Psychosomatics 49:178-179, April 2008
doi: 10.1176/appi.psy.49.2.178
© 2008 Academy of Psychosomatic Medicine
Psychodynamic Diagnostic Manual (PDM) PDM Task Force
Stanley I. Greenspan, M.D., Chair, Silver Spring, MD, Alliance of Psychoanalytic Organizations, 2006, 857 pages, ISBN 0-9767758-2-4 (paper); 0-9767758-1-6 (cloth)
Craig Lichtman, M.D., M.B.A.
In 1982, in "A Psychoanalyst-Liaison Psychiatrist’s Overview of DSM–III," Stanley Grossman, M.D. reviewed the then-recently-published DSM–III. As he stated, roughly 25 years ago, "while providing advances in many areas, it ignores psychodynamic causal factors, levels of developmental functioning, and the dynamic equilibrium that exists between symptoms and character, and fails to explain the spectrum of normal-to-pathologic reactions to stress.... It ...falls short in the area of Somatoform Disorders (some of which are neurotic disorders)...."
The recently published Psychodynamic Diagnostic Manual (PDM) appears to answer some of the concerns of Dr. Grossman and other psychoanalytically-trained consultation–liaison psychiatrists, such as myself. As is highlighted on the title page and in the Introduction, this manual was the result of "a collaborative effort of the American Psychoanalytic Association, the International Psychoanalytical Association, 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." It provides the reader with "a diagnostic framework that attempts to characterize an individual’s full range of functioning—the depth as well as the surface of emotional, cognitive, and social patterns.... The goal of the PDM is to complement the DSM and ICD efforts of the past 30 years in cataloguing symptoms by explicating the broad range of mental functioning."
The PDM is organized into three parts—Part I: Classification of Adult Mental Health Disorders; Part II: Classification of Child and Adolescent Mental Health Disorders; Part III: Conceptual and Research Formulations for a Psychodynamically-Based Classification System for Mental Health Disorders. Within Parts I and II, the PDM uses a multidimensional approach, which is similar to and an expansion upon the DSM multi-axial system.
Part I includes the P Axis (Personality Patterns and Disorders), the M Axis (Profile of Mental Functioning), the S Axis (Symptom Patterns: The Subjective Experience), and ends with a section containing case illustrations. The P Axis elaborates on types of personality disorders, many of which are similar to those in DSM–IV-TR. But instead of emphasizing categories based on overtly observable clusters of symptoms and attributes, the PDM emphasizes descriptions of levels of personality organization within each Personality Disorder category. Each diagnostic category ends with a schematic summary according to the following outline.
- Contributing constitutional–maturational patterns
- Central tension/preoccupation
- Central affects
- Characteristic pathogenic belief about self
- Characteristic pathogenic belief about others
- Central ways of defending
The M Axis offers a microscopic view of mental life by providing illustrative descriptions of ranges and adequacy of functioning within each of the capacities listed below and then offers a table to consolidate the results.
- Capacity for regulation, attention, and learning
- Capacity for relationships and intimacy (including depth, range, and consistency)
- Quality of internal experience (level of confidence and self-regard)
- Capacity for affective experience, expression, and communication
- Defensive patterns and capacities
- Capacity to form internal representations
- Capacity for differentiation and integration
- Self-observing capacities (psychological-mindedness)
- Capacity to construct or use internal standards and ideals (sense of morality)
Examples of research efforts that have demonstrated measurements of these components of mental functioning are provided, as well. This Axis, especially, fills a needed expansion of the DSM Axes II and V.
The S Axis builds upon the manifest symptom descriptions of DSM–IV-TR by emphasizing the patient’s experience of symptoms. Descriptions of affective states, cognitive processes, somatic experiences, and relational patterns are added, along with clinical examples.
A very informative Part II: Classification of Child and Adolescent Mental Health Disorders is organized in a similar fashion to Part I. There is an additional IEC Axis (Classification of Mental Health and Developmental Disorders in Infancy and Early Childhood), which considers Interactive Disorders, Regulatory/Sensory-Processing Disorders, and Neurodevelopmental Disorders of Relating and Communicating.
Part III contains samples of conceptual and empirical research literature supporting the development of PDM, which is in addition to the many references throughout the Manual. Examples of articles in this part include
- Psychoanalytically Based Nosology: Historic Origins by Robert Wallerstein, M.D.
- Personality Diagnosis with the Shedler-Weston Assessment Procedure (SWAP): Bridging the Gulf Between Science and Practice by Jonathan Shedler, Ph.D., and Drew Westen, Ph.D.
It is difficult to review the PDM in a concise manner, given the wealth of information it contains. It does fill in many nosological gaps left by the DSM system, and, as such, it represents a very scholarly attempt to create a useful companion to DSM–IV-TR. The Case Illustration sections of Parts I and II highlight the invaluable potential uses of the PDM for psychodynamic case-formulation and psychotherapy treatment-planning. But, at the same time, this attempt to create a psychodynamic supplement with a categorical approach similar to DSM detracts from some aspects of psychodynamic clinical work. This view of categorical diagnosing has been emphasized by Arnold Rothstein, M.D., in his article titled, "Reflections on Creative Aspects of Psychoanalytic Diagnosing," in which he links the act of diagnosing with the concept of countertransference enactment.
In the Introduction to Part I, the PDM states: "DSM is a taxonomy of diseases or disorders of function. Ours is a taxonomy of people." I think the PDM does represent a step toward a more humanistic view of clinical conditions. I hope that it will add depth to discussions of psychiatric assessment and treatment considerations, especially with regard to the conceptualization of "psychological factors" formerly limited by the DSM. Perhaps the PDM effort will help bridge the divide between the academic research and psychodynamic clinical communities and will influence approaches to further revisions of the DSM as a continuation of the explicit collaborative effort that produced the PDM. Thus, it is an important first step in a process that is long overdue. I anticipate that my psychosomatic-medicine colleagues will find this manual both interesting and useful in their work. Further information about the PDM is available at www.pdm1.org.
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FOOTNOTES
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Craig Lichtman, M.D., M.B.A., is Clinical Assistant Professor of Psychiatry at the University of Pennsylvania School of Medicine and a member of the Faculty of the Psychoanalytic Center of Philadelphia. He maintains private practices of psychoanalysis, psychosomatic medicine, and conflict mediation.
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REFERENCES
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- Grossman S: A psychoanalyst-liaison psychiatrist’s overview of DSM-III. Gen Hosp Psychiatry 1982; 4:291–295[CrossRef][Medline]
- Rothstein A: Reflections on creative aspects of psychoanalytic diagnosing. Psychoanal Q 2002; 71:301–326[Medline]
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