Thank you for coming. So we want to start right on time. I want to first give you a little bit of what the plan is for this morning. And Dr. Alarcón will be presenting roughly around 60 minutes. And as you know, the meeting is scheduled for an hour and a half. So the idea is that afterwards we turn this into sort of a conversation. And I want to bring your attention to the microphone here in the middle of the room. So if you want to contribute, ask questions, whatever, after Dr. Alarcón presents, please feel free to do so and just get to the microphone so everybody can hear. Oh, I didn't introduce myself. I'm Bernardo Eng. I am based in California. Also director for a clinic that's in rural California. The joke is that it's not the real California because there is no beach and palm trees and stuff like that. It's just the desert. But that's really what most of California is when you get away from the coast. And I'm really, really honored to present my friend, and she's never been my teacher really, but she's my teacher, Renato Alarcón, whom I've had the privilege of knowing and work with for many years. He is a distinguished emeritus professor in the Department of Psychiatry and Psychology at Mayo Clinic School of Medicine in Rochester, Minnesota. He's also emeritus professor and Honorio Delgado Chair at the Universidad Peruana Cayetano-Heredia in Lima, Peru. He occupied leadership positions in the Department of Psychiatry at the University of Alabama in Birmingham and Emory University School of Medicine in Atlanta, Georgia. He's also a distinguished lifetime fellow of the American Psychiatric Association. He was Secretary General of the World Association of Cultural Psychiatry and has also served in numerous committees of the American Psychiatric Association, including the DSM Steering Committee and its PDs work group. So for those of us who've been very interested in following the DSM evolution on the cultural section, well, Renato has been behind it for many, many years. He's author or co-author of over 270 articles, author-editor of 26 books and 130 book chapters. Dr. Alarcón has received, among other distinctions, the American Psychiatric Association Simone Bolivar Award and the George Tarjan Awards. And these are for the distinguished Hispanic psychiatrist and the other one for international medical graduate. And he's also received from the World Association of Cultural Psychiatry the Wenxin Zeng Award and the Gene Garrave Award. His academic and clinical interests include personality disorders, that's why we're here, mood disorders, PTSD, psychiatric diagnosis, global mental health, and of course, cultural psychiatry. Please, let's welcome Dr. Renato Alarcón. Thank you. Good morning to all of you and thank you. Thank you very much for accompanying us in this presentation early in the morning. I also want to thank the American Psychiatric Association, the president, Dr. Livunes, for inviting me to give this lecture in the Congress. My good friend, Bernardo Eng, who, by the way, will deliver the Simone Bolivar lecture in the American Psychiatric Association meeting, this meeting, later in the week. And my great friend who has exaggerated a number of things about me, but I think it speaks of our friendship. And the topic, as you can see here, deals with an old interest of mine in the academic field, culture and personality disorders, and examining the social diagnostic and therapeutic aspects of personality disorder from a cultural perspective. Let me present first the agenda. I want to start by saying that one of the most fascinating developments in today's psychiatry across the world is the increasing presence and prominence of cultural psychiatry and the global implications in different fields and subfields of our discipline. The complexity of this phenomenon is even more evident in the face of the continuous and powerful advances of biological psychiatry and neurosciences. It is sort of a parallel advance, and that is an unusual happening in our discipline. Among the clinical conditions that psychiatry takes care of, the personality disorders present one of the most significant multidimensional challenges in symptomatological, etiopathogenic, diagnostic, and therapeutic terms, including, of course, the cultural perspective. Such is the main objective of this presentation, the challenges and accomplishments of the cultural personality perspectives on several study areas, but particularly on the social or community-based involvement of personality disorders, their diagnostic approaches, and the therapeutic management modalities. At the end of my presentation, a brief discussion and conclusions will be elaborated. Excuse me, can you adjust the mic? Thank you. I don't know if it's—I have to be closer. So once I present the agenda for you, let's get started talking about an overall perspective on psychiatry and cultural psychiatry. Culture, the basic term of this presentation, is defined as a set of meanings, behavioral norms, and values used by members of a particular society or community to elaborate their unique view of the world. These reference points, as I mentioned here, include habits, customs, social relationships, political beliefs, ethical standards, religious practices, traditions, race, ethnicity, language, technology, educational perspectives, and financial philosophy, as well as material elements such as diet, clothing, and housing. Culture is both changing and permanent, material and spiritual. In turn, cultural psychiatry is a discipline that deals with the description, definition, evaluation, and management of all psychiatric conditions in as much as they are both subject and reflection of cultural factors within an integrated biopsychosocial context. The fundamental objectives of cultural psychiatry entail, first, the delineation and definition of what is, quote, normal or abnormal in behavioral conditions, evaluated by mental health professionals, of course, and second, to ensure the thorough understanding and interpretation, as well as the background, occurrence, interactive connections, and treatment approaches of psychopathological events. An area of growing relevance in the field of cultural psychiatry, so sanctioned by powerful national and international mental health organizations, such as the American Psychiatric Association and the World Health Organization, is the one known as social determinants of health, more specifically mental health. The recognition that health and disease are not only reflections of a biophysiopathological status, but conditions also linked to emotional, environmental, cultural, and spiritual factors operating around the life of humans has generated this notion, constituted by formal elements such as language, individual, family, educational, occupational, and financial levels, and subsequent changing and incident human conditions, such as poverty, tolerance, violence, corruption, discrimination, respect, solidarity, et cetera, et cetera. All those are included into the so-called social determinants of health and mental