Fonctionnement conjugal et sexuel des personnes souffrant de troubles de la personnalité : survol des connaissances actuelles impliquant le Modèle alternatif pour les troubles de la personnalité

Les personnes ayant un trouble de la personnalité (TP) font face à une multitude de défis, particulièrement dans leurs relations interpersonnelles. Parmi les problèmes rencontrés figurent la difficulté à établir des relations intimes durables, les cycles rapides de séparation et de réconciliation, les comportements sexuels extraconjugaux, la violence conjugale, ainsi que la détresse sexuelle. Introduit en 2013 dans le DSM-5, le Modèle alternatif pour les troubles de la personnalité (MATP) offre un cadre théorique qui combine une approche dimensionnelle et catégorielle, reposant sur des appuis empiriques et cliniques grandissants. Ce modèle est sensible à la sévérité des difficultés et aux traits de personnalité pathologiques spécifiques, ce qui en fait une perspective intéressante pour mieux comprendre les difficultés conjugales et sexuelles des personnes présentant un TP. Cet article vise à décrire la contribution du MATP à la compréhension du fonctionnement conjugal et sexuel, incluant la satisfaction conjugale et la violence conjugale, la détresse sexuelle, la satisfaction sexuelle et la fonction sexuelle. Pour ce faire, une synthèse des connaissances actuelles sur le MATP et les aspects conjugaux et sexuels issus d’études empiriques menées auprès de différentes populations a été effectuée. La pathologie de la personnalité, de façon générale, pourrait affecter le fonctionnement conjugal et sexuel. Notamment, le domaine du Détachement, identifié systématiquement à travers les études, semblerait contribuer de façon néfaste, durable et constante à la sphère conjugale et sexuelle. En plus du Détachement, les autres domaines du MATP, particulièrement l’Antagonisme, seraient impliqués dans la problématique de violence conjugale. Les implications cliniques sont discutées, notamment en soulignant l’utilité respective de l’évaluation du fonctionnement de la personnalité et des traits pathologiques, ainsi que des pistes d’intervention pour l’accompagnement des personnes présentant différents traits pathologiques. Les limites des études disponibles et des pistes de recherches futures sont abordées. Individuals with personality disorder (PD) face numerous challenges, particularly in their interpersonal relationships. Issues frequently encountered include difficulties in establishing lasting intimate relationships, rapid cycles of breakup and reconciliation, infidelity, intimate partner violence, sexual distress, and risky sexual behaviors. Introduced in 2013 in the DSM-5, the Alternative Model for Personality Disorders (AMPD) provides a theoretical framework that combines dimensional and categorical approaches, based on growing empirical and clinical support. This model considers the severity of personality difficulties (Criterion A), describing self (including Identity and Self-direction elements) and interpersonal (including the elements of Empathy and Intimacy) impairment. Criterion B of the AMPD details 25 specific pathological personality facets regrouped into five domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. The PD conceptualization of this model makes it a promising perspective to improve our understanding of the intimate and sexual issues of people with PD. This brief review aims to describe the contribution of the AMPD to the understanding of relationship functioning (including relationship satisfaction and intimate partner violence), as well as sexual functioning (including sexual distress, sexual satisfaction, and sexual function). A literature review involving the aforementioned areas of functioning and the AMPD across various samples was conducted. Various personality components appeared to be involved in relationship and sexual functioning. Personality pathology, regardless of its nature, seems negatively associated with relationship satisfaction, but pathology of the Detachment domain seems particularly consistent across studies. As for intimate partner violence, in addition to an elevation of the Hostility facet (Negative affectivity) and the Detachment domain, a more disinhibited profile appears to be particularly associated with violence perpetration in men, while women may have a profile of traits that is more antagonistic. For sexual health, a single listed study showed that personality, as conceptualized by the AMPD, predicts sexual health beyond factors such as distress and relationship satisfaction, with specific personality domains and facets contributing to sexual satisfaction or distress across genders. Women with an elevation in the Detachment domain suffer more from sexual functioning issues, while for men, several facets from different AMPD domains contributed to lower sexual functioning, namely Separation Insecurity, Intimacy avoidance, and Anhedonia. Additionally, unexpected positive effects of personality pathology were found in men. In fact, it seems that Intimacy impairment, Rigid perfectionism, and Irresponsibility are related positively to particular aspects of their sexual functioning. Results suggested that personality pathology, in general, is likely to contribute negatively to relationship and sexual functioning. The severity of personality impairment (Criterion A) could serve as a general treatment prognosis indicator informing about present introspective capacities, the required therapeutic framework, and the necessity of a safety plan (Waugh et al., 2022). Identifying pathological domains or facets enriches clinical understanding by enabling the formulation of targeted and realistic therapeutic objectives (Waugh et al., 2022). Additionally, the paper highlights the clinical implications of the AMPD, especially in helping patients suffering from relationship and sexual issues. Because the Detachment domain seems to have notable and consistent associations with relationship and sexual functioning, the therapeutic objective would be to support individuals in gradually increasing their emotional activity and seeking interactions within the context of intimate and meaningful relationships where they can express their emotions. Also, well-known and validated approaches in the treatment of PDs could prove effective, even if the cut-off for a formal PD diagnosis is not reached. Moreover, the limitations of the current literature are examined and suggested avenues for future research are discussed. First, more studies focusing on personality impairment (Criterion A) and using validated measures of personality pathology need to be pursued. Second, multimethod and multi-informant assessment methods should be prioritized using semi-structured interviews and self-report instruments administered to the person and their intimate partner. Third, diversifying samples and employing longitudinal and dyadic designs could enhance and strengthen the understanding of relational difficulties in individuals with PD.

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