The Psychodynamic Diagnostic Manual: an adjunctive tool for diagnosis, case formulation, and treatment.
In today's psychotherapeutic climate, classical psychoanalysis, as conceived by Freud and his early followers, is neither practical nor indicated for many patients. Generally, to benefit from traditional psychoanalysis, a client needs to have a relatively secure global attachment style and the ability to explore and tolerate intense emotional experiences. Unfortunately, deficits in these very areas are commonly what bring people into therapy in the first place. Such persons are often better suited for other therapy formats (McWilliams, 2004).
One such format is psychoanalytic psychotherapy, an offshoot of psychoanalysis. Psychoanalytic psychotherapy--sometimes referred to as psychodynamic psychotherapy--is characterized by many of the same theoretical underpinnings as classical psychoanalysis (e.g., emphases on unconscious cognitions, emotions, wishes, conflicts, and defenses and on enduring influences from early childhood; McWilliams, 2004; Westen, Gabbard, & Ortigo, 2008). However, it typically also differs in substantial ways. For example, psychoanalytic psychotherapy tends to involve one or two sessions per week (as opposed to the four or five that is customary for traditional analysis). Moreover, it tends to involve a shorter duration of treatment, and the clinician typically adopts a more active therapeutic stance (McWilliams, 2004). It is important to note that there are several different types of psychoanalytic psychotherapy. In fact, Stolorow (1994) has suggested that it is intrinsic criteria (e.g., sustained empathic inquiry, analysis of the transference and countertransference, etc.) and not extrinsic features (e.g., use of the couch, frequency of sessions, etc.) that distinguish psychoanalytic from nonpsychoanalytic treatments (cf. Westen et al., 2008).
Within the contemporary psychoanalytic community, there is an increasing call for an inclusive and flexible approach to psychoanalytic treatment (McWilliams, 2004; Stricker & Gold, 2005; Wachtel, 2008). One renowned practitioner who calls for such an approach is Nancy McWilliams, whose books Psychoanalytic Diagnosis (McWilliams, 1994), Psychoanalytic Case Formulation (McWilliams, 1999), and Psychoanalytic Psychotherapy (McWilliams, 2004) are seminal texts in the modern psychodynamic field. As it relates to psychotherapy in particular, McWilliams (2004) views classical psychoanalysis and contemporary psychoanalytic psychotherapies as theoretically consonant and as existing along a continuum. Speaking to this point, she explained
I prefer to envision a continuum [ranging] from psychoanalysis through the exploratory psychodynamic therapies in which transferences are invited to emerge and be examined in light of the client's history, then the transference-focused or expressive treatments that zero in on the here-and-now use of pathological defenses, and finally, the supportive approaches for people who are in crisis or are struggling with severe psychopathology or are simply unable to afford treatments of more than a few sessions. (p. 13)
As can be seen from this description, for a given client, there are many factors that play into determining (a) whether or not traditional psychoanalysis or a psychoanalytic therapy is indicated and (b) if so, which modality along McWilliams's (2004) continuum is optimally promising. Many factors play into these two determinations, including the client's symptom severity, functional impairments, and financial constraints (see McWilliams, 1994, 2004). Perhaps most importantly, these decisions are informed by an accurate diagnosis and a solid case formulation (e.g., Pine, 1998; Hedges, 1995; McWilliams, 1994, 1999). We believe that the adjunctive use of the PDM can assist greatly in this decision-making process.
The Psychodynamic Diagnostic Manual: Connections with Christian Theology
The PDM Task Force provided the following description of the overall content and goal of the PDM:
The Psychodynamic Diagnostic Manual (PDM) is 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. It emphasizes individual variations as well as commonalities.... The goal of the PDM is to complement the DSM and ICD [i.e., the International Classification of Diseases] efforts of the past 30 years in cataloguing symptoms by explicating the broad range of mental functioning. (p. 1)
First of all, from the standpoint of orthodox Christian theology, the PDM's content and purpose resonates with a biblical view of personhood--that is, an embodied, holistic, dialectic view of persons as both autonomous and relational, self- and other-referential, and unique and communal (see Vitz & Felch, 2006).