health. In this poly-facetic process, cultural psychiatry counts on the valuable contributions of a variety of social sciences that add their original and enriching perspectives to its heuristic, that is, investigation, research-oriented projects and findings. Sociology and anthropology, preceded by a very useful label, medical sociology and medical anthropology, provide or add both a group and an individual look at clinical phenomena of diverse nature. Newly created and vigorously developing disciplines such as global health and global mental health confer unique views and observations about rapidly changing cultural and psychopathological scenarios. Migration and technology, both combined, in my modest opinion, are the two main driving forces of globalization and global health and global mental health. Migration and refugee-seeking situations generate a multitude of socialization practice changes across the world, thus the younger field of social psychiatry gets increasingly closer to cultural psychiatry, working together in and for the creation of a solidly fresh discipline. Let's talk now, enter into the field of, briefly, the field of personality disorders. A personality disorder is defined, as DSM-5TR says, as an enduring pattern of inner experience and behavior that deviate markedly from the norms and expectations of the individual's culture. It's pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress and impairment. A personality disorder obviously disrupts the affected person's life and the homeostasis of his or her social group as it portrays extreme deviations from conventional interactive patterns and generates inflexible and maladaptive responses to a broad range of situations. People with a personality disorder may also show different ways of perceiving and interpreting themselves, others, and external events, a picture akin to, basically, an abnormal cognition. A variety of research studies identify low self-directedness and low cooperativeness as core features of all personality disorders and together with all the other social and behavioral manifestations are not perceived by the affected individual as a personal deficit or handicap. They do not perceive that as such, but rather as a result of, you can imagine, powerful, hostile, adverse, and intimidating external circumstances. Due to all these characteristics, the two world-dominant diagnostic systems, the APA-DSM-5-TR and WHO-ICD-11, International Classification of Diseases-11, have devoted long, specific periods of time to the elaboration of their personality disorder chapters. The latest DSM version devotes part of two of its three sections, the currently formally operating version in Section 2, as a minor text update of the DSM-5 criteria, which in turn was carried over from DSM-4-TR and represents a categorical perspective on the diagnosis of personality disorder. It includes, in DSM-5-TR, 10 personality disorder types, plus one due to another medical condition and other specified grouped into three clusters, these 10 types, the A, odd, eccentric, B, dramatic, emotional, erratic, and C, anxious or fearful, based on descriptive similarities, of course. On the other hand, the version in Section 3 of DSM-5-TR is a hybrid, categorical, and dimensional model that represents maladaptive variants of personality traits, and I quote, that merge imperceptibly into normality and into one another. Now, the ICD-11 approach to the classification of personality disorders materialized more quickly than the DSM-5 the growingly accepted dimensional trend in replacement of the traditional categorical model. In fact, this version, the ICD-11 personality disorders in the psychiatric disorder section, this version makes severity of personality disturbance the primary norm for the diagnosis and classification of personality disorders. That is the point of the dimensional, severity as a dimension. Calculating five levels of severity and through the use of five trait domains, qualifying the main nature of the disturbance and making less critical the point of separation between having the disorder or not. It is or it is not the diagnosis of personality disorder, and that is clinically inappropriate and insufficient. This diagnostic strategy would put an end to the artificial dichotomy of personality diagnosis, while maintaining a degree of categorical demarcation to facilitate the clinician's recognition. That is the hybrid nature of this approach. Psychiatry debates and research advances on the clinical assessment and management of personality disorders contribute substantially to the prominence of this nosological chapter of world psychiatry. These advances come from different sources, including biological, psychological, ecological, and therapeutic ones. It is clear that applying a cultural seal to each of these fronts will lead to findings of universal significance. Let's talk about personality disorders and culture. The cultivation of an egocentric versus social or ecocentric dichotomy is part of a continuous interpersonal exchange and makes a significant impact on two very important concepts, identity and otherness. Identity, a construct equally applicable to individuals and communities, is a singular composition of a series of variables that allow both a characterization and a recognition of traits and features that respond to sociocultural conditionings. This brings up the otherness notion, the issue of individual and collective differences, the not-me phenomenon, with affective, cognitive, and relational distinctions dressed up with degrees of preference, privilege, and advantages. The qualification of Anglo-Saxon cultures as egocentric and of European, particularly Eastern and mostly Asian and Latino cultures as sociocentric is well-known and generally accepted. In both cases, however, otherness has emerged carrying both positive and negative meanings. Among the positive meanings, recognition and acceptance of differences, negative, rejection, discrimination, exclusion. Let's get now into the central topic of this presentation, talking about the different perspectives I mentioned, social, diagnostic, and therapeutic. The first one has to do with the social perspectives. This approach provides an initial notion of crucial importance in the assessment of personality and its disorders, and crucial importance particularly from the cultural perspective, of course. Context, and its processing background that we call contextualization. Context covers micro-cultural systems and subsequent family dynamics, as well as macro-cultural systems and community or society-inspired attitudes. It also includes value-oriented and ethical perspectives, a product of history, habits, traditions, and beliefs, leading to individual and collective practices of judgment and management of oneself and others. So the context, the circumstances of any happening and any behavioral piece in patients that we are examining and we are suspecting personality disorders is extremely important. Social conditions create a group or groups of