ETZI - 2014 - The Psychodynamic Diagnostic Manual M Axis

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Psychoanalytic Psychology © 2014 American Psychological Association

2014, Vol. 31, No. 1, 119 –133 0736-9735/14/$12.00 DOI: 10.1037/a0031907
THE PSYCHODYNAMIC DIAGNOSTIC

MANUAL M AXIS: Toward an Articulation of
What It Can Assess
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Janet Etzi, PsyD

Immaculata University
The Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006) is a

bold step toward an integrative, science-based, psychologically oriented, in-
depth approach to personality assessment. The M Axis of the PDM focuses on
mental functioning and contains a wealth of concepts useful for the complicated
task of evaluating the range of psychological and personality functioning, both
adaptive and maladaptive. This article analyzes the nine capacities of the M
Axis in the light of some recent advances in neuropsychoanalytic studies,
especially Allan Schore (1994, 2003, 2012) and Daniel Siegel (1999, 2010) as
they emphasize the integration of emotional and social development beginning
in infancy with neurobiological structures and functions. Bowlby’s (1969)
attachment theory is the foundation for new interdisciplinary exploration and
Schore (2012) points to three main trends: 1) New data from right brain
developmental studies; 2) An emphasis on emotion; 3) Models of self-
regulation. The M Axis capacities will be analyzed using these three trends as
a framework.
Keywords: Psychodynamic Diagnostic Manual, M Axis, mental functioning,

mental capacities
The Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006) is the first bold
step in providing an integrative, science-based, psychologically oriented in-depth ap-
proach to assessment in contrast to a medical model approach exemplified by the
Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision [DSM];
American Psychiatric Association, 2000). The PDM was developed to assess psycholog-
ical functioning without overlooking its full complexity, range, and depth. In doing so, the
person’s unique individuality and subjectivity are emphasized, and adaptive as well as
maladaptive functioning is addressed because clinical utility demands that both be taken
I acknowledge and thank Dr. Robert Gordon for his friendly encouragement and support of my
interest in the M Axis, and for his gentle, helpful suggestions in the writing of this article.
Correspondence concerning this article should be addressed to Janet Etzi, PsyD, 18 Druim
Moir Lane, Philadelphia, PA 19118. E-mail: jetzi@immaculata.edu
119
Copyrighted Material. For use only by 20021. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).
120 ETZI
into account, in order to come up with the most effective and well-rounded therapeutic
interventions. An individual profile is developed by assessing psychological functioning
using three broad dimensions: the P Axis covers personality patterns and disorders; the M
Axis covers mental functioning or mental capacities; the S Axis integrates manifest
symptoms including a DSM diagnosis into personality and mental functioning.
Psychology’s reliance on the DSM for diagnosis has had the detrimental effect of
allowing us to think that a psychodynamic conceptualization, or perhaps any conceptu-
alization, is unnecessary for comprehensive and clinically useful assessment for the work
of psychotherapy. The DSM diagnosis has been very useful for research purposes but it
precludes further thinking about psychological/personality functioning, or about what the

