راه اندازی کلینیک تعدیل شخصیت در ایران: رهیافت نوین برای روان پزشکی شخصیت با رویکرد ابعادی

اهمیت سلامت روان روز به روز در مراقبت های بهداشتی برجسته تر می شود و رویکرد درمان از اختلالات شدید و مزمنی که موضوع غالب در گذشته بود به سمت درمان طیف هایی از اختلالات خفیف تر و نیز کمک به ارتقای عملکرد، سلامت، شادمانی و تعالی پیش می رود. در این راستا سیستم های تشخیصی جدید بر تغییر موضع از رویکرد قبلی، یعنی تشخیص و درمان طبقه ای (categorical) به رویکرد ابعادی (dimensional) راهنمائی شده اند. این تغییرِ موضع ممکن است شیوه های رایج مراقبت روان را تحت تاثیر قرار داده و نیازمند رهیافت ها، دستورالعمل ها و مراقبت های طراحی شده ی جدیدی باشد که می توانند انقلابی در مقوله ی سلامت روان ایجاد کنند. لذا در این راستا راه اندازی کلینیکی مانند کلینیک تعدیل شخصیت (personality modulation) و ارائه خدمات آموزشی- درمانی در قالب این کلینیک راهبردی با هدف مراقبت و ارائه خدمات منطبق با به روزترین نظام طبقه بندی تشخیصی لازم می بود؛ به صورتی که بتوان رشد و اعتلای سلامت روان را به طور گسترده تر و حتی در مورد افراد روی هم رفته سالم یا افرادی با اولویت رشد و ترقی روان تسهیل نمود. در این رویکرد به کسانی خدمات ارائه می شود که در تقسیم بندی های جدید روان پزشکی یازدهمین بازنگری طبقه بندی بین المللی بیماری ها (international classification of diseases (icd-11))، تحت کد دشواری شخصیت (personality difficulty) قرار می گیرند و خدمات مزبور منجر به ارتقای ایشان در زمینه های شخصی، شغلی و اجتماعی خواهد شد. در پاسخ به کاستی های سیستم های طبقه بندی قبلی، نسخه یازدهم طبقه بندی بین المللی بیماری ها، رویکرد جدیدی را برای طبقه بندی اختلالات شخصیت اتخاذ کرده است که از نوع رویکرد ابعادی بوده و در آن تمرکز در وهله اول بر تشخیص و تعیین شدت بیماری و سپس تعیین دامنه ی علائم مشتمل بر پنج دامنه ی صفاتی دخیل در اختلالات شخصیت می باشد. این پنج دامنه شامل عواطف منفی (negative affectivity)، غیراجتماعی بودن (negative affectivity)، علیه اجتماع بودن (dissociality)، عدم کنترل تکانه (disinhibition) و وسواسی گری (disinhibition) است، . تایرر (tyrer) و همکاران ضمن پایه گذاری این طبقه بندی جدید ابعادی، همچنین فضا را برای ارائه تشخیص جدید تحت عنوان دشواری شخصیت باز نمودند. تشخیص دشواری شخصیت به خودی خود یک اختلال روان شناختی محسوب نمی شود، اما برای سودرسانی بالینی در افراد تقریباً نرمال قابل استفاده است و جزو z-score های نسخه یازدهم طبقه بندی بین المللی بیماری ها برای افراد غیر بیمار تعیین شده است. این تشخیص برای توصیف افرادی می باشد که به صورت تیپیک بیمار یا دچار اختلال شخصیت نیستند، اما مشکلات مرتبط با مدیریت زندگی دارند که باعث مسائل طبی شده و صرف هزینه برای جامعه و سیستم های درمانی را ایجاب می نماید. محققین مزبور در نهایت به این نتیجه دست یافتند که تغییرات پیشنهادی باعث بهبود کارایی بالینی در تشخیص اختلال شخصیت و کاهش برچسب ننگآور آن شده و به تسهیل انتخاب درمان مناسب کمک می کند.

The Establishment of a Clinic for Personality Modulation in Iran: A Novel Approach in Personality Psychiatry with a Dimensional Approach

