Robert M. Gordon,Ph.D., ABPP, LLC

The Psychodynamic Diagnostic Manual (PDM)
Robert M. Gordon, Ph.D., ABPP in Clinical Psychology and in Psychoanalysis in Psychology

WHY A NEW DIAGNOSTIC MANUAL?

 

The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) is the first psychological diagnostic classification system that considers the whole person in various stages of development. A task force of five major psychoanalytic organizations and leading researchers, under the guidance of Stanley I. Greenspan, Nancy McWilliams, and Robert Wallerstein came together to develop the PDM. The resulting nosology goes from the deep structural foundation of personality to the surface symptoms that include the integration of behavioral, emotional, cognitive, and social functioning.

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The PDM improves on the existing diagnostic systems by considering the full range of mental functioning. In addition to culling years of psychoanalytic studies of etiology and pathogenesis, the PDM relies on research in neuroscience, treatment outcome, infant and child development, and personality assessment.

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The PDM does not look at symptom patterns described in isolation, as do the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). Research on brain development and the maturation of mental processes suggests that patterns of behavioral, emotional, cognitive, and social functioning involve many areas working together rather than in isolation. Although it is based on psychodynamic theory and supporting research, the PDM is not doctrinaire in its presentation. It may be used in conjunction with the ICD or DSM. The PDM Task Force made an effort to use language that is accessible to all the schools of psychology. It was developed to be particularly useful in case formulation that could improve the effectiveness of any psychological intervention.

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The PDM has received very favorable reviews from mostly the psychoanalytic community (Clemens, 2007; Ekstrom, 2007; Migone, 2006; and Silvio, 2007).  However, even non-psychodynamic psychologists that were introduced to the PDM as part of MMPI-2 and ethics/risk management workshops had a positive reaction to the new diagnostic system.  Ninety percent of 192 psychologists surveyed (65 Psychodynamic, 76 CBT and 51 Family Systems, Humanistic/Existential, Eclectic with no primary preference) rated the PDM as favorable to very favorable (Gordon, 2008).   

 

CLASSIFICATION OF ADULT MENTAL HEALTH DISORDERS 
 

Personality Patterns and Disorders- P Axis

The PDM covers the full range of human development: adults, adolescents, children, and infants. The adult diagnostic section begins with personality. The P axis- Personality Patterns and Disorders has been placed first in the PDM system because of the accumulating research findings that symptoms cannot be understood or well treated in the absence of an understanding of the deeper personality traits of the adult who has the symptoms.

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The P axis takes into account two areas. We are first asked to consider the person's level of personality organization or severity of personality disorder. This continuum goes from a mainly healthy personality (absence of a personality disorder), to a mainly neurotic-level personality disorder, and at the most severe end- a mainly borderline-level personality disorder. “Borderline” is used by the PDM as a level of severity and not as a specific personality disorder as in the DSM.

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The levels of personality organization (healthy, neurotic or borderline) are determined by assessing one’s capacities. These capacities are: identity maturation, ability for stable satisfying relationships, affect tolerance and regulation, moral reasoning, reality testing and the ability to respond to and recover from stress.  

After determining the over-all level of personality organization, we consider the P axis personality patterns (which may be adaptive and cause minimum if any impairment) or the more pervasive personality disorders (which repeatedly cause pain to ourselves or to others). The personality patterns or disorders are:  schizoid; paranoid; psychopathic (antisocial), subtypes- passive/parasitic and aggressive; narcissistic, subtypes- arrogant/entitled and depressed/depleted; sadistic and intermediate manifestation- sadomasochistic; masochistic (self-defeating), subtypes- moral masochistic and relational masochistic; depressive, subtypes- introjective and anaclitic, converse manifestation- hypomanic; somatizing; dependent, passive-aggressive versions of dependent, converse manifestation- counterdependent; phobic (avoidant), converse manifestation- counterphobic; anxious; obsessive-compulsive, subtypes- obsessive and compulsive; hysterical (histrionic), subtypes- inhibited and demonstrative or flamboyant; dissociative; and mixed/other.

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Then the PDM P axis considers each personality disorder in terms of temperamental, thematic, affective, cognitive, and defense patterns.  The psychopathic (antisocial) personality for example has aggressiveness and a high threshold for emotional stimulation as part of the temperamental or contributing constitutional-maturational factors. The main thematic or central tension/preoccupation is manipulating/being manipulated. The central affects are rage and envy. Characteristic pathogenic belief about the self is, “I can make anything happen.” Characteristic pathogenic belief about others is, “Everyone is selfish, manipulative and dishonest.” Central ways of defending is reaching for omnipotent control over others.

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The PDM does not consider disorders as artificially isolated and distinct. For example, depression can be a mood disorder on the symptom axis, and also a personality disorder on the P axis with different traits. The PDM classifies a depressive personality disorder with the subtypes of introjective (self critical), anaclitic (high reactivity to loss and rejection) and the converse manifestation: hypomanic personality disorder (high energy, counter-depressive, fear of closeness). The PDM also makes treatment suggestions when there is sufficient data. The introjective type tends to respond better to interpretations and insight, while the anaclitic type tends to respond better to the actual therapeutic relationship. The hypomanic type often flees from commitment and therefore does not stay long enough in treatment. The PDM suggests emphasizing that the commitment to the treatment is important to improvement. People with hypomanic personality disorders are most likely to be at the borderline level favoring defenses such as idealization of self and the devaluation others, as compared to those with depressive personalities who favor

defensives such as devaluation of self and the idealization of others.

 

Profile of Mental Functioning- M Axis

 

The second PDM dimension, the M axis- Mental Functioning is a detailed look at the capacities that contribute to an individual's personality and overall level of psychological health or disturbance. These are: the capacity for regulation, attention, and learning; the capacity for relationships (including depth, range, and consistency); the quality of internal experience (level of confidence and self-regard); the capacity for affective experience, expression, and communication; the level of defensive patterns; the capacity to form internal representations; the capacity for differentiation and integration; the self-observing capacities (psychological-mindedness); and the capacity for internal standards and ideals, that is a sense of morality.

 

Symptom Patterns: The Subjective Experience- S Axis

 

Lastly, the PDM considers the S axis- Manifest Symptoms and Concerns. These are the DSM-IV-TR symptom patterns, but with an emphasis on the patient’s subjective experience of the symptoms. The patient may evidence a few or many patterns, which may or may not be related. The PDM does not regard them as highly demarcated biopsychosocial phenomena. These symptom patterns should be seen in the context of the person's personality (P axis) and mental functioning (M axis).

 

CLASSIFICATION OF CHILD AND ADOLESCENT MENTAL HEALTH DISORDERS

 

Profile of Mental Functioning for Children and Adolescents- MCA Axis

The classification of child and adolescent disorders begins with the MCA Axis- Profile of Mental Functioning for Children and Adolescents. These are how the child or adolescent’s mental functions deal with such experiences as relationships, emotions and anxiety.

Child and Adolescent Personality Patterns and Disorders- PCA Axis

Next, the PDM looks at the emerging patterns of personality tendencies. These emerging personality styles that may change or remain relatively stable throughout the course of life. As with adults, we are asked to first assess the level of severity: “normal” emerging personality patterns, moderately dysfunctional emerging personality patterns, and severely dysfunctional emerging personality patterns. Then the PDM asks us to consider the specific dysfunctional personality patterns: fearful of closeness/intimacy (schizoid); suspicious/distrustful; sociopathic (antisocial); narcissistic; impulsