“Perrotta Integrative Clinical Interview” (PICI) for adults and teenagers (1TA version) and children (1C version): new theoretical models and practical integrations between the clinical and psychodynamic approach

Citation: Perrotta G (2021) “Perrotta Integrative Clinical Interview” (PICI) for adults and teenagers (1TA version) and children (1C version): new theoretical models and practical integrations between the clinical and psychodynamic approach. Ann Psychiatry Treatm 5(1): 001-0014. DOI: https://dx.doi.org/10.17352/apt.000024 https://dx.doi.org/10.17352/apt DOI: 2640-8031 ISSN: M E D I C A L G R O U P

each different from the others). The diffi culties related to a general defi nition of personality are more than legitimate, as it is diffi cult to frame in a structured and unifi ed way all the theories of personality that have been proposed so far [1].
1. Hippocrates' historical or biological theory: Which defi nes four "personal types", based on the basic mood present in the body (melancholic, choleric, phlegmatic and sanguine), while Cicero defi nes it as the appearance and dignity of a human being or that part that is played in life. These concepts will then be taken up by Pavlov in his refl exological and behavioral theorization and by Sheldon with the intent to identify the links between biological and behavioral structures (starting from the soft, solid, or fragile physical constitution).  : Eysenck was the fi rst to defi ne the personality of the individual according to a general concept, labeling it as the stable and lasting organization of a person's character, temperament, intellect, and physique; an organization that determines his full adaptation to the environment.

Allport's trait theory:
Resuming the concept of traits, Allport believed that each individual was a unique combination of "personality traits", and for this reason, it was impossible to identify two identical personalities.
He hypothesized the fi rst division into common traits and personal traits: the former are those that can be identifi able for a group of people or category (e.g., boxers defi ned as "aggressive"); the latter are specifi c to each individual, and cannot be defi ned in a single word.

Cloninger's neurobiological theory:
The author The structural, dynamic, and functional relevance of the personality. Persistent traits and patterns [12].
Trying therefore to defi ne the concept of "personality" in a unifi ed way, the synthesis could be the following: <<the organized and complex, stable and lasting whole, of the psychic characteristics and of the behavioral and relational modalities that defi ne the person>>>. From this defi nition, however, it is necessary to distinguish the concept of "personality trait" which instead represents only a constant way of perceiving and relating to oneself and the environment concerning that specifi c modality (and consequently the personality is given by the sum of the traits of an individual that would be able to explain the observed behavior). The "trait", in turn, is distinguished from "attitudes" (behavioral modes reinforced by the environment that predispose the subject to certain actions repeated over time) and from "habits" (behavioral integrations repeated over time because they are structured in a complex of actions aimed at satisfying an unconscious pleasure) [13][14][15][16][17][18].
The term "personality" must also be clearly distinguished from [13] 1) "character", which indicates the characteristics of the person most in conformity with social values and standards: in fact, it is said "you have a good character", "a bad character", underlining the adherence to a shared social and ethical criterion; 2) "temperament", which is the innate component of personality, although, at least in part, it can be modifi ed in interaction with the environment. The temperament is, therefore, the biological substrate, the average level of activation of the organism; 3) "constitution", which is the external and anatomical confi guration of the person.  [19].
The "personality structure" [13,15]  Within the personality structure then we distinguish [13,15]. When the totality of the emotional and behavioral traits typical of a person deviates from the culturally expected and accepted limits or when one is faced with rigid and nonadaptive personalities that cause social or environmental dysfunctions or marked subjective discomfort, a "Personality Disorder", understood as a deviation of personality and behavior from "normal" cultural peculiarities, is confi gured.
The therapeutic path, in this sense, aims at promoting the development of each person according to his or her potential, correcting dysfunctional manifestations, and improving the interaction of the individual both concerning the external world (relational sphere) and concerning himself or herself (intrapsychic sphere) [15].
The "personality dynamic" [13,15,20], on the other hand, concerns the functioning of the personality, both as a selfreferential system (capable of refl ecting on itself to achieve the objectives and respect the norms) and as a self-regulating function, to use the ego defense mechanisms [22], the balance of psychic instances among themselves and about the external environment, the strength of the Ego, internalized relational objects, the image of the Self, self-esteem, attachment styles [23] and the ability to relate to oneself (concerning emotions) and to others (concerning affections and feelings) [24].

