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Perspectives in Global Mental Health
Published Online: 1 August 2016

Personality Disorders in the Basque Region of Spain: Applicability of DSM-5’s Alternative Criteria for Personality Disorders

“Ms. E,” a 24-year-old unemployed Basque-speaking woman born in a village near Bilbao, presents with mood and anxiety symptoms, irritability, ideas of reference, feelings of “emptiness,” and self-harm behaviors. She reports having problems maintaining stable relationships and fears of abandonment. She also reports instances of impulsive sexual behavior as well as eating disorders (periods of anorexia and bulimia). She has had two hospitalizations for suicide attempts.
Over the past 5 years or so, Ms. E has seen several psychiatrists and psychologists, who recommended various interventions (psychotherapies and medications), but she has not followed their advice. She says that she does not believe in these approaches and, adhering to the traditional Basque proverb “Medikuak gorputza garbitu, apaizak arima, abokatuak poltsa” (“The doctor cleans the body, the priest the soul, and the lawyer the pocket”) (1), she sticks to physical, natural, or supernatural remedies. Such proverbs collect traditions and customs cultivated and developed by the community of Basque speakers over many centuries. Many traditional Basque people, Ms. E included, do not understand the notion of mental disorders or the potential benefit of interventions, often believing instead that the problem arose because someone cast an “evil eye” on them—begizkoa, a popular belief related to magic and witchcraft (2). After experiencing some of her outbursts of anger, Ms. E blurted out, “Bigarren arimak urten dotzu!” (“The soul has left the body”), a traditional belief in her Basque village.
After her most recent hospital admission, Ms. E was referred to a day-center psychiatrist who spoke Euskera, the Basque language. Basque was Ms. E’s first language, the language of her childhood, in which she uttered her first words and around which she began building her identity. Not surprisingly, Ms. E and the Basque-speaking clinician established a good connection, as the clinician understood well her situation and concerns. She explained, in Basque, her feelings of uneasiness, expressed as ezinegona, a term implying psychological distress (the literal English translation is “unable to be”). This was the first time that Ms. E had met a professional who spoke her native language, and it appeared to make her feel much more comfortable, leading to a closer attachment than had been the case with other therapists. This unique meaning of Euskera as an emotional language has been immortalized in a line by Jon Maia, a singer, writer, and improviser: “Amaren sabeletik erditzen gara, ama hizkuntzaren sabeletik” (“We are born from our mother’s womb, the womb of our mother tongue”) (3).
The psychiatrist administered a structured clinical interview that had been prepared as part of DSM-5’s field trials, translated and adapted from the original English to Euskera. According to the interview results, Ms. E had the essential features of a personality disorder outlined in the alternative criteria, including “moderate or greater impairment in personality (self/interpersonal) functioning” and “one or more pathological personality traits” that “are relatively inflexible and pervasive across a broad range of personal and social situations” and “are relatively stable across time” (DSM-5, p. 761). On the Level of Personality Functioning Scale in DSM-5’s alternative model, which rates disturbances in personality functioning on a 5-point scale (0–4), our patient scored at least a 3. The alternative criteria also incorporate four elements of personality functioning identified with descriptive charts, to evaluate degree of impairment in the dimensions of identity, self-direction, empathy, and intimacy. These charts were very helpful for the clinical assessment and showed that our patient had significant impairment in all areas. The new criteria also offer five broad domains—negative affectivity, detachment, antagonism, disinhibition, and psychoticism—containing 25 specific personality traits. Our patient had several traits of the negative affectivity domain (emotional lability, anxiousness, separation insecurity, hostility, and suspiciousness) and some traits of the disinhibition domain (impulsivity and risk taking). Of the six specific personality disorders listed in the alternative criteria (compared with 10 in the current official criteria), the best fit for our patient was borderline personality disorder.
After making the clinical diagnosis, the psychiatrist prescribed fluoxetine (20 mg/day), topiramate (200 mg/day), and lorazepam (1 mg at bedtime) and referred the patient to a day center for individual, group, and family psychotherapies (4). This time, the patient adhered to the treatment recommendations. In the 6 months since she started the new treatment, her condition has stabilized, and functionally she is doing much better, working full-time and relating well to family and friends. She exhibits better control of her anger, and her anxiety and depressive symptoms have been minimized.

