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

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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 (2,3). 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 Z-scores of the ICD-11 for Non-Patients. 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 al-Muta'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 self-aware 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 self-aware 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 self-awareness. 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 self-direction, 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 self-awareness on the physiological and psychological processes of the mind so that the person becomes more self-aware. Hitherto, no educational-therapeutic 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 educational-therapeutic 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 non-specific 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 up-to-date approaches in the country and the region to prevent the progression of personality difficulty to severe psychiatric disorders, increasing self-satisfaction 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.