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Concluding comments from Drew Westen’s paper: “Personality Profiles in Eating Disorders: Rethinking the Distinction Between Axis I and Axis II.”

https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.158.4.547

“The data also raise questions about the extent to which axis II is adequate for describing clinically meaningful patterns of personality pathology, at least for women with eating disorders. Patients in the high-functioning/perfectionistic cluster generally lacked diagnosable axis II pathology; indeed, in our study (as in the other studies that have isolated a similar cluster), they were defined by the absence of such pathology. These patients are articulate, conscientious, and empathic, and they tend to elicit liking in others. Yet they clearly have personality pathology—that is, enduring, problematic patterns of thought, feeling, motivation, and behavior. They are self-critical, perfectionistic, competitive, anxious, and guilt-ridden, and these aspects of their personality require clinical attention. The data reported here make sense in light of other findings that roughly 60% of patients treated for clinically significant personality pathology do not have problems severe enough to be diagnosable on axis II and that their personality problems (e.g., perfectionism and chronic feelings of guilt) generally are not reducible to any axis I syndrome (21, 22). Available data suggest that these patients represent the majority of patients treated in clinical practice and are not simply the “worried well.” Either axis II needs to be expanded from a personality disorder axis to a personality axis that includes the range of functioning (from relatively healthy to relatively impaired), or subtypes such as those uncovered here need to be built into axis I.”

May I offer conjecture that the patients Westen describes here are more or less “Freud’s neurotics?”