therapist can expect, at least potentially, regarding the dynamics or process of the
therapeutic relationship itself. Psychodynamic psychotherapists have been working within
the framework of a co-constructed relationship all along and so may never have had
reason to use the PDM or for that matter, to think about assessing their clients’ personality
functioning at all. However, if we are to think critically about the assessment process that
we may be utilizing implicitly already, it becomes very important to articulate and
systematize it so that we can standardize its use, at least for purposes of teaching and
training, and for improving the system itself, especially in an age of accountability in
health care and treatment interventions.
The purpose of this paper is to take another step in the direction of systematizing the
PDM. Clinicians could benefit greatly from having a practical manual with which they
could not only conceptualize personality functioning in all its dynamic complexity but
also methodically assess individuals with whom they work clinically in the early phase of
a course of psychotherapy. The M Axis, Mental Functioning, consists of nine capacities
encompassing information processing; self-regulation; forming and maintaining relation-
ships; emotional experience, expression and organization; integrating experience; coping
strategies and defenses; observing self and others; and forming internal standards (pp. 8).
Each of these nine capacities represents a wealth of concepts built on a wide range of
psychoanalytic and developmental theory and research important for a depth psycholog-
ical approach to personality functioning and to the psychotherapy process. Indeed each
one of the capacities probably warrants a manual of its own. The nine M Axis capacities
will be analyzed here with two questions in mind: 1) What is being assessed in each
capacity? 2) How is it or how can it be assessed systematically and practically to aid in
the work of psychotherapy? In addition, each capacity will be linked to three important
areas of recent theoretical advances in developmental neuropsychoanalysis (Bateman &
Fonagy, 2012; Schore, 1994, 2003, 2012; Siegel, 1999): 1) Unconscious/implicit pro-
cesses or the dual nature of the self; 2) Infant– caregiver interactions or modern attachment
theory (Bateman & Fonagy, 2012; Schore, 2012); 3) Affect regulation theory (Schore,
2012) or emotion processing. Each of these areas emerges out of psychoanalytic theory,
and each of them can be viewed as an extension of psychoanalytic theory into current
interdisciplinary studies including neuroscience. In other words, they are conceptually
related, and explicating those relationships is part of the purpose of this paper. The
relatively narrow focus taken in this paper is intentional, but it should be recognized that
the theories addressed here do not represent all of the important work that is taking place.
Important advances being made by other theorists, for example Peter Fonagy (2012) on
mentalization, are very closely related to this endeavor. For purely practical reasons
related to the length of this paper, this area will not be addressed in any real depth and
therefore is a limitation of the suggestions being made here for the continued systemati-
zation of the PDM. It is my hope that this paper offers one possible direction for the
ARTICULATING WHAT THE M AXIS CAN ASSESS 121
eventual distillation of such a vast amount of theory into a more manageable form to be
used by psychotherapists as an alternative to diagnosing with the DSM and more
important, to reintroduce conceptualization into the diagnostic process, more accurately,
the assessment process (Bornstein, 2011).
The three areas of development are understood as being situated in neurobiological
processes, which is not equivalent to reducing the mind or psyche to the brain or its
structures and functions. Rather, recent theorizing views psychological development and
by extension psychopathogenesis as the coevolution of genetically predetermined struc-
tures and functions, in tandem with the influences of the socioemotional environment,
namely the mother–infant attachment relationship (Bowlby, 1969), including those expe-
riences lying outside of conscious awareness.
The M Axis implicitly conceptualizes the personality as the integration of nature
(temperament, genetic predisposition, innate traits) and nurture (experience, attachment
style, cultural and social context). In other words the concepts already contain the
integration of the biological and the psychological. Making this integration explicit serves
to clarify the complex nature of what is being conceptualized in each of the nine capacities
so that the work of streamlining an assessment method of such complex phenomena might
continue. The organizers of the PDM do not explicitly articulate this conceptualization.
Nowhere in the PDM does it say that personality functioning is viewed as the integration
of neurobiology and experience, but when the M Axis capacities are analyzed keeping in
mind on one hand the neurobiological structures underlying functions like affect regula-
tion, mental representations, emotional expression, and defenses (Bateman & Fonagy,
2012; Schore, 1994, 2003, 2012), and on the other hand the socioemotional environment,
namely, the attachment bond between caregiver and infant, then we can see this integra-
tion as being part of the framework with which the M Axis capacities can be thought about
and utilized.
The Dual Nature of the Self
Key to psychodynamic theory is the concept of the unconscious. The PDM represents the
conceptualization of personality functioning including what lies outside of conscious
awareness (Huprich, 2011). As in the psychoanalytic psychotherapy process where the
dual nature of consciousness is a given and part of the work and experience of both
members of the psychotherapy relationship, so in the assessment process the clinician is
at least implicitly aware of the nonconscious aspects of the subject’s psychological
functioning. Psychoanalytic psychotherapy has long understood that much of what is
communicated in therapy sessions lies outside of conscious awareness and requires the
therapist to receive it perhaps first implicitly and then come to some means of managing
it and incorporating it into what is most therapeutic about the work. Bromberg (2006)
provides vivid and illuminating examples of working with enactments in therapy and how
this work involves the therapist’s capacity to engage with the patient’s immediate
self-states. Psychotherapy patients communicate emotional stress states unconsciously or
implicitly through enactments and transference, and the therapist experiences them im-
mediately before they can be processed for therapy to proceed well. Ginot (2007)
addresses enactments in the context of recent research in neuroscience. It can be assumed
that the same kind of implicit communication takes place in the assessment process and
that the psychodynamic clinician using the PDM is at least being informed by how
unconscious/implicit aspects of personality are essential to fully understanding personality
122 ETZI
functioning (Kernberg, 1984; Kernberg & Caligor, 2005). So the question arises, “how do
we systematically assess our patients’ range of distress, personality functioning, and
psychopathology, given the fact that much of it is processed, communicated, and received
outside of conscious awareness?” Asking this question in the context of the M Axis mental
capacities and how they might be utilized in a practical and methodical way, leads me to
a two part answer: 1) The PDM represents what we are assessing; it gives us the concepts
for operationalizing the complexity and dynamism of personality functioning and psy-
chopathology. These concepts will be delineated more specifically later in the paper. 2)
The PDM does not address how we are to go about the very complex and difficult task of
personality assessment when we want to include both conscious and unconscious aspects.
A number of excellent assessment tools are listed in the PDM which can help to measure
components of mental and personality functioning. But without a way to make explicit the
implicit aspects of the assessment process, those aspects conveyed and received implicitly,
we lack a fully systematic way of assessing the dual nature of the self. Newton and Schore
(2012) take up the idea of building in the implicit awareness of the clinician doing
infant-mother dyad assessment.
In this approach, the assessment technique is not as important as the assessment
process. The interdisciplinary trans-theoretical lens of regulation theory can be applied to
any clinician’s understanding of how one’s subjectivity and implicit corporeal self is used
in both assessment and treatment at all stages of the life span. . .” (p. 394).
(W)hat is learned cognitively and stored in the left hemisphere has little to do with the
affective relational, two-person experiences stored in the right hemisphere. Clinicians
can only assess these patterns through their own implicit right brain connections with their
clients, that is, by accessing their own bodily based instinctive responses (p. 400).
Psychodynamic theory and the PDM have provided the concepts with which we can
comprehend and articulate the full range and depth of an individual’s personality func-
tioning. Psychodynamic psychotherapists directly address the dual nature of the self in the
work of psychotherapy. What is not made explicit in the PDM is how to go about
assessing the nonconsciously experienced aspects either by the subject or the clinician to
inform the work of the therapy. It may be sufficient in this regard to be aware of the
difficulties in attuning to the subject, much like awareness of intense countertransference
feelings informs us about the internal state of the subject (Kernberg, 1984). In affect
regulation theory this process is addressed by Schore.
(T)he psychobiologically attuned empathic therapist, on a moment-to-moment basis,
implicitly tracks and matches the patterns of rhythmic crescendos/decrescendos of the
patient’s regulated and dysregulated ANS with his or her own ANS crescendos/
decrescendos (pp. 93).
The moment-to-moment tracking that psychoanalytic psychotherapists are familiar
with may be applied to the assessment process to good effect. The work of standardizing
this type of assessment process still needs to be done.
Infant–Caregiver Relationship
The infant– caregiver relationship is part of the framework being utilized here to articulate
the M Axis capacities in line with psychoanalytic theory, and developmental theory more
generally. Recent research from several related disciplines clearly demonstrates the role of
the critical periods in infancy for the development of both healthy and disrupted
personality and mental functioning. In addition, recent research is highlighting the role of
the infant– caregiver relationship on the developing mind of the infant. The self develops
only in relation to the primary caregiver(s) (Siegel, 1999). Personality is the internalized
enduring legacy of the early infant– caregiver relationship.
The theories of Allan Schore (1994, 2003, 2012) and Daniel Siegel (1999, 2012)
address the developing capacity of the self to organize or self-regulate one’s own
emotional experience. This evolving capacity to self-regulate or self-organize can only
come about with the help of an affectively attuned caregiver. And the nature of the
infant– caregiver relationship determines the shape and quality of the infant’s developing
affective life.
The preverbal interactions between caregiver and infant are quintessentially socioaf-
fective or psychobiological interactions. The infant who develops a secure attachment
style has done so as a result of the affective attunements of a responsive caregiver; these
interactions are preverbal, presymbolic, and sensation and bodily based. For example,
eye-to-eye gazing between infant and caregiver, largely based in the right hemisphere of
both members of the dyad (McGilchrist, 2009; Schore, 2012), is a sensory emotional
coregulating experience. “In mirroring transactions, a dyadic reciprocal stimulating sys-
tem generates an elevation of regulated sympathetic arousal that supports heightened
levels of interest-excitement and enjoyment-joy” (Schore, 1994, p. 91).
If the infant– caregiver relationship is defined as the crucial “emotion-communicating
system” (Schore, 2012), or emotion-regulating system for the development of the self,
then it functions as the foundation for psychological health and for psychological dys-
function, and for everything in between. Schore’s affect regulation theory spells out how
the formation of an increasingly complex emotion-communicating system, which is
dependent on the caregiver’s capacity to be affectively attuned to the infant, “allows for
an expanding ability to flexibly switch internal bodily based affective states in response to
perceived changes in the external social environment via autoregulation or interactive
regulation(.)” (p. 238). One could say that the personality or the self is the summation of
one’s complex system of self or affect regulation, both autonomously and in interaction
with others, and that adaptive or healthy personality functioning is equivalent to higher
levels of flexibility in affect regulation in response to more complex and varied environ-
mental, specifically socioaffective, environmental demands.
Affect Regulation Theory
It should be clear that Schore’s affect regulation theory is being used here as the main part
of the framework for conceptualizing the M Axis capacities in dynamic relation to both
implicit processes and to the infant–mother relationship. The remaining sections of this
paper will explore whether or not the nine capacities can be viewed to be the result of
affect regulation, or in the case of a lack of capacity or dysfunction, affect dysregulation.
The other two components of the framework for this paper, dual nature of the self and
infant– caregiver relationship are inherently intertwined conceptually and phenomenally
with affect regulation theory.
Capacity 1: Capacity for Regulation, Attention, and Learning

Put most simply, the developers of the PDM had in mind “fundamental processes that
enable human beings to attend to and learn from their experiences” (p. 73). The PDM
notes that constitutional and maturational contributions should be considered when
assessing this capacity, taking into account at the outset the innate or constitutional basis
124 ETZI
for structures and functions underlying regulation, attention, and learning. More specifi-
cally, it includes auditory processing, language, visual–spatial processing, motor planning
and sequencing, and sensory modulation. However, clinicians are left to their own devices
as to how to assess these processes and to come to any conclusions regarding their
influence on the more comprehensive capacity for regulation, attention, and learning.
Users of the PDM are encouraged to consider executive functioning, memory, attention,
overall intelligence, and the processing of affective and social cues. There is a vast
literature addressing both theory of how these capacities are intertwined with personality
development and functioning, and how to assess and measure these capacities. Porcerelli,
Cogan, and Bambery (2011) present an assessment of an adolescent boy using psychody-
namic measures that help them complete the M Axis for children and adolescents. What
the PDM does not provide in this context is a way to adequately integrate the capacity for
regulation, attention, and learning, and all the subcomponents that this capacity includes,
with a psychodynamic conceptualization of personality functioning. The PDM user is free
to study the psychodynamic theory behind this capacity, but in order to make the PDM
more user friendly and provide it with a broader base of users, critics, researchers, and
educators, the work of explicating Capacity 1 and of integrating it in a systematic way
with complex personality functioning including unconscious/implicit processes, will need
to be done. In other words, once the clinician has assessed what they think of as regulation,
attention, and learning, how is it used for clinical purposes within the psychodynamic
framework, or for that matter any theoretical framework being used by psychotherapists?
Consistent theoretical advances being made in several related disciplines are demon-
strating that the development of psychopathology is the result of both genetic predispo-
sition, temperament, or neurobiological substrate on one hand, and the shaping of that
genetic potential as a result of the early socioemotional attachment to the primary
caregiver on the other hand. In relation to Capacity 1, constitutional contributions can be
understood in conjunction with maturational influences that are the result of the dyadic
socioemotional interactions between infant and caregiver, in other words, attachment
style.
While the PDM does not elaborate in this regard, without the capacity for self-
regulation or affect regulation, individuals will present with disrupted or dysfunctional
ability “to attend to or learn from their experiences” (p. 73). Schore (2012) and Porges
(2012) provide a comprehensive conceptualization based on conclusive empirical support
of the development of adaptive regulation of arousal and psychobiological states, both of
which arise out of autonomic nervous system functioning. Adult affective, cognitive, and
behavior functioning emerge directly out of the development of adaptive regulation of
psychobiological states, and, important to psychodynamic theory, this adaptive regulation
can only occur within the context of the mother–infant dyad wherein the first nonverbal
affective communication takes place. Psychodynamically speaking, the mother functions
as the infant’s auxiliary ego. Also important to psychodynamic theory is the science
clearly demonstrating the “essential psychological processes and biological mechanisms
that underlie the psychobiological substrate of the human unconscious described by
Freud” (Schore, 2012, p. 119).
Greenspan (1989) has discussed ego development in terms of sensory processing and
the organization of sensory/perceptual experience. Stern (1985) and Siegel (1999) have
addressed perception and the mind’s processing of information in terms of representing
reality or organizing incoming stimuli in direct relationship to the caregiver’s simultane-
ous processing and organizing of experience. All of this takes place within the emotional
context of the attachment bond. The early patterns or ways of organizing experience,
according to Greenspan (1989), “may form the basis for later disorders, including
avoidance of the human world, and defects in such basic personality functions as
perception, integration, regulation, and motility” (pp. 9 –10). The work of Fonagy et al.
(2012) demonstrates the role of attachment in the development of the mentalization
capacity for optimal psychological functioning. Ego development, as Greenspan has used
the term, may be viewed as a synonym for the emerging self as the organizer of
experience. Psychoanalysis has long viewed functions such as perception, regulation, and
motility as personality functions, part of the conflict-free ego sphere (Hartmann &
Rapaport, 1958). Therefore, to conceptualize the self as resulting from coregulation of
experience or organization with the primary caregiver of experience is common to both

psychodynamic and affect regulation theory.
The importance of Capacity 1’s inclusion in an assessment manual for personality
functioning cannot be overstated. Recent advances in interdisciplinary developmental
science bolster the case to be made that sensory, perceptual, and executive functioning
structures and functions are intertwined with socioemotional developmental processes,
and must be part of the overall conceptualization of personality and psychopathology,
instead of assessing this domain exclusively in the context of learning disabilities or
information processing and attention deficits. Moreover, a psychodynamically oriented
assessment manual is well suited to undertake this project, because it already includes the
role of unconscious/implicit processes. The M Axis is a contribution to assessment in
these areas, because it conceptualizes the self as the integration of information processing
capacities, emotion regulation, and the development of self and other representations.
Capacity II: Capacity for Relationships and Intimacy

Psychoanalysis has a long tradition of theorizing about the capacity for relationships and
intimacy in relation to personality functioning and psychological and emotional well-
being. Object relations theory provides an in-depth understanding of the development of
an individual’s capacity for intimacy and of the individual’s unconscious characteristic
stance in relation to others. This understanding is utilized in the psychotherapy process in
the form of working with transference, countertransference, and enactments. While the
PDM provides the concepts necessary for understanding this capacity, that is, the “what”
of the assessment of this capacity, and its importance for personality functioning and for
the therapy process, it does not give us a practical way of accomplishing the assessment
of this capacity. This is a significant limitation due to the centrality of the role of
relationships in personality functioning overall.
In line with this paper’s goal of distilling the concepts that are spread throughout the
PDM, my reading of Capacity II is that it represents the adult outcomes of Capacity VI,
the capacity to form internal representations. In other words, one’s capacity for relation-
ships and intimacy are the developmental result of internal representations, in addition to
being the result of other capacities. Moreover, if it makes sense to understand internal or
mental representations as the developmental outcome of primary object relations, or the
primary attachment bond, then perhaps these two capacities should be condensed into one
that more directly addresses an individual’s relationship functioning, which would have to
include attachment style. In fact, attachment style may be at the core of Capacity II
(Bateman & Fonagy, 2012; Schore, 2012; Siegel, 1999).
Greenspan (1989) refers to mental representation as multisensory in nature, which
makes it conceptually related to Capacity I: attention, regulation, and learning. He
explains that an internal representation is the construction or organization of experience
126 ETZI
including all the sensory and affective features of that experience. The individual’s
internal representations take shape or emerge out of the dynamic interplay between his
biology (sensory processing) and the earliest socioemotional experiences with the primary
caregiver. Schore (1994, 2012) conceptualizes internal representations in the same vein:
For the rest of the life span, internal working models of the attachment relationship with the
primary caregiver, stored in the right brain, encode strategies of affect regulation that
nonconsciously guide the individual through interpersonal contexts (p. 77). (I)nternal repre-
sentations encode the infant’s physiological–affective responses to the emotionally expressive
face of the attachment figure. They can be accessed for regulatory purposes even in the
mother’s absence (p. 186).
In other words, internal representations are the accumulation of socioemotional

