Emerging Personality Stles and Diosrders In Adolescence - PA Axis

The PA Axis is grounded in the concept of “emerging personality,” which reconciles two needs. On the one hand, it underscores the continuity of the pathways that contribute to the structuring of personality pathology, and the possibility of identifying, even at relatively early stages, psychopathological markers that may, in some cases, consolidate in adulthood. On the other hand, it acknowledges the fluidity of developmental processes, which may entail considerable change: during these years, a crystallized diagnostic definition would be not only inappropriate but also static and reifying. Assessment proceeds in two steps: evaluating the level of personality organization and identifying emerging personality styles or disorders (Tanzilli, Sharp, 2025). Drawing on Kernberg’s structural model (1984; see also Normandin, Ensink, Weiner et al., 2021), that is, on the degree of functioning or impairment in identity, object relations, defense mechanisms and reality testing, four levels are distinguished: healthy, neurotic, borderline (high and low) and psychotic. The thirteen emerging styles/disorders, which may be located at any point along this continuum, are arranged along two spectra, primarily internalizing and primarily externalizing, consistent with other systems such as the Hierarchical Taxonomy of Psychopathology (HiTOP; Kotov, Krueger, Watson et al., 2017) and the Shedler-Westen Assessment Procedure (SWAP-200; Shedler, Westen, Lingiardi, 2014). Emotionally dysregulated personalities, which in the PDM-3 replace the former diagnosis of borderline personality, are not assigned to either spectrum. Compared with the PDM-2, which included ten syndromic configurations, the PDM-3 introduces somatizing personalities and grants greater diagnostic autonomy to hypomanic and counterphobic personalities, now described specifically while remaining associated with depressive and phobic personalities, respectively (Table 1). The manual also accommodates new forms of dimensional continuity, linking, for example, dependent personalities to dependent-victimized ones and hysteric personalities to impulsive-histrionic ones. As in the other sections of the PDM-3, personality diagnosis is not based on the sum of traits or criteria; rather, it estimates the overall degree of correspondence between the patient’s presentation and a prototype, or “ideal type,” of the condition under consideration (prototype matching), giving priority to underlying psychological themes (McWilliams, 2011). In the PA Axis, the evaluator rates how closely the adolescent resembles each profile on a 5-point scale, ranging from full correspondence to no similarity. This approach rests on solid empirical foundations: while many configurations of the adult P Axis derive from research conducted with the SWAP-200, a clinician-report instrument that combines clinical sensitivity with psychometric rigor, the PA Axis was largely built on the adolescent version of the SWAP (SWAP-II-A; DeFife, Malone, DiLallo et al., 2013; Westen, DeFife, Malone et al., 2014). Through the Q-sort method, the SWAP-II-A makes it possible to outline the personality of adolescents aged 14 to 18 in jargon-free language accessible to professionals from different backgrounds. Most of the profiles presented originate from these analyses; for conditions still lacking quantitative support, such as hypomanic personalities, narrative descriptions grounded in case observation have been proposed. Finally, two further innovations introduced in the PA Axis concern: (a) a closer examination of the transference and countertransference dynamics that tend to recur across the different personality styles or disorders; and (b) the main therapeutic indications that can help clinicians navigate their relationship with these young patients.