people, particularly fragile, we call them vulnerable, due to their propensity to different types of emotional, affective, or behavioral decompensations. To be sure, vulnerability reflects both genetic predispositions and early adversity-charged and traumatic experiences that lead, more or less gradually, to behavioral and emotional changes eventually accompanied by neurobiological alterations. From a cultural viewpoint, circumstances such as early care, neglect, or abandonment, poverty, violence, or malnutrition operate as pathogenic factors uncovering possible bio-genetic brain-related predispositions. More socially inclusive, however, is a process that I already mentioned, but nowadays exhibits an increscendo global incidence. I'm talking about migrations. With their overwhelming waves in many regions of the globe, migrations bring up an unavoidable phenomenon, acculturation, that is, the acceptance or rejection of the particular sociocultural aspects of the host society values and context. Acculturation and the related concept acculturative stress are so important in the development of personality disorders, perhaps as the most important psychopathological expression of acculturative stress. Two other social phenomena have similar relevance from a sociocultural perspective. Discrimination and violence. Both have also links, of course, with personality disorders, as they are found among their perpetrators and their victims. A large number of individuals and groups that practice unfair and abusive discrimination and violence, supported by a variety of justifications and aware or not of their presence, show traits or declare pictures of personality disorders. On their side, the victims of these gross maneuvers and behaviors may already show characterological and personality deficits, or in any case, due to the pervasive aggressions or deficient emotional experiences, as they have been called by numerous researchers. Last but not least, the characterization of social factors in the delineation of personality disorders may obey to cultural differences in the meaning of subjective, intra and interpersonal perceptions. Social processes also involve psychodynamic mechanisms, of course, as personality disorder features may represent the individual's desperate attempts to escape the conflicts of adult life when following models offered by the prevailing social values. Let's move now to the next step. The diagnostic perspectives from a cultural perspective, from a cultural viewpoint. Diagnosis is a complex process of evaluation, recognition, identification, and utilization, decisively important in every medical field, of course. Some clinicians may consider the adaptive role of personality features as symptoms of the disorder, and that is very important to keep in mind, the difference between that and the tendency to label as symptoms aspects of human behavior that are eminently culturally related. That implies the reinforcing role of cultural factors in the occurrence of good or bad outcomes. Ethiopathogenesis is an important component of this diagnostic process, and culture, again, plays an undeniable role in the causality and the evolving route of personality disorders, shaping up eventually vulnerable or predisposing traits through negative child-rearing practices, family-based customs and traditions, defensive postures towards societal norms, economic realities, and concrete events, such as racism, racialization, which is a term that implies how we tend to qualify behaviors or things as result of racial characteristics, and in fact, that such a thing may not exist. The concept has been elaborated throughout the years, and may result, all of this may result in anomalous acculturative practices. By the same token, clinicians must be aware of pseudo-Ethiopathogenic elaborations born out of precipitated cultural misinterpretation of ethnic habits, moral or religious beliefs, age and gender considerations, and even of traits and features of emotional and behavioral expressiveness. There are also behaviors that can be erroneously associated with personality disorders, instead of, for instance, considering them within the so-called cultural concepts of distress, and that is another set of ideas included in DSM-5-TR. Now, the relative easiness and subsequent convergence of labels and stereotypes leads to a final common pathway, stigmatization, and the damaging impact of the name-calling practices. Beyond the normal, abnormal distinction of personality styles, the well-known current debates between the categorical and dimensional approaches and the hybrid, although predominantly dimensional, as I mentioned, nosology of personality disorders, have also included valid cultural considerations. Following the typical medical model in theory and structure, the categorical approach entails an apparently practical usefulness and plays a convenient role in public awareness and stigma-reduction management campaigns. The categorical is used to have people identifying, quotes unquote, some behaviors. Nevertheless, a well-organized cultural perspective is affected by the extreme heterogeneity and extensive co-occurrence of personality disorders types by the fact that the diagnostic criteria are made up of inconsistent amalgams of symptoms, traits, and impairments, arbitrary diagnostic thresholds, and artificial dichotomies that result not only in low reliability or limited predictive validity, but also produce temporal instability and, in general, a questionable clinical utility. The cultural view of the categorical approach in the diagnosis of personality disorder is, therefore, predominantly negative. On its side, the dimensional approach conceptualizes personality disorder along the lines of one or a series of features and two key criteria. This, by the way, is in discussion, still under discussion for the next edition of the ESM-5. And these features or criteria are, as I mentioned, one, the dimension of severity, and the other one is style. Severity captures the core distress common to all personality disorders and measures that. And, of course, the impact on intra- and interpersonal functions. While style is related to personality trait domains and their qualitative and quantitative variations. That is the style. In such context, this approach documents simpler, but, at the same time, much broader empirical basis supported by validated instruments and their clinical usefulness. Numerous studies have also contributed with improved scales and other measurement tools applied in different countries. The most frequent conclusion confirms the generalizability of tools across different cultures. Finally, a cultural neutrality on the side of clinicians, patients, relatives, neighbors, community, and society in general is not easy to achieve and should not be strictly based on exclusionary approaches. Paradoxically, the purely biological approach represented by NIMH Research Domain Criteria, RDoC, and its demand for, I quote, rigorously tested, reproducible, clinically actionable biomarkers, close quotes, could