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Introduction and Background
PART I of IV
By: Birgit Wolz, Ph.D.
1. INTRODUCTION
2. HISTORY OF DIAGNOSTIC MANUALS
DSM and ICD
* DSM-I and ICD-6
* DSM-II
* DSM III and ICD-9
* DSM-IV
* The DSM in the Future
PDM
3. THE PDM RESPONDS TO
PROBLEMS WITH THE DSM
Concerns with the DSM
* Complexity of Mental Functioning
* Reification versus Describing the
Whole Person
* Inconsistent Traits and Behaviors
* Subjective Experiences
* Subclinical Phenomena
* Other Concerns
Goals of the PDM
* Rejuvenate Psychoanalytic
Practices
* Serve Different Purposes than
the DSM
* Remedy Some of the Limitations
and Shortfalls of the DSM and
the ICD
* Advocate for a Comprehensive
Approach
For many decades, mental health providers have used the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the prime reference source for diagnosing mental illness. This manual is based on the assumption that people’s symptoms are the most reliable way to classify their mental troubles, and does not speculate about internal thoughts or unconscious assumptions, which some researchers say are all but impossible to scientifically standardize. (Carey, 2006)
When psychologists have written about diagnostic classification, they have generally taken a somewhat critical stance to the American Psychiatric Association’s DSM. In the last few decades the divide in the USA between psychotherapists, who generally have degrees in clinical psychology, social work, or counseling, and psychiatrists seem entrenched. (Perring, 2003) When there are antagonisms between these disciplines, psychiatrists may accuse psychologists of talking for weeks without actually helping the patient, while psychologists accuse psychiatrists of using a reductionist medical model that simply sees the patient as a collection of symptoms. The average time a patient spends talking with a psychiatrist to get a refill of medication is relatively short. In contrast, psychologists and counselors normally talk to patients once a week for 45-50 minutes, sometimes for a few weeks, sometimes for several months, or occasionally for years. They tend to get a detailed picture of the patient’s whole life and the complexities of their relationships with other people. (American Psychological Association, 2004)
But the two sides are not always so neatly separated. In the last twenty years, many psychotherapists have largely come to accept that psychotropic medications can be helpful to clients (the terms, clients and patients are use interchangeably in this course), and may even help the process of therapy. On the other side, there are many psychiatrists who believe that psychotherapy is a very important mode of treatment for a wide array of mental disorders, and that it is often essential to help the patient gain psychological insight into his or her problems and reach a new perspective. Psychologists have come to realize that since the reimbursement side of the mental health profession is dominated by the diagnostic codes of DSM, they have to live with it and the best way to make improvements to the classification system is through giving careful constructive criticism and conducting research. (Perring, 2003) Creating the complementary Psychodynamic Diagnostic Manual (PDM), in which such research is described on more than 300 pages, is another attempt to help clinicians understand the extend and the psychological roots of mental suffering.
Within a period of 18 months, a collaborative task force, which was appointed by a coalition of organizations representing psychoanalytically oriented therapists, completed a diagnostic manual of its own, the PDM. This manual is designed to complement the DSM and ICD (International Statistical Classification of Diseases) efforts of the past 30 years in cataloguing symptoms. Following a multi-dimensional approach, the PDM explores personality patterns and disorders, mental functioning and manifest symptoms. The manual emphasizes individual personality patterns, which are found in many people but which qualify as disorders only at the extremes. It characterizes the whole person–the depth as well as the surface of emotional, cognitive, and social functioning of an individual in order to promote deeper understanding. Individual variations as well as commonalities are emphasized. Therefore the new classification allows a clinician to look in detail at each of the client’s capacities. The PDM incorporates possible etiologies, case histories, and implications for treatment into the description of personality patterns and symptoms.
The PDM is based on current neuroscience, treatment outcome studies, and other empirical investigations, as well as psychoanalytic theory. The manual covers all ages from infancy and early childhood through adulthood and old age.
