Original article JOURNAL OF PSYCHOPATHOLOGY 2019;25:132-138

Personality, mental functioning, V. Lingiardi1, G. Di Cicilia1,T. Boldrini1,2 and symptoms: assessing suicidal risk 1 Department of Dynamic and Clinical Psychology, Faculty of Medicine with the Psychodynamic Diagnostic Manual, and Psychology, Sapienza University of Rome, Italy; 2 Department nd 2 ed. (PDM-2) of Developmental Psychology and Socialization, University of Padua, Italy

Summary Comprehensive and careful diagnostic assessment is a crucial aspect of the clinical manage- ment of suicidal patients. The new edition of the Psychodynamic Diagnostic Manual (PDM-2; Lingiardi & McWilliams, 2017) adds a needed perspective on symptom patterns depicted in existing taxonomies, enabling clinicians to describe and categorize personality patterns, related social and emotional capacities, unique profiles of mental functioning, and subjective experiences of symptoms. This paper provides an overview of the PDM-2, focusing on its diagnostic approach to evaluating patients presenting suicidal intention and behaviors. First, the basic premises of the PDM-2, including its rationale and structure, are briefly discussed. Second, following the multiaxial organization of this diagnostic system, the features and main innovations that can guide clinicians in their assessment and clinical management of suicidal risk are examined.

Key words Suicide • Psychodynamic Diagnostic Manual • Diagnosis • Assessment

Introduction Clinicians routinely investigate the presence of suicidal ideation, suicidal intention, a history of such ideation and intention, and the nature and se- verity of any suicide attempts in all patients they encounter in their prac- tice. Suicide is the second leading cause of death among persons aged 15 to 29, and almost 800,000 people die by suicide worldwide, each year 1. Therefore, for many patients, the clinician’s highest priority when determining the therapeutic intervention is to assess the risk of suicidal behavior. As suicidality is widely considered a transdiagnostic dimen- sion 2 3, it can assume different meanings, functions, and clinical priori- ties according to the presence of other psychiatric comorbidities, as well as the cognitive, affective, and interpersonal patterns demonstrated by the patient 4 5. Accordingly, a comprehensive, careful, and wide-ranging diagnostic assessment is a crucial aspect of the clinical management of © Copyright by Pacini Editore Srl suicidal patients 6 7. OPEN ACCESS Notwithstanding the advantages of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases Received: May 06, 2019 (ICD) systems, their classifications often fail to meet the needs of clini- Accepted: June 20, 2019 cians. In particular, several scholars have questioned the usefulness of such diagnostic categories in guiding clinicians to formulate a manage- ment plan and predict outcomes 8-10. A recent global survey reported that Correspondence a large sample of mental health professionals rated the ICD-10 and some Vittorio Lingiardi editions of the DSM as having the lowest utility in “selecting a treatment” Department of Dynamic and Clinical and “assessing probable prognosis”; the frameworks were deemed pri- Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, 11 marily useful for administrative purposes . The limitations of these offi- via dei Marsi 78, 00185 Rome, Italy cial diagnostic systems are significantly problematic in the context of the • E-mail: [email protected]

132 Personality, mental functioning, and symptoms: assessing suicidal risk with the Psychodynamic Diagnostic Manual, 2nd ed. (PDM-2)