1) "Healthy" level of organization of the personality:
Individuals with a healthy personality score very good or good scores in the above areas. They can have different styles but are fl exible and adapt to the challenges of the environment.

2) "Neurotic" level of personality organization:
Neurotic subjects tend to highlight some specifi c emotional issues around which discomfort is organized: for example, loss or rejection or self-punishment in people with a depressive personality.

Towards an integrative model
In general, personality disorders are diagnosed in more than half of psychiatric patients, making them the most frequent in psychiatric diagnoses. Personality disorders are generally recognizable in adolescence, early adulthood, or sometimes even childhood, and can affect two or more of the following areas: the way you think about yourself and others; how you respond emotionally; how you relate to other people; how you control your behavior [25].
Taking into consideration the "DSM-V (Diagnostic Statistical Manual)" [16], this instrument speaks of "mental disorder" as a syndrome that groups together clinically signifi cant and individual disorders by criteria of Cognition (A), Regulation of emotions (B) and Behavior (C). They correspond to a specifi c dysfunction in the psychological, biological and developmental processes underlying mental functioning. These conditions lead to discomfort and social, occupational or other disability.
It also lists eleven indicators of possible diagnostic criteria: shared neurological substrates, family traits, genetic risk factors, specifi c environmental risk factors, biological markers, temperament background, abnormalities in emotional or cognitive processes, the similarity of symptoms, disease course, high comorbidity, shared response to treatment, whether cognitive-behavioral, psychodynamic, humanistic or strategic [58]. With reference, in particular, to personality disorders, the DSM-V groups them into three clusters, based on descriptive similarities: 1) "Cluster A". It is characterized by eccentric behavior, distrust, and a tendency to isolation; it includes the following three personality types: a) "Paranoid personality": characterized by distrust and suspicion towards others, to whom it tends to attribute bad intentions; it fears to be damaged or deceived, even in the face of lack of concrete evidence.  Taking into consideration the "PDM-2 (Psychodynamic Diagnostic Manual)" [15], unlike the fi rst edition, which was

Clinical implications based on the new ''Integrative Psychodiagnostic Model'' (IPM) and the new Psychopathological Investigation Model (PIM)
Based on the new model, the psychopathological investigations also change the focus completely. If everything is "personality" and not just a simple stable and lasting representation, it is clear that a diagnosis of a psychopathological condition such as anxiety or obsessive disorder must necessarily be framed within a new theorization and classifi cation of personality disorders (while up to now personality disorders have always been distinguished from other psychopathological disorders, possibly connected by clinically relevant comorbidities), which however takes into account not only categorical and structural profi les, but also and above all functional, dynamic and clinical profi les.
Continuing to trace this line of investigation, we propose a new Psychopathological Investigation Model (PIM) that takes into account the following rules of style:

Diagnosis in the psychological clinic and psychiatry
Psychopathological diagnosis is always "personological" and always refers to a habitual, stable, persistent, and pervasive pattern of experiences and behaviors that differ signifi cantly from the culture to which the individual belongs and manifests itself in at least two areas between cognitive experience, affective, interpersonal functioning and impulse control. The "personological diagnosis" can be made from the age of twelve years, while for patients below the threshold the diagnosis is always of "psychopathological presumption of personality", deserving of clinical treatment if the number of traits and/or dysfunctional behaviors found to cause signifi cant anomalies that deserve intervention. In these cases, we will not talk about personality disorders but simply about "specifi c disorders" (as the requirement of stability is missing in a personality not yet perfectly structured) and they will be followed by a precise nosographic categorization that tends to be different from the actual personality disorders. In adolescents and adults, on the other hand, each diagnosis is framed in a precise personological framework that defi nes the specifi c personality disorder, according to the specifi c nosographic list.

