Introduction: An Essential Part of the Mental Health Evaluation

February 29, 2016

An exploration topics that are relevant to most clinicians who work with patients with personality disorders.


At the end of the 1970s there would have been substantial discussion about whether personality disorders were worth the effort of a Special Report. There were disagreements as to whether personality disorders were “real” psychopathology in contrast to the axis I mental states, or whether they were simply retained in DSM to garner support from psychodynamic psychiatrists for the more atheoretical (and perhaps more biological) leanings of DSM-III. The then categorical diagnoses of personality disorders were relegated to axis II, an axis separate from the mental states.

[[{"type":"media","view_mode":"media_crop","fid":"46035","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6840338713557","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5309","media_crop_rotate":"0","media_crop_scale_h":"142","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The idea of an axis II (in the then 5-axes model of DSM) was a way to have clinicians pay attention to the possibility of a primary or a comorbid personality disorder as part of a diagnostic assessment. If clinicians were to consider an entry on each of the 5 axes, they might pause and ask which patients might possibly harbor a personality disorder-something many of us interested in personality disorders thought useful. However, probably because of time constraints, insurance company requirements, and possibly many in the field not thinking that the concept of personality disorders was useful (there were then no effective treatments save perhaps for psychodynamic or psychoanalytic approaches), most clinicians did not linger very long on personality disorders. Instead, they opted for “Axis II, deferred” or “Personality Disorder Not Otherwise Specified.”

This problem was addressed by the DSM-5 Personality and Personality Disorders Work Group, which suggested new ways of approaching personality disorders so that clinicians might pause and consider the presence or absence of a personality disorder as either a primary diagnosis or as a major confounding comorbidity to a mental state disorder. Although the Work Group’s somewhat controversial suggestions were wise, they did not make it into the main body of DSM-5 but were placed in Section 3 of DSM-5.

When I attempted to decide what topics might be included in this Special Report, the choices were numerous. I tried to choose a few topics that would be relevant to most clinicians who work with patients with personality disorders. I first turned to borderline personality disorder (BPD), which seems to give clinicians the most angst. Patients with BPD use more services than those with other personality disorders and in general compose the majority in community treatment for a primary personality disorder.

Over the past 25 years a number of effective treatments have been subjected to rigorous trials. In Part 2 of this Special Report, we review one from the cognitive-behavioral therapy (CBT) camp, dialectical behavior therapy, and one from the psychodynamic camp, mentalization-based therapy, though there are other effective treatments in both the CBT and psychodynamic camps.

Turning from these effective psychotherapeutic treatments, we explore issues that cut across the personality disorders in general while staying close to issues prevalent among patients with BPD. The first is narcissism and narcissistic personality disorder. The section here is not only well-written but illuminates some of the issues, controversies, and differing views of that concept. While narcissism is considered a diagnosis in its own right, it also cuts across the personality disorders, especially the cluster B disorders. The article adds a decent dollop of clinical wisdom about narcissism and its various presentations and permutations.

Two other articles also deal with concepts that cut across the personality disorders while resting quite comfortably close to BPD. The first deals with suicide and suicidal ideation and the risk of and perhaps predictors of suicidal ideation and behaviors among these patients. As is the problem with most suicide research, although the results and behaviors are terrifying, the actual base rate is low, and it is hard to gather sufficient data to make more solid predictions. Nonetheless, we are reminded of its importance-something we should always pay attention to even when we might think the statements and behavior are manipulative.

Finally, we turn to the neurobiology of patients with personality disorders, also in Part 2. Almost unheard of 25 years ago, studies of neurobiological mechanisms, both ordered and disordered, among patients with personality disorders are growing rapidly. Information from neurotransmitters, genetics, all forms of neuroimaging and, recently, work on attachment and pain has begun to come together to give us a greater understanding of the biological complexities that underlie some of the difficult issues we struggle with in the treatment of patients with personality disorders.

The increasing number of academic journals that address personality disorders illustrates the growing interest in this subject. While for decades academic journals on personality existed, such as Journal of Abnormal Personality, Journal of Personality and Social Psychology (American Psychological Association), and Journal of Personality and Individual Differences (Elsevier), as well as a number that addressed personality and social psychology (Sage), multidisciplinary publications that reach out to include psychiatry have become more prevalent. This less than comprehensive list includes the first of the broader journals, the Journal of Personality Disorders (Guilford), the official journal of the International Society for the Study of Personality Disorders, now in its 30th year. That was followed 10 years ago by Personality and Mental Health (Wiley), affiliated with the Section on Personality Disorders of the World Psychiatric Association as well as the British and Irish Group for the Study of Personality Disorders. Most recently, 2 additional journals have initiated publication: Personality Disorders: Theory, Research, and Treatment (American Psychological Association), affiliated with the North American Society for the Study of Personality Disorders, and Borderline Personality and Emotion Regulation (BioMed Central), affiliated with the European Society for the Study of Personality Disorders.

In a little more than a generation, the concept of personality disorders-while reluctantly recognized by much of the psychiatric community-has slowly worked its way closer into the mainstream of psychiatric diagnoses. The current decision to eliminate placing personality disorders on their own axis in DSM-5 may or may not facilitate recognition of their importance as an essential part of the evaluation of mental health patients, but the idea that they do not exist or are unimportant in the evaluation and assessment of patients has passed.


Dr Silk is Professor Emeritus of Psychiatry at the University of Michigan Medical School in Ann Arbor, MI and adjunct Clinical Professor, department of psychiatry at Michigan State University in East Lansing, MI. He reports no conflicts of interest concerning the subject matter of this Special Report.