routine management of suicidal risk, due to the urgent coping with stress and anxiety, regulating impulses, ob- requirement for the careful and accurate evaluation and serving one’s own emotions and behaviors, and forming assessment of patients. moral judgments); and symptom patterns, including pa- The recently published 2nd edition of the Psychodynam- tients’ personal, subjective experiences of symptoms. ic Diagnostic Manual (PDM-2) 12 13 adds a much needed The PDM-2 devotes specific sections to discrete age new perspective on the symptom patterns depicted in groups and developmental stages (adults, adolescents, existing taxonomies, enabling clinicians to describe children; infancy and early childhood, later life), and it and categorize personality patterns, related social and structures and operationalizes diagnoses around three emotional capacities, unique profiles of mental function- axes: the P Axis (“Personality Syndromes”), the M Axis ing, and subjective experiences of symptoms. Specifi- (“Profile of Mental Functioning”), and the S Axis (“Symp- cally, the PDM-2 highlights patients’ internal experienc- tom Patterns: The Subjective Experience”). The P Axis es, adopting a multidimensional approach to describe comprehensively describes a range of healthy to disor- the intricacy and depth of patients’ overall functioning in dered personality functioning. Its major organizing prin- various areas (e.g., interpersonal, cognitive, emotional). ciples relate to levels of personality organization (i.e., This comprehensive diagnostic framework can guide on a spectrum of personality functioning ranging from clinicians in formulating individual cases and planning healthy to neurotic, borderline, and psychotic levels 18) treatments, and hence improve the clinical utility of psy- and personality styles (i.e., clinically familiar personal- chiatric diagnoses 14. ity styles/types that intersect with levels of personality In this article, we provide an overview of the PDM-2, fo- organization). The M Axis provides an assessment of cusing on its diagnostic approach to evaluating patients overall mental functioning based on 12 specific capaci- presenting suicidal intention and behavior. First, we ties (i.e., the capacities involved in overall psychological briefly describe the basic premises of the PDM-2, includ- health or pathology) grouped into four main domains: ing its rationale, structure, and organization. Second, we cognitive and affective processes; identity and relation- review, following the multiaxial organization, its features ships; defense and coping; and self-awareness and and primary innovations that can guide clinicians in their self-direction. Finally, the S Axis, while retaining a high assessment and clinical management of suicidal risk. degree of overlap with DSM and ICD diagnostic catego- ries, provides a more specific description of individual experience of the patient related to any symptom pat- Rationale of the PDM-2 classification system tern, and any non-pathological conditions that may re- 15 The PDM-2 reflects an effort to articulate a diagnostic quire clinical assessment (relating to, e.g., demograph- system that bridges the gap between clinical complex- ic minorities, LGB populations, and gender incongru- ity and empirical and methodological validity. Taking a ence). Moreover, it thoroughly emphasizes the critical “prototypic” approach to diagnosis, the manual rejects role of transference and countertransference patterns the idea that a diagnostic category can be merely de- relative to distinct clinical syndromes (e.g., 19-23). scribed as a collection of symptoms (e.g., 16 17). Spe- cifically, the PDM-2 diagnostic categories emphasize PDM-2 S Axis: the subjective experience both individual variation (i.e., an individual’s unique ex- of suicidal patients perience and personal history) and commonalities (i.e., In all S Axes of the PDM-2, the clinical importance of patterns of intercorrelated reported experiences [symp- the proper assessment of suicidal risk is emphasized. toms] and observed behaviors [signs]), integrating According to most psychodynamic and neurobiological nomothetic understanding and idiographic knowledge literature (e.g., 4 24), suicidal ideations, behaviors, and of clinical presentations. attempts are typical “cross-sectional” symptoms, atti- Although the PDM-2 differs in its diagnostic approach tudes, and behaviors that may be present in many disor- to the DSM and ICD, it also aspires to complement ders at different times. From this standpoint, suicidality these manuals in their efforts to catalogue symptoms does not have diagnostic specificity; rather, it is a trans- and syndromes. Therefore, the manual is not intended diagnostic dimension. According to the PDM‑2, “sui- to replace the official diagnostic systems, but aims at cidal risk should be carefully assessed for any patient, improving the diagnostic process with the richness regardless of the ‘primary diagnosis’ or the patient’s pri- and complexity of psychoanalytic constructs, infant re- mary treatment request” (3, p. 137). Thus, subjective ex- search, developmental psychopathology, attachment periences of suicidal thoughts and behaviors may vary theory, and neuroscience. widely within a single patient, over the course of life or The PDM-2 framework attempts to systematically de- treatment, and they should always be considered one scribe personality functioning; individual profiles of of the main risk factors for suicide attempts. In addition, mental functioning (including, e.g., patterns of relat- to support the assessment of the clinical complexities ing to others, comprehending and expressing feelings, of suicide risk, the PDM-2 provides guidelines that can