Dysfunctional traits and behaviors
Each personality disorder is described in its nine fundamental characteristics, called "dysfunctional personality traits", and to be diagnosed it must present fi ve or more specifi c traits of the same personality disorder, in a dysfunctional personality pattern that is habitual, stable, persistent and pervasive, on a scale ranging from mild (or oriented, with fi ve traits), signifi cant (or sensitive, with six traits), moderate (or vulnerable, with seven traits), severe (or compromised, with eight traits) and extreme (or severely compromised, with nine traits). To be considered a "dysfunctional trait", however, the symptoms must have persisted for at least three months continuously, otherwise, we will have to speak of "dysfunctional behavior" and this circumstance will not contribute to the diagnosis of a personality disorder, even though it may still be worthy of psychological support.

Dysfunctional behavior
It is a personality trait that has been present in the patient for less than three months (for example, having obsessions). In this case, the diagnosis will be "obsessive behavior" (because, in the proposed example, the specifi c item is part of the obsessive model).

Dysfunctional personality traits
It is a personality trait that has been present in the patient for at least three months (for example, having obsessions). In this case, the diagnosis will be an "obsessive trait" (because, in the proposed example, the specifi c item is part of the obsessive model).

Psychopathological attitude
In the absence of a diagnosis of specifi c personality disorder (in adolescents and adults) / specifi c disorder (in children), it is the diagnosis in the presence of two traits in one or more specifi c disorders. If the disorder is only one (for example, two anxious traits) the form will be mild, if it is two traits in two or more disorders (for example, two anxious traits and two obsessive traits) the form will be moderate. In this case, the diagnosis will be an "anxious attitude" (mild form) or "anxious-obsessive attitude" (moderate form), because, in the proposed example, the specifi c items are part of the anxious and obsessive model.

Psychopathological inclination
In the absence of a diagnosis of a specifi c personality disorder (in adolescents and adults) / specifi c disorder (in children), it is the diagnosis in the presence of three traits (signifi cantly dysfunctional form) of the same disorder (for example, three anxious traits). In this case, the diagnosis will be "anxious inclination", because, in the proposed example, the item belongs to the anxious model.

Psychopathological predisposition
In the absence of a diagnosis of specifi c personality disorder (in adolescents and adults) / specifi c disorder (in children), it is the diagnosis in the presence of four traits (moderately dysfunctional form) of the same disorder (for example, four anxious traits). In this case the diagnosis will be "anxious predisposition", because in our example the item is part of the anxious pattern.

Personality disorder of another type or not otherwise specifi ed
In the absence of a diagnosis of specifi c personality disorder (in adolescents and adults) / specifi c disorder (in children), is the diagnosis in the presence of: a) three simultaneous traits in two or more different disorders (e.g. three anxious and three obsessive traits); b) four simultaneous traits in two or more different disorders (e.g. four anxious and four obsessive traits); c) three or four simultaneous traits in two or more different disorders (for example, four anxious and three obsessive traits); d) at least twelve traits in different disorders, of which at least one has four (e.g. four anxious, three obsessive, three phobic, two paranoid). In this case, the diagnosis will be "personality disorder of another type or not otherwise specifi ed with anxious-obsessive and phobicparanoid traits", because in our example the specifi c items fall into all those patterns. This category is completely absorbed if there are fi ve or more dysfunctional traits of the same disorder (for example, six obsessive traits).

Specifi c personality disorder
It is the diagnosis, for adolescents and adults, of fi ve or more traits of the same disorder (for example, fi ve anxious traits). In this case, the diagnosis will be "anxious personality disorder", because in the proposed example the item is part of the anxious model. The diagnosis of personality disorder absorbs the diagnoses of aptitude, predisposition, inclination, and other types or not otherwise specifi ed; the possible presence of two or more traits of a specifi c disorder (for example, six anxious, three phobic, one obsessive) turns the diagnosis into "anxious personality disorder with phobic traits", because in the proposed example the items are part of the anxious and phobic model (but not the obsessive model, because the trait is only one).