Discussion

Culture is the whole system of knowledge, concepts, rules, and practices that are learned and transmitted across generations. It includes language, religion, family structures, life cycle, ceremonial rituals, customs, and legal and moral systems. The Basque Country includes an autonomous community and historical region of northern Spain that includes the provinces of Biscay, Gipuzkoa, and Álava, and a region of southwestern France (French Basque Country) in the Pyrénées-Atlantiques. The Basque language (Euskera) is the oldest language in Western Europe, and it is a pre-Indo-European language very different from Spanish, the official language of Spain, resembling more other languages such as Hungarian and Finnish (6). A sociolinguistic survey conducted in 2011 showed that 52.5% of the Basque population is euskaldun zaharra, meaning that they have spoken Basque since childhood.
While some authors have posited that personality disorders are Western clinical entities illustrating the process of medicalization of social behavior (6), others argue that personality disorders are now well accepted as important conditions in mainstream psychiatry across the world and that a new system of classification is needed (7). A useful feature of DSM-5’s alternative personality disorders model is that it can be used to assess personality functioning and traits, regardless of whether or not a personality disorder is suspected. This increases the model’s clinical utility because it helps clinicians identify not only areas of weakness but also areas of relative strength.
The text in DSM-5 emphasizes the relevance of culture as well as language for a proper clinical assessment. The Basque Country is a bilingual country (Basque and Spanish), and in many instances, as in the case presented here, proficiency in the Basque language is an important tool that can allow the therapist to properly understand the patient’s unique circumstances and his or her perceptions of illness, expectations, conflicts, concerns, and life goals.
The DSM-5 alternative personality disorders criteria, translated and adapted into the Basque language, appear to have the same meaning as originally devised in the English version (as indicated by back-translation), and after using them in this and several other cases as part of a pilot trial of DSM-5 personality disorders in Bilbao, we found that they showed a good fit in a majority of clinical cases with personality problems that were examined. As it is said in Basque, “Minik handienak, burutik heldu direnak” (“The greatest pains are those coming from the head”) (1).

References

1.
Garate G: 27,173 Atsotitzak, refranes, proverbs, proverbia, 2nd ed. Bilbao, Spain, Bilbao Biskaia Kutxa Fundazioa, 2004
2.
Erkoreka A: Análisis medicina popular Vasca. Bilbao, Spain, MHM, 2014
3.
Garabide Elkartea: La experiencia Vasca: Claves para la recuperación lingüística e identitaria. Lore Agirrezabal Pertusa, coordinator. Eskoriatza, Gipuzcoa, Spain, Imprenta Gertu, 2010
4.
Bateman A, Fonagy P: Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 2001; 158:36–42
5.
Nuñez Astrain L: El euskera arcaico: Extensión y parentescos. Tafalla, Spain, Txalaparta, 2003
6.
Widiger TA (ed): The Oxford Handbook of Personality Disorders. New York, Oxford University Press, 2012
7.
Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective. World Psychiatry 2010; 9:56–60

Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 769 - 770
PubMed: 27477137

History

Received: 11 April 2016
Accepted: 19 April 2016
Published online: 1 August 2016
Published in print: August 01, 2016

Authors

Details

Naiara Ozamiz Etxebarria, Ph.D.
From the School of Medicine, University of the Basque Country, Bilbao, Spain; and the Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
Agurtzane Ortiz Jauregi, M.D.
From the School of Medicine, University of the Basque Country, Bilbao, Spain; and the Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
Jose Guimon Ugartechea, M.D.
From the School of Medicine, University of the Basque Country, Bilbao, Spain; and the Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
Javier I. Escobar, M.D.
From the School of Medicine, University of the Basque Country, Bilbao, Spain; and the Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.

Notes

Address correspondence to Dr. Escobar ([email protected]).

Funding Information

The authors report no financial relationships with commercial interests.

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