The Psychodynamic Diagnostic Manual (PDM) is a diagnostic framework that describes the whole person—both the deeper and surface levels of an individual's personality and emotional and social functioning. It emphasizes individual variations as well as commonalities. This framework opens the door to improvements in diagnosis and treatment of mental health disorders and to a fuller understanding of the functioning and development of the mind and brain. The goal of the PDM is to complement the DSM and ICD efforts in cataloguing symptoms and behaviors.
The PDM is based on current neuroscience and treatment outcome studies (discussed in the research section) that demonstrate the importance of focusing on the full range and depth of emotional and social functioning. For example, research on the mind and brain and their development shows that the patterns of emotional, social, and behavioral functioning involve many interconnected areas working together, rather than in isolation. Treatment outcome studies point to the importance of dealing with the full complexity of emotional and social patterns and show that the therapeutic relationship is the major predictor of outcomes. They further show that treatments that focus on isolated symptoms or behaviors are not effective in sustaining gains or addressing complex personality patterns.
Created through a collaborative effort of the major psychoanalytic organizations (the American Psychoanalytic Association, the International Psychoanalytical Association, the Division of Psychoanalysis (39) of the American Psychological Association, the American Academy of Psychoanalysis, and the National Membership Committee on Psychoanalysis in Clinical Social Work), the PDM diagnostic framework systematically describes:
The continuum from healthy to disordered personality functioning
Individual profiles of mental functioning, including patterns of relating, comprehending, and expressing feelings; coping with stress and anxiety; observing one's own emotions and behaviors; and forming moral judgments
Symptom patterns, including differences in each individual's personal or subjective experience of his or her symptoms
The PDM was developed on the premise that a clinically useful classification of mental health disorders must begin with an understanding of healthy mental functioning. Mental health involves more than simply the absence of symptoms. It involves a person's overall mental functioning, including relationships, emotional 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.
That a full conceptualization of health is the foundation for describing disorders may seem self-evident, and yet the mental health field has not developed its diagnostic procedures accordingly. In the last two decades, there has been an increasing tendency to define mental problems more and more on the basis of presenting symptoms and their patterns, with overall personality functioning and levels of adaptation playing a minor role. The whole person has been less visible than the various disorder constructs on which researchers attempt to find agreement.
Recent reviews of this effort raise the possibility that such a strategy was misguided. Ironically, emerging evidence suggests that oversimplifying mental health phenomena in the service of attaining consistency of description (reliability) and capacity to evaluate treatment empirically (validity) may have compromised the laudable goal of a more scientifically sound understanding of mental health and psycho-pathology. Most problematically, reliability and validity data for many disorders are not as strong as the mental health community had hoped they would be. Allen Frances, chair of the DSM-IV American Psychiatric Association Task Force, commented in The New Yorker magazine that the reliability hoped for has not been realized and that, in fact, the reliability among practicing clinicians is very poor. Consequently, in moving towards DSM-V, the APA Task Force is reported to be shifting towards a more dimensional, rather than purely categorical, approach.
Nancy McWilliams, Ph.D., is visiting professor of clinical psychology at the Graduate School of Applied & Professional Psychology, Rutgers University; senior psychoanalyst at the Institute for Psychoanalysis and Psychotherapy of New Jersey; president-elect of the Division of Psychoanalysis (39), American Psychological Association.
Robert S. Wallerstein, M.D., is emeritus professor and former chair of the Department of Psychiatry, University of California, San Francisco; emeritus training and supervising analyst at the San Francisco Psychoanalytic Institute; former president of the American Psychoanalytic Association and the International Psychoanalytical Association.
Stanley I. Greenspan, M.D., is clinical professor of psychiatry and pediatrics, George Washington University Medical Center; chair of the Interdisciplinary Council on Developmental and Learning Disorders; and supervising child psychoanalyst at the Washington Psychoanalytic Institute.
The psychoanalytic tradition has a long history of examining overall human functioning in a searching and comprehensive way, with an emphasis on both dimensionality and context of mental problems. Nevertheless, the diagnostic precision and usefulness of psychoanalytic approaches have been compromised by at least two problems. First, until fairly recently, in an attempt to capture the full range and subtlety of human experience, psychodynamic accounts of mental processes have been expressed in competing theories and metaphors that have, at times, inspired more disagreement and controversy than consensus. Second, there has been difficulty distinguishing between speculative constructs on the one hand, and phenomena that can be observed or reasonably inferred on the other.
In recent years, however, having developed empirical methods to quantify and analyze complex mental phenomena, depth psychology has been able to offer clear operational criteria for a more comprehensive range of human social and emotional functioning, as described by Westen, Shevrin, Shedler, Blatt, Dahlbender, and others in the PDM research section. The challenge has been to systematize these advances with a growing body of rich clinical experience in order to provide a widely usable framework for understanding and specifying complex and subtle mental phenomena.
The PDM uses a multidimensional approach to describe the intricacies of the patient's functioning and ways of engaging in the therapeutic process. It begins with a classification of the spectrum of personality patterns and disorders found in individuals. It then describes a “profile of mental functioning” that permits a clinician to look in more detail at each of the patient's capacities. This is followed by a description of the patient's symptoms, but with a focus on the patient's internal experiences as well as surface behaviors. The PDM covers adults, as well as infants, children, and adolescents.