Specifi c disorder
It is the diagnosis, for children, of fi ve or more traits of the same disorder (for example, fi ve anxious traits). In this case, the diagnosis will be "anxious disorder", because in the proposed example the item is part of the anxious model.

Mixed personality disorder
It is the diagnosis, for adolescents and adults, in the presence of equal traits in two or more disorders, in the number equal to or greater than fi ve (for example, fi ve anxious traits and fi ve phobic traits, or six phobic traits and six obsessive traits). In this case, the diagnosis will be "mixed anxiety-phobic personality disorder" or "mixed phobic-obsessive personality disorder", because in the proposed examples the items fall within the anxiety-phobic and phobic-obsessive model. If two or more traits of a specifi c disorder (e.g. three obsessive traits) are present in addition to the mixed diagnosis, it becomes a "mixed anxiety-phobic personality disorder with obsessive traits", because in the proposed example the items are part of the anxiety-phobic and obsessive (in the form of traits) models.

Mixed disorder
It is the diagnosis, for children, in the presence of equal traits in two or more disorders, in the number equal to or greater than fi ve (for example, fi ve anxious traits and fi ve phobic traits, or six phobic traits and six obsessive traits). In this case, the diagnosis will be "mixed anxiety-phobic disorder" or "mixed phobic-obsessive disorder", because in the proposed examples the items fall within the anxiety-phobic and phobic-obsessive model. If two or more traits of a specifi c disorder (e.g. three obsessive traits) are present in addition to the mixed diagnosis, it becomes a "mixed anxiety-phobic disorder with obsessive traits", because in the proposed example the items are part of the anxiety-phobic and obsessive model (in the form of traits).

Psychopathological condition common to all disorders
These are psychopathological conditions that can be common to all personality disorders, always according to a comorbidity profi le, and are in any case related to the personological sphere: a) neurodevelopmental disorders; b) short or acute psychotic disorder; c) catatonic disorder; d) selective mutism; e) nutrition disorders; f) evacuation disorders; g) sleep-wake disturbance; h) gender identity disorders; i) paraphiliac disorders; j) sexual dysfunction disorders in adolescents and adults, in the absence of organic basis; k) drug and/or behavioral addiction disorders; l) suicidal tendencies.

Comorbidity and unitary diagnosis
The disorder with the most dysfunctional traits represents the main diagnosis, while all the other disorders with at least fi ve traits represent the representative trait (for example, in a patient with seven anxious traits, fi ve phobic traits, and four obsessive traits, the main diagnosis will be "personality anxiety disorder, with phobic traits", while the four obsessive traits will not be reported but will serve the therapist to build a psychotherapeutic work more focused on the patient's needs, working also on the obsessive components). The traits of other disorders that better defi ne the main disorder must be numerically the most other of all the disorders present in the graph; if at least four dysfunctional traits are present in other disorders, they must be considered as "psychopathological traits" worthy of a clinical study.

Absorbances
In Absorption occurs only if the number of traits of the absorbent pathology is higher than the number of traits of the absorbed pathology (for example, normally the bipolar disorder absorbs the manic disorder but if the latter has a higher number of traits, the diagnosis will be a manic disorder with bipolar traits).

Health diagnosis
The absence of pathological traits is equivalent to a diagnosis of "healthy subject".