claim to be the most objective, prejudice-free diagnostic approach by denying the obvious relevance of sociocultural data or qualifying them as superficial or confusing. Most importantly, cultural studies on different personality disorders, although uneven due to being more focused on two or three types, contribute with valuable findings. Let me show some of them on two of the most studied types of personality disorders. Borderline personality disorder, probably the most frequently studied type, is important due to its powerful symptomatological appearance, co-occurrence with other conditions, and elevated frequency in adolescents. The symptoms may decline across adulthood, but negative social, interpersonal, emotional, vocational, and, more seriously, suicidal tendencies persist, particularly in middle and low-income nations, according to many findings, disproportionately affected by adversity. Yet, some authors consider it a post-industrial society disorder, a contemporary psychopathology frequently seen in information-based communities or nations. Along the same lines, some of its associated symptoms, suicidality and self-harm, have a higher prevalence in developed countries. Borderline personality disorder is considered a symptom bank of relevance for its role in the so-called social contagiousness, related, according to some authors, to a decrease in social cohesion and social capital in modern societies. Furthermore, the diagnostic of borderline personality disorder can also vary according to the ethnicity of the clinician. Gender differences and the complex intersection of borderline personality disorder vulnerabilities and motherhood calls, that calls for integrated and cultural sensitivity, lengths that should be used in the assessment and therapeutic interventions, that is, to use a truly contextual understanding. That is crucial. About the antisocial personality disorder. Antisocial is still the most pervasive biopsychosocial model of personality disorders. Although the, I mentioned about the intersection. The concept of harmful dysfunction, the criterion of harmful dysfunction, applies to a high number of psychiatric diagnosis. It is most frequently mentioned in connection with antisocial personality disorder. Critics, however, argue that doing this pathologizes the evil by focusing clinically on the, quotes, morally wrong, socially unacceptable, or criminal behavior. A study showed that most adult symptoms of antisocial personality disorder among homeless province and adoptees were significantly associated with childhood conduct disorder that, however, usually preceded the onset of homelessness. A work on antisocial behavior among adoptees indicated that the higher the adoptive parental social class, the lower the antisocial behavior rates in the adoptees, even though the latter cannot be exclusively attributed to a concentration of such behaviors in the lowest class. Additional data on other personality disorders. The schizotypal personality disorder is a type with varying epidemiological data and expressions across countries. Potentially confounding cultural and translation issues may explain the lack of consistency of some instruments used in populations from different countries to the assessment of this personality type. Even though positive findings in this area have also been reported. The role of cultural factors in the generation of hysterical or histrionic personality disorder and its eventual correlations with clinical phenomena like hysteria appears to be more evident in European psychiatry on the basis of repression of conversion manifestations and hyper-expressivity of affects studied from different research centers. Among the other personality disorders, obsessiveness, agreeableness, and negative affectivity, key components of disorders such as orthorexia nervosa and internet smartphone use disorders, a newly now tending to be included among psychiatric or emotional mental disorders, and do have also important sociocultural components. Personality features such as conscientiousness, introversion, openness, social anxiety, and impulsivity show significant positive and negative correlations with these two types of disorders. Interestingly, a notable low reporting of curiolus paranoia in Chinese patients has been attributed to sociocultural traditions, a lower incidence of curiolus paranoia. In the idiopathogenic terrain, the internalization of sometimes culturally unattainable ideals such as body image satisfaction, one feels good with how he or she looks, appears to be unequivocally linked to personality disorder features. A Japanese study showed that subjects with so-called high personal sensitivity, interpersonal sensitivity, type of personality, had it as an increased risk factors for experiencing lifetime depression. A similar finding related anxiety, anxiety sensitivity, and dissociation predispositions with the occurrence of the cultural Hispanic syndrome, ataque de nervios. Let's get now in the therapeutic perspectives or cultural perspectives on therapeutic issues about personality disorders. General aspects of a good management of personality disorders have psychoeducation, interpersonal focus, and active family participation as some of their main characteristics. An open and continuous improvement of communication channels, an objective description and discussion of behavioral difficulties, and a measured use of diagnostic labels decrease stigma issues. It is important to be careful before assigning a diagnosis of personality disorders of any patient we evaluate. The management of personality disorders, probably more than any other diagnostic group, requires a solid level of cultural competence. Cultural knowledge on the therapy side is a preventive tool for a potential medicalization or pathologization of personality traits. The acceptance of and respect for the professional and patient differences, attention to the dynamics of such differences, a flexible application of service models responsive to the needs of the diverse population, and a continuous self-evaluation on the side of the clinician. The provider regarding the cultural aspects of the clinical encounter are essential features. From the patient's perspective, culture can be considered a protective buffer, using even dependence as a defensive or adaptational resource and conferring additional value to his or her reference groups. All these features reinforce the patient's and provider's mutual attributes of recognition, adaptability, respect, and empathy. That is equally crucial. Resilience is a poly-faceted concept in contemporary neuropsychiatric language with growing prominence as a clinical component, an existential resource, and a cultural dynamics aimed at the management of adversity and pathogenic processes. Levels of resiliency vary from light, elusive, or limited features to a strong set of characterological and temperamental attributes that converge on what has been called by some resilient personality. The cultural dynamics of the psychotherapeutic encounter