This course will only focus on the section of the PDM, which describes adult mental health disorders. The following text introduces the psychodynamic manual by explaining its evolution in the context of other diagnostic manuals before giving an overview over the content of the new manual in the following sequence:
2. HISTORY OF DIAGNOSTIC MANUALS
DSM and ICD
Although mental disorders have been classified throughout the history of medicine, there has been little agreement on what should be considered a mental disorder and what is the optimal method of their organization. “Many nomenclatures that have been developed during the past two millennia have differed in their relative emphasis on phenomenology, etiology, and course as defining features.” (American Psychiatric Association, 2000, p. xxiv).
In the United States a classification of mental disorders was first developed in the 19th century because of a need to collect statistical information in the census. At the beginning of the 20th century more attention was devoted to developing a system that had a more clinical utility. In order to include psychophysiological, personality, and acute disorders of World War II veterans, the U.S. Army and Veterans Administration developed a broader categorization. When the World Health Organization, contemporaneously, included a section for mental disorders for the first time, the new ICD-6 heavily influenced by the Veteran Administration’s nomenclature.
The ICD-6 was considered unacceptable by most countries, including the U.S., because of its heavy reliance on unproven etiological concepts (First, Tasman, 2004). In the United States, there were 5 competing systems. To lessen the confusion, APA’s (American Psychiatric Association) Committee on Nomenclature and Statistics began work on the first edition of the DSM. The final version of the DSM-I, which assigned 3 categories based on lists of symptoms, and with 106 diagnoses, was approved by a vote of the APA membership and published in 1952. It was the first official manual of mental disorders in the United States that focused on clinical utility. “The use of the term reaction throughout DSM-I reflected the influence of Adolf Meyer’s psychobiological view that mental disorders represent reactions of the personality to psychological, social, and biological factors.” (American Psychiatric Association, 2000, p. xxv).
The DSM-II with 11 major categories, 185 diagnoses, and 92 pages was published in 1968 to further facilitate communication among professionals. Like the DSM-I, it retained many etiological concepts but eliminated the term reaction. Both of these editions were strongly influenced by a psychodynamic approach, and therefore provided no sharp distinction between normal and abnormal. Mental disorders were considered reactions to environmental events, as they exist on a continuum of behavior. Consequently, everyone is more or less abnormal. A person with more severe abnormalities has more severe difficulties with functioning. The classificatory structure in these two editions of the DSM was rooted in a distinction between two poles of mental disorder, psychosis and neurosis. A psychosis was a severe mental disorder characterized by a disconnection from reality (hallucinations and delusions). A neurosis, however, was a milder mental disorder characterized by distortions of reality, but not a complete break with reality (anxiety and depression).
The DSM-I and the DSM-II were widely criticized for their lack of empirical basis, reliability, validity, and detailed description. (Blashfield, 1998; Kirk & Kutchins, 1994). Many psychiatrists were concerned about the implicit medical model, stating that it was inappropriate because the cause of most disorders was unknown. Among the most noted examples of controversial diagnoses was the classifying of homosexuality as a mental disorder. This classification was removed by vote of the APA in 1973 after various gay activists groups demonstrated at APA meetings for three years.
After reviewing the early drafts of the ICD-9, the APA decided to publish the DSM-III (American Psychiatric Association, 1980) in 1980 because of concerns that the international nature of the ICD-9 might result in inconsistent terminology and definitions and that the sub-typing was inadequate for clinical and research use. Largely because the primary function of the ICD-9 was to facilitate health statistics, it did not include diagnostic criteria or a multiaxal system. The DSM was intended for use by mental health professionals, third party payers, and in research and administration. On 482 pages the DSM-III contained now 265 diagnoses. This edition presented a major paradigm shift from the psychodynamic view and the etiologically based frameworks of the DSM-I and the DSM-II, to a biopsychological model as the primary approach. This methodological innovation introduced a clear distinction between normal and abnormal. Disorders were defined by the use of explicit diagnostic criteria and separated by developmental and personality disorders (Axis II), physical disorders (Axis III), stressors (Axis IV), and level of adaptive functioning (Axis V) from the presenting diagnosis (Axis I). The DSM became atheoretical since it had no preferred etiology for mental disorders. The new descriptive approach was meant to facilitate communication among mental health professionals operating from various theoretical orientations. (First, Tasman 2004). The dissatisfaction with the lack of specificity with the ICD-9 resulted in a modification of this manual for the use in the United States: the ICD-9-CM (for Clinical Modification).