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be applied in various clinical conditions. Specifically, it According to the PDM-2, suicide attempts frequently is fundamental for clinicians to assess the following vari- occur in adolescents and young adults with various ables: presence of suicidal or homicidal ideation, intent, mental disorders; but they are also observed in youth or plans; ready access to means for suicide, and the with no specific pathology, particularly in certain cultural lethality of those means; presence of psychotic symp- contexts (e.g., India, China 30-32). Consequently, particu- toms, especially command hallucinations; presence of lar attention should be paid to young patients reporting suicidal or homicidal alters in dissociative identity dis- suicidal ideations, behaviors, or attempts of any clini- order; distinction between suicidal intent and parasu- cal manifestation, even though these may be difficult icidal intent (especially regarding self-injury); presence to correctly identify. The PDM-2 can guide clinicians in of serious alcohol or other substance misuse; history this crucial evaluation, for example by listing and illus- and seriousness of previous self-harm attempts; family trating the main affective states and cognitive patterns history of, or recent exposure to, suicide; and absence described by suicidal adolescents and young adults. of a significant network of supportive relationships and Specifically, in addition to feeling sadness, sorrow, de- social services. spair, detachment, and anger, suicidal patients may ex- Another key issue highlighted by the PDM-2 is the dis- perience negative emotions about themselves, such as tinction between suicidal and parasuicidal behavior a devalued sense of self or reduced self-esteem, with (e.g., SA28 Non-Suicidal Self-Injury). Most commonly, feelings of failure, uselessness, incompetence, and un- the aim of parasuicidal action is to reduce negative emo- worthiness. Their inner experience may be one of a loss tions, such as tension, anxiety, and self-reproach, and/ of life meaning and a feeling of being trapped in a suf- or to resolve an interpersonal difficulty. Though these fering present, with no possibility of a better future. The self-harming behaviors are not intended to destroy one’s suicidal act may seem to offer them an escape from an life, they represent a maladaptive way of expressing overwhelming, unmanageable life situation and to give distress and seeking help, and their seriousness should devastated adolescents a feeling of mastery over their not be minimized. Since impulsive self-harm generally bodies and the lives they feel they have lost. Likewise, stems from emotional pain, in therapeutic work it is es- self-injury, which is frequently associated with suicidal sential to help patients improve their affective language attempts, may express a similar effort to regain control. and other communication skills in order to reduce these Moreover, a failed suicide attempt may be experienced behaviors. as yet another demonstration of ineptitude and thus Given that the highest suicide rate is recorded in youth may reinforce an adolescent’s negative perception of populations 25 26, the PDM-2 devotes a specific sec- the self. The somatic states of suicidal adolescents are tion to suicidality in both of the sections on diagnosis mainly characterized by high levels of anxiety. Anxiety in childhood and adolescence, including specific di- can be a proximal risk factor for the suicidal act and agnoses of suicidality (SC27, SA27) that are classified should be monitored attentively in at-risk adolescents. among those included within mood disorders. These The PDM-2 describes the main relational patterns of diagnostic categories overlap that of “Suicidal Behavior suicidal adolescents, illustrating how relational dynam- Disorder,” as illustrated in Section III of the DSM-5. Nev- ics characterized by rigidity, conflict, separation, lack of ertheless, for all S Axes (as applied in adulthood to old trust and acceptance, and incommunicability, as well age), the PDM-2 highlights patients’ subjective experi- as feelings of being different or rejected, can all explain ences within cognitive, affective, somatic, and relational the decision to act. In essence, suicidal behavior can patterns. The essential manifestation of suicidal behav- be considered predominantly interpersonal, concerning ior disorder is a suicide attempt, which is defined as a not only oneself, but also significant others. It can thus behavior that the individual has undertaken with at least be interpreted as a last option when all other attempts some intent to die. According to the DSM-5 2, the be- at communication have failed. havior may or may not lead to injury or serious medical In addition to its section on adolescents, the PDM-2 also consequences, because several factors can influence contains a dedicated section on childhood. Many clini- the outcome of the attempt (e.g., poor planning, lack cians tend to underestimate suicidal risk in childhood, of knowledge about the lethality of the chosen method, because the idea that a child might choose suicide to low intentionality or ambivalence, or the chance inter- escape unbearable pain is generally considered over- vention by others after the behavior is initiated). In ad- whelmingly tragic and unimaginable. In addition, there dition, it can be challenging to determine the degree of is widespread belief that children lack a sufficient cog- intent, as this may not be clearly acknowledged by the nitive understanding of the biological/scientific concept individual involved, also because of the common pres- of death to contemplate suicide. Although this assump- ence of dissociative symptoms that may be difficult both tion is not empirically justified, it has led to a clinical and to recognize and to express 27-29. epidemiological underestimation of suicidal behavior