Furthermore, in many ways, the PDM parallels an orthodox Christian view of sin, chiefly in how the former affirms the pervasive reach of psychopathology, even as the latter affirms the pervasive reach of sin. From a traditional Christian perspective, sinful words and actions flow from a person's sinful nature, which is viewed as the inevitable result of the Fall. Here, the theological supposition is that we are born into a world where humans are separated from the Divine presence, and thus from the outset of our lives, "our understanding is darkened, our will is seized by wrong tempers, our liberty is lost, and our conscience is left without a standard" (Maddox, 1994, p. 82). It is from this spiritual corruption that our sins emerge. We can no longer love and serve rightly, but rather we are prone to turning inward--toward selfishness, self-love, and self-protection (see Vitz & Felch, 2006).
Recognizing this pervasive reach of sin, our fundamental human need then becomes not just forgiveness from sin but also healing of our corrupted nature--through "the renewing of our minds" (Romans 12:2) and participating in ongoing, sanctifying relationship with the Trinitarian God and His body--the Church. It is our belief that even as sanctification inherently necessitates deep-level changes in the "roots" of sin, so does lasting therapeutic change call for deep-level changes in the "roots" of psychopathology. Again, we propose that the adjunctive use of the PDM can facilitate this goal.
Comparing and Contrasting the DSM and the PDM
First of all, it is important to note that the PDM's developers (a large working group of psychoanalytic experts) never intended for the PDM to supplant the DSM. Instead, they envisioned the PDM serving as an orthogonal supplement, mainly for the purpose of aiding individualized case formulation and treatment planning. In particular, they highlighted the myriad benefits the PDM offers for clinicians who conduct long-term, intensive psychotherapy that is psychoanalytically informed (PDM Task Force, 2006).
A comparison of the DSM and the PDM not only demonstrates their similarities and differences, but it also underscores their potential ability to complement each other in powerful ways. With this viewpoint in mind, Table 1 compares and contrasts the two nosologies. Among other things, this table also highlights the incremental validity of the PDM.
An Overview of the PDM Nosologies
Essentially, the PDM attempts to maintain the importance of diagnostic classification systems while also emphasizing individual subjectivity. It is comprised of three separate but related nosologies, based on the three major life stages: (a) Adulthood, (b) Childhood and Adolescence, and (c) Infancy and Early Childhood. The former two systems are used to systematically describe:
* Healthy and 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; and
* Symptom patterns, including differences in each individual's personal, subjective experience of symptoms. (PDM Task Force, 2006, p. 2)
Similarly, the latter diagnostic framework seeks to comprehensively describe the infant/child's symptoms, capacities, and experiences, but it uses a slightly different axial system (PDM Task Force, 2006). In what follows, we will summarize each nosology in turn.
The PDM's Adult Nosology: The P-M-S Diagnostic Framework
The PDM's nosology for use with adults is tridimensional. According to this diagnostic framework, Dimension I (the P Axis) calls for the diagnosis of the client's personality patterns and disorders, similar to the DSM-IV-TR's Axis II personality-disorder nosology. Dimension II (the M Axis) calls for the diagnosis of the client's mental functioning. Finally, Dimension III (the S Axis) calls for the diagnosis of the client's manifest symptoms and concerns, similar to the DSM-IVTR's Axis I nosology (APA, 2000; PDM Task Force, 2006).
Personality patterns and disorders (the P Axis). The P Axis has clinicians diagnose the patient's personality structure along two dimensions: the severity dimension and the typological dimension (cf., McWilliams, 1994). As its name implies, the severity dimension reflects the client's relative level of personality pathology, according to three categories: (a) healthy personalities (i.e., absence of personality pathology), (b) neurotic-level personality disorders (i.e., mild-to-moderate personality pathology, with intact reality testing), and (c) borderline-level personality disorders (i.e., severe personality pathology, possibly with impaired reality testing; PDM Task Force, 2006).
