|Publications: Book Reviews
Review of Psychodynamic Diagnostic Manual
Title: Psychodynamic Diagnostic Manual
Author: Weiner, Irving
Publisher: Alliance of Psychoanalytic Organizations
Reviewed By: PDM Task Force, PsycCRITIQUES December 13, 2006 Vol. 51 (50), Article 1
Please note: This review originally appeared in PsycCritiques, an online journal of APA, and is reprinter here with the permission of APA and the review author.
Enrichment of Diagnostic Classification
Mental health professionals and behavioral scientists have long been concerned with diagnostic classification. In clinical psychology, classification was heir to the formal study of individual differences, which began in the 1880s with Sir Francis Galtons establishment of a laboratory in London for studying psychophysical variations in performance and James McKean Cattells arrival as a research assistant in Wundts laboratory in Leipzig. Cattell persuaded Wundt, a nomothetic scientist who regarded differences among people as troublesome error variance, to allow him to study individual variations in reaction time, which he did for his doctoral dissertation. Cattells subsequent pursuit of measures for classifying individual differences led him to coin the term mental test and to be considered the father of psychological assessment (see Weiner, 2003).
Among psychiatrists, Emil Kraepelin was not the first to label mental disturbances, but he was a master systematizer whose classification of disorders in his Lehrbuch der Psychiatrie, published in nine editions between 1883 and 1927, served as a bible of descriptive diagnosis for at least two generations of psychiatrists. Kraepelins contributions were later memorialized by the common reference to the 1980 publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) as representing a “neo-Kraepelinian” emphasis in mental health science and practice. This appellation reflected that fact that diagnostic classification had fallen on hard times between the heyday of Kraepelins influence and a revival of interest in diagnosis that spurred the DSM-III effort.
Decline and Revival of Interest in Diagnostic Classification
Although it continued to have enthusiasts and defenders, diagnostic classification came under heavy attack during a roughly 30-year period beginning in the 1950s and extending through the 1970s, mainly in the form of behavioristic and humanistic perspectives that discouraged categorization of disorders. Skinnerian behaviorism, with its emphasis on what can be observed and its distaste for subjectivity and abstract inference, was keynoted clinically by the influential contributions of Wolpe (1958) and Eysenck (1961), who contended that disorders consist of their symptoms and are cured by removal of these symptoms. From this perspective, traditional diagnostic categories are abstract conceptualizations that serve little purpose and are more likely to interfere with effective intervention than facilitate it: “There is no neurosis underlying the symptom, but merely the symptom itself. Get rid of the symptom… and you have eliminated the neurosis” (Eysenck & Rachman, 1965, p. 10).
Humanistic perspectives in clinical work took their cue from Rogers (1951), who lodged his client-centered therapy in subjectivity and maintained that people can be understood only from their own vantage point and not on the basis of any external observations. Rogers regarded prior information about the nature and origins of a persons adjustment difficulties as unnecessary in initiating psychotherapy, and he expressed concern that determining a diagnosis can have the antitherapeutic effect of valuing the clinicians judgment over a patients self-perceptions. Rogerss dim view of diagnostic classification gained strong support from an emerging humanistic emphasis in psychology on the uniqueness of individual persons and their differences from each other, not their shared characteristics.
Perhaps most influential among the humanistic pioneers was Maslow (1962), who wrote, “I must approach a person as an individual unique and peculiar, the sole member of his class” (p. 10). Such firm commitment to idiography leaves little room for efforts to categorize people as belonging to a group who share a similar disorder. To make matters worse for diagnosticians, some psychologists who embraced humanistic perspectives decried classification as a dehumanizing procedure that strips people of their dignity and wrongfully entitles one person to pass judgment on another.
Psychology was not alone in its mid-20th-century rejection of diagnostic classification. Karl Menninger (1959), the long-time dean of psychiatric education in the United States, proposed a “unitary concept” according to which all mental illness is the same in quality and differs only in quantity. Menninger favored placing people on a continuum according to how relatively healthy or disturbed they are, with no need for traditional psychiatric labels, which he regarded as artificial and illusory: “I not only believe that no such disease as schizophrenia can be clearly defined or identified or proved to exist, but I also hold that there is no such thing as a psychosis or neurosis” (Menninger, 1959, p. 517).
In a similar vein, psychiatrist Thomas Szasz (1961, 1970) devoted a long and highly visible career to calling the notion of mental illness a myth. He castigated diagnostic classification for leading to erosion of personal responsibility (as in finding a criminal not guilty by reason of insanity) and for providing persons in authority a tool for abrogating human rights and depriving people of their liberty (as in involuntary commitment to a mental institution). Szasz saw schizophrenia as a particularly harmful and misleading term that was being used to fill a gap in scientific knowledge and as a label that would become obsolete when “the real facts” emerged (Szasz, 1961, 1970).
Over time, the influence of these extreme perspectives gave way to renewed recognition that diagnostic classification serves important purposes in clinical science and practice. Studies of the origin, characteristics, and course of psychological disorders require guidelines for designating persons as appropriate for inclusion in research samples of individuals with these disorders. Effective treatment planning calls for clinicians to assess the nature of prospective patients problems and felt needs, and adequate outcome evaluation depends on criteria for assessing individuals current diagnostic status and level of adjustment. Additionally, among the purposes it serves, a systematic and widely endorsed diagnostic classification scheme promotes clear communication among professionals and among informed members of the lay public as well.