134 Personality, mental functioning, and symptoms: assessing suicidal risk with the Psychodynamic Diagnostic Manual, 2nd ed. (PDM-2)

in this age group. By contrast, suicide is currently the ical”. Nevertheless, living in stigmatizing environments fourth leading cause of death among young persons may undermine one’s psychological and relational well- aged 10 to 14; for even younger children, it is likely to being by routinely subjecting them to experiences of be underreported 33. In fact, more than 12% of children social oppression, stereotyping, “minority stress” (i.e., aged 6 to 12, across both genders, report having had psychological stress derived from belonging to a mi- suicidal thoughts 26. The PDM-2 notes, however, that nority 35), and internalized homophobia (i.e., the men- there is a developmental sequence in the manner in tal condition of believing same-sex sexual orientation which children think about and discuss death. In par- to be wrong, sick, or inferior, while simultaneously ex- ticular, four stages of the biological/scientific concept periencing oneself as having that orientation). It is not of death have been identified 34: universality (the under- uncommon for patients living in minority conditions to standing that death must happen to all living things), ir- resort to suicide as a last tragic solution to escape the reversibility (the recognition that the dead cannot come overwhelming experience of minority stress 36-39. Con- back to life), non-functionality (the understanding that sequently, in the diagnostic assessment of such pa- death is characterized by bodily processes ceasing to tients, suicidal risk should be constantly monitored. By function), and causality (the understanding that death describing minority conditions along standardized sub- is ultimately caused by a breakdown of bodily func- jective experience areas (i.e., affective states, cogni- tion). Children under the age 5 do not recognize death tive patterns, somatic states, relationship patterns, and as final, but instead think of it as reversible. Likewise, the subjective experiences of the therapist), the PDM-2 children between the ages of 5 and 9 tend to consider provides a guide for clinicians to assess and manage death temporary, although by age 7 they are thought to suicidal risk in such at-risk populations. be cognitively able to understand death as irreversible and permanent. These stages of cognitive development The role of personality organization may play a pivotal role in the assessment of suicidal risk in children. Consequently, the PDM-2 provides the and patterns clinically useful suggestion to consider developmental Another innovation provided by the PDM-2 is its empha- norms in the assessment of suicidality in childhood. sis on the importance of personality constellations in the 40 The manual also describes the affective states of suicid- assessment of an individual’s symptoms . Such con- al children, which are characterized by hopelessness, stellations are particularly important in assessments of anhedonia, impulsiveness, and high emotional reactiv- suicide risk, which, as already mentioned, represents a ity. In addition, suicidal children may express feelings of cross-sectional diagnostic entity. The long-term predic- omnipotence, manifested in a need for power and con- tion of suicide according to personality disorders rep- 4 41 trol over others, as well as the opposite – profound feel- resents an important challenge for clinicians , and ings of hopelessness and helplessness. Their thoughts some studies have indicated that specific personality 6 42 and fantasies may include obsessive ruminations about traits can be important predictors of suicide . Moreo- painful relationships with family members and peers, ver, contextualizing suicidal behaviors in a personal- desire for retaliation and revenge, and curiosity about ity diagnosis can promote clinical case formulation by the death of people and/or animals; they may also ask helping clinicians understand an individual’s difficulties questions about what happens after death. The somat- in the broader context of his/her personality functioning. ic states of suicidal children may also relate to mood Such an understanding can inform treatment planning and physiological responses to trauma and abuse (if to better prevent suicide. present). Finally, the PDM-2 points out the importance In the P Axis of the PDM-2, suicidal ideation, behav- of the relationship context in understanding children’s iors, and attempts represent possible symptoms of both borderline and psychotic personality organization at all suicidal behavior, with particular regard to attachment a style, familiarity, abuse, lack of parental warmth, bully- ages . In fact, in patients with borderline personality or- ing, and rejection by peers. ganization, suicidality may be explained by their typical identity diffusion, their prevalence of primitive defensive operations, and their difficulties with affect and impulse Suicidal risk and psychological experiences regulation. Such individuals may engage in suicidal or that may require clinical attention parasuicidal behaviors when they become unable to tol- The PDM-2 pays particular attention to psychological experiences that may derive from ethnic, cultural, lin- guistic, religious, and political factors, as well as from is- a With regard to adolescence and childhood, the PDM-2 refers sues of sexual orientation and gender incongruence. All to emerging personality patterns because the personality is of these experiences, in themselves, are “non-patholog- still under development in these age ranges.

