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.