Axis II Personality Disorder: What It Meant And How It's Classified Today

If you have come across the term "Axis II personality disorder" in medical records, legal documents, or older mental health literature, you may be wondering what it means. Axis II was a classification system used in the Diagnostic and Statistical Manual of Mental Disorders (DSM) prior to 2013 that separated personality disorders from other mental health conditions. While this terminology is now outdated, many people still encounter it when reviewing historical documentation or researching personality disorders. Below, explore the history of the axis system, why it changed, and how personality disorders are classified and treated today.

What were Axis II disorders in the DSM-IV?

The multiaxial system was introduced in the DSM-III in 1980 and continued through the DSM-IV-TR in 2000. This approach was designed to help clinicians consider multiple dimensions of a person's mental health rather than focusing on a single diagnosis. Axis II specifically included personality disorders and intellectual disabilities (then called mental retardation), which were viewed as enduring patterns that typically developed early in life and remained relatively stable over time.

The five axes of the multiaxial system covered different aspects of a person's functioning:

• Axis I: Clinical disorders such as depression, anxiety, schizophrenia, and substance use disorders
• Axis II: Personality disorders and intellectual disabilities
• Axis III: General medical conditions that might be relevant to understanding or treating mental health
• Axis IV: Psychosocial and environmental problems such as housing issues, relationship difficulties, or occupational stress
• Axis V: Global Assessment of Functioning (GAF), a numerical scale rating overall psychological functioning

This system was intended to ensure that clinicians considered both immediate symptoms and underlying personality patterns when evaluating someone's mental health. Understanding this historical framework can help clarify why older records may reference Axis II diagnoses.

Axis I vs Axis II: Understanding the difference

One of the most common questions about the old diagnostic system involves the distinction between Axis I and Axis II conditions. The key difference related to how clinicians viewed the nature and course of these conditions. Axis I disorders were considered more acute or episodic, while Axis II conditions were seen as enduring patterns of behavior that shaped how a person perceived themselves and interacted with the world over time.

Conditions that fell under Axis I

Axis I encompassed what were considered clinical disorders, including mood disorders like major depression and bipolar disorder, anxiety disorders such as generalized anxiety and panic disorder, psychotic disorders like schizophrenia, substance use disorders, and eating disorders. These conditions were often viewed as having a more defined onset and potentially being more responsive to specific treatments or medications.

Conditions that fell under Axis II

Axis II personality disorders included conditions characterized by long-standing patterns in thinking, feeling, and behaving that differed significantly from cultural expectations. These patterns typically emerged by adolescence or early adulthood and affected multiple areas of life. Intellectual disabilities were also included on this axis because they were similarly viewed as stable, lifelong conditions rather than episodic illnesses.

Why the DSM-5 eliminated the multiaxial system

When the DSM-5 was published in 2013, the multiaxial system was discontinued. Several factors contributed to this decision. Evidence increasingly indicated that the distinction between "clinical" disorders and "personality" disorders was somewhat artificial. Personality disorders were found to be just as clinically significant and treatable as conditions that had been placed on Axis I.

The change also helped align the DSM with international diagnostic standards, particularly the International Classification of Diseases (ICD). Additionally, the multiaxial system sometimes led clinicians to view personality disorders as secondary concerns rather than primary treatment targets. By eliminating the axes, the DSM-5 placed all mental health conditions on equal footing, encouraging clinicians to give personality disorders the same attention as other conditions.

It is important to understand that personality disorders did not disappear with this change. They are now listed in Section II of the DSM-5 alongside other mental health conditions, and an alternative dimensional model appears in Section III for further research and clinical consideration.

How personality disorders are classified today

The DSM-5 recognizes 10 personality disorders, organized into three clusters based on shared characteristics. This organizational approach helps clinicians and individuals understand the common features among certain disorders while recognizing that each condition has its own distinct diagnostic criteria.