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erate the emotional burden that arises from significant iors, and attempts in each patient. While the evaluation relationships. Furthermore, individuals with psychotic of suicidality may benefit from a complete assessment organization may be at risk of suicide due to significant of all mental capacities, some mental functions are more deficits in their capacity for reality testing and forming a directly involved in this assessment. Specifically, suici- coherent sense of self, manifested in their consistently dality may be explained by dysfunctions in the follow- maladaptive ways of dealing with feelings about them- ing mental capacities: (2) capacity for affective range, selves and others. communication, and understanding; (7) capacity for im- In the context of personality patterns, the meaning of pulse control and regulation; (9) capacity for adaptation, suicidal intent can be understood along the anaclitic–in- resiliency, and strength; and (12) capacity for meaning trojective (or relatedness vs self-definition) polarity pro- and purpose. Thus, suicidal persons may be unable to posed by Blatt and colleagues 43-45. According to this symbolize affectively meaningful experiences (i.e., to model, personality evolves through dialectic interaction represent such experiences mentally rather than in so- between two fundamental psychological coordinates: matic or behavioral form) and to appropriately verbalize anaclitic (or relatedness) and introjective (or self-defi- affective states – all difficulties that should be carefully nition). More specifically, relatedness and self-definition considered by clinicians in choosing the proper treat- are involved in the development of the capacity to es- ment 46 47. They may show unmodulated expressions of tablish and maintain (respectively): reciprocal, mean- impulses (impulsivity) with a concomitant inability to tol- ingful, and satisfying relationships; and a coherent, re- erate frustration. This may lead to a loss of ability to ad- alistic, differentiated, and positive sense of self. These just to unexpected events and changing circumstances two developmental processes influence each other. and to cope effectively and creatively when confronted High-level personality organization is characterized by with uncertainty, loss, stress, and challenge. In addition, feelings of satisfaction and well-being on both poles of individuals with suicidal intent may have lost the ability the spectrum; on the contrary, personality pathology is to construct a personal narrative that gives coherence characterized by excessive and defensive emphasis in and meaning to personal choices, a sense of directed- one of the two dimensions, at the expense of the other. ness and purpose, and a concern for succeeding gen- Consequently, among personality syndromes that fall erations that imbues one’s life with meaning. mainly on the anaclitic pole (e.g., dependent, border- line, or histrionic personalities), suicidal intent may have greater relational significance and may emerge in re- Conclusions action to loss or rejection, accompanied by feelings of Suicidal risk is a central concern and serious challenge emptiness, inadequacy, and shame. On the other hand, for clinicians assessing patients with a wide variety of in patients with personality syndromes that fall mainly psychopathological profiles. Suicidal ideation and be- on the introjective pole (e.g., narcissistic, antisocial, or haviors may be predictable or unpredictable, accord- obsessive-compulsive personalities), feelings of guilt, ing to several variables that require careful assessment. self-criticism, and perfectionism may increase the risk The PDM-2 provides a valid cross-sectional prospective of suicidal intent through the tendency to isolate oneself on suicidality, focusing on personality patterns, related and not ask for help. social and emotional capacities, unique mental profiles, and personal experiences of symptoms. When assess- ing a complex phenomenon such as suicidality, it can Suicidality and mental functioning domains be more important for clinicians to consider who one is The assessment of mental functioning (M Axis) repre- rather than what one has 12. Accordingly, the compre- sents an additional PDM-2 diagnostic tool to evaluate hensive approach to diagnosis provided by the PDM-2 suicide risk. An understanding of patients’ basic mental can enable clinicians to capture the subjective experi- functioning can provide therapists with useful insight in- ences of suicidal patients, allowing for more effective to the development of symptoms and help them capture strategies to be developed for the early assessment of the complexity and individuality of each patient, espe- suicidal behavior and the preventive treatment of sui- cially when dealing with the intricacies of suicidal be- cide attempts. havior. By systematizing and operationalizing numerous dimensions of mental functioning, the M Axis helps clini- cians flesh out – at a granular level – the mechanisms Conflict of interest that contribute to and shape suicidal ideation, behav- The Authors have no conflict of interest to declare.