interactions between infant and caregiver that become generalized over time and provide
the developing individual with a schema, working model, template from which to
anticipate and respond to future interactions. When psychotherapists confront them in
the therapy session, the individual’s internal representations prime him to approach the
therapist in his characteristic fashion. Psychodynamic psychotherapists experience the
individual’s internal representations before the individual may be aware of them himself.
They are attending to the immediate experience of interacting with the individual, or to the
nonverbal, emotionally felt aspects of the relationship. So, while we have made explicit
how we are to approach and work with the individual’s capacity for relationships in our
psychotherapy sessions, it is far less clear how we are to assess this capacity in all its
complexity and to integrate it into the individual’s profile. Psychodynamic theory informs
clinicians regarding the unconscious aspects of the capacity for relationships, the influence
of early object relations on this capacity, and the effect of emotion regulation or emotion
tolerance on this capacity, as well as the effect of this capacity on emotion regulation. The
PDM directs us to address the depth, range, and consistency of relationships and intimacy,
but it does not make explicit how to go about assessing the patient’s capacity for
relationships either inside or outside the session. Once again there are many excellent
assessment tools referenced for this purpose, but even the job of selecting one and
becoming fluent in it is far from practical for most clinicians. Moreover, these tools may
take care of the assessment of relationships at the conceptual level. The Structured
Interview of Personality Organization (STIPO) is an example of an interview that uses the
clinician’s immediate experience of the subject’s implicitly felt object relations (Kernberg,
1984; Stern et al., 2010), but this aspect of the interview process is downplayed in favor
of its psychometric properties for measuring personality organization. Can an experien-
tially oriented assessment add to what is learned from the subject’s self-report regarding
relationships? If the nonconscious communications are essential to effective psychother-
apy, what is being missed by not including them more formally in the early assessment
process?
Capacity III: Quality of Internal Experience (Level of Confidence and

Self-Regard)
The PDM describes Capacity III as that of realistic self-esteem and a sense of well-being
or vitality when the individual is healthy. Incapacity in this domain would involve feelings
of emptiness, depletion, and incompleteness, and vulnerable self-esteem. This capacity is
easily viewed from the perspective of attachment theory as resulting from a secure
attachment. When the primary caregiver is consistently affectively attuned to the infant,
a secure attachment is established and an enduring sense of being worthwhile, loved, and
loveable is experienced, even in the face of stress and adversity. Secure attachment sets
the stage for emotional resilience and range of affect tolerance, because the infant has been
attuned to consistently while experiencing a wide range of affects, and therefore antici-
pates that these states can be navigated and tolerated, whether they are pleasant or
unpleasant, whereas insecure attachment raises the risk for psychopathology and dysfunc-
tion in this capacity.
Capacity III may be the most straightforward and self-explanatory of the nine capac-
ities on the surface. However, when unconscious functioning is taken into account, the
assessment of this capacity becomes more complicated. An individual can appear to be

confident and express good levels of vitality and well-being consciously, as a means of
defense against feelings of vulnerability and inadequacy, as in the case of narcissism
(McWilliams, 1994). Therefore, self-report regarding this capacity is insufficient to the
task at hand. Psychodynamic psychotherapists understand that once an individual expe-
riences anxiety or stress in the psychotherapy session or even in an early diagnostic
evaluation (Kernberg, 1984), her defenses will be activated and the affectively attuned
therapist will sense, whether consciously or unconsciously, the underlying affects which
may convey vulnerability of self-esteem. So the PDM accounts conceptually for the
complex nature of internal experience in relation to self-esteem and internal well-being,
especially because it does address the disruption of self-esteem under stress. But if the
PDM is meant to be used to assess psychological functioning early on in a course of
therapy, the same question emerges regarding the “how” of assessing this capacity. So
much of psychodynamic assessment takes place implicitly as the therapy progresses to the
degree that often clinicians do not distinguish sharply between psychotherapy and assess-
ment, and so they let one inform the other. Perhaps Capacity III is already being addressed
as part of assessing one or more of the other nine capacities; this is more likely if quality
of internal experience is viewed as inextricably related to affect regulation and the
capacity for relationships, which both emerge from the primary attachment bond. In any
case, the task of assessing Capacity III is much more complicated than the current
description of it implies.
Capacity IV: Affective Experience, Expression, and Communication

The PDM states that affective experience, expression, and communication are combined
in a unique pattern that should be described in the clinician’s profile once this capacity is
assessed. It also states that each component of this capacity can have its own character-
istics in any one individual so that the subject may have a good capacity for compre-
hending but not communicating affect. Clinicians are directed to capture the subject’s
unique patterns in the narrative, and illustrative examples are provided to help assess this
capacity.
It would be helpful to clarify Capacity IV’s relationship to social cognition for the purpose
of more concretely defining what is meant by affective experience, expression, and commu-
nication. In addition, because recent interdisciplinary research demonstrates that affective
experience and comprehension emerge out of the early infant– caregiver attachment, further
clarification and operationalization of this capacity may link it more closely to what is already
being assessed in affect regulation and/or capacity for relationships, or for that matter in
Capacity III: quality of internal experience.
Schore (2003) gathers strong and convincing evidence to show that early shame
experiences may be the key component in determining the developing self’s overall
128 ETZI
affective experience and functioning in Capacity IV. When shame is experienced to an