In comparison, the typological dimension of the P Axis reflects the patient's personality type(s) or style(s), again following McWilliams's (1994) nosology. The PDM's typological framework coincides with the DSM-IV-TR's personality-disorder taxonomy (i.e., it includes categories for Schizoid, Paranoid, Antisocial [Psychopathic], Narcissistic, Dependent, Avoidant [Phobic], Histrionic [Hysterical], and Obsessive-Compulsive Personality Disorders), with some additional, distinctly psychodynamic categories (i.e., Sadistic/Sadomasochistic, Masochistic [Self-Defeating], Depressive, Somaticizing, Anxious, and Dissociative Personality Disorders). (For an extensive review of most of these P-Axis categories, see McWilliams, 1994.) Each of the P-Axis personality disorders includes a description of contributing constitutional-maturational patterns, central tensions/preoccupations, central affects, characteristic pathogenic beliefs about the self and others, and central ways of defending (i.e., characteristic defense mechanisms). Several of the disorders also include subtypes (e.g., Introjective- vs. Anaclitic-Depressive Personality Disorders; PDM Task Force, 2006).
Within the PDM's adult nosology, the P Axis is placed foremost largely "because of the accumulating evidence that symptoms or problems cannot be understood, assessed, or treated in the absence of an understanding of the mental life of the person who has the symptoms" (PDM Task Force, 2006, p. 8). In this regard, an understanding of the adult client's personality organization is critical. Indeed, as McWilliams (1994) and others have suggested (e.g., PDM Task Force; Widiger & Smith, 2008), people with different personality styles can manifest the same type of symptoms in vastly different ways (e.g., depression in a person with Narcissistic Personality Disorder vs. depression in a person with Avoidant Personality Disorder). Thus, an accurate P-Axis diagnosis is meant to offer invaluable guidance to all subsequent diagnostic, case formulation, and treatment endeavors.
Mental functioning (the M Axis). Next, in an effort to "capture the complexity and individuality of the patient" (PDM Task Force, 2006, p. 73), the M Axis calls for a diagnosis of the client's mental functioning along nine dimensions:
1) capacity for regulation, attention, and learning; 2) capacity for relationships and intimacy (including depth, range, and consistency); 3) quality of internal experience (level of confidence and self-regard); 4) capacity for affective experience, expression, and communication; 5) defensive patterns and capacities; 6) capacity to form internal representations; 7) capacity for differentiation and integration; 8) self-observing capacities (psychological mindedness); and 9) capacity to construct or use internal standards and ideals (sense of morality). (PDM Task Force, 2006, p. 73)
The M-Axis nosology includes diagnostic codes related to the nine mental-functioning dimensions described above, along with some descriptions (PDM Task Force, 2006).
Manifest symptoms and concerns (the S Axis). The S Axis calls for a diagnosis of the client's subjective experience of his or her symptom pattern. Specifically, it takes several of the existing DSM-IV-TR Axis I disorders (APA, 2000) and has clinicians (a) first diagnose the type(s) of disorder(s) that the client is experiencing and (b) then "capture the patient's unique subjective experience in a narrative form by considering the applicable descriptive patterns" (PDM Task Force, 2006, p. 94).
In particular, the S Axis offers an opportunity to describe the client's individual subjectivity "in terms of affective patterns, mental content, accompanying somatic states, and associated relationship patterns" (PDM Task Force, 2006, p. 93). The S-Axis taxonomy consists of the following disorders, some of which include subtypes: Adjustment Disorders, Anxiety Disorders, Dissociative Disorders, Mood Disorders, Somatoform (Somatization) Disorders, Eating Disorders, Psychogenic Sleep Disorders, Sexual and Gender Identity Disorders, Factitious Disorders, Impulse-Control Disorders, Addictive/Substance Abuse Disorders, Psychotic Disorders, and Mental Disorders Based on a General Medical Condition (PDM Task Force, 2006).