With these considerations in mind, the American Psychiatric Association undertook the major effort to develop a generally accepted diagnostic classification scheme for mental disorders that resulted in the 1980 publication of the DSM-III. The DSM-III had been preceded by a DSM-I, published in 1952 (American Psychiatric Association, 1952), and a DSM-II, published in 1968 (American Psychiatric Association, 1968), but these were thin and imprecise manuals that did not function well in practice or gain wide acceptance. By contrast, the DSM-III and its successor volumes—DSM-III-R in 1987 (American Psychiatric Association, 1987), DSM-IV in 1994 (American Psychiatric Association, 1994), and DSM-IV-TR in 2000 (American Psychiatric Association, 2000)—are detailed compendia that have, for the most part, served commendably the purposes of diagnostic classification. They have provided a carefully delineated and commonly used basis for identifying participants in research studies; they have functioned as a guide for differential selection of treatment strategies; and they have increased the likelihood that persons talking about a disorder will be talking about the same disorder, whatever their training background, theoretical persuasion, or primary work setting.
As has frequently been pointed out, however, the DSM process and the DSM-IV-TR have some notable shortcomings (e.g., Beutler & Malik, 2002; Nathan & Langenbucher, 2003). These shortcomings include (a) having been developed solely on the basis of consensus among a group of clinicians, with insufficient attention to research reports; (b) containing categories that lack reliability and show considerable overlap, especially among the personality disorders; and (c) emphasizing categorical rather than dimensional diagnosis, with inadequate allowance for comorbidity and degree of disturbance. Psychodynamically oriented mental health professionals have additionally expressed concern that the symptom-based DSM classification scheme fosters treatment of disorders rather than treatment of people who happen to have some disorder.
Enter the Psychodynamic Diagnostic Manual (PDM)
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
The PDM and DSM manuals differ with respect to their treatment of reliability and validity. Regarding reliability, the DSM-III included the results of field trials for interrater agreement involving several hundred respondents, with kappa coefficients listed for its major categories. The DSM-IV refers to the collection of information on reliability in 12 field studies conducted at more than 70 sites and involving more than 6,000 participants. By contrast, there is no mention of field trials in the PDM and no information concerning interrater agreement in its use. It is reasonable to expect that the many PDM P axis and S axis categories, which closely resemble DSM Axis I and Axis II diagnoses, as well as the M axis, which parallels DSM Axis V, will show interrater reliabilities similar to those of their DSM counterparts. However, the greater complexity of the PDM, particularly with its numerous personality disorder categories, and the intended focus of the PDM on capturing unique features of the individual may combine to limit the reliability with which a full, three-axis PDM diagnosis can be coded. This speculation aside, the fact remains that there are no interrater agreement data in the PDM, and the reliability of the proposed classification scheme accordingly remains to be demonstrated.
With respect to validity, the DSM, as previously mentioned, has been criticized for having emerged from opinion rather than established fact and for representing a consensus of clinicians rather than a body of research. This is not to say that the DSM has failed to generate research support over the years or that its categories lack validation. However, the DSM itself does not present any evidence or reference any literature bearing on its validity. By contrast, the individual sections of Parts 1 and 2 of the PDM are heavily annotated and include long lists of references to relevant theoretical discussions and research studies. This literature does not directly validate the PDM classification, but the fact that the decision-making process of the PDM work groups was guided by conceptual frameworks and empirical findings enhances the likelihood that many of its component pieces can and will be validated. By virtue of this extensive citation of the literature, moreover, the PDM manual is a valuable reference source as well as a guide to diagnostic classification.
To the credit of the task force that created it, the PDM succeeds admirably in achieving its stated purpose, which was to complement the DSM with psychodynamically enriched and person-oriented descriptions of patterns of personality disorder, global functioning, and symptom formation. The text is systematically organized, clearly written, and extraordinarily informative with respect to motivational factors that commonly underlie the emergence of particular personality and symptomatic disorders and the ways persons with these disorders are likely to experience them. On the basis of its comprehensive coverage of mental disorders and its extensive reference to the literature, the manual is highly recommended reading at both the graduate student and the professional levels. For students, the PDM can serve in many respects as a basic or supplementary text that identifies for them the nature of diagnosable mental health conditions, directs them to relevant theoretical formulations and research findings, and encourages them to attend to the uniqueness of individuals and the importance of diagnosing and treating people, not disorders. For experienced clinicians, the elaborations of motivational and experiential aspects of mental disorders are likely to enhance their understanding of their patients and their ability to work effectively with them.
Despite the considerable value of the PDM text, however, it seems unlikely that the PDM classification scheme will be embraced as a replacement for the DSM. Aside from the fact that replacing the DSM was not its intended purpose, the PDM codification does not yet have the established reliability necessary to warrant its widespread adoption. As anticipated earlier in this review, the PDM seems likely to prove more valuable for its textual enrichment than for its proposed classification scheme. Whether the PDM will gain widespread endorsement as a complement to DSM descriptions is likely to depend on the results of appropriately designed research studies that examine (a) whether use of the PDM in conjunction with the DSM makes a difference in how therapists plan and conduct treatment for their patients and (b) whether reliance on the PDM promotes treatment progress and improves treatment outcome beyond what would have occurred following an evaluation based solely on the DSM.
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