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The Psychodynamic Diagnostic Manual (PDM) is a diagnostic handbook similar to the International Statistical Classification of Diseases and Related Health Problems (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM). The PDM was published on May 28, 2006.
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Although it is based on current neuroscience and treatment outcome studies, Benedict Carey pointed out in an 2006 New York Times article that many of the concepts in the PDM are adapted from the classical psychoanalytic tradition of psychotherapy. For example, the PDM indicates that the anxiety disorders may be traced to the "four basic danger situations" described by Sigmund Freud (1926)[1] as the loss of a significant other; the loss of love; the loss of body integrity; and the loss of affirmation by one's own conscience.[2] It uses a new perspective on the existing diagnostic system as it enables clinicians to describe and categorize personality patterns, related social and emotional capacities, unique mental profiles, and personal experiences of the patient.[3]
The PDM is not intended to compete with the DSM or ICD. The authors report the work emphasizes "individual variations as well as commonalities" by "focusing on the full range of mental functioning" and serves as a "[complement to] the DSM and ICD efforts in cataloguing symptoms.[4] The task force intends for the PDM to augment the existing diagnostic taxonomies by providing "a multi dimensional approach to describe the intricacies of the patient's overall functioning and ways of engaging in the therapeutic process.".[5]
With the publication of the DSM-3 in 1980, the manual switched from a psychoanalytically influenced dimensional model to a "neo-Kraepelinian" descriptive symptom-focused model based on present versus absent symptoms. The PDM provided a return to a psychodynamic model for the nosological evaluation of symptom clusters, personality dimensions, and dimensions of mental functioning.
The third dimension starts with the DSM-IV-TR diagnostic categories; moreover, beyond simply listing symptoms, the PDM "goes on to describe the affective states, cognitive processes, somatic experiences, and relational patterns most often associated clinically" with each diagnosis.[4] In this dimension, "symptom clusters" are "useful descriptors" which presents the patient's "symptom patterns in terms of the patient's personal experience of his or her prevailing difficulties".[4] The task force concludes, "The patient may evidence a few or many patterns, which may or may not be related, and which should be seen in the context of the person's personality and mental functioning. The multi dimensional approach... provides a systematic way to describe patients that is faithful to their complexity and helpful in planning appropriate treatments".[4]
Against this background, the PDM was conceived as a way to correct deficiencies in the DSM by complementing its symptom-based approach with an individualized, dimensional, and motivationally attuned classification of persons with mental health disorders. Preparation of the PDM was a collaborative effort among five psychoanalytic organizations: the American Psychoanalytic Association, the International Psychoanalytic Association, the Division of Psychoanalysis 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 text itself was authored by a task force consisting of Stanley Greenspan as chair, Nancy McWilliams and Robert Wallerstein as associate chairs, and an interdisciplinary group of 37 other task force members and consultants. Drawing on empirical findings as well as clinical experience, the task force worked in small groups to draft various sections of the document. The manual they produced to complement the DSM is in many respects quite similar to it but in some respects dramatically different from it.To begin with its physical appearance, the paperbound PDM has much the same trim size and thickness as the paperbound DSM-IV-TR. However, whereas 762 of the 932 text pages (81.8 percent) in the DSM-IV-TR are devoted to presenting the classification scheme, only 365 of the 837 text pages (43.6 percent) in the PDM directly concern the proposed alternative classification. These 365 pages compose Part 1 of the book, which deals with classification of adult mental health disorders, and Part 2, which addresses classification of child and adolescent mental health disorders. The remaining 56.4 percent of the PDM text pages, which constitute Part 3, consist of 12 authored chapters on conceptual and research foundations for a psychodynamically based classification system of mental health disorders.Consistent with its intent to complement the DSM, not replace it, the PDMs stated aim is to enrich classification in ways that will help therapists work effectively with their patients. The PDM design for attaining this enrichment calls for describing people with respect to their personality characteristics, the adequacy of their mental functioning, and whatever patterns of symptom formation they may show, with particular attention to how they are experiencing these symptoms. Accordingly, each person being evaluated with the PDM is diagnosed on three axes that closely resemble DSM Axes I, II, and V and are labeled S (Symptom Patterns), P (Personality Patterns and Disorders), and M (Profile of Mental Functioning). As a departure from the DSM sequence, however, a PDM diagnosis begins with the P axis, considers next the M axis, and concludes with the S axis. This PDM sequence reflects a conviction that symptomatic disorders are embedded in an individuals personality structure and manifest in ways that vary with each persons functioning capacities.The personality disorder categories on the PDM P axis replicate the DSM Axis II categories for the most part, but with one significant and several minor differences. The major difference involves the removal of borderline personality disorder from this axis, for reasons based on the theoretical formulations of Kernberg (1975) and McWilliams (1994), among others. The term borderline is conceived as referring not to a disorder but to a level of personality organization that is more maladaptive than a neurotic level of organization and less maladaptive than a psychotic level of organization. In this framework, individuals with a personality disorder can vary with respect to the level of organization at which they are functioning.As for the minor differences, the PDM, for reasons given in the text, also removes the DSM schizotypal personality disorder and avoidant personality disorder from its P axis, uses psychopathic rather than antisocial and hysterical rather than histrionic in its terminology, adds categories for sadistic and masochistic personality disorders, and concludes that five DSM Axis I conditions occur not only as episodic symptomatic disorders but also as persistent maladaptive dispositions: depressive, somatizing, phobic, anxious, and dissociative personality disorders. The P axis thus comprises 15 main categories (coded from P101 to P115), some of which are divided into subcategories. This brings the total number of possible PDM personality disorder diagnoses to well over 20, compared with just 11 in the DSM Axis II.For each personality disorder on the P axis, the PDM text discusses briefly the behavior patterns and levels of personality organization (neurotic, borderline, psychotic) that are likely to be associated with it; the constitutional factors and life experiences that tend to foster it; the affects, beliefs, concerns, and defensive maneuvers that typify persons with the disorder; and considerations in providing effective psychotherapy for people who show this personality pattern. Reflecting the psychodynamic perspective of the PDM approach, these discussions stress that there is more to people than their observable behavior. Instead of taking appearances at their face value, the PDM instructs, clinicians should seek to understand the underlying motives of persons they are evaluating and to recognize ways an individuals maladaptive behavior may be serving defensive purposes. As examples from the text of such depth psychological formulations, persons who are determinedly independent may have powerful dependent longings that are being defended against with denial and reaction formation, counterphobic people may thrust themselves into high-risk situations as a defense against underlying fearfulness, and hypomanic individuals may be struggling to avoid becoming depressed.Persons being evaluated with the PDM are assigned a P code for each personality disorder they appear to have or show some features of having, and they are given as many of these codes as seem in evidence. These provisions for coding a disorder or just features of a disorder, rather than having to make a yes or no decision, and for coding multiple disorders without having to choose one from among them, give the P axis diagnosis a dimensional quality and eliminate any concerns about comorbidity.The M axis closely parallels the DSM Axis V Global Assessment of Functioning (GAF) by assigning people to one of eight levels of functioning, ranging from optimal age- and phase-appropriate mental capacities (M201) to major defects in basic mental functions (M208). Guidelines are given for arriving at an M axis diagnosis through consideration of a persons capacities for cognitive control, interpersonal intimacy, positive self-regard, self-observation, moral judgment, affect modulation, formation of internal representations, and use of adaptive defenses. Whereas the final M axis diagnosis by itself adds little information to a DSM GAF rating, the guidelines for coding it spell out useful criteria for capturing the complexity of a persons functioning capacities and level of adjustment. This observation foreshadows an overall evaluation of the PDM, in that its enduring value may rest less with its recommendations for revised