excessive degree, or when the caregiver is not able to repair disrupted interactions in
which the infant experiences shame, humiliation becomes the dominant emotion resulting
in a breakdown in this capacity. It becomes difficult to integrate emotional patterns and to
comprehend the emotional and behavioral intentions of others when one’s own self-
affective experience is colored predominantly by shame.
The question of how to assess this capacity in a practical way in the early phase of a
course of psychotherapy is difficult to answer. Looking at the descriptions of examples in
the PDM, it is apparent that a therapist who has interacted with the patient long enough
to have experienced that patient’s emotional comprehension or expression would be able

to assess this capacity and place the patient in one of the predetermined categories. For
example, the PDM tells us that those with minimal capacity “(d)istort the intents of others
(e.g., misreads cues and therefore feels suspicious, mistreated, unloved, angry, etc.)” (p.
78). The psychotherapist will eventually have this knowledge of the patient from having
directly experienced it. But how is the evaluating clinician to learn about such a subject’s
dysfunction in this domain without experiencing it directly?
Capacity V: Defensive Patterns and Capacities

The M Axis describes succinctly the range of healthy or flexible ways of coping, through
maladaptive defenses that distort experience, to the failure of defensive regulation that
results in a break with reality. This way of conceptualizing defenses and their role in
psychological functioning is corroborated by the advances already reviewed in this paper.
Schore’s (1994, 2003, 2012) gathering of the neuroscience data strongly suggests that
secure attachment bonds result in efficient affect regulation and a capacity to tolerate and
enjoy a wide range of experiences and relationships. Schore (2012) refers to defenses in
terms of these data in describing them as “forms of emotional regulation strategies for
avoiding, minimizing, or converting affects that are too difficult to tolerate” (p. 85). When
one can tolerate and experience a wide range of emotions and relationships, there is less
need to utilize defenses. The person is open to novel stimuli and situations and will be
relatively unafraid to confront ambiguous situations. This openness in turn carries with it
the potential for new learning to occur and for increasing complexity and integration of
overall psychological functioning. McWilliams (1994) has given a lucid account of
defenses and their role in organizing character or personality structure and in organizing
emotional processing. Character is viewed as the summation of preferred defenses that
bias the individual to characteristic attitudes and behaviors.
Bellak and Hurvich (1969) discussed defenses in relation to reality testing. The PDM
notes that an overall failure of “defensive regulation” leads to “a pronounced break with
reality through the use of delusional projection and psychotic distortion” (p. 79). There-
fore, rigid use of primitive or maladaptive defenses leads to an inability to distinguish
between one’s own inner experience and stimuli coming from the external environment.
Without an accurate sense of inner reality, it can be said that the individual’s psycholog-
ical mindedness and awareness of inner states will be compromised.
Capacity VI: Capacity to Form Internal Representations

The PDM describes Capacity VI as the use of internal representations “to experience a
sense of self and others. . .to express the full range of emotions and wishes. . .to use
internal representations to regulate impulses and behavior” (p. 80). Greenspan’s (1989)
definition of mental representation adds an important dimension to this description, that is,
the multisensory construction of experience including all sensory and affective features of
the experience. Schore (1994) refers to an enduring interactive representation, which
emerges from the way the caregiver regulates or dysregulates the affective experiences of
the infant. It is the experience of being with the caregiver that is internalized or
consolidated into a working model of the relationship.
Internal representations develop during infancy and emerge from the repeated inter-
actions with the caregiver. These interactions are constituted by visual–facial, auditory–
prosodic, and tactile/gestural communications. They are simultaneously bodily and social
communications. If these interactions are predominantly characterized by stress and do not

engender a sense of security in the infant, then the resulting internal representations will
be encoded as stressful, setting up a long-term pattern of psychobiological functioning
dominated by stress responses. Internal representations are the multisensory laying down,
hard-wiring in the brain, of those repeated interactions with the caregiver; they are the
basic building blocks of personality functioning.
Secure attachment bonds lead to representational elaboration and increasing differen-
tiation and complexity, which in turn results in more complex symbolization of internal
life, as compared with insecure attachment bonds, which tend to rigidify around defensive
modes of relating and functioning. The early attachment interactions are internalized and
function throughout the life span as a regulator of affect and interpersonal behavior
(Schore, 2012).
In order to utilize this capacity when assessing individuals’ personality functioning, it
would be important to answer the question, what does it mean to be unable to form internal
representations? And what does it mean that an individual is unable to use them to
experience a sense of self and others? The PDM describes dysfunction in this capacity in
the following statement:
Unable to use internal representations to experience a sense of self and others or to elaborate
wishes and feelings (e.g., acts out or demands excessive physical closeness when needy)
(p. 80).
It may be that dysfunction in this domain is the result of relational trauma occurring in infancy
and that the internal representation of the caregiver is itself disorganized sufficiently to
incapacitate the infant and later the adult regarding affect regulation and with it a coherent
sense of self and others. If so, then rather than being unable to use internal representations, the
representations are themselves encoded dysfunctional interactions, which are being used
leading to a sense of self that is incoherent or severely depleted. Schore (2012) talks about “the
implosion of the implicit self” (p. 92).
Capacity VII: Capacity for Differentiation and Integration

