An APA-sponsored volume on “DSM-III and Treatment Planning” is currently being edited by Jerry Lewis, M.D. The DSM-III subcommittee of the Psychoanalytic Association's Peer Review Committee, chaired by William Offenkrantz, M.D., is working on a chapter to be entitled Psychodynamic Therapies. Dr. Offenkrantz has suggested that Dr. Lewis' introductory chapter include the following orienting comments:
The fact that even behavioral descriptions necessarily include psychodynamic inferences about unconscious motivation, intrapsychic conflict, etc., can be demonstrated by a number of examples from the DSM-III. In the description of 301.40 Compulsive Personality Disorder, for example, a statement on page 185 of the Quick Reference Volume to DSM-III notes the patient's ‘insistence that others submit to his way of doing things, with lack of awareness of the feelings elicited by this behavior’ (italics added). A psychodynamic psychiatrist infers that this is not insensitivity in the ordinary use of the word, namely, a quality that may simply be descriptively unconscious. He recognizes that this is more likely to be a lack of awareness reflecting intrapsychic conflict, possibly about dominance vs. submission.
A second example may be found under 301.84 Passive-Aggressive Personality Disorder, on page 328 of the full volume DSM-III, which indicates a ‘pessimistic attitude with no realization that their behavior is responsible for their difficulties’ (italics added). Also, under the Diagnostic Criteria for the same Personality Disorder, on page 186 of the Quick Reference volume is found “Forgetfulness,” in quotation marks. It is a clinical observation that a patient with Passive-Aggressive Personality Disorder “forgets” under certain circumstances. But the clinical inference to be drawn from the quotation marks is that the descriptive psychiatrist also recognizes that there is unconscious intention in the forgetting, possibly as a result of unconscious intrapsychic conflict. Another possibility is that the patient does not forget at all, but only pretends to and is really lying. If this is what the quotation marks are intended to convey, it would suggest a diagnostic criterion for 301.7 Anti-Social Personality Disorder, and would not fit the “no realization” described earlier for the same Personality Disorder.
The justification for the systematic effort to exclude all reference to psychodynamics includes the objection that psychodynamic concepts are by their very nature etiological. We believe this is not entirely accurate. While the psychodynamically oriented psychiatrist will be able to describe any patient's behavior in psychodynamic terms, he does not necessarily imply that this level of description is etiologic. Patients with schizophrenia, or bipolar affective disorder, or an organic mental disorder still function according to psychodynamic principles. It is an inescapable quality of mental functioning in everyone. The psychodynamic aspects which can be described are unlikely to be etiologic in any of the conditions just listed, but they may still be of major significance in understanding both the precipitants of the current episode of illness and in treatment planning. For example, understanding a schizophrenic patient's conflict between his fear of engulfment and his need for attachment may enable the therapist better to guide his interventions to assure compliance with the prescribed medication program. This does not in any way imply that a fear of engulfment or the need for attachment is the cause of schizophrenic disorders.
The chapter itself is being written by a committee which includes
representatives of the Academy of Psychoanalysis in collaboration with the Association's subcommittee. It will survey a variety of short and long-term psychotherapies as well as present a case vignette illustrating the indications for psychoanalysis and the criteria for analyzability.