considers the interaction between cultural elements, such as assumptive positions, meaning, identity, stigma, etc., of patient and therapist surrounded by a variety of factors from socioeconomic to placebo-response-based and religious ones. General principles of psychotherapeutic management of personality disorder cases can be summarized as kind firmness, aimed at bringing patients back to the assumption of their own responsibilities. A more or less large percentage of borderline personality disorder patients eventually improve or even recover with the use of techniques as different as cognitive behavioral therapy, dialectic behavioral therapy, mentalization-based therapy, transference-focused psychotherapy, and classical psychodynamic psychotherapies. Stone, a very important figure in the research on personality disorders, explained these findings as related to personality traits of both patient and therapist, unpredictable life events, placebo effects, and the patient's socioeconomic and cultural background. That explains in many ways why patients with personality disorders respond to different characteristics or different techniques. To this, I would add the concept of hope as a universal ingredient of every school of psychotherapy in the good response of patients. Hope that the patient brings with himself or herself, and hope that is also cultivated, stimulated by the therapist's attitude. All these factors constitute the contextual model that I alluded to before and operate alongside the medical model. Intercultural and transcultural psychotherapy research studies of so-called fractured personalities, postulate that recovery cannot be fully understood unless situated in a socio-political, cultural, and historical context. Let's get into a brief discussion of additional issues. The cultural focus facilitates the rapport between and the joint work of professional and patient, empowering the latter in terms of identity and potential recovery, and making it possible a well-defined involvement of the family and others in the cases evaluation and management. In short, the cultural evaluation or assessment must be integral, systematic, and exhaustive, encompassing all relevant factors of the clinical condition and exploring them with thoroughness and depth. It must start with primarily patient-centered strategies without previous assumptions about identity or identities of original groups, and being solidly standardized. That is, reproducible in diverse scenarios and populations. Culture plays, as I mentioned, a decisive pathogenic role in the involvement of personality disorders, be that through defective child-rearing practices, negative family-based customs and traditions, defensive postures towards an arbitrary set of societal norms, economic factors, and the many times mentioned racism and acculturation processes. On the positive side, however, culture can operate as a de-pathologizing agent by identifying, many times uncovering, sources of cultural misinterpretation, such as moral beliefs, religious and ethnic practices, levels of expressiveness, social and societal habits, age and gender-based attitudes, that leads to patterns of pathological labeling. The social component in the definition and understanding of personality disorder is a matter of persistent debates. Primarily among those debates are those related to narcissistic and borderline personality disorders. To a small number of studies, let's talk about narcissistic, literature reviews added quite variable prevalence rates, the use of strong ideological or theoretical basis in its definition, frequent comorbidities, inconsistencies of diagnostic criteria, stigmatizing, therefore denaturalizing, the public use of the label, varieties of subtypes, and proposals of using narcissism as domain, trait, or symptom that creates a lot of controversies. Similarly, this situation has also been described in borderline personality disorders. The presence of somatomorphic, psychotic-like, and obsessive-compulsive manifestations, descriptions of borderline as ultra-rapid cyclers, pre-morbid factor in the autistic spectrum, etc. Adolescents from sexual minorities show highest scores in the measurement of borderline personality disorder traits, after controlling for depression and anxiety, and also report narcissistic injuries, or subtypes of so called mental pain, are detected in childhood and adolescence as part of impulsive, non-conformism, and aggressiveness, predictive factors of borderline personality disorder in the adult life. The comprehensive assessment of stress levels and of degrees of cognitive dissonance, knowledge of cultural deviance theories, and all the cultural variables I have mentioned many times, constituting the individual's identity and cultural congruency, lead unquestionably to the adoption of appropriate, culturally specific treatment approaches, including techniques that must address intensively ingrained coping styles. Strengthening resilience has also been mentioned as the culture-based reinforcement of an essential component of the social fabric, quotes and quotes, of each person. Reinforcing social and interpersonal connections, social and emotional skills, fostering self-esteem, decision-making abilities, and a rational deployment of personal potentials. Personality markers could be stable vulnerability indicators for some clinical conditions in different cultural groups. Finally, the erroneous use of personality disorder labels, as I said, can be prevented by continuous use of and studies on the so-called cultural concepts of distress and the use of the cultural formulation interview in DSM-5TR, and familiarity with the components of the cultural concepts of distress. Three, cultural syndromes, cultural explanations, and idioms of distress. Those are contents of the cultural concepts and can be resorted to in cases that we initially may think are personality disorders, but can be better explained and better dealt with by using these resources. Let me conclude, and I apologize for the length of this presentation, but let me say that one of the most common and severe varieties of psychopathology, personality disorders constitute a growing field of clinical and research and ontological inquiries, a complex challenge in biological, psychodynamic, and socio-cultural study areas addressing individual, society-based, and even religious or spiritual characteristics. Personality disorders have, as well, public health implications and obviously very relevant diagnostic and therapeutic demands. If we apply an extensive cultural perspective to the study of these components, the resulting concepts would better describe personality disorders as expressions of a basic deterioration of intra-individual, that is self-related, and interpersonal functioning. Intra-personal and interpersonal. Sophisticated and promising epidemiological studies and measurement tools will clarify the current diagnostic heterogeneity and provide an accurate, flexible estimation of clinical cause, comorbidities, risk, and protective