, only those which represent symptoms should be considered

IV. SEMIOLOGY OF PERSONALITY DISORDERS 4. PROBLEMS: - some items contain more than one symptom - some items are excessively descriptive and reformulation is needed - some items indicate the same symptom

IV. SEMIOLOGY OF PERSONALITY DISORDERS 5. FORMULATION - name of the symptom + type of the personlity disorder + the source + the indicative of the item in the source e.g: SUGGESTIBILITY , histrionic personality disorder, ICD 10 B2 criterion and DSM IV A7 criterion

IV. SEMIOLOGY OF PERSONALITY DISORDERS 6.

SYMPTOM CLASSIFICATION SOURCE - ICD 10 , general criteria for specific personality disorders, G1 criterion - DSM IV TR, general diagnostic criteria a personality disorder, A criterion

In these instruments “markedly deviant pattern of inner experience and behavior may be manifest in the following psychological areas: - cognition (ways of perceiving and interpreting things, events, people: self, other) - affectivity (range, intensity, lability and appropriateness of emotional arousal and response - impulse control - interpersonal functioning (manner of relating to others, handling interpersonal situations

IV. SEMIOLOGY OF PERSONALITY DISORDERS 7. THE TAXONOMICAL FRAMES in authors’ opinion : a) abnormal cognitive patterns of perception and thinking e.g. suspiciousness - paranoid personality disorder, ICD 10 B3, B5 criteria, DSM IV TR A1, A7 criteria - schizotypal personality disorder, DSM IV TR A5 criterion b) abnormal affective patterns e.g. emotional coldness - schizoid personality disorder, ICD 10 B2 criterion, DSM IV TR A7 criterion c) abnormal conative patterns e.g. suggestibility - histrionic personality disorder, ICD 10 B2 criterion, DSM IV TR A7 criterion

IV. SEMIOLOGY OF PERSONALITY DISORDERS 7. THE TAXONOMICAL FRAMES in authors’ opinion : d) abnormal behavioral patterns e.g. perfectionism - anankastic personality disorder, ICD 10 B3 criterion, obsessive compulsive personality disorder, DSM IV TR, 2 criterion e ) abnormal interpersonal functional patterns e.g. persistent disregard / nonconformism for / to social norms - dissocial personality disorder ICD 10 B2 criterion, antisocial personality disorder DSM IV TR A1 criterion

V. CONCLUSIONS 1. The paper brought into attention that there is an unsolved issue regarding the semiology of personality disorders 2. The authors believe that a complete semiology of personality disorders is possible and necessary to be realized