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Division of Psychoanalysis (Division 39)
American Psychological Association

Psychodynamic Diagnostic Manual Reviewed in The New York Times

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For Therapy, a New Guide With a Touch of Personality
New York Times, Jan. 24, 2006

The encyclopedia of mental disorders known as the Diagnostic and Statistical Manual is built on a principle that many therapists find simplistic: that people's symptoms are the most reliable way to classify their mental troubles.

The manual, often called the D.S.M., does not speculate about internal thoughts or unconscious assumptions, which researchers say are all but impossible to scientifically standardize.

The result, many psychotherapists believe, is a document that is comprehensive but shallow, ultimately too superficial to capture the complexity of human motivation, the depth of emotional pain. Students, clinicians and especially patients yearn for some discussion of these dimensions, they say, some guide to understanding the human stories behind the checklists of symptoms for everything from depression to agoraphobia.

Now, in an effort to provide more of this context, a coalition of organizations representing psychoanalytically oriented therapists has produced a diagnostic manual of its own. Unlike most psychiatrists, psychoanalysts focus their efforts on understanding the meaning and the psychological roots of mental suffering, rather than on diagnosing mental disorders and treating them with drugs or less intensive methods of talk therapy.

The new guidebook, unveiled Saturday at the annual meeting of the American Psychoanalytic Association, is modeled on the standard diagnostic manual in its format and its title, the Psychodynamic Diagnostic Manual. But it emphasizes the importance of individual personality patterns, like masochistic, dependent or depressive types, which are found in many people but which qualify as full-blown disorders only at the extremes.

The manual incorporates several new elements, like case histories and brief psychic X-rays into what many people who suffer from mental disorders are feeling. Four other groups, including the International Psychoanalytic Association and the American Psychological Association, collaborated on the manual. A working draft of it was provided to The New York Times.

"It is meant to be a complementary" to the psychiatric association's manual, said Dr. Stanley Greenspan, a professor of psychiatry and pediatrics at George Washington University medical school in Washington, who proposed the new guide and coordinated the writing.

"We wanted to say to therapists: find out and discover the nature of the internal experience before you pigeonhole a person based on symptoms only," Dr. Greenspan said.

Once the personality patterns are understood, he added, "you would see if the person was interested in exploring broader goals for himself, looking at these patterns through therapy."

The D.S.M., he said, offers little that is relevant to guide such therapy.

Few expect the new manual to have much effect on the psychiatric association's diagnostic franchise. The 1980 version of the D.S.M. laid a scientific foundation for the field, which had previously based treatment decisions on Freudian theory and the experience of individual therapists. Standardized diagnoses gave researchers a basis for testing many drug treatments and short-term talk therapies popular today.

Dr. Robert Spitzer, a professor of psychiatry at Columbia and the principal architect of the 1980 D.S.M., said that the new manual was impressive but that the authors "now have to demonstrate that it's reliable and feasible to use clinically."

"That's not going to be easy; it's very complex," Dr. Spitzer said.

The new guidebook, some experts said, is partly intended to reassert the value of psychoanalytic thinking before it is lost for good. "Psychoanalysts have recognized that they are getting more and more outside the mainstream," said Dr. Drew Westen, a professor of psychiatry and psychology at Emory University in Atlanta. "And this project is an attempt to say, Wait, there is something that this tradition really has to offer."

The most striking proposal in the new manual is its insistence that personality be evaluated first, and symptoms considered secondary. The first section of the book describes 14 different personality patterns. It also restores others that were dropped from recent editions of the D.S.M., like sadistic, masochistic and passive-aggressive personality patterns. "The D.S.M. is a taxonomy of diseases or disorders of function. Ours is a taxonomy of people," the new manual declares.

Drawing on personality research, the new guidebook identifies two types of depression. In one, people begin to feel exceedingly weak and helpless, say, after a breakup, to the extent that they wish "to be soothed, helped, fed and protected."

These types of people have difficulty expressing anger for fear of losing any relationship, especially the connection with the therapist. Their despair reflects in part a deep fear of abandonment.

The other type of depression develops in people who are far more focused on themselves than on others, and become severely self-critical.

They feel that they have failed to meet expectations and that they do not deserve the love or approval of others, and they lose faith in their ability to make good decisions. Fantasies of humiliation are common. The intensity of their thoughts "may be disturbing by itself," the manual reads.

Distinguishing these underlying patterns may be at least as important in planning treatment as describing symptoms, if not more so, psychoanalysts say.

Either type of person may benefit from an antidepressant, but to effect more fundamental and lasting change, both types may have to address the source of their habitual self-punishment or neediness, whether that means exploring early family experience, everyday conscious assumptions or some combination of the two through psychotherapy.

"Many therapists out there already are familiar with these ideas, whether they use family system approaches, or short-term cognitive therapies, but we wanted to provide some guide to the process," said Dr. Nancy McWilliams, a psychologist at Rutgers University who wrote much of the new manual.

For all its references to new research, the psychodynamic manual still relies on many observations by Freud. It traces the source of many anxiety disorders to Freud's "four basic danger situations," described in 1926: 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.

"I think it's a wonderful idea to broaden the scope of the current diagnostic manual, to give a sense of context, richness, and detail to the understanding of mental disorders," said Dr. Theodore Millon, dean and scientific director of the Institute for Advanced Studies in Personology and Psychopathology in Coral Gables, Fla., who read a summary of the new manual. But, he continued, if the manual is "too doctrinaire, too dependent on a single psychoanalytic viewpoint, that could be a problem; it would be seen as simply too narrow."

The new manual also incorporates case histories into the description of personality patterns and symptoms. (The D.S.M. casebook is separate.) Some are composites that do not seem to add much; others describe people who have sought therapy and whose stories have a human pulse.

One describes a 40-year-old lawyer whose career plateaued for reasons neither he nor his wife could pinpoint. He was a loyal friend, a devoted husband, a person often sought out for his clear, decisive advice.

But he "waits to be discovered as the expert," the manual says, and dithers when making decisions about his own life. A scuba diver, he daydreams about life as an undersea explorer. He fantasizes about "the one who got away," a woman from his past he felt he should have married.

Using the standard diagnostic manual, this man would probably receive a diagnosis of moderate depression and most likely get a prescription for an antidepressant to start, said Dr. Greenspan, who is familiar with the case. Using the new diagnostic manual, he is identified as having mildly compulsive, masochistic and self-critical tendencies that predispose him to passivity and feelings of worthlessness.

The manual leaves the case there: it is a guide to diagnosis, not treatment. The lawyer himself decided to pursue psychotherapy to address his basic personality patterns, and his mood and relationships began to improve, Dr. Greenspan said.

Whether the world's psychotherapists, or the public, will find the new manual helpful remains to be seen. But few experts doubt that there is an appetite for a guidebook that adds to the D.S.M..

"Honestly," Dr. McWilliams said, "most of the people who come in for therapy do so for a kind of sickness of the soul, or for some interpersonal disaster. It's very artificial to chop them up into these symptom syndromes."

News posted: Jan 31, 2006

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