factors, and prognosis. The generation of a resilient personality would be a culminating step of this process. Personality disorders, the study and the management, generate a source of multiple additional study topics. For clinicians and researchers, these topics are extremely important. And numerous. Context, vulnerability, identity, otherness, discrimination, resilience, social determinants of mental health, etc. In short, there is a lot to be done, but I have no doubts that we will do it. Thank you very much. All right, Renato. Okay, well, the room is full and the microphone is open. Who wants to start making any comments, questions? And while we let Renato take a sip of water and get on with addressing your concerns or your comments. Oh, excuse me. Can you say your name and where you're coming from? My name is Valerie Poore, and I run an organization for borderline personality disorder. And we basically focus a lot on training families, particularly in mentalization-based therapy. And I've been doing this for 30 years, and in the last couple of months, I had this revelation, which is very much in line with what you're presenting. We have people from all different countries, and the cultural thing is quite apparent, which tends to deal with the expectations of the family. I have a family from Persia, and the idea of what the son should be is completely different than an American family. But in the last couple of weeks, I realized something that I'd never thought of before. You have to know the age of the person you're dealing with, and the age of the parents, because the generations, Generation X, I never knew what all of those were. But I went on the internet, and I just looked up generations, and I looked up images. And for all of you, if you look it up, every chart goes along with the device that was developed for each generation. So I'm old. I only barely deal with computers. I had a couple who were complaining all the time about the kid only communicating by text. The family was going crazy because they didn't know how to deal with that. And yet, the newest generation only deals with text, and people like me, I hate text. So I think it's really important that you establish the age of the person you're treating, and the age of the family, and see where they fit generationally, which is in addition to culture. And I just think it makes a huge difference. So I'm now teaching by ages. I don't know if anybody's thought about that. Okay. Thank you very much for the comment. You mentioned borderline, but you mentioned family, and that is a source of cultural factors that is very important. And I assume the evaluation of the patient goes together with the assessment and the contribution of the family in order to understand some of those behaviors from the cultural perspective. So, obviously, the work you do is extraordinary, and age is important, the generational issues, the intergenerational issues. And the other thing here is acculturation on the side of parents who may have been the ones who migrate, and then the child who was born here and faces a different reality. It's extraordinary in the varieties that come in. But I will say that when we analyze the diagnostic situation for people with personality disorders, I've been running a helpline for 30 years, and I have data if anybody wants to look at it, 30 years. It takes about 10 years to get even a moderate diagnosis. They all walk in with a minimum of five diagnoses, and of late, I throw it all out, and I only look at diagnosing according to RDoC. And if you look at RDoC and negativity and positivity, you start to understand them. But if you look at any of the DSM criteria, they don't make any sense. And the other thing I would like to say is Adolph Stern, in 1938, decided what borderline was. It was never a personality disorder. He diagnosed people who his treatment didn't fit, and they were not delusional, and they were not cognitively impaired. And if you read what he described, it's absolutely the RDoC criteria, and it's the best way to diagnose today. And I tell you all to look up the 1938 actual research of Adolph Stern. It's absolutely amazing. Thank you very much. You see how personality disorders generates debates that are extremely important, of course, to clarify issues, but also to make precise concepts. RDoC is a strictly biologically-oriented perspective, and I think by advocating for the search, and I am not saying it should not be, it should not take place, but the search of biological markers may induce a number of problems there, really. The cultural approach complements itself. It is not antagonistic. That's important. It's a complement. And the good clinician, the good therapist will be able to combine those approaches. To finish this particular point, personality disorders as psychiatric disorders do exist. Let's not say, oh, they are other things, other diagnosis. No, they do exist. They are tough, complicated, difficult, but we should look for them and be aware that we should not use the label, so... A difficult patient, for example, right. And using judgments that have nothing to do with a clinical objective approach. Next person. Thank you. Please, name. My name is Krista Roybon, and I am a founder of an integrative mental health center, IOPPHP level of care in San Diego. Hello. San Diego. I'm also a Chicana from East LA. There you go. And I have a lot of questions. Thank you so much for this very rich and deep presentation that you offered us. You brought up so many questions, and I love the concept of hope as an essential ingredient that we hold as clinicians. But as a Chicana from East LA, I'm very curious your thoughts on, through a cultural lens, how machismo would be understood as related or not to narcissistic personality. I also would like to... Estoy muy curiosa. Muy curiosa. And I also, I have a couple of questions. The second one would be the concept of cultural humility versus cultural competence. And the stance of sitting in a framework of constant curiosity in cultural humility is that the clinician is never the expert, and the patient is always the expert. And we must sit in that stance of wanting to understand more deeply. And then the third question, unless there's a line behind me, would be, is there a view of compassion in naming personality disorders as related to hope? Because if we have a compassionate stance for personality disorders, then perhaps people can grow and change, and societies can grow and change because we give them a way to improve and evolve. Okay, thank you very much. Really very profound and complex questions. The first one, machismo and narcissism. That is a very important association, but very important, I would say interesting association, but we have to be careful in terms of labeling that, and by label I mean narcissism. Machismo is a description, is a culturally based collective approach or consideration of gender, et cetera, et cetera, and their level of authority. Remember, Latino cultures pay a lot of attention and cultivation to the notion of