Because of several inconsistencies in the system and a number of instances in which criteria were not entirely clear, the DSM-III-R (American Psychiatric Association, 1987) was published in 1987 with substantive corrections and revisions and 297 diagnoses. Six new categories were deleted while others, such as Trichotillomania, were added.
The DSM-IV (American Psychiatric Association, 1994) was timed for publication in 1994 in order to coincide with the publication of the ICD-10 in 1992. The most significant change in this issue was the process in which the DSM-III-R was revised to produce the DSM-IV (Widiger et al., 1991). Prior revisions were mostly guided by expert consensus. Their decisions were subject to potential biases. “In contrast, whenever possible, DSM-IV decisions were based on systematic review of the then current empirical database.” (First & Tasman, 2004, p. 6) The method used to establish an empirical basis was divided into three stages:
1) comprehensive and systematic reviews of the published literature, based on about 150 questions about most conserving considerations,
2) approximately 40 reanalyzes of previously compiled data sets,
3) 12 issue-focused field trials at more than 70 sites with more than 6,000 patients. (American Psychiatric Association, 2000; Frances, Mack, Ross, & First, 2000).
A summary of the results of this review process as well as the rationale for the changes in the DSM-IV was published in the four-volume DSM-IV Sourcebook (Widiger et al. 1994, 1996, 1997, 1998). On 886 pages with 365 Diagnoses, the DSM-IV offered detailed information about each disorder, including essential and associated features; presence, course, and familial pattern; differential diagnosis; and age, gender, and culture.
Given that no anticipated date for commencing work on the ICD-11, there is no externally imposed time frame for the DSM-V. Undertaking an extensive revision of the classification relatively frequently was disruptive to researchers and not necessarily justified by the pace of psychiatric research. (Zimmerman et al., 1991) Therefore it was decided that the interval between the DSM-IV and the next revision would be extended from 7 to at least 16 years. But the DSM-IV was based on a literature review that extended only to mid-1992. To provide continuity and educational value, changes to the text were made on the basis of a comprehensive review of the literature relevant to the text categories that was published since 1992. These changes manifested in the DSM-IV-TR (for Text Revision) (American Psychiatric Association, 2000), which was published in 2000 with 374 diagnoses. Some factual errors were also corrected and the ICD-9-CM was updated.
The publication of the DSM-V is tentatively scheduled for 2011. Some suggest that it might become more descriptive with the removal of all etiological implications, even the phrase “due to a General Medical Condition.” (Brendel, 2001). Others talk about developing an etiologically based scientifically sound classification system. A preliminary research–planning process has been initiated to stimulate research and devise a research agenda that would facilitate the integration of findings from animal studies, genetics, neuroscience, epidemiology, clinical research, and cross-cultural and clinical services research. (Regier et al., 2002)
HIPAA regulations mandate the use of the ICD rather than the DSM, which might put into question whether the DSM has a future. (Zur, 2005)
PDM
Depth psychology has a long history of examining overall human functioning in a searching and comprehensive way. But the diagnostic precision and usefulness of psychodynamic approaches have been compromised by at least two problems. First, until fairly recently, psychoanalytic accounts of mental processes have been expressed in competing theories and metaphors. These attempts to capture the range and subtlety of human experience have, at times, inspired more disagreement and controversy than consensus. Second, there has been difficulty distinguishing between speculative constructs and phenomena that can be observed or reasonably inferred. While the tradition of descriptive psychiatry has a tendency to reify “disorder” categories, the psychoanalytic tradition had tended to reify theoretical constructs. (PDM Task Force, 2006)
Psychodynamically-based systems highlight the processes that contribute to emotional and social functioning. Earlier psychodynamic theories had speculated about etiological factors. As in medicine, however, clinicians and researchers quickly learned that the etiologies of psychological disorders are more complex than initial observations and theory had suggested. Consequently, psychodynamic models have now moved toward functional understanding of psychopathologies, with the expectation that such understanding will guide the identification of etiological patterns.
In recent years empirical methods to quantify and analyze complex mental phenomena have been developed. Therefore depth psychology has been able to offer clear operational criteria for a more comprehensive range of human social and emotional conditions (see (Lingiardi, Shedler, et al. 2005, and in Part III of the PDM essays by Blatt, Dahlbender, Westen, Shedler). Outcome studies point to the importance of dealing with the full complexity of emotional and social patterns. Reliable ways to measure complex patterns of personality, emotion, and interpersonal processes that constitute the active ingredients of the psychotherapeutic relationship have been developed in recent years. Research (e.g. Norcross 2002; Wampold 2001) has presented evidence that treatments that focus on isolated symptoms or behaviors (rather than personality, emotional, and interpersonal patterns) are not effective in sustaining even narrowly defined changes.
Many psychotherapists believe that the DSM is comprehensive but shallow, ultimately too superficial to capture the complexity of human motivation and the depth of emotional pain. They desire some discussion of these dimensions, some guide to understanding the human stories and deeper causes behind the checklists of symptoms. (Carey, 2006) In an effort to provide this context, a task force representing the major national and international psychoanalytic organizations completed the PDM. These organizations include the American Psychoanalytic Association, the International Psychoanalytical Association, the Division of Psychoanalysis of the American Psychological Association, the American Academy of Psychoanalysis, and the National Membership Committee on Psychoanalysis in Clinical Social Work. A big number of people served on sub-committees and helped bring the project to successful completion. (Hanlon, 2006)
The PDM “systematically describes:
3. THE PDM RESPONDS TO PROBLEMS WITH THE DSM
Concerns with the DSM
The DSM treats personality disorders as discrete, mutually exclusive entities rather than complex and inevitably overlapping combinations. “In many empirical critiques of the DSM Personality Disorders section, writers have lamented the fact that when a patient meets the criteria for one personality disorder, he or she often meets the criteria for one or more others.”(PDM Task Force, 2006, p. 21)
Mental functioning, whether optimal or compromised, is highly complex. Therefore, mental health in general as well as psychopathology involve many subtle features of human functioning, including affect tolerance, regulation, and expression; coping strategies and defenses; capacities for understanding self and others; and quality of relationships. By ignoring mental complexity, we ignore the very phenomena of concern because mental complexity defines our most human qualities.
Mental health professionals may have uncritically and prematurely adopted methods from other sciences instead of developing empirical procedures appropriate to the complexity of the data in our field. Consequently the whole person has become less visible behind the various disorder constructs in the DSM on which researchers can find agreement. (PDM Task Force, 2006)
An unintended consequence of this phenomenon is an increasing antagonism between researchers and clinicians. The primary consumers of the DSM-IV-TR are clinicians, who frequently consider this manual artificial or irrelevant to treatment decisions. In clinical practice, we usually try to get the “gist” of a client’s pathology. If a client feels depressed, has trouble sleeping, loses weight, and thinks about suicide, most of us would diagnose major depression, whether or not the client has three, four or five of the criteria for this diagnosis. Researchers tend to view clinicians as sloppy diagnosticians who do not use structured interviews, which, in fact now provide the only way to make reliable diagnoses because accurate diagnosis requires knowing exactly how many criteria a client meets. Clinicians often view researchers as symptomatic bean counters, when they require knowing exactly how long and how often a client has had symptoms of major depression. Clients often cannot answer accurately and the precise answer may not even be relevant to treatment planning. “The real question, then, pertains to the incremental validity of counting symptoms over prototype matching—particularly if clinicians were to learn criterion sets as prototypes rather than as sets of isolated symptoms to be counted.”(Westen, et al., 2004, p. 224).