The PDM's Child and Adolescent Nosology: The MCA-PCA-SCA Diagnostic Framework
Like its adulthood counterpart, the PDM's child and adolescent nosology is tridimensional. More specifically, it includes the same three axes: (a) personality patterns and disorders (the PCA Axis), (b) mental functioning (the MCA Axis), and (c) symptom patterns (the SCA Axis). However, it places the PCA Axis secondary to the MCA Axis, in an effort to affirm the plastic, developing nature of personality during childhood and adolescence (see Roberts, Wood, & Caspi, 2008). Also, the child and adolescent nosology calls for an enhanced appreciation of developmental context (PDM Task Force, 2006).
Child and adolescent mental functioning (the MCA Axis). The MCA Axis is highly similar to its adult counterpart, the M Axis. Specifically, it too is used to capture the individuality of the child/adolescent's mental functioning, along the same nine dimensions, with some age-appropriate modifications (PDM Task Force, 2006, p. 181).
Child and adolescent personality patterns and disorders (the PCA Axis). The PCA Axis is somewhat similar to its adult counterpart, the P Axis. The main difference is that the PCA Axis is designed to serve as a "low power lens" (p. 175) through which to diagnose the child/adolescent's emerging personality patterns. It is also comprised of a different severity continuum (i.e., normal, mildly dysfunctional, moderately dysfunctional, and severely dysfunctional emerging personality patterns) and typological taxonomy (i.e., Fearful of Closeness/Intimacy [Schizoid], Suspicious/Distrustful, Sociopathic [Antisocial], Narcissistic, Impulsive/Explosive, Self-Defeating, Depressive, Somatizing, Dependent, Avoidant/Constricted, Anxious, Obsessive-Compulsive, Histrionic, Dys-regulated, and Mixed/Other Personality Disorders; PDM Task Force, 2006).
Child and adolescent symptom patterns (the SCA Axis). Likewise, the SCA Axis is somewhat similar to its adult counterpart, the S Axis. For example, even as the S Axis largely parallels DSM-IV-TR Axis I diagnoses, so the SCA Axis similarly mirrors DSM-IV-TR Axis I diagnoses that are usually first diagnosed in childhood or adolescence (e.g., Disruptive Behavior Disorders and Developmental Disorders; APA, 2000). In addition, similar to the S Axis (but dissimilar to the DSM-IV-TR), the SCA Axis emphasizes the unique subjective experience of the child/adolescent's symptom pattern. Distinctively, the SCA Axis encourages an enhanced emphasis on the child/adolescent's developmental context.
Of note, the SCA taxonomy includes some DSM-IV-TR Axis I disorders that are not usually first diagnosed in childhood or adolescence (e.g., Anxiety Disorders, Affect/Mood Disorders, Reactive Disorders [trauma and adjustment disorders], and Psychophysiologic Disorders [eating disorders]). Moreover, it includes some symptom patterns that do not appear either in the DSM or in the PDM's adult nosology (e.g., Suicidality, Prolonged Mourning/Grief Reaction, Neuropsychological Disorders). Lastly, it includes a Healthy Response category to describe a child/adolescent's time-limited, expectable reactions to developmental and/or situational crises (PDM Task Force, 2006).