authority, and the paternal authority, the maternal authority, the parental authority to the kids, the children. So this is important to delineate what is cultural from what is clinical or pathological, and I personally don't think that machismo should be considered a narcissistic feature. That doesn't mean that there may not be narcissistic personality types among those who profess machismo, but I'm sure many of you who deal with Latino families and patients recognize that the machismo entails, in many cases, good intentions towards the family, the children, et cetera, et cetera. So it is an interesting dialectic discussion and clarification. The second is cultural humility versus cultural competence. That's very interesting, and again, they are not incompatible. They are not one against the other. The fact that every clinician should keep what we call cultural humility, that is to realize that myself, I am different from the person who comes to see me, to the hospital, to the office, is different. Therefore, I am not going to try to impose my views on him. I am not going to try to see him as inferior or different to me. Different, yes, but not inferior. So humility is objectivity in a reasonable sense, whereas competence is to be aware of all the cultural and social differences between patient and clinician and the need to apply a given approach to a given patient. It is not that we apply the same thing to everybody. We have to early in the interaction figure what is the cultural endowment that the patient has or the cultural background, and then try to learn more about it and adapt the questioning, the dialogue to those characteristics. So that is important. And the third point is a very interesting distinction also, compassion and hope. Again, they are not incompatible, but they should be well understood. Compassion, and by the way, you know that compassion has a different meaning in English than in Spanish, for instance, but that's not the topic of this issue. From the English perspective, compassion is the capacity to understand a number of things globally and coherently, okay? And of course it entails an interest in helping the patient, a social flexibility, the ability to relate. All that is included in compassion, and that is an important, very important ingredient of our behavior as clinicians and therapists, particularly with personality disorders because sometimes, as I have said several times here, we tend to a quick diagnosis, a quick labeling of our patients, and that is a problem because that not only slows down our reasoning but also leads it into a different and erroneous way. Hope. Probably some of you know or have heard, and we were talking with Bernardo yesterday about this, you may have heard about Jerome Frank. Jerome Frank was a professor of psychiatry and psychotherapy researcher at Johns Hopkins. I had the extreme fortune of being his resident when he was not to the end of his career at Hopkins, and he was the first psychiatrist who obtained money from NIMH to do research on psychotherapy. Can you imagine NIMH back in those years? Of course, everything was biological. The funding was for biological projects, and somebody comes here and says, I want to study psychotherapy in clinical centers and how it works, why it works, et cetera, et cetera. And his classical book, Persuasion and Healing, which had three editions, is really, as I said, a classic because it develops the concept of hope. In his research, his postulate was many schools of psychotherapy with different background theories or ideologies, they all claim that they are successful with patients. And he says, yet they have different theoretical issues, theoretical basis. His reasoning was very simple, but at the same time, very profound. That only means that all those schools of psychotherapy have common ingredients, that they all have something that puts them together and help to explain the effect, the good effect of that technique. And he focuses his studies on the cultural ingredients of all psychotherapies, all psychotherapies. Well, among the ingredients of all schools of psychotherapy by interviewing thousands of patients, he found that hope was one of the most powerful common ingredients. No matter what kind of therapist the patient went to see, if the patient had with him a big, high, solid component of hope, and if the therapist had a strong notion of what hope is and why or how we should cultivate it in our patients, that was the most powerful common ingredient for all psychotherapies. And either it should be brought in by the patient, if they go to see a doctor, they may have some hope, right? And cultivate that. And at the same time, the clinician, the therapist, must be able to reinforce that attitude on the side of the patient and know how to stimulate hope as a therapeutic ingredient. So what I am saying is that it is a solid concept, not a rhetorical word, no. I mean, we can use it from time to time as a rhetoric figure but I think it's important to consider it a solid part of our work. Sorry for the length. Okay, well, we really wanna, we're not done yet. We really wanna thank you that the room is full, some people standing up. Since there's nobody on the microphone, is it okay if I ask you a question? Oh, please. Yeah, okay, so, fortunately, I'm from Mexico and some areas of Mexico, for those who know, have been known for being violent and dangerous. Not all the countries that way, let me clarify that. But you were talking about the context in childhood and also the biological factors in childhood and your concept of harmful dysfunction. So for those children that grow up in these environments, and this could be true for many places in Latin America, can you expand a little bit about that factor and antisocial personality disorder? Thank you. First of all, I think violence as a collective behavior, or an individual, of course, and violence as a social determinant of mental health. Let's not forget that. Exists, is present in many cultures, many human groups. However, of course, in some of them, the way to deal with taking care of children or from the birth time or moment to the early development, the harmful dysfunction consists of, as the name says, the wrong way to deal with what we call discipline, for instance, or what we call education of the interpersonal transactions for the child, et cetera, et cetera. Those are definitely, the parents have to be careful about that in terms of helping to the involvement of a normal personality. Yet, as you know, children develop a heavy sense of imitation, a heavy sense of copying behaviors, reproducing behaviors. And whether the parents wanted it or not, that gradually over the years may create habits, may create styles of interpersonal transaction, et cetera. And if that, together with other factors, in the bio, psycho, social, cultural areas, and spiritual areas, contribute to this, may evolve into a personality disorder. So I am insisting on the pathogenic value or pathogenic relevance of cultural issues and the way the child