Personality and Psychiatric disorders: Four blind men and an elephant or chicken and egg?

If there is one thing that gets psychiatrists riled up and in a disagreement it is the diagnosis of a patient.  Treatment always follows diagnosis, so you can see how important it is to get it right.  Unfortunately, mental health professionals are divided.  Some choose Axis I as primary, others Axis II.  What?  Axis I explains troubles in terms of a medical illness or state, Axis II explains it in terms of personality traits.  Of course, both can apply, but inevitably,  you have to choose which to prioritize.  Axis I lends itself to medications, Axis II to psychotherapy.   This is called the state/trait dichotomy, and the “lumpers” say states are in a continuum of trait while the “splitters” say traits are seperate from medicaly ill states.

There are four models out there to approach this thorny question.  Are emotional troubles due to your traits or a disordered mental state?  In other words, when you aren’t doing well  is it you or are you ill?

Model one argues only your personal makeup determines your symptoms, and treating things like mistrust, attachment difficulties, relationship troubles, and self-esteem regulation make you better.  The second model argues that you always have a medical disorder of the brain when you in an unwell state of depression, anxiety, psychosis etc.  The third model argues both can be true because of an underlying shared vulnerability.   The fourth theory argues there are two independent problems–personality disorders and psychiatric disorders — which occur together or individually depending on circumstances and environment.

This article (cited below) avers that treatment of the personality disorder often resolves the mood/anxiety disorder 60-80% of the time, while treating the mood disorder does not resolve the personality disorder.  They conclude:  Treat Axis II, and Axis I will follow.  This is taken as compelling evidence that Axis II is primary and model I is correct.  Axis I is unnecessary, for it is an extension of Axis II.  Axis II has a dimensional component from mild to severe, which captures more and more Axis I diagnoses as severity increases.  The more severity, the more work for the psychotherapist.

I like this article, for I am at heart a “lumper.”  What I confronted through this reading, however, was how limited medications are for treating personality traits, and psychiatric symptoms in general, by extension of Model One.  Medications have their place, yes, to ameliorate traits like aggression, psychotic thinking, mood instability, avoidance/anxiety, etc.,  but resolution often requires psychotherapy.  Evidence of treating traits with medications is meager at best;  I am less certain how much good medications are for many patients, especially if a good psychotherapist is available.

So what?  For me,  I think I will be more eager to push psychotherapy as the more lasting solution, and cite this article as further evidence that this is the correct approach.

Article from 2013 FOCUS, Journal of Continuing Education, for psychiatrists:


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