Ironically, emerging evidence suggests that simplifying mental health phenomena in the service of attaining consistency of description (reliability) and capacity to evaluate treatment empirically (validity) while refining the symptom-counting algorithms may have compromised the goal of a more scientifically sound understanding of psychopathology. Allen Frances, Chair of the DSM-IV American Psychiatric Association Task Force, recently acknowledged that the desired reliability has not been obtained. (Spiegel, 2005)
In recent editions of the DSM, personality disorders are also generally described by observable traits. This approach is inconsistent with longstanding clinical observations and much current research, which shows that traits often coexist with their seeming opposites. (PDM Task Force, 2006) People typically show characteristics that express both polarities of a certain character dimensions (McWilliams, 1994). This idea is succinctly captured by Philip Stater:
“Generations of humanists have exited themselves and their readers by showing “contradictions” and “paradoxes” in some real or fictional person’s character, simply because a trait and its opposite coexisted in the same person. But in fact traits and its opposites always coexist if the traits are of any intensity, and the whole tradition of ferreting out paradoxes of character depends upon psychological naïveté of the reader for its impact.” (Philip Stater, 1970, pp. 3n-4n)
The PDM points to clinical experience and research findings (e.g., Silberschatz, 2005; Weiss, 1993; Weiss et al., 1986), which suggests that particular unconscious beliefs can produce behaviors that may appear inconsistent, but may amount to contrasting ways of expressing the same central issue. For example, an obsessive-compulsive woman, unconsciously preoccupied with the issue of control of aggression, may be either compulsively prompt or regularly late, neat in most areas yet messy in some, compliant or stubborn, depending on how, at the moment, she tries to solve the problem of feeling controlled by others. Or people with conflicts about closeness can get upset by both closeness and distance. (PDM Task Force, 2006)
All approaches to assessment and treatment rely at least in part on a person’s report of their thoughts, feelings, and behaviors. Questions can be: Does the person feel depressed? Anxious? Does the he or she hear voices? Think about suicide? In the most recent versions of the DSM and ICD systems some of the more subtle features of many basic symptom patterns have been lost. Most notably, despite the fact that it is usually the patient’s subjective suffering that brings him or her to treatment, a full description of the patient’s internal experience of the symptoms is often absent. The underlying assumptions for the DSM is that with more elaborated depictions, we can make more progress on understanding naturally occurring patterns.
Westen et al. (2004) point out that a growing body of research suggests that subclinical cases are at least as prevalent as clinical cases of many if not most disorders. Roughly 60% of clients treated for enduring, maladaptive personality patterns cannot be diagnosed on Axis II in the DSM (Westen & Arkowitz-Westen, 1998). Nevertheless, these clients suffer from clinically significant problems recognized and treated by clinicians of all theoretical orientations, ranging from difficulties regulating self-esteem to repetitive interpersonal patterns that interfere with relational functioning and satisfaction.
Zur & Nordmarken (2006), summarize the critique of the DSM in the following way:
Goals of the PDM
The PDM has several stated goals outline in the manual itself as well as additional unstated goals.
Psychoanalysis has suffered an almost deadly blow by managed care and other professional development in the field since the 1980’s. The focus on symptoms reduction, protocol-based, cost-saving and short-term treatments has, obviously, eliminated psychoanalysis and long term psychodynamic treatments as approved and reimbursed services by managed care companies. Even before managed care took center stage psychoanalysis reputation has been increasingly dampened. As depicted in Woody Allen’s movies and New Yorker’s cartoons, psychoanalysis has earned the reputation for being outdated, ineffective, pretentious and expensive. The PDM is partly intended to reassert the value of psychoanalytic thinking before it is lost for good. (Carey, 2006)
While the DSM is geared to the reliability of its designated categories for
the taxonomy of the PDM is geared toward the central purpose of
for psychodynamic therapy and other therapies that attempt to address the full range and depth of human cognitive, emotional, and behavioral functioning.