The PDM's Infancy and Early Childhood Nosology: The IEC Diagnostic Framework
As its name implies, the PDM's Infant and Early Childhood nosology is used to diagnose infants and very young children. This PDM taxonomy is quite different from its adult and child/adolescent counterparts. The primary two differences are that the infant/early-childhood nosology calls for diagnosis (a) of both the infant/toddler and his or her familial environment framework and (b) along five axes instead of three. In particular, the infant/toddler receives a primary diagnosis on Axis I, which is then supplemented by an idiographic, narrative description of "(1) six basic functional, emotional, developmental capacities [Axis II]; (2) constitutional and maturational variations (regulatory-sensory processing patterns) [Axis III]; (3) caregiver-infant or caregiver-child and family interaction patterns [Axis IV]; and (4) other medical or neurological diagnoses [Axis V]" (PDM Task Force, 2006, p. 321).
Using the PDM for Case Formulation Purposes
In large part, the PDM rests upon the assumption that two foundations undergird effective treatment: an accurate, comprehensive diagnosis and a solid, thoughtful case formulation (McWilliams, 1994, 1999, 2004; PDM Task Force, 2006). Here, the idea is that diagnosis informs case formulation, which in turn informs treatment planning. Importantly, whether or not a clinician uses a psychodynamic framework to inform the case formulation is irrelevant; that is, a precise PDM diagnosis can assist case formulation and treatment planning regardless of the theories that inform these latter two endeavors. Naturally a PDM diagnosis is most helpful for informing a psychodynamic case formulation and corresponding psychoanalytic treatment. Even so, as Eells (2007) has suggested, the goal of any case formulation is an optimal fit between the client's subjective experiences and the theories that inform the conceptualization of that client.
Unfortunately, many clinicians tend to formulate cases in a rigid, biased way--usually according to their own theoretical orientation and not their client's "experience-near" subjectivity. In stark contrast to such theoretical rigidity, we (like Eells, 2007) believe that a competent case formulation reflects a goodness of fit between client subjectivity and relevant theoretical informers, from a stance of maximal theoretical objectivity and minimal theoretical bias. Included in this type of conceptualization is a comprehensive and precise description of the patient's unique subjectivity. When diagnosis and case formulation are conducted in this manner, treatment implications become much clearer.
Terrell's (2007) case example illustrates many of the contemporary psychodynamic ideas that we have presented here. Terrell used the PDM to inform his work with a client named Jim, a 45 year-old businessman who had presented for therapy at his wife's insistence, due to marital difficulties. On the P Axis, Terrell diagnosed Jim as exhibiting a narcissistic personality organization (grandiose subtype), at the neurotic-level of severity. (Of note, Jim did not meet the DSM-IVTR criteria for Narcissistic Personality Disorder, so without a PDM diagnosis, this major contributor to his subjectivity may have been overlooked.)
Based on Terrell's (2007) description of the treatment, we can infer that he used Jim's PDM diagnosis to inform his case formulation and his selected treatment strategies and tactics. For example, Terrell understood that shame was an underlying affect fueling Jim's habitual use of idealization/devaluation (McWilliams, 1994). He also recognized that confrontational interventions would probably damage the therapeutic relationship, perhaps irrevocably. Further, Terrell appreciated that part of his individualized treatment strategy was to hold/contain both the client's "bravado" and his underlying shame (McWilliams, 1994). As McWilliams (1994) advised, "in working with narcissistic people, practitioners have to become accustomed to absorbing a great deal that they would address with other types of patients" (p. 184). If Terrell had not utilized the PDM as an adjunctive tool, he might not have recognized the client's narcissistic personality organization, perhaps leading to recurrent alliance strain or maybe even eventual rupture.
Another key factor was that Terrell (2007) diagnosed Jim as exhibiting neurotic-level personality pathology, a determination which had several treatment implications. For example, it suggested that Jim was relatively high functioning and that he had some capacity for insight and for exploratory, affect-laden therapy. Based on this understanding (and presumably other factors), Terrell was able to determine that psychoanalytic psychotherapy was indicated in Jim's case and that exploratory psychodynamic psychotherapy was the most promising modality (McWilliams, 2004).
