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 133 V. Lingiardi et al. be applied in various clinical conditions. Specifically, it According to the PDM-2, suicide attempts