1. Avoiding Exclusive Reliance of Symptoms and Arbitrarily Made up Patterns
Paul McHugh (2005) points out that medicine has moved beyond simply describing symptoms to categorizing disorders according to the nature of the impairment. Therefore he recommends that the classification of mental disorders also reflect the quality and degree of functional impairment.
As in the development of many fields, an effort to describe symptom patterns began with pioneers who made meticulous observations and discovered common clusters of patient complaints, symptoms, and behaviors. This approach was also taken in order to increase the reliability of the diagnostic manual when the DSM-III was published in 1980. Based on empirical studies, fine distinctions were made that combined isolated symptoms to diagnose a person. Subsequent editions of the DSM continued with this tendency to define mental problems primarily on the basis of observable symptoms, behaviors, and traits, with overall personality functioning and levels of adaptation noted only secondarily. (Westen, 2004) As a result, patterns and diagnosis criteria have continuously changed, redefined and reformulated over the years. Some have asserted that these changes were primarily in response to newly develop and available medications rather than to new understanding of the nature of mental illnesses.
Because the authors of the DSM intended their manual to be atheoretical, they built it around overtly observable clusters of symptoms and attributes without any necessary imputations of meaning. The authors of the PDM emphasize that they appreciate the intent of the DSM and ICD classifications to build a strong foundation for the diagnosis and treatment of psychopathology by moving in the direction of specifying discrete, externally observable disorders. They also believe that it is time now to take a look at the phenomena with which mental health professionals regularly deal and adapt the methods to these phenomena rather than vice versa (see Part III, review essays by Blatt, Shedler, Westen, 2006).
The new manual attempts to do this by employing many of the descriptions of symptoms and patterns of symptoms used in the currently prevailing taxonomies, the DSM-IV-TR and ICD-10, systems that represent a valuable history of careful observation and description. The authors of the PDM intend to portray the nature of patients’ internal experience rather than view them in terms of their symptoms. Therefore they set their nosology explicitly within a psychoanalytic framework that focuses on the full range and depth of human mental functioning. They intend to ascribe meanings, as best they can discern and formulate them, to the observed and described phenomena; i.e., symptoms, behaviors, traits, affects, attitudes, thoughts, fantasies, and so on. The authors of the PDM state that the DSM is a taxonomy of diseases or disorders of function while theirs is a taxonomy of people.
Therefore the PDM adds a new perspective to existing diagnostic systems. “In addition to considering symptom patterns, it enables clinicians to describe and categorize personality patterns, related social and emotional capacities, unique mental profiles, and personal experiences of symptoms.” (PDM Task Force, 2006) This allows the manual to provide “a framework for improving comprehensive treatment approaches and understanding both the biological and psychological origins of mental health and illness.” (PDM Task Force, 2006)
2. Consideration of Overlapping Symptom Patterns
“Since DSM categories consist of distinct clusters of symptoms and attributes, which frequently overlap in part with the clusters of symptoms and attributes of other DSM categories, an individual’s difficulties can then be put into two (or more) illness categories, called comorbidity, implying that the person is suffering from two different illnesses.” (PDM Task Force, 2006, pp. 13,14) In the DSM and ICD systems, the use of fixed definitions forces an artificial separation of conditions that are frequently related. In these diagnostic systems, the use of fixed definitions and strict criteria (e.g., four out of six, not three out of six, items on a diagnostic checklist) creates these artificial separations. They might be etiologically, phenomenologically, or contextually interconnected though. As if these discrete problems coexist more or less accidentally in the same person (much as a sinus infection and a broken toe might coexist), symptoms are described as co-morbid conditions. These assumptions are rarely justified by compelling data such as clear genetic, biochemical, and neurophysiological distinctions between syndromes. In spite of much effort that the creators of the DSM put into research, the cut-off criteria for diagnoses were frequently still the results of arbitrary decisions of committees rather than conclusions drawn from scientific evidence. The nosology of the PDM is built, for each individual, on the conception of a single coherent and meaningful character organization, which can, of course, represent, uniquely for that individual, a particular admixture of the defining characteristics of two (or more) character organizations and symptom patterns.