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References 2nd ed. (PDM-2). World wisqars/pdf/leading_causes_of_ 1 World Health Organization. Interna- 2015;14:237-9. death_by_age_ group_2015-a.pdf). tional statistical classification of dis- 13 Lingiardi V, McWilliams N, Eds. The 26 Nock M, Green J, Hwang I, et al. Prev- eases and related health problems psychodynamic diagnostic manual alence, correlates, and treatment of (11th Revision), 2018. (PDM-2), 2nd ed. New York, NY: Guil- lifetime suicidal behavior among ado- 2 American Psychiatric Association. ford Press 2017 (Tr. it. Milano: Raffael- lescents: results from the national co- Diagnostic and statistical manual of lo Cortina 2018). morbidity survey replication adoles- mental disorders, 5th ed. Washington, 14 Jablensky A. Psychiatric classifica- cent supplement. JAMA Psychiatry, DC: APA 2013. tions: validity and utility. World Psychi- 2013;70:300-10. 3 Mundo E, O’Neil JA. Symptoms pat- atry 2016;15:26-31. 27 Patel V, Ramasundarahettige C, Vijay- terns: the subjective experience-S Ax- 15 Lingiardi V, McWilliams N, Bornstein akumar L, et al. Suicide mortality in is. In: Lingiardi V, McWilliams N, Eds. RF, et al. The psychodynamic diag- India: a nationally representative sur- Psychodynamic diagnostic manual. nostic manual version 2 (PDM-2): as- vey. Lancet 2012;379:2343-51. 2nd ed. New York, NY: Guilford Press sessing patients for improved clinical 28 Calati R, Bensassi I, Courtet P. The 2017, pp. 134-259. practice and research. Psychoanal link between dissociation and both 4 Kernberg OF. The suicidal risk in se- Psychol 2015;32:94-115. suicide attempts and non-suicidal vere personality disorders: differential 16 Borsboom D. Psychometric perspec- self-injury: meta-analyses. Psychiatry diagnosis and treatment. J Pers Dis- tives on diagnostic systems. J Clin Res 2017;251:103-14. ord 2001;15:195-208. Psychol 2008;64:1089-108. 29 Fagioli F, Telesforo L, Dell’Erba A, et 5 Kernberg OF. Suicide prevention 17 Westen D, Shedler J, Bradley R. A al. Depersonalization: an exploratory for psychoanalytic institutes and prototype approach to personality factor analysis of the Italian version societies. J Am Psychoanal Assoc disorder diagnosis. Am J Psychiatry of the Cambridge Depersonalization 2012;60:707-19. 2006;163:846-56. Scale. Comprehensive Psychiatry 2015;60:161-7. 6 Pompili M, Rihmer Z, Akiskal HS, et al. 18 Kernberg OF. Severe personality disor- 30 Temperament and personality dimen- ders: psychotherapeutic strategies. New Levinger S, Somer E, Holden RR. The sions in suicidal and nonsuicidal psy- Haven, CT: Yale University Press 1984. importance of mental pain and phys- ical dissociation in youth suicidality. J chiatric inpatients. Psychopathology 19 Betan E, Heim AK, Zittel Conklin C, et Trauma Dissoc 2015;16:322-39. 2008;41:313-21. al. Countertransference phenomena 31 7 Van Meter AR, Algorta GP, Young- and personality pathology in clinical Phillips MR, Yang G, Zhang Y, et al. strom EA, et al. Assessing for suicidal practice: an empirical investigation. Risk factors for suicide in China: a na- behavior in youth using the Achen- Am J Psychiatry 2005;162:890-8. tional case-control psychological au- topsy study. Lancet 2002;360:172836. bach system of empirically based as- 20 Colli A, Tanzilli A, Dimaggio G, et al. 32 sessment. Eur Child Adolesc Psychia- Patient personality and therapist re- Radhakrishnan R, Andrade C. Sui- try 2018;27:159-69. sponse: an empirical investigation. cide: an Indian perspective. Indian J 8 Hyman SE. The diagnosis of mental Am J Psychiatry 2014;171:102-8. Psychiatry 2012;54:304-19. 33 disorders: the problem of reification. 21 Tanzilli A, Colli A, Del Corno F, et al. World Health Organization. Fact Annu Rev Clin Psychol 2010;6:155-79. Factor structure, reliability, and validity sheets: suicide, 2018. 9 Lingiardi V, Boldrini T. The diagnos- of the Therapist Response question- 34 Speece MK. Children’s concept tic dilemma of psychosis: reviewing naire. Personal Disord 2016;7:147-58. of death. Michigan Family Review the historical case of pseudoneurot- 22 Tanzilli A, Muzi, L, Ronningstam E, et 1995;1:57-69. ic schizophrenia. J Nerv Ment Dis al. Countertransference when working 35 Comas-Diaz L. Ethnopolical psychol- 2019;207:577-84. with narcissistic : ogy: healing and transformation. In: 10 Maj M. Why the clinical utility of di- an empirical investigation. Psycho- Aldarondo E, Ed. Advancing social agnostic categories in psychiatry therapy 2017;54:184-94. justice through clinical practice. New is intrinsically limited and how we 23 Tanzilli A, Colli A, Gualco I, et al. Patient York, NY: Routledge 2007. can use new approaches to com- personality and relational patterns 36 Baams L, Grossman AH, Russell ST. plement them. World Psychiatry in : factor structure, Minority stress and mechanisms of risk 2018;17:121-2. reliability, and validity of the Psycho- for depression and suicidal ideation 11 Reed GM, Keeley JW, Rebello TJ, et therapy Relationship questionnaire. J among lesbian, gay, and bisexual al. Clinical utility of ICD-11 diagnos- Personality Assess 2018;100:96-106. youth. Dev Psychol 2015;51:688-96. tic guidelines for high-burden mental 24 Roy B, Dwivedi Y. Understanding epi- 37 Baiocco R, Ioverno S, Cerutti R, et al. disorders: results from mental health genetic architecture of suicide neuro- Suicidal ideation in spanish and italian settings in 13 countries. World Psychi- biology: a critical perspective. Neuro- lesbian and gay young adults: the role atry 2018;17:306-15. sci Biobehav Rev 2017;72:10-27. of internalized sexual stigma. Psico- 12 Lingiardi V, McWilliams N. The psy- 25 Centers for Disease Control. Youth thema 2014;26:490-6. chodynamic diagnostic manual, suicide, 2015 (www.cdc.gov/injury/ 38 Lea T, de Wit J, Reynolds R. Minority

