New Diagnostic Manual

A new tool for psychotherapists

Five psychoanalytic associations collaborate to publish a new diagnostic manual.

By Erika Packard
Monitor Staff
Print version: page 30

Five major psychoanalytic groups, including APA’s Div. 39 (Psychoanalysis) have unveiled a new manual that authors say will improve the diagnosis and treatment of mental disorders. The Psychodynamic Diagnostic Manual (PDM), though not APA policy, is a collaborative project of Div. 39, the American Psychoanalytic Association, the International Psychoanalytical Association, the American Academy of Psychoanalysis and the National Membership Committee on Psychoanalysis in Clinical Social Work. The manual (Alliance of Psychoanalytic Organizations, 2006) is an 857-page diagnostic framework seeking to describe the range of mental functioning in adults, children, adolescents and infants.

PDM authors view it as a complement to the Diagnostic and Statistical Manual of Mental Disorders (DSM) that describes both healthy and disordered personalities and symptom patterns. It also offers individual profiles of mental functioning that include patterns of relating, comprehending and expressing feelings.

“The PDM talks about internal experience, and seeks to answer the question, ‘What does it feel like to be someone with a certain mental health disorder?,’” says Div. 39 Secretary Marilyn Jacobs, PhD, a private practice psychoanalyst and assistant clinical professor at the University of California Los Angeles Medical Center who worked on the project.

A new manual is born

Spearheading the new manual’s creation was Stanley Greenspan, MD, a practicing child and adult psychiatrist and psychoanalyst. For many years, Greenspan and his colleagues talked about the need for a diagnostic system that looked at the whole person and would help guide treatment plans. In particular, Greenspan and others were concerned that the DSM inadvertently supports a tendency toward shorter-term treatments and using medication without psychotherapy.

“It was maybe serving the insurance companies’ interests or HMO’s interests, but not patients’ interests,” says Greenspan, who is also clinical professor of psychiatry and pediatrics at the George Washington University Medical School.

His concern grew in 2003 when he heard from a supervisor at a public mental health clinic in Washington, D.C., that city clinics were using the DSM as rationale to offer only medication or short-term treatment instead of longer-term psychotherapies.

Greenspan contacted the presidents of the five psychoanalytic organizations, including Jaine Darwin, PsyD, a clinical psychology instructor in the department of psychiatry at Harvard Medical School, who was Div. 39 president at the time. The presidents of each of these organizations recommended experts to be on task forces to write the PDM as a way of broadening the DSM’s scope.

Task force members drew on their own clinical experience, as well as the clinical literature, available research, and the experiences of other practitioners to represent the current state of understanding of personality patterns and disorders in adults, adolescents, children and infants.

The five associations self-published the manual in an effort to keep the price low—at $35.00 for the softcover and $45.00 for the hardcover—and accessible to students and practitioners, notes Darwin. All proceeds from the sale of the PDM go to the PDM Fund, designated for updating future editions of the manual and for research funding.

A DSM complement

The manual’s authors hope that the PDM will fill a void left in the diagnostic literature with the publication of the DSM-III and subsequently, the DSM-IV. Up through the DSM-II, says Nancy McWilliams, PhD, president of Div. 39, a psychodynamic assumption was built into the DSM. But as psychotherapists developed different orientations (such as biological, cognitive-behavioral and family-systems approaches) there was a push for DSM-III and subsequent manuals to describe disorders from a point of view that was less psychoanalytically oriented and more purely descriptive of easily observable symptoms, says McWilliams.

This standardization was a boon to researchers, she adds.

“With DSM-III, diagnostic categories could be used across orientations and local habits of diagnosis, so that a person in Phoenix doing research on borderline personality disorder would be doing research on the same kinds of patients as somebody in Boston doing research on borderline personality disorder.”

Managed-care organizations and insurance companies also found the later editions of the DSM convenient because they codified mental disorders into discrete, easily billable categories, adds Jonathan Shedler, PhD, an associate professor of psychiatry at the University of Colorado Health Sciences Center who contributed to the manual.

However, many therapists felt that information important to therapy had been lost.

The DSM catalogs symptoms well, but with each edition, it has become less effective at guiding treatment plans, identifying underlying disorder patterns and helping therapists determine where a patient is on the continuum from healthy to disordered, notes Greenspan

Breakdown of the PDM

The PDM is divided into three sections, the first of which begins with the P Axis, a description of personality patterns and disorders such as schizoid, paranoid and narcissistic personalities. The first section continues with the M Axis, which profiles mental functioning. This axis includes topics such as an individual’s capacity for regulation, attention and learning, and capacity for relationships. The first section concludes with the S Axis, or the subjective experience of symptom patterns. In this section, the manual’s authors sought to describe what it feels like to have a particular disorder, such as obsessive-compulsive disorder, in terms of associated affects, cognitions, somatic states and interpersonal experience.

