Psychodynamic Diagnostic Manual (PDM)

Psychodynamic Diagnostic Manual (PDM)

by PDM Task Force. Alliance of Psychoanalytic Organizations, Silver Spring, MD, 2006, 857 pages, $45.00; $35.00 (paper).

This timely and provocative work demonstrates with force the relevance and sheer life of the psychodynamic approach to psychiatric diagnosis and treatment. The aim of this strikingly creative volume, Psychodynamic Diagnostic Manual (PDM), is to complement the behavioral, symptomatic descriptions in the existing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) and the International Classification of Diseases, Tenth Revision (ICD-10), both of which eschew clinical inferences, with a diagnostic framework that can capture not only overtly observable behavior and symptoms but also internal structural personality organization, the idiosyncratic complexity of a person’s self and biopsychosocial functioning, ie, the subtle, intensely private affective, cognitive, perceptual, and social patterns, coping strategies, and capacities for understanding oneself and others. Beneficiaries of this strongly conceived and balanced account are meant to be not only patients of psychodynamically oriented psychiatrists and psychotherapists but also those whose treatment is within biologic, cognitive-behavioral, and other communities of thought. The book clocks in at an unnecessarily long 857 pages.

It is clear that the motivation for this undertaking was a high level of dissatisfaction and unhappiness among psychiatrists, psychoanalysts, and psychodynamically informed psychotherapists with the narrow focus on symptom clusters for psychiatric diagnosis in DSM-IV-TR and ICD-10 and the major tensions this narrow focus introduces into the examiners’ struggle to communicate both an external, descriptive, neurobiologic, categorical diagnosis and the more uniquely individual, intuitive, psychodynamic, and substantially dimensional impressions of their patients’ problems.

Thus, this volume came into being through a massive collaborative effort of 5 sponsoring organizations: the American Psychoanalytic Association, the International Psychoanalytical Association, the Division of Psychoanalysis (39) of the American Psychological Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, and the National Membership Committee on Psychoanalysis in Clinical Social Work. The steering committee and task force comprised 18 psychiatrists, 15 clinical psychologists, and 7 clinical social workers, a total of 40 members and 4 consultants; 39 of these were affiliated with US academic institutions and 1 each with universities in Argentina, Canada, France, Great Britain, and Germany. Stanley I. Greenspan, MD, chaired both the steering committee and the task force; associate chairs of the task force were Nancy McWilliams, PhD, and Robert S. Wallerstein, MD.

Separate work groups of the task force dealt with classification of mental health disorders of adults (pp 1-172) and of children and adolescents (pp 173-380), the latter including both a novel description of "Emerging Personality Styles in Children and Adolescents" (pp 207-232) and a uniquely valuable "Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood" (pp 319-380). The third and final part of the PDM is devoted to "Conceptual and Research Foundations for a Psychodynamically Based Classification System for Mental Health Disorders" (12 essays, pp 381-837).

The first section of the Manual is devoted to adult mental health disorders in terms of a triaxial diagnostic scheme: the P Axis to describe Personality Patterns and Disorders, the M Axis for a Profile of Mental Functioning, and the S Axis for Symptom Patterns: The Subjective Experience.

The P Axis (Personality Patterns and Disorders) is placed first because of evidence that the relatively stable ways of behaving, feeling, relating to others, and thinking and the severity of disorders in these characteristic patterns, ie, the level of personality organization—healthy, neurotic, or borderline1—have an essential bearing on the manner in which a person experiences problems and symptoms and his or her ability to cope with them. Enumerated here are the various personality types, some familiar from Axis II of DSM-IV-TR, enriched with introductory essays that, among others, contrast observable overt behavior with underlying covert feelings. Added are subcategories, eg, arrogant/entitled versus depressed/depleted narcissistic personality disorder, but not including the most recently described construct of its subtypes2,3; other personality variants not part of DSM-IV-TR (sadistic, self-defeating, depressive, somatizing, and anxious); and disagreements, eg, the alleged lack of evidence for qualitatively differentiating between schizoid and schizotypal individuals. Briefly listed for each personality disorder are contributing constitutional patterns, central preoccupations, predominant affects, characteristic defensive maneuvers, and pathogenic beliefs about self and others. Of course, not included here is DSM-IV-TR’ s borderline personality disorder per se because, in this conceptualization, borderline personality organization is viewed as a category comprising several severe personality disorders rather than as a single diagnosis.

Next is the M Axis (Profile of Mental Functioning), a systematic evaluation of 9 crucial categories of a person’s inner experience: (1) capacity for regulation, attention, and learning; (2) capacity for relationships and intimacy; (3) level of confidence and self-regard; (4) affective experience, expression, and communication; (5) defensive patterns and capacities; (6) capacity to form internal representations; (7) capacity for differentiation and integration; (8) self-observing capacity; (9) capacity to construct or use internal standards and ideals: sense of morality. Consideration of these 9 categories of basic mental functioning is then summarized along an 8-level continuum ranging all the way from "M201. Optimal Age- and Phase-Appropriate Mental Capacities with Phase-Expected Degree of Flexibility and Intactness" to "M208. Major Defects in Basic Mental Functions."

Finally, the S Axis (Symptom Patterns: The Subjective Experience) is placed third in this diagnostic profile because of the authors’ belief that only in the context of a person’s personality structure (P Axis) and mental functioning profile (M Axis) can the symptoms and their pattern be truly understood as a personal experience of that individual’s problems. Enumeration of the Axis I disorders of DSM-IV-TR is further elaborated here with the patient’s individual, subjective experience of the symptoms along affective patterns, mental content, and accompanying somatic states. Numerous clinical illustrations are interspersed in the discussion of the various symptomatic diagnoses. Three detailed case illustrations are offered for complete PDM profiles of adults.

The authors do not discuss categorical versus dimensional approaches to classifying psychopathology. However, I need to clarify that, in the triaxial approach of the PDM, the P Axis and the S Axis present clinically familiar categorical (prototypical) disordered personality functioning and symptomatic patterns, while the M Axis attempts to systematize individual emotional life along dimensional representations of multiple mental functions, all the way from optimal to severely defective. It is important to note that the introduction of dimensions on the M Axis, as described, automatically complements both the P Axis and the S Axis and obviates the necessity to introduce dimensional details on those axes. Thus, the entire triaxial P-M-S diagnostic schema is a hybrid categorical-dimensional system, as discussed by John Strauss4 in his seminal contribution as far back as 1973, most likely even before work on DSM-III had begun.

The second section of the Manual deals first with child and adolescent mental health disorders and then separately with mental health and developmental disorders in infancy and early childhood. In the first subsection on children and adolescents, because of the fluidity of a young person’s experience of relationships and ability to cope with anxiety, the Profile of Mental Functioning for Children and Adolescents-MCA Axis is listed first, followed by the Child and Adolescent Personality Patterns and Disorders-PCA Axis and the Child and Adolescent Symptom Patterns: The Subjective Experience-SCA Axis. These axes are different from those of adults because young people’s personality patterns are both emerging and relatively stable and their symptomatic presentation is vastly different, including arrays of developmental, disruptive behavioral, learning, motor skill, neuropsychological, and tic disorders. Again, 3 detailed case illustrations are offered (as for adults in section 1) for complete PDM profiles of adolescents and children.

The second half of this section of the PDM is devoted to mental health and developmental disorders in infancy and early childhood, the IEC Axis, in 3 broad categories: (1) interactive disorders (anxiety, depression, disruptive behavior); (2) regulatory-sensory processing disorders (inattention, overreactivity, sensory seeking); and (3) neurodevelopmental disorders of relating and communicating (self-absorption, perseveration, dysfunctional communication-autism spectrum disorders).

The third and final section of this Manual presents conceptual and research foundations for a psychodynamically based classification system for mental health disorders. Twelve essays comprise 456 pages, 53% of the total pages and of the 4-lb weight of this volume. Only 7 of the 12 essays pertain to issues of diagnosis. They are "Psychoanalytically Based Nosology: Historic Origins" by Wallerstein; "A Developmental Framework for Depth Psychology and a Definition of Healthy Emotional Functioning" by Greenspan and Shanker; "The Contribution of Cognitive Behavioral and Neurophysiological Frames of Reference to a Psychodynamic Nosology of Mental Illness" by Shevrin; "Evaluating Efficacy, Effectiveness, and Mutative Factors in Psychodynamic Psychotherapies" by Blatt et al; "Personality Diagnosis With the Shedler-Westen Assessment Procedure (SWAP): Bridging the Gulf Between Science and Practice" by Shedler and Westen; "Psychic Structure and Mental Functioning: Current Research on the Reliable Measurement and Clinical Validity of Operationalized Psychodynamic Diagnosis (OPD) System" by Dahlbender et al; and "Overview of Empirical Support for the DSM Symptom-Based Approach to Diagnostic Classification" by Herzig and Licht. The other 5 articles do not deal with diagnosis but with suitability, history, empirical status, and outcome studies of, and evidence for, psychodynamic psychotherapy. These 5 essays take up 200 pages, 23% of the volume.

While all 12 essays by eminent clinicians and theoreticians are valuable and of very high quality, the authors’ understandable desire and impulse to share their knowledge and insight in this Manual should have been resisted. Publishing these contributions within the PDM, rather than in a contemporaneous separate book, was an error that detracts from the usability of this massive volume. To be consulted frequently, the Manual needs to be compact and easy to handle. That is not the case. Missing is a handy spiral-bound version of the diagnostic part of the Manual that all users, particularly psychiatric residents and other trainees, can have with them wherever they evaluate and serve patients.

In a recent editorial, Skodol and Bender,5 respectively chair and member of the Personality and Personality Disorders Work Group for DSM-V, described the 5 parts of a dimensional proposal under current consideration for assessment of personality disorders in DSM-V. Four of these 5 tasks have been accomplished by the PDM: (1) "prototype descriptions of major personality (disorder) types"5(p390)—on the P Axis; (2) "generic criteria for personality disorder consisting of severe deficits in self-differentiation and integration and in the capacity for interpersonal relatedness"5(p390)—on the M Axis; (3) "an overall rating of personality (self and interpersonal) functioning ranging from normal to severely impaired"5(p390)—on the M Axis; and (4) "measures of adaptive functioning"5(p390)—also on the M Axis. Thus, the PDM represents a significant advance toward the formulation of an integrated, hybrid categorical-dimensional diagnostic scheme for DSM-V. Whether the fifth task, "a personality trait assessment, on which the prototypes are based but that can also be used to describe major personality characteristics of patients who either do not have a personality disorder or have a personality disorder that does not conform to one of the prototypes,"5(p390) can be integrated into the overall schema of the PDM only further research and literature review can establish.

The Psychodynamic Diagnostic Manual is a bold and lucid summary of peoples’ psychiatric disorders, including those the eye cannot see. It was not meant to replace the DSM; the authors were wise to work with the nomenclature of DSM-IV-TR on the S Axis. This important volume risks remaining insufficiently known because it was published noncommercially, with little publicity, at a reduced price, and with support from 2 research organizations. Yet its content needs to be familiar to clinically active psychiatrists, particularly psychiatric residents, other trainees, and those involved in the development of DSM-V. The M Axis, at the very heart of this book, is brilliant. It burrows inward to take an emotional inventory of a patient’s internal experiences. Rolling the M Axis into DSM-V would go a long way toward creating a taxonomy that does not lead to the description of people as suffering from multiple, apparently unrelated psychiatric disorders but attempts to capture their problems in a unitary, hybrid categorical-dimensional diagnosis. The ultimate and most impressive achievement of this work is its obstinate insistence that to understand individual psychiatric patients, with great care and dynamic patience, is the touchstone for their successful diagnosis and treatment in a humanistic, enlightened community.

References

1. Kernberg O. Borderline personality organization. J Am Psychoanal Assoc. 1967;15(3):641-685. PubMed doi:10.1177/000306516701500309

2. Russ E, Shedler J, Bradley R, et al. Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry. 2008;165(11):1473-1481. PubMed doi:10.1176/appi.ajp.2008.07030376

3. Kay J. Toward a clinically more useful model for diagnosing narcissistic personality disorder. Am J Psychiatry. 2008;165(11):1379-1382. PubMed doi:10.1176/appi.ajp.2008.08081238

4. Strauss JS. Diagnostic models and the nature of psychiatric disorder. Arch Gen Psychiatry. 1973;29(4):445-449. PubMed

5. Skodol AE, Bender DS. The future of personality disorders in DSM-V? [editorial]. Am J Psychiatry. 2009;166(4):388-391. PubMed doi:10.1176/appi.ajp.2009.09010090

Robert Stern, MD, PhD

[email protected]

Author affiliation: Yale University School of Medicine, New Haven, Connecticut. Financial disclosure: None reported.

doi:10.4088/JCP.09bk05461

© Copyright 2009 Physicians Postgraduate Press, Inc.