137 V. Lingiardi et al.

stress in lesbian, gay, and bisexual sonality assessment. New York, NY: Ox- psychodynamic approach to classify young adults in Australia: associa- ford University Press 1995, pp. 367-9. psychopathology. In: Millon T, Krueger tions with psychological distress, sui- 42 Heisel MJ, Duberstein PR, Conner RF, Simonsen E, Eds. Contemporary cidality, and substance use. Arch Sex KR, et al. Personality and reports of directions in psychopathology. Sci- Behav 2014;43:1571-8. suicide ideation among depressed entific foundations of the DSM-V and ICD-11. New York, NY: Guilford 2010, 39 Mereish EH, Peters JR, Yen S. Minori- adults 50 years of age or older. J Af- pp. 483-514. ty stress and relational mechanisms fect Disord 2006;90:175-80. 46 Boldrini T, Nazzaro MP, Damiani R, of suicide among sexual minorities: 43 Blatt SJ. Polarities of experience: et al. Mentalization as a predictor of subgroup differences in the associa- Relatedness and self-definition in psychoanalytic outcome: an empirical tions between heterosexist victimiza- personality development, psychopa- study of transcribed psychoanalytic tion, shame, rejection sensitivity, and thology, and the therapeutic process. sessions through the lenses of a com- suicide risk. Suicide Life Threat Behav Washington, DC: American Psycho- puterized text analysis measure of 2019;49:547-60. logical Association 2008. reflective functioning. Psychoanalytic 40 Hilsenroth MJ, Katz M, Tanzilli A. Psy- 44 Blatt SJ, Blass RB. Attachment and Psychology 2018;35:196-204. chotherapy research and the psycho- separateness: a dialectic model of 47 Ogrodniczuk JS, Piper WE, Joyce A. dynamic diagnostic manual (PDM-2). the products and processes of psy- S. Effect of alexithymia on the process Psychoanal Psychol 2018;35:320-7. chological development. Psychoanal and outcome of psychotherapy: a 41 Stelmachers ZT. Assessing suicidal Study Child 1990;45:107-27. programmatic review. Psychiatry Res clients. In: Butcher JN, Ed. Clinical per- 45 Blatt SJ, Luyten P. Reactivating the 2011;190:43-8.

How to cite this article: Lingiardi V, Di Cicilia G, Boldrini T. Personality, mental functioning, and symptoms: assessing suicidal risk with the Psychodynamic Diagnostic Manual, 2nd ed. (PDM-2). Journal of Psychopathology 2019;25:132-8.

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