3. Inclusion of the Complexities of the Whole Person
The PDM points out that personality types are complex. For example, all personality disorders involve self-defeating behavior—otherwise they would not be considered disorders. Therefore they all have masochistic aspects by definition. This complexity needs to be understood because at different points in treatment, varying aspects of a client’s personality come into sharp focus.
Psychodynamically oriented clinicians tend to pay careful attention to the whole person and the therapeutic relationship, noting interpersonal patterns, feelings, coping strategies, and other indicators of mental processes. Although under-researched for decades, several recent meta-analyses and reviews reveal evidence of the efficacy of psychodynamically based treatments (see Part III of the PDM review essays by Fonagy and Leichsenring, as well as Hilsenroth, Ackerman, et al., 2003; Leichsenring & Leibing 2003). Process-oriented research, in particular, has demonstrated that essential characteristics of the psychotherapeutic relationship as conceptualized by psychodynamic models, such as the working alliance, transference phenomena, and stable characteristics of patient and therapist, are more predictive of outcome than any designated treatment approach per se.
The authors of the PDM consider it vital to embrace the tension between the goals of capturing the complexity of clinical phenomena (functional understanding) and developing criteria that can be reliably judged and employed in research. They introduce a step-wise approach in which complexity and clinical usefulness influence operational definitions and can inform research.
“A scientifically based system begins with accurate recognition and description of complex clinical phenomena and builds gradually toward empirical validation. Relying on oversimplification and favoring what is measurable over what is meaningful do not operate in the service of good science.” (PDM Task Force, 2006)
While DSM categories are constructed to put symptoms and attributes that people have in common into the same diagnostic compartment, the PDM tries to elucidate through dimensional categorizations what makes each individual unique and recognizably different from every other person in the world.
This systematic way to describe individuals that is faithful to their complexity is designed to be helpful in planning appropriate treatments.
4. Avoidance of Reification to Describe the Whole Person
The PDM avoids capitalization and initials. The authors try to resist a tendency that has crept into the mental health field, under the influence of pharmaceutical and insurance companies, to reify complex syndromes, implying that they exist as discernible “things” rather than as interrelated patterns of cognition, emotion, and behavior that are frequently seen in clinical practice. They emphasize that people whose personalities are problematic do not have something comparable to a disease, nor does a personality completely define who they are.
5. Inclusion of Opposing Traits and Behaviors
The Psychodynamic Diagnostic Manual tries to represent various conditions more organically, given that seemingly opposing traits serving the same purpose can coexist within the same personality type. A paranoid person, for example, may alternate between feeling tempted to attack others and being terrified of attack by others. The manual takes a different approach than the DSM by emphasizing that personality distinctions have more to do with differences in underlying themes, schemas, or conflicts than with differences in traits, which may represent particular expressions of unconscious preoccupations.
6. Inclusion of the Subjective Perspective
The PDM attempts to remedy the concern with the DSM that despite the fact that it is usually the patients’ subjective suffering that brings them to treatment, an articulation and/or a description of the patient’s subjective experience of the symptoms is often absent. The psychodynamic manual takes on a different perspective by considering subjective experiences in the description of the intricacies of a clients’ overall functioning, their ways of engaging in the therapeutic process, and their symptom patterns.