The second section of the PDM applies the same diagnostic framework as the first section to infants, children and adolescents. The manual’s third section, which is more than half of the book, presents the conceptual and research literature that supports the underlying premises of the PDM.

The differences between the DSM and the PDM come to light when one examines the indexes of both books, says Jacobs. In the DSM, for example, there is no index listing for “suicidality.” Instead, suicide is mentioned under the category of depression as an associated descriptive feature of the disease. In the PDM, however, “suicidality” is listed in the index, along with page numbers referring to sections on the affective and somatic states that accompany it, clinical illustrations, relationship patterns and thoughts and fantasies associated with the desire to end one’s life.

“Suicidal ideation occurs in a number of mental states,” says Jacobs. “Each paragraph [of the PDM entry] talks about a different reason why someone might be suicidal, such as their concept of death, aggressive dynamics or negative mental states. This is a much richer, complex view of why people develop mental disorders than in the DSM.”

Greenspan agrees the new manual can serve as a holistic diagnostic tool. He believes it can help not only psychodynamically oriented but also cognitive and behavioral, family and systems therapists “understand their patients more fully.”

Indeed, even disciplines outside of psychology will find relevant information in the PDM, claims Greenspan.

“We’ve seen interest from people in anthropology, sociology, educators, legal scholars and people in the justice system,” he notes. “It’s broadened the purview of psy-chology to reach into all the related disciplines that deal with human beings.”

APA Treasurer Carol Goodheart, EdD, adds that the PDM “is a rich contribution that deserves to be taken seriously and discussed widely,” as does the World Health Organization’s descriptive International Classification of Function, Disability, and Health (ICF).The ICF classifies function, not disease or disorder, and was developed in collaboration with APA and a multidisciplinary team. It is a companion to the International Classification of Diseases-10, to which APA contributed, and, says Goodheart, which is the standard international classification system for functioning as it relates to health.


For more information on the PDM, visit www.pdml.org.

excellent! i believe that this will change things........thanks, pat

Hrm. That is very interesting to me... Thanks for posting the link, I will check it out.

I'm not sure that it is *scientific* progress. It might be a useful therapy tool, but I don't think that carving up different kinds of mental disorders on the basis of phenomenology (subjective resports of experience) is terribly helpful...

I'm also wary of the kinds of inner causes that they are talking about. I have a feeling they mean something a little different from 'attention' and the like than the cognitive neuropsychologists mean...

I'm not sure how much it will change things. I don't think that the health insurance companies will provide reimbursements or bulk billing or whatever on the basis of those diagnostic categories. I imagine it will get a hammering (and be subsequently ignored) by scientific researchers even though it might be adopted as a tool for practicing clinician's.

But then maybe that is the point?

I guess part of it depends on what you mean by science. People seem to have this notion that sociology is less scientific than biology and that psychoanalysis is less scientific than neurobiology or cognitive psychology.

I'm not sure... I will certainly check out the link though, thanks for that.

Thank you. This sounds exciting and I hope it will become widely used. I hope too that it will open eyes to the need for more psychotherapy treatment and get the insurance companies to stop pushing medications so fervently. Medications treat symptoms; psychotherapy treats the whole person.

Insurance companies have been expecting medication treatment... or possibly medication with CBT... to work for everyone and they want it done as quickly as possible. Their attitude has even adversely affected the attitudes of some providers.

The laws also should be changed to make insurance companies honor mental health issues as real health issues. Benefits need to be upgraded for mental health issues as well.

This is hopefully a big move in the right direction and it will be interesting to see how widely it is accepted outside of the immediate mental health community.

ECHOES

Everything helps!

I think that part of the trouble comes from the psychotic / neurotic distinction. I know that to even talk about 'psychotic' compared to 'neurotic' disorders isn't terribly politically correct these days but seems to me that there is a distinction to be had...

The distinction between the people who (prior to the development of medications) needed to be restrained by their families because they would run around naked or because they were a serious risk of hurting themselves and others. People who smeared their own %#@&#! all over their faces or people who gave away their inheritance in a fit of mania. Those people. The ones who are fairly uncontroversially regarded as having a biologically based mental illness. Compared with the middle class 'worried well' or those with significant 'problems in living' who came right with strategically applied magnets or prescriptions for spa visits or some care from a caring clinician or a prescription for prozac or xanax. Sure it is hard to draw the line... I'm not at all meaning to undermine the distress of the so called 'neurotics' (of which I am one). But there is a great deal of controversy over whether the latter people actually have a psychiatric illness at all. It all depends on how you delimit what psychiatry should be dealing with, you see.