Mental health and treatment approaches have indeed garnered attention in health care. Treatment approaches have shifted from severe and chronic disorders prevalent in the past to milder disorders. Further, these approaches aid in improving performance, health, happiness, and superiority (1). To this end, new diagnostic systems have been introduced to move away from traditional approaches (i.e., stratified diagnosis and treatment) to a dimensional approach. This shift in attitude may affect major current mental health practices requiring innovative approaches, guidelines, and care to revolutionize mental health. Thus, setting up the clinic of personality modulation was inevitable as it provides educationaltherapeutic services in accordance with the most uptodate diagnostic classification system. It can also promote the growth of mental health. Even healthy people or those who pay attention to their mental growth and development can also benefit from the clinic's services. In a dimensional approach, services are provided for those who fall in the category of difficult code of personality in the new psychiatric divisions of the ICD-11. These services will lead to their personal and professional development.To compensate for the shortcomings of previous classification systems, the ICD-11 has adopted a dimensional approach, a new approach to the classification of personality disorders, in which the focus is primarily on diagnosing and determining the severity of the disease. Moreover, the range of symptoms includes five ranges of traits related to personality disorders. These five domains encompass Negative Affectivity, Detachment, Dissociality, Disinhibition, and Anankastia (23). Thierry, Crawford, Mulder, Bleschfeld, Farnam, et al. (4), establishing this dimensional classification, proposed a new diagnosis called personality difficulty. Diagnosis of the personality difficulty is not a psychological disorder in itself. However, it can still be used for the clinical benefit of virtually normal individuals and has been included in the Zscores of the ICD-11 for NonPatients. This diagnosis consists of people who are neither typically ill nor have a personality disorder. Rather, these people have problems with life management that causes medical problems and incurs costs for the community and treatment systems (5). The researchers concluded that the proposed changes could aid clinical efficacy in diagnosing the personality disorder and selecting appropriate treatment. In this way, the misconceptions concerning the false label attached to the disorder term can be dispelled (4).Therefore, current psychiatry is moving in a direction with a program not only for patients but also for almost normal people who have problems in their lives or feel that there are some difficulties in developing their personality. One style of psychiatric treatment called cosmetic psychiatry (6) or positive psychiatry (7) has attracted attention among the whole range of psychiatric disciplines. Cosmetic Psychiatry refers to the empowerment and strengthening of people's cognitive, behavioral, and emotional processes who do not suffer from a specific disorder. In other words, the treatment is to improve a person's mental state in the absence of any clinical disorder (8). The development of the ICD-11 has led to innovative approaches which were not available before. The reason for the clinic's foundation lies in the philosophical theories presented by Georg Wilhelm Friedrich Hegel and Sadr alMuta'allehin Shirazi. They saw soul and psyche as a constantly evolving category. According to their theories, the soul is inherently growing and ascending unless a factor disrupts this process (9). The theoretical foundation of the approaches used in the personality modulation clinic rests on Cloninger's personality theory. This theory is known as the model of temperament and character. Cloninger divides personality into three components: temperament, character, and selfaware psyche. Temperament concerns the genetic and inherited aspect of individuals and has certain biological elements. Character deals with the semantic component of human personality and considers the individual's relationship with himself, others, and the universe. The third component is the selfaware psyche which its definition hinges on the individual's sense of intuition towards his inner abilities (10). Each element has its own characteristics and brain structures. The elements of this model and the treatment strategies presented in Cloninger's theory are employed to regulate the clinical approach in the personality modulation clinic. In this regard, pharmacotherapy and new neuroscience therapies (e.g., Biofeedback, Neurofeedback, and rTMS) are implemented to moderate temperament status and its extreme features, which can worsen the condition by affecting the patient's somatic state and ultimately inhibit Rhythmic growth of selfawareness. Understanding the neurotransmitters involved in the four temperamental traits (i.e., harm avoidance, novelty seeking, reward dependence, and persistence) and the role of neuroscience trends in our context are vital. After identifying and determining the fundamental conflicts related to character traits, pertinent psychodynamic analysis methods and eclectic psychotherapy are used for their treatment. Character aims to identify and remove barriers to the growth of all three components of selfdirection, cooperation, and self Transcendence involved in the relevant conflicts. In this particular treatment, different interventions are regarded for each person commensurate with his/her inner problems and conflicts. To develop the personality of these people, participatory intervention methods are opted. This model combines the training and supervision of a specialized psychiatric team to identify and treat clients' problems. The ultimate aim of this treatment method is to expand selfawareness on the physiological and psychological processes of the mind so that the person becomes more selfaware. Hitherto, no educationaltherapeutic program with the objectives of the personality modulation clinic has been introduced and implemented neither in our country nor in the world. Hence, there is a call for a codified and coherent program with regard to the educationaltherapeutic course of personality modulation due to lack of evidence. Considering the importance of this field of psychiatry, as described earlier, setting up such a clinic becomes indispensable. Also, finding such a place to get medical care is difficult for people with personality difficulty who feel that their existing personality practices do not match their capacity for growth and development. These people need to receive services with a biopsychosocial approach, although they might receive some degrees of nonspecific services. This sort of service is offered to them in psychological clinics. On the other hand, counselors' opinions were based on scattered styles derived from schools of psychoanalysis they often considered the psychological development of character and lacked a biological component (i.e., biological therapies such as pharmacotherapy and advanced neuroscience techniques used as accelerators). In sum, the clinic was established to adapt mental health services to uptodate approaches in the country and the region to prevent the progression of personality difficulty to severe psychiatric disorders, increasing selfsatisfaction in society, facilitating personal growth, and lowering high medical costs. This clinic was established by the suggestion of the first author in 2016 to combine the existing knowledge in psychotherapy, personology, and psychiatric pharmacotherapy leading to a new solution for people in need of receiving the diagnosis of personality difficulty.In addition, there is a golden opportunity for training skilled psychiatrists and residents in this field to provide services for clients in the future.