is raised up, the way the interactions between parents and children take place at home early in the life of these children, that may be pathogenic on the basis or not of biological factors. By the way, biological and sociocultural, the amount, the volume of those two components varies in personality disorders. And in some cases, it is mostly socioculturally determined, the behavior that brings the patient into consultation. And in others, the biological factors are important. By the way, antisocial has a strong biological thing also. So it is an important thing to delineate these two components. And I put out, I am not aware of particular studies about a strong relationship between the harmful dysfunction that is the way of raising children say the Latino society, the Latino culture, vis-a-vis the evidence, the incidence of personality disorders. But that we have to be careful about that, that not only parents, but teachers, friends, neighbors, community, et cetera, should be aware in order not to reinforce those negative approaches. Thank you. On that, I wanna say that on, yes, yes, we're gonna get to your question, I'm sorry. No, I just wanna make the plug that on Monday at 1.30, we're gonna be talking about the sociocultural and biological factors in the Latinx 2024 with our good friend Eugenio Roth. So that's at 1.30. Sir, go ahead. Sorry, I think we're going towards our last question. Go ahead. Yeah. I don't steal the time from you guys. I want to share experience on the culture of my research. Please state your name and where you're coming from. Last, yes. My name is Mario Weiss. I'm a medical doctor from Germany. Thank you. My period from the accident. So no Latino. We are developing in our research group since 10 years what you call digital psychotherapy software. And we started, of course, in Germany. And then we had research in Texas, in New York, in Brazil. And we found out that we have to adapt the software culturally. So we taught the software to be flexible to different cultures over the last 10 years. And now I think we have over 100,000 patients from China to Brazil and Italy that use the software. And I want to share with you all what we found out. We found out that there is, of course, a difference how the software adapts to Brazilian and to, let's say, Germans. But that the diversity inside the population is bigger than the diversity between what you call cultures. So you have very Brazilian Germans and very German Brazilians. Yeah? And, yeah, it seems to be obvious, but it was not for us. And now, and that's why I'm really happy that I made it here, we have developed a program for borderline disorders. And it's only in German. And I would really love to see how this software has to be adapted to different cultures. So all of you that are interested in doing some research in other areas, come to me. And thanks for giving me the opportunity to tell a little bit about our research. Thank you. Well, we actually have time for one more, yes. Yeah, let me just comment. I think it's significant information that you bring us about international research on personality disorder and other psychiatric conditions. I think the personalities particularly are going to be, you are going to have lots of findings there that will establish distinctions. Again, having to do with biogenetic factors and having to do with socio-cultural issues. And artificial intelligence will work into this very soon also in terms of delineating diagnosis and management. We have done two large clinical trials with a couple of hundred patients with borderline personality disorders. And we had positive outcomes. And it was kind of, of course we were happy. But then the diagnosis, as you described, with all these patients, when we looked at the diagnosis, it's not so clear what we actually diagnosed, you know? It's not that easy. It's not in, with depression, the other program wasn't depression. We are really curious what we'll find out. It's kind of, yeah. I'm not that young anymore. So I don't know if I will have the 10 years looking what will happen. But maybe someone else can take over. That's excellent, thank you very much. Okay, last question. Thank you for allowing me to be the last. Also, thank you for that wonderful presentation. My question is related to. State your name, your name. I'm Miguel Hernandez. I'm psychiatrist, CEO, founder of Global Psychiatric Services in New York. Exposing somebody to trauma, violence, and different environment in person is different from exposing or being exposed to violence through social media, TV, you know, radio, what we see now in the internet. Do you see, or do you think there is a strong significant between these two items in the shaping of personality traits and personality disorders? Like especially like antisocial personality disorder, borderline, and so on. Wow. It's a very excellent question and complex. I think that, as any other social product, internet and social networks are good and bad resources. In the bad or negative impact, I am afraid that the internet use, particularly among children and adolescents, can become a strong pathogenic factor. If it is not well regulated, controlled by family and society in general. That collides with issues such as freedom of expression, freedom of contact, freedom of whatever I want to do, et cetera, et cetera, as part of the social philosophy in countries like the US. So, I think the families and communities should be aware of ways, and authorities at higher levels, should be aware of how to regulate this. The use, the intensity, the topics, the aspects of scheduling internet transactions, et cetera, et cetera. I think that is crucial. Because those can operate as precipitating, triggering clinical disorders. And in a way, it may be good, because if it opens up the pathology, the psychopathology, the parents may be finally able and decided to take the child to consultation or evaluation. But the process, the time that goes between that and the decision to take the child to the doctor may be difficult and may be decisive. So, that is one aspect. I am talking about children and adolescents. But among adults also. And I think there are documentations about how internet, social networks, et cetera, et cetera, can impact on collective violence or can stimulate those issues. That has to do with predisposition. Not everybody who hears that or listens to that or sees that is going to end up as a violent person. But the susceptible, predisposed, et cetera, individuals can. So, your question is very important to distinguish between personality disorder as such and behavior, violent behavior, or undesirable behavior induced by social media. It's an important aspect, definitely. Thank you. Okay, it's exactly 9.30. Thank you very much for being here.

cultural psychiatry

personality disorders

Dr. Renato Alarcón

cultural factors

diagnosis

treatment

cultural competence

cultural humility

borderline personality disorder

antisocial personality disorder

technology in therapy

media exposure

clinical practice