Severe personality disorders and their treatment are the chief concerns of clinicians who maintain a psychotherapeutic focus and who feel a compelling need to understand psychopathology in terms of psychic processes and structural defects. This is also a psychoanalytic focus that pursues etiology radier than phenomenology, although as Akhtar demonstrates, it does not ignore surface behavior and symptomatic constellations, that is, the descriptive approach.

Many psychiatrists as well as other mental health professionals do not seem to require a conceptual system, such as psychoanalysis, which emphasizes causal chains to explain how and why psychic equilibrium has been disrupted. Such an approach requires investigators to pursue diverse frames of reference, such as developmental vicissitudes, psychic trauma, object relationships, and yes, even constitutional vulnerabilities. The latter and their neurochemical characteristics, however, do not fill the stage; they are significant variables among many others.