Lastly, though unspecified in Terrell's (2007) article, it is assumed that Jim's PDM diagnosis was grounded in a comprehensive understanding of his interpersonal style; affective expression, regulation, and tolerance; characteristic defensive tendencies; subjective experience of his symptoms; and so forth--that is, his diagnoses on the M and the S Axis of the PDM's adult nosology. This thorough case conceptualization helped Terrell navigate his intentional, incarnational relationship with Jim.
Summary and Conclusion
We have attempted to demonstrate that diagnostic and case-formulation considerations have vast treatment implications, particularly for informing psychoanalytic/psychodynamic psychotherapy. We have further suggested that the PDM is a valuable adjunct to the DSM-IV-TR, regardless of the therapist's theoretical orientation or the selected treatment modality. In particular, we have argued that the adjunctive use of the PDM can add incremental validity to the keystone clinical practices of diagnosis, case formulation, and treatment planning, enabling practitioners to better pinpoint, understand, and treat the "roots" of psychopathology--an endeavor that parallels biblical views of personhood and of sin.
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Edward B. Davis
Brad D. Strawn
Southern Nazarene University
(1) In this article, we use the terms psychoanalytic and psychodynamic interchangeably, as is common in the pluralistic, contemporary psychoanalytic community (e.g., see McWilliams, 1994, p. 3; PDM Task Force, 2006, p. 13).
Edward "Ward" B. Davis (M.A. in Clinical Psychology, Regent University, 2007) is an adjunct undergraduate professor and a Psy.D. candidate at Regent University, and he is a predoctoral psychology intern at Louisiana State University. Ward's interests include interpersonal neurobiology, psychology of religion/spirituality, God image, narrative identity, attachment, integrative psychotherapy, psychoanalysis and supervision.
Brad D. Strawn (Ph.D., Clinical Psychology, M.S., Theology, Fuller Theological Seminary) is professor, Vice President for Spiritual Development, and Dean of the Chapel at Southern Nazarene University, Bethany, OK and Associate Director of the Society for Exploration of Psychoanalytic Therapies and Theology. His specialties include integration of psychology and theology, psychoanalytic psychotherapy, Wesleyan theology and spiritual formation.
Please address correspondence regarding this article to Edward B. Davis, M.A. Doctoral Program in Clinical Psychology, Regent University, 1000 Regent University Dr., CRB 161, Virginia Beach, VA 23464; firstname.lastname@example.org.
Table 1 Comparison and Contrast of the Diagnostic and Statistical Manual (DSM) and the Psychodynamic Diagnostic Manual (PDM) Diagnostic and Psychodynamic Statistical Manual (DSM) Diagnostic Manual (PDM) Focuses on symptoms and behaviors Focuses on subjectivity and psychodynamics Focuses on the "fruits" of Focuses on the "roots" of psychopathology psychopathology Symptom-based view of the person Holistic view of the person Emphasizes a descriptive Emphasizes a functional understanding understanding Nomothetic Nomothetic and idiographic Multidimensional Multidimensional Categorical Categorical and dimensional Enumerates diagnostic Does not enumerate diagnostic criteria sets criteria sets Extensive empirical-research base Lacking empirical-research base Extensive clinical-literature base Extensive clinical-literature base Atheoretical Theoretically grounded Ideal for use in short--term Ideal for use in long-term or therapy intensive therapy Useful for insurance purposes Not useful for insurance purposes Useful for research purposes Potentially useful for research purposes Little help with case formulation Much help with case formulation Little help with etiological Much help with etiological understanding understanding Little help with Much help with therapy--relationship navigation therapy--relationship navigation Little help with Much help with treatment--modality treatment--modality selection selection Little help with treatment Much help with treatment planning planning Clinically useful across Clinically useful across theoretical orientations theoretical orientations
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|Author:||Davis, Edward B.; Strawn, Brad D.|
|Publication:||Journal of Psychology and Christianity|
|Date:||Jun 22, 2010|
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