• Cluster A (odd or eccentric): Includes paranoid, schizoid, and schizotypal personality disorders
• Cluster B (dramatic or emotional): Includes antisocial, borderline, histrionic, and narcissistic personality disorders
• Cluster C (anxious or fearful): Includes avoidant, dependent, and obsessive-compulsive personality disorders

Cluster A personality disorders

Cluster A personality disorders are characterized by patterns of thinking and behavior that may appear odd or eccentric to others. Paranoid personality disorder involves a deep level of suspiciousness and mistrust of other people. Someone with this condition may believe others are disloyal or seek to harm them, often becoming hostile or defensive without objective reason.

Schizoid personality disorder is characterized by a lack of interest in social relationships. These individuals usually prefer to be alone and tend to lack emotion when interacting with others. They often have difficulty forming attachments to people but may have extensive fantasies about others.

Schizotypal personality disorder involves intense social anxiety and unconventional beliefs about forming relationships. These individuals may have superstitious beliefs and unusual manners of speech and dress. This disorder is related to but distinct from schizophrenia.

Cluster B personality disorders

Cluster B personality disorders involve patterns that may appear dramatic, emotional, or erratic. Antisocial personality disorder is characterized by a disregard for the rights of others. Individuals with this disorder may lack a conscience or have few moral values and may have a criminal history related to impulsive behaviors and aggression.

Borderline personality disorder often involves instability in relationships, sense of self, and emotional control. Individuals may fear abandonment and frequently feel empty inside. They may also engage in dangerous activities and self-harm or act out after everyday events. Individuals with this disorder may have co-occurring mental health conditions such as depression or eating disorders and may face an elevated risk of suicide.*

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Histrionic personality disorder involves craving attention and often exhibiting seductive or inappropriate behavior toward others. Individuals can be extremely dramatic, enthusiastic, and lively, and their behavior may be perceived as self-indulgent. They also tend to exaggerate whatever emotions they feel.

Narcissistic personality disorder usually involves a strong need for admiration, a lack of empathy, and a grandiose idea of one's importance. These individuals tend to require attention and believe they are more important than others, often taking advantage of other people without remorse.

Cluster C personality disorders

Cluster C personality disorders are characterized by anxious or fearful patterns of thinking and behavior. Avoidant personality disorder involves feelings of inadequacy and inferiority. Individuals often have extreme sensitivity to criticism and fear humiliation and rejection, leading them to avoid social interaction unless they feel sure of being liked and accepted.

Dependent personality disorder is characterized by clinginess, submissiveness, and dependence on someone else. An individual with this disorder typically forms a strong emotional and physical reliance on a specific person, requiring that person to make decisions for them.

Obsessive-compulsive personality disorder includes a preoccupation with perfection, control, and order. A person with this condition typically spends excessive time on scheduling and attending to details, often to the exclusion of making time for friends and family. It is important to note that obsessive-compulsive personality disorder differs from obsessive-compulsive disorder, or OCD. People with OCD tend to have intrusive thoughts and feelings that lead them to engage in compulsive behaviors to relieve their anxiety and distress.

Other specified and unspecified personality disorders

Some people have subclinical symptoms of the above personality disorders, which may lead to a diagnosis of "other specified personality disorder" or "unspecified personality disorder." The DSM-5 also includes a classification called "personality disorder-trait specified," which may be used when a clinician identifies impairments in specific personality traits that do not fit another personality disorder diagnosis.

The alternative model for personality disorders (AMPD)

The DSM-5 includes an alternative model for personality disorders in Section III, which is designated for emerging measures and models requiring further research. This dimensional approach assesses personality functioning across four domains: identity, self-direction, empathy, and intimacy. Rather than placing individuals into distinct categories, this model evaluates the severity of impairment along a continuum.

The alternative model also identifies pathological personality traits organized into five broad domains. While this approach is currently used more in research settings, it represents the direction that personality disorder diagnosis may take in the future as the field continues to evolve toward more nuanced, dimensional assessments.

How personality disorders are diagnosed

According to available research, over 9% of people may have a personality disorder. Each personality disorder has separate diagnostic criteria that a qualified clinician must assess in order to make a diagnosis. Diagnosis may be made by licensed professionals who are qualified to assess mental health conditions, based on their training and scope of practice.