Elaboration proposal of a clinical interview for the analysis of personality disorders (Perrotta Integrative Clinical Interview or PICI-1)
Based on the proposed model, revised as follows, two distinct clinical interviews are structured below, which must follow the following style rules [7]. The clinical interview referring to children takes into consideration the following specifi c personality disorders:

Practical example of clinical interview administration
The patient is forty years old, has an excellent cultural and professional level, and comes from a close family. The father has diffi culty in physically manifesting affection and feelings for his childhood past but is present and available for the needs of all members; the mother has an attention defi cit, a slight fl uency disorder, and a manic personality disorder, she cannot physically manifest affection but is always present, even if she has never developed a good level of empathy. The patient has siblings who have found their familiar and professional place. Compared to the total traits typology, the patient is present on fi fty dysfunctional traits: nineteen neurotic, eighteen at the limit, and thirteen psychotic. Moreover, out of scale, on the value of the psychopathological class no. 28 (clinical conditions common to all disorders), further data emerge: fl uency disorder, TIC disorder, paraphiliac disorder, and behavioral dependence disorder due to the internet and social network use.
From the outcome of the anamnestic, personal and family examination, from the previous clinical fi ndings and the administration of the clinical interview, according to the rules determined by the clinical interview, it is therefore evident that the patient is suffering from "manic personality disorder, with somatic, borderline and psychopathic traits, in the presence of fl uency disorders, TIC disorder, paraphilias and Internet/social networks dependences", as: a) the maniacal traits are the highest (6), so this disorder is the main one; b) the anxious, somatic, bipolar, borderline and psychopathic traits are the psychopathological classes that total the number of traits (4) immediately after the manic traits, for which these characterize the personality of the patient as a whole, anchored to the main disorder. However, corrective measures must be taken: -bipolar traits are absorbed by borderline traits; -anxious traits are absorbed by manic traits. Therefore, the somatic, borderline and psychopathic traits remain active.
All other psychopathological classes with three or less traits (3 / -), in this case, are not taken into account, although they can be examined during psychotherapy sessions to "adjust the shot".
Let's take other examples: 1) after the main disorder (i.e. the largest number present of the same disorder), e.g. no. 7 of the narcissistic, the patient presents no. 6 traits of another disorder, e.g. borderline, and then no. 5 traits of another disorder, e.g. anxious; in this case, the diagnosis will be: "narcissistic personality disorder, with borderline traits and anxious characteristics".
2) After the main disorder, e.g. no. 7 narcissistic disorder, the patient presents no. 5 traits of another disorder, e.g. borderline, and then no. 3 traits of another disorder, e.g. anxious; in this case, the diagnosis will be: "narcissistic personality disorder, with borderline traits" (since the other traits are less than 4 and cannot be taken into account even as "characteristics"). Secondary traits (i.e. those following the main disorder are taken into account if they are not less than 4 -of the same disorder).
3) after the main disorder, for example n. 6 of the narcissistic disorder, the patient presents n. 3 traits of another disorder, for example anxious; in this case, the diagnosis will be: "narcissistic personality disorder" (since the other traits are less than 4 -of the same disorder-and cannot be taken into consideration even as "characteristics"), however they will be elements to be considered in psychotherapy.

