DOI: 10.1097/01.pra.0000281487.42441.f9

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PMID: 17667739

Issn Print: 1527-4160

Publication Date: 2007/07/01


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The Psychodynamic Diagnostic Manual: A Review

NORMAN A. CLEMENS

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Long frustrated by perceived shortcomings of successive recent editions of the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders (DSM-III through IV-TR)1-4 in defining the psychic ills that plague mankind, a collaboration of psychoanalytic organizations has produced a diagnostic manual that offers a more refined way of categorizing these ills. In the view of at least some psychodynamically oriented mental health professionals, the DSMs focus exclusively on symptoms, behavior, and external appearances, but do not integrate the many individual features of the clinical picture into a coherent understanding of that patient's basic problem. All too often in the real world, signs and symptoms fall into several categories so that a patient carries multiple "comorbid" diagnoses-when in fact there is a core problem with a multifaceted presentation. While recent DSMs have facilitated certain kinds of research and recognition of a medical perspective, it is often difficult to find pure cases to assemble a series or construct a study reflecting real-life conditions.
From DSM-III on, there was an explicit effort (not entirely successful, some believe) to base the criteria on evidence and measurable or observable data, not theory. These purely descriptive DSMs do not assume any relationship between a symptomatic diagnosis and etiology or theoretical basis. However, there is an inherent bias in focusing on symptom constellations, which inclines towards targeted, so-called specific biological or psychological treatments for symptoms. Psychodynamic therapists are disposed to look for underlying psychological issues, such as internal conflicts, unconscious defenses against unacceptable impulses or affects, problems in relationships and self-image, dysfunctional responses to traumatic experiences or losses, or other issues unique to the person. Whereas DSM lumps patients into categories, psychodynamic thinking recognizes major descriptive patterns but individualizes treatment to the life history, needs, developmental stage, and distinctive psychology of each patient.
To fill this gap, an alliance of five major psychoanalytic organizations assembled a Psychodynamic Diagnostic (PDM) Task Force* of leading scholars. This group conducted an extensive literature review and produced a monumental work, The Psychodynamic Diagnostic Manual (PDM).5 The PDM is divided into three sections: 1) adult mental health disorders, 2) child and adolescent mental health disorders, and 3) papers on conceptual and research foundations for a psychodynamically based classification system for mental health disorders. The child and adult sections both include three axes: personality patterns/disorders (P axis), profile of mental functioning (M axis), and subjective experience (S axis). The child and adolescent section is further broken down into child and adolescent disorders and mental health and developmental disorders of infancy and early childhood. Cases illustrate how to apply the diagnoses in both the adult and child/adolescent sections. When possible, the diagnostic categories are numbered parallel with the DSM, but the larger number of categories and different theoretical basis often lead down a different path. Diagnostic numbers are preceded by P, M, or S in the adult section; MCA, PCA, or SCA in the child/adolescent section; and IEC in the infancy/early childhood section. The adult section begins with personality patterns/disorders, whereas the child/adolescent section begins with mental functioning, reflecting developmental differences. Statements are frequently supported by citations; long lists of references complete each chapter. The authors frankly admit their psychodynamic bias but hope their work will also be useful to those trained in other traditions.
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