To do so, the mental health professional conducts an extensive interview with the person and possibly with other people who know them well. They tend to look for long-standing patterns in how the person perceives themselves compared to what is typical for their culture. The diagnosis process typically requires multiple sessions to establish that patterns are present across different life areas and have been stable over time.

What clinicians look for during assessment

During the diagnostic process, clinicians typically examine four key areas of functioning. They assess cognition, which involves how a person perceives and interprets themselves, others, and events. They evaluate affectivity, looking at the range, intensity, and appropriateness of emotional responses. Interpersonal functioning is examined to understand how the person relates to others and maintains relationships. Finally, clinicians assess impulse control to determine how well the person can regulate their behavior and urges.

Ruling out other conditions

Clinicians must also rule out other mental health conditions, such as depression and anxiety, as the cause of the person's behavior. Medical conditions that might affect personality or behavior are also considered. This differential diagnosis process helps ensure that the patterns observed are truly reflective of a personality disorder rather than another treatable condition.

Treatment approaches for personality disorders

Various treatment options exist for personality disorders, and these conditions can respond well to appropriate interventions. Personality disorders that go untreated can significantly affect quality of life, which is why finding appropriate support matters.

Psychotherapy options

Several evidence-based psychotherapy approaches have been developed for personality disorders. The following therapeutic modalities may be helpful:

• Cognitive behavioral therapy (CBT): Helps identify and change unhelpful thought patterns and behaviors
• Dialectical behavior therapy (DBT): Originally developed for borderline personality disorder, focuses on mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness
• Psychodynamic therapy: Explores how past experiences and unconscious processes influence current patterns
• Mentalization-based therapy: Helps individuals understand their own mental states and those of others
• Schema therapy: Addresses deep-rooted patterns that developed in childhood

Medication considerations

While there are no medications specifically designed to treat personality disorders, some medications may be considered to help manage certain symptoms when clinically appropriate. Depending on a person's needs and a licensed psychiatric provider's evaluation, this may include medication to address mood symptoms, emotional instability, distorted thinking, or anxiety symptoms. Medication is one possible tool in a broader treatment plan and is often considered alongside psychotherapy. BetterHelp now offers psychiatry services through Uplift as an additional care option alongside therapy. Medication availability and coverage may vary by member location, clinical appropriateness, and individual pharmacy/insurance benefits. Prescribing decisions are made by the treating clinicians. We do not guarantee that any specific medication will be prescribed or covered by a member's insurance plan.

*Medication is prescribed only when clinically appropriate and is not guaranteed. Pricing, availability, insurance coverage, and copays vary by plan, location, and provider availability are not guaranteed.

Support for individuals and families

Support groups may provide valuable connection with others who understand similar experiences. Family therapy and psychoeducation may help loved ones understand the condition and learn effective ways to communicate and support recovery. For some people with severe personality disorders, hospitalization or residential care may be an appropriate option during crisis periods.

Benefits of online therapy for personality disorder support

Online therapy may offer benefits for individuals seeking support for personality disorder symptoms, with 72% of BetterHelp users experiencing a reduction in symptoms in 12 weeks. For those with avoidant personality disorder or social anxiety, connecting with a therapist from home may feel less intimidating than visiting an office. The flexibility of online platforms like BetterHelp—one of the world's largest networks of therapists with over 30,000 qualified providers globally—also allows for ongoing messaging support between sessions, which may be particularly helpful for those who benefit from consistent connection with their therapist.

How effective online therapy can be

While research on online therapy specifically for personality disorders continues to develop, one Fernandez et al. study from 2021 in Clinical Psychology & Psychotherapy suggests that live psychotherapy by video may have outcomes comparable to in-person therapy for several mental health concerns. Personality disorders often accompany other conditions such as anxiety and depression, which may respond well to the type of talk therapy available through online mental health platforms. With BetterHelp, users can reach out to their therapist between sessions through in-app messaging, and therapists respond as soon as they can.

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