Conclusions
Starting from the general concept of "personality", therefore, we proceeded towards the analysis of the main theories, to conclude that a better understanding of this theme should pass through the modifi cation of the psychodynamic model and then of the psychodiagnostic ones. On this assumption, the writer proceeded with the detailed analysis of the psychodynamic models referred to the theme under examination, to make three main corrections that would act as systematic ordinators for the creation of a new spherical model (the integrated psychodynamic model, IPM) with the following characteristics: 1) The Ego is equipped with the following functions: a) mediation and fi ltering by the mechanisms of defense, and the sense of guilt and shame, on the instincts of the Ego (deriving from a specifi c function called "Superego", which no longer appears to be an instance in itself, as in the Freudian model); b) conservation, maintenance and re-enactment of the memories not removed, called "Person"; c) relational contacts with the external environment, using perceptions, emotions and feelings, through the use of the mask, called "Character"; d) relational contacts with the Id, through the borderline that divides them (and never directly), called "Self" (exactly the opposite of the Jungian theorization, which considers the Ego a part of the Self).
2) the Id is endowed with the following functions: a) preservation and maintenance of the removed, partly inaccessible personal memories, b) conservation and maintenance of destructive drives and energies, completely inaccessible, called the "Shadow"; c) conservation and maintenance of ancient energies, deriving from an ancestral past (identifi ed with the collective unconscious and the biological matrix of the family tree), called the "Past".
Again on this assumption, the writer concluded that "personality" is, from a functional point of view, as already mentioned, the stable and lasting organization of a person's character, temperament, and cognitive functions; from a structural point of view, on the other hand, personality is the totalitarian representation of the model (what the Gestaltics would label with the assumption that "the whole is more than the sum of the individual parts"). It is therefore the totalitarian whole of the single parts but able to interact with the outside world. The "personality traits", instead, are nothing but the social expression of the personality (the external expression of an inner trajectory), by the theories of Eysenck and Allport. Based on the new model, also the psychopathological investigations completely change the focus. If everything is "personality" and not only a simple stable and long-lasting representation, it is clear that a diagnosis of a psychopathological condition such as anxiety or obsessive disorder must necessarily be framed within a new theorization and classifi cation of personality disorders (while up to now personality disorders are always distinct from other psychopathological disorders, possibly connected by clinically relevant comorbidities), which however takes into account not only categorical and structural profi les, but also and above all functional, dynamic and clinical.
Finally, the work concludes with the listing of the new psychopathological personality disorders classes (twentyseven) and with the listing, for each class, of the nine dysfunctional personality traits, according to four areas of domain (neurotic, latent, psychotic, mixed or residual), also leaving room for the psychopathological conditions common to all twenty-seven personality disorders and any medical and socio-environmental conditions relevant to the diagnosis.
This research work aims to lay the foundations for a structured investigation aimed at supporting the approval of the suggested model (more adherent and compatible with the best defi nition of "personality").
In the light of the integrative psychodynamic model and the fi rst model of psychodiagnostic investigation, the present work has focused on the revision of these models (with the separation for patients under twelve years of age and those above this threshold), to refi ne these useful and functional tools to help the therapist in the clinical diagnosis, essential in a clinical interview and anamnestic study (personal and family), achieving the goal set at the beginning of the project: to reorganize the diagnostic profi les of psychopathologies based on nosographic and functional knowledge, integrating them, to achieve a better awareness of the knowledge shared until now by the scientifi c community on psychodiagnostic.
In particular, based on a sample of one hundred units for adolescents, one hundred units for adults and one hundred units for children, in compliance with the self-imposed rules indicated in the previous paragraphs, the proposed and revised model (PICI-1) is compatible with the current more widespread psychodiagnostic systems (mentioned in the research) and is even more detailed than the MMPI-II, as it focuses more on personality traits to provide a broader overview, necessary to build a personalized psychotherapeutic plan targeted and adapted to the patient, taking into account both nosographic and psychodynamic profi les and functional, cognitive and strategic ones. From a parallelism with the diagnoses made based on MMPI-II, the diagnoses obtained using PICI models are identical and more useful in practice (in psychotherapy); precisely for this reason, the proposed interviews do not need results about the validity and reliability of the instruments, as they adhere perfectly to the results of the MMPI-II and the nosography of the DSM-V (integrated with the psychodynamic profi les of the PDM-II), with specifi c variants that do not change the diagnosis at all but enrich it with technical details useful in psychotherapy. Again along the same lines, the limits only concern the descriptive content of the individual traits specifi c to each psychopathological disorder, which could be more enriched and varied in the future.
However, it should be borne in mind that by modifying the basic theoretical paradigm (the psychodynamic model), even the structure at the basis of the psychodiagnostic model cannot be compared with the current models in use; therefore, the basic idea is that of a clinical interview administered directly by the therapist, who before that moment proceeded to the clinical evaluation based on anamnestic and documentary evidence, with the testimonial evidence of the closest family members. On this basis, the implant appears to be solid and robust and functional to the set goal.