“Despite the fact that mental health professionals are always inevitably dealing with the elusive world of subjectivity, we require a fuller description of the patient’s internal life to do justice to understanding his or her distinctive experience. We are hoping that with more elaborated depictions, we can make more progress on understanding naturally occurring patterns. The rapidly advancing neuroscience field, including genetic studies, can only be as useful as our understanding of the naturally occurring basic patterns of mental health and pathology. We cannot expect our colleagues in genetics to separate the apples and oranges for us. If we do not properly separate them, we will continue to frustrate the search for underlying biological pathways and common experiential etiologies.”(PDM Task Force, 2006, website)
7. Inclusion of Healthy Patterns
The authors of the PDM explain their rational as follows:
“A clinically useful classification of mental health disorders must begin with an understanding of healthy mental processes. Mental health comprises more than simply the absence of symptoms. It involves a person’s overall mental functioning, including relationships; emotional depth, range, and regulation; coping capacities; and self-observing abilities. Just as healthy cardiac functioning cannot be defined simply as an absence of chest pain, healthy mental functioning is more than the absence of observable symptoms of psychopathology. It involves the full range of human cognitive, emotional, and behavioral capacities . … There is increasing evidence, however, that both mental health and psychopathology involve many subtle features of human functioning, including affect tolerance, regulation, and expression; coping strategies and defenses; capacities for understanding self and others; and quality of relationships. Mounting evidence from neuroscience and developmental studies supports the position that mental functioning, whether optimal or compromised, is highly complex. To ignore mental complexity is to ignore the very phenomena of concern. After all, our mental complexity defines our most human qualities.” (PDM Task Force, 2006, website)
Unlike the other manuals, which focus exclusively on pathology, the PDM describe 15 personality patterns as a continuum ranging from a description of a predominant character organization operating within a “normal” range of functioning through a neurotic level of functioning, and beyond—in most instances—onto the most severe extremes of borderline functioning. In this way, the new manual addresses the above-mentioned concern about the fact that the DSM doesn’t allow for a diagnosis of many subclinical phenomena.
8. Less Pathologizing
The authors of the PDM are particularly uncomfortable with the categorical depiction of as sexual and gender identity phenomena as “disorders” in the DSM because they consider sexual inclinations and experiences as sufficiently diverse among human beings.
9. Inclusion of Etiological Factors
The PDM is attempts to remedy one of the most critical factors absent in the DSM, the etiological factors. The manual mentions the following thoughts about including etiology:
“Even in general medicine, instances in which etiological factors are fully understood are rare. Most commonly, we are at the level of functional rather than etiological explanation. Neoplastic disorders, for example, are often thought to be understood etiologically, but we are still searching for the causes of many malignancies, as we attempt to comprehend the relationship between genetic, environmental, and, in some instances, viral and other infectious processes. We are nonetheless able to describe various malignancies in detail in terms of their functional characteristics. Both in general medicine and in mental health, progress in understanding the functional nature of disorders should eventually facilitate a greater understanding of etiological factors. Functional and etiological understanding together provides the fullest basis for diagnosis and treatment.” (PDM Task Force, 2006)
10. Inclusion of Implications for Treatment
Unlike the DSM, the PDM offers insights and guidelines for therapists as it describes how clients with a certain personality pattern and/or a certain severity of personality disorder respond to specific treatment approaches, behave in therapy, and elicit countertransference reactions.
11. Inclusion of Case Descriptions
Unlike the DSM, which describes cases only in a separate casebook, the PDM incorporates case histories into the manual.
The new manual is one more round in the debate regarding Evidence Based or Protocol Based Treatment.
“In addition, we are learning that when therapists apply manualized treatments to selected symptom clusters without addressing the complex person who experiences the symptoms and without attending to the therapeutic relationship that supports the treatment, therapeutic results are short-lived and rates of remission are high (Westen, Novotny, et al., 2004; Hilsenroth, Ackerman, et al., 2003; Baumann, Hilsenroth, et al., 2001; Stiles, Agnew-Davies, et al., 1998). A recent meta-analysis of outcomes of manualized treatments for targeted symptoms found that symptomatic improvement often did not persist and that fundamental psychological capacities involving the depth and range of relationships, feelings, and coping strategies did not show evidence of long-term change. In a number of studies these critical areas were not even measured (Westen, Novotny et al., 2004).” (PDM Task Force, 2006)