The biologically inclined psychiatrists often feel that they should be dealing with the severe cases that are distinctly biological in origin. Schizophrenia, bi-polar and (before they gave this success away to general medicine) neuro syphilis.

The rest can be dealt with by the psychologists / social workers / councellors.

There was a time in the history of psychiatry where there was a lot of stigma around mental illness (of the psychotic and institutionalised variety). It was found that for several disorders (Huntingtons for example) there was a high degree of heritability and subsequent generations tended to have more severe forms of the disorder. People mistakenly came to believe that the mentally ill people were leading to the degeneration of the human race and eugenic policies were on the cards.

Given that situation many people kept the mentally ill at home (in confinement) rather than having them institutionalised. Nobody would marry the eligable daughters if elder son was known to me mentally ill because people would worry about the genetic worth of the whole family, you see.

Around that time neurologists came up with the notion of 'nerve disorders' (which of course don't really have anything to do with the nerves at all). One could take on the wealthy middle class people who reported subjective distress (but surely didn't need to be institutionalised) and treat them with little stigma. In fact it became fashionable to go to the nerve doctor (neurologist) and get a prescription for some time away in a spa or whatever. This was around the time that Freud (a neurologist) came up with his 'talking cure' (psychoanalysis) as well...

It never was suitable for the severely mentally ill (those with psychiatric conditions like schizophrenia and bi-polar and neuro syphilis). It was a way of making loads of money off wealthy individuals who reported subjective distress. Many biologically oriented psychiatrists would say that these people aren't mentally ill in the sense of having a psychiatric condition.

That is why people with personality disorders and psychosomatic symptoms and neurotic anxiety and depression and the like are often given a hard time by time pressured biologically inclined clinicians.

The DSM casts the net widely...

And the health insurance companies go with the DSM...

There are fairly convincing arguments that health insurance companies shouldn't reimburse for 'problems in living', however, as this isn't a medical problem. While people might be subjectively distressed (and that is a truely horrible thing) it doesn't constitute a biological mental disorder.

Psychoanalysis used to be tied to psychiatry. Psychiatrists were either alienists (that is the proper name for someone running a psychiatric institution) or they worked in private practice treating (mostly) wealthy neurotics. Psychoanalysis was useful for the neurotics, medication was useful for the psychotics. After some time... Especially after the development of new medications (the success of xanax and prozac) psychoanalysis started to be disowned by psychiatrists. Some psychologists sued psychoanalytic associations too because you used to have to be an MD before you could train as a psychoanalyst. The psychologists rightly pointed out that psychoanalysis has nothing to do with biological / medical psychiatry. Nowdays a number of people with backgrounds in education, councelling, nursing, psychology, english literature, philosophy etc train as analysts (though I think only people with prior clinical experience are allowed to practice).

Most of the biological psychiatrists are very keen to distance themselves from psychoanalysis which they see as part of the regrettable past of the profession. I really don't think that they will see adopting a manual with psychodynamic entities structures and processes (which have little scientific validity) to be a step forward. I'm fairly sure they will see it as a step backwards.

Moreover, the manual appears to be more interested in classifying neurotic rather than psychotic disorders and hence it would be of limited utility to the average biologically inclined psychiatrist at any rate.

Don't get me wrong I'm sure the neurotic patients will love it.

I'm just not sure that scientifically it is a step forward.

I suppose it has appeal to psychologists / psychoanalysts / social workers etc...

But I don't think it will influence biological psychiatry at all.

I think there would be more chance of integrating cognitive psychology with biological psychiatry than of integrating psychoanalysis with biological psychiatry. Basically... The problem is... That the psychoanalytic processes structures functions etc really don't seem to have a biological basis. The cognitive psychological structures functions and processes on the other hand... Have better prospects for being integrated into the other sciences.

That being said I'm shooting off at the mouth without having read it and I'll interloan it right now ;-)

Thanks very much for the link :-)

I think the link should be a "1" rather than an "l"

http://www.pdm1.org/

anything to challenge the big pharma/biomedical complex/pseudoscientific paradigms that dominate the field sounds good to me…

It's been over 2 and a half years since this thread was started. I wonder what has happened to this manual during that time. Did it catch on with clinicians?

i don't know whether it has caught on or not but it is being favorably reviewed on amazon. here's the link

When I was in school, it's the only one we used. We did not use the DSM. I went to a psychodynamic-oriented school.