The differentiation and integration of experience imply a certain level of complexity of
experience versus a premature constriction and oversimplification of experience. Schore’s
gathering of neuroscience data (1994, 2003) shows that secure attachments promote
openness to novel experience and better opportunities to process and organize more and
more complex and varied types of experiences. The PDM considers the varieties of
experience to include that of self and nonself; self and others; fantasy and reality; past,
present and future; and a range of wishes, emotions, and feeling states. Siegel (1999)
discussed at length the relevance of differentiation and integration for the development of
optimal personality functioning, and he also traced their origin to the early affectively
attuned attachment with the primary caregivers. It is well established that the complexity
130 ETZI
of functioning is based on the experience dependent neurophysiological development that

is an outcome of the unique style of interactions between infant and caregiver.
Differentiation, as a component of psychological functioning, refers to the separation
of elements of experience and functioning, that is, the ability to distinguish among these
elements. The science of development is trending toward theories of complexity to
comprehend the ways in which the mind/brain organizes the complexity of experience for
adaptive and coherent functioning in a complex environment. So, differentiation involves
the separation and handling of separate aspects of experience in their separateness. Wallin
(2007) tells us that differentiation “creates psychological boundaries, particularly between
self and other, and between the internal world and external reality” (p. 65). With a capacity
for differentiation comes an increasing ability to tolerate a wider range and depth of
experiences and external socioaffective demands. When the PDM refers to the fragmen-
tation of internal experience, for example, a psychotherapy patient is unable to differen-
tiate between feelings originating within himself and those feelings he perceives in the
therapist, the capacity for differentiation is involved.
Closely connected to differentiation is the other part of Capacity VII—integration. As
the counterpart to differentiation, integration has to do with bringing the separate elements
together in a more or less coherent and organized way. Wallin (2007) describes integration
as “synthesis and connection. . .[which]fosters balance and an awareness of the nuances
and complexity of experiences.” (p. 65). The inherent complexity of personality func-
tioning and psychological and emotional experience require integration if experience is to
be meaningful and organized, if the person is to be able to adapt flexibly to novel
situations. Schore (2003) linked integration with self-organization: “the process whereby
order and complexity create more order and complexity” (p. 93). Siegel (1999) addresses
integration as the “capacity to interconnect a range of processes within [the mind’s]
present activity, [and] across time.”(p. 301). Contained within integration are “the col-
laborative, linking functions that coordinate various levels of processes within the mind
and between people.”(p. 301). With the inclusion of Capacity VII, the M Axis becomes
capable of assessing the most complex aspects of personality functioning, both those that
occur within the individual and those that occur between and among individuals.
Perhaps the most important result of the capacity for differentiation and integration is
explained by Schore (1994) to be a continuity of inner experience. When separate
self-states or inner states can be integrated within the self, across time, and between self
and others, then the individual’s sense of self is characterized by a high degree of
coherence and continuity. For example, an adolescent struggles with the demands placed
on him by the culture to be a hardworking and conscientious student, to negotiate
increasingly intimate and mutually gratifying relationships, and to get along with peers
and authority figures, to name just a few of the sometimes conflicting roles and demands
he may experience. Some experiences may trigger intense anxiety, others excitement, but
they require the ability to have them cohere and exist alongside each other; the adolescent
is required to move in and out of them with flexibility.
Capacity VIII: Self-Observing Capacity (Psychological Mindedness)

The PDM’s conceptualization of this capacity is relatively self-explanatory. It is easy to
see how it is useful for clinicians to assess for the purposes of the work of psychotherapy,
as psychological mindedness is conducive to productive and effective psychotherapy in
addition to the creation of the psychotherapeutic working alliance. Like the other eight
capacities of the M Axis, this one describes a wide range of functioning within the
capacity itself so that the clinician can assess how the client’s ability to observe feelings
will be impacted by how one handles stress, the type of defenses used and their relative
rigidity or flexibility.
It is possible to link the self-observing capacity to other capacities and elements of
other M Axis capacities, but notably specifically to affect regulation, affect comprehen-
sion and emotion experiences. In Schore’s words: “Self-organizing appraisals thus involve
feedback between social cognition and emotion” (2003, p. 36). My reading of “self-
organizing appraisals” in the present context has to do with the ability to organize one’s
own emotional experiences, especially when under any amount of emotional distress, as
a result of the ability to stop and think or reflect on that experience in spite of its intensity
or discomfort. Like all the other capacities, this one also depends on the early infant–
caregiver interactions. Because those earliest interactions take place within a certain
emotional atmosphere, the ability to experience oneself in an organized way will become
internalized and endure as part of the developing individual’s personality functioning. The
capacity to evaluate change in the environment, especially the socioemotional environ-
ment, and in the self, is crucial to adaptive personality development, and the self-
observing capacity is an essential part of evaluating that change relevant to one’s own
experience. Peter Fonagy’s (2012) work on mentalization may be especially relevant to
this capacity, but it is beyond the scope of this paper to address it properly.
Capacity IX: Capacity to Construct or Use Internal Standards or Ideas: Sense

of Morality
Psychoanalysis has a long tradition of taking into account the individual’s construction of
internal standards or superego functioning as part of personality functioning. The PDM
continues the delineation of the elements of this capacity by addressing the individual’s
way of integrating internal standards with the social context and with other features of his
or her personality. Similar to other capacities, a clinician would assess this one on a
continuum from inflexibility to openness to nuance in moral standards, as a person
struggles to make meaningful interpretations of his own behaviors in addition to others’
behaviors. Also, this capacity is very intertwined with functioning in the other capacities.
For example, the types of defenses one uses will affect the sense of morality and vice
versa. A person may be more or less comfortable with certain emotions and may construct
a moral sense or set of internal standards as a way of coping with the more distressing
emotions. In other words, the moral sense of oneself is part of the overall representation
of oneself to oneself or how one organizes self-experience overall. Schore (2003), bases
the formation of internal standards in early shame experiences. Shame is characterized as
the socialization emotion when it is used empathically and in an attuned way by the
mother, but when it turns into humiliation, as a result of lack of attunement to the infant’s
experience or lack of ability to repair disruptions in interactions, it interferes with secure
attachment and with flexible, integrated, and realistic internal standards, as well as realistic
self-esteem.
Summary
After delineating the elements of the PDM’s M Axis, I hoped to have shown that it
contains a wealth of tools in the form of concepts and ideas that describe the very complex
and dynamic reality of personality functioning, both adaptive and maladaptive. Psycho-
therapists of all theoretical orientations have long recognized the inadequacy of the DSM
132 ETZI
for providing anything beyond a label of mental dysfunction derived from a short list of
surface-based symptoms, which have not held up well under the scrutiny of research. The
medical model approach does not come close to meeting the needs of psychotherapists,
especially those who work with a depth-psychology orientation, for example, psychoan-
alytic and psychodynamic psychotherapists, because the medical model’s focus on symp-
toms implies a treatment that will reduce or eliminate symptoms. On the contrary,
psychodynamic psychotherapists are keenly attuned to the psychotherapy process, most of
which is unspoken and unconscious and psychodynamic developmental theory acknowl-
edges the profound influence that unconscious processing has on personality development
and personality functioning, including as it is experienced in the moment-to-moment

interactions of the therapy session.
The PDM M Axis outlines several of the critical capacities of personality functioning.
Its inclusion of capacities that are implicitly or unconsciously experienced by both patients
and therapists within psychotherapy sessions makes it arguably the best conceptual system
for assessing psychological functioning that can inform the psychotherapy process. It is
able to take into account aspects of personality that are outside of conscious awareness,
yet exert a powerful impact on the patient’s everyday emotional/psychological functioning
and on the microinteractions of the psychotherapy work itself. One needs only to reflect
on an experience like projective identification, when therapists are likely to feel intensely
chaotic emotions that are hard to think about and make sense of as they are occurring. The
concepts articulated in the M Axis and in the PDM more broadly have provided an
extremely valuable first step on the road to devising a system of assessment for evaluating
patients as they begin the work of in-depth psychotherapy and for evaluating the process
of the psychotherapy work itself. The complexity of personality requires a tool by which
clinicians, educators, and researchers can systematically reflect upon, articulate, and
perhaps standardize to a certain degree, how we conceptualize personality functioning and
then how we go about working with the psychotherapy process based on these concep-
tualizations.
The strength of the PDM, its ability to address both nonconscious and conscious
aspects of psychological functioning, may also be what makes it so difficult to utilize in
its current form. But psychodynamic clinicians have integrated the unconscious into their
work and now that recent advances in psychoneurodevelopment and psychopathogenesis
are demonstrating scientifically the significance of implicit process in psychological
functioning, psychodynamic theory is well positioned to provide an assessment procedure
that matches the complexity of the human beings with whom we work.
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Psychoanalytic Psychology © 2014 American Psychological Association

THE PSYCHODYNAMIC DIAGNOSTIC

Janet Etzi, PsyD

The Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006) is a

Keywords: Psychodynamic Diagnostic Manual, M Axis, mental functioning,

precludes further thinking about psychological/personality functioning, or about what the

ARTICULATING WHAT THE M AXIS CAN ASSESS 121

The Dual Nature of the Self

ARTICULATING WHAT THE M AXIS CAN ASSESS 123

Affect Regulation Theory

Capacity 1: Capacity for Regulation, Attention, and Learning

ARTICULATING WHAT THE M AXIS CAN ASSESS 125

experience or organization with the primary caregiver of experience is common to both

Capacity II: Capacity for Relationships and Intimacy

mother’s absence (p. 186).

In other words, internal representations are the accumulation of socioemotional

Capacity III: Quality of Internal Experience (Level of Confidence and

ARTICULATING WHAT THE M AXIS CAN ASSESS 127

assessment of this capacity becomes more complicated. An individual can appear to be

Capacity IV: Affective Experience, Expression, and Communication

affective experience and functioning in Capacity IV. When shame is experienced to an

to have experienced that patient’s emotional comprehension or expression would be able

Capacity V: Defensive Patterns and Capacities

Capacity VI: Capacity to Form Internal Representations

ARTICULATING WHAT THE M AXIS CAN ASSESS 129

communications. If these interactions are predominantly characterized by stress and do not

Capacity VII: Capacity for Differentiation and Integration

of functioning is based on the experience dependent neurophysiological development that

Capacity VIII: Self-Observing Capacity (Psychological Mindedness)

ARTICULATING WHAT THE M AXIS CAN ASSESS 131

Capacity IX: Capacity to Construct or Use Internal Standards or Ideas: Sense

and personality functioning, including as it is experienced in the moment-to-moment

ARTICULATING WHAT THE M AXIS CAN ASSESS 133

Madison, CT: International Universities Press. doi:10.1037/13180-000

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