codification than with its textual enrichment of considerations in evaluating personality disorders, functioning capacities, and patterns of symptom formation.The S axis is organized around 13 categories of disorder (S301-S313) that, for the most part, mirror traditional DSM Axis I categories. For each category, the text reviews the DSM definition and then elaborates on it with descriptions of how this disorder is likely to evolve developmentally and how people with the disorder tend to experience their symptoms affectively, cognitively, somatically, and in their interpersonal interactions. In so doing, the PDM descriptions address the inner life of people in ways that seldom appear in the DSM.Part 1, on adult disorders, closes with three case illustrations of how the PDM P, M, and S codes can be applied. The three persons in these cases have the same PDM S axis diagnosis of depressive disorder (S304.1), but their P axis and M axis diagnoses differ in ways that have implications for their uniqueness as people and for treatment strategies tailored to their individual needs.Part 2 of the PDM, on child and adolescent disorders, is organized around the same P, M, and S axes as are used with adults, but in a different sequence. The PDM diagnosis of young people begins with attention to the adequacy of their basic functioning capacities, in the form of an MCA axis that provides guidelines for classifying mental functioning and coping capacities along an 8-point continuum ranging from optimal (MCA201) to major defects (MCA208).The P axis for children and adolescents, considered next, describes 15 patterns of emerging or relatively formed personality disorders, coded from PCA101 to PCA115. With a few minor modifications, these disorders replicate the P axis categories used with adults, and a brief age-related description is provided for each. The S axis, coded last from SCA301 to SCA327, consists mostly of traditional DSM categories. Noteworthy are the addition of a diagnostic category for suicidality (SCA308) and the expansion of DSM-type descriptions of disorders to include comments on childrens subjective experience of them. A summary table of concordance provides a helpful comparison of the PDM SCA categories with the DSM-IV Axis I categories for children and adolescents.As in the case of the adult disorders, the PDM presentation of child and adolescent disorders includes three case studies that illustrate application of the diagnostic system. Part 2 of the manual then concludes with a further innovation, a section on classification of mental health and developmental disorders in infancy and early childhood. Brief descriptions are provided of several interactive disorders of early life (IEC101-IEC116; e.g., anxiety disorders, attentional disorders), several regulatory-sensory processing disorders (IEC201-IEC-207; e.g., underresponsive, disorganized), and several neurodevelopmental disorders of relating and communicating (IEC301-IEC304; e.g., symbolic constriction).Part 3 of the PDM, as previously noted, consists of 12 individually authored chapters that address (a) the history of psychoanalytically based nosology and psychoanalytic therapy research, (b) recently developed diagnostic measures for assessing psychotherapeutically induced personality change, (c) research findings concerning the effectiveness of psychodynamic psychotherapy and indications for undertaking it, and (d) psychodynamic conceptualizations of normal and abnormal development. These chapters could almost stand in their own right as a well-written and extensively referenced scholarly monograph on contemporary psychodynamic perspectives in psychological assessment and therapy. This having been said, readers might wonder whether these Part 3 chapters belong in the diagnostic classification manual. The text states that these contributions are intended to provide conceptual and empirical support for the PDMs individualized, dimensional, and depth psychology approach. However, a question to consider is whether the sensitivity of psychodynamically formulated assessment methods and the effectiveness of psychodynamic psychotherapy have any direct bearing on the need for or utility of a psychodynamic classification of disorders.One answer to this question can be formulated with reference to the three previously noted purposes of diagnostic classification: to assist in treatment planning, help identify participant samples for research studies, and facilitate communication. Whether a diagnostic classification scheme serves these purposes adequately is an empirical question to be answered with appropriately designed research studies. The availability of solid conceptual and research foundations for psychodynamically based assessment and treatment methods may enhance the likelihood that a psychodynamically informed classification scheme will prove effective, but the reliability and validity of the scheme must be established in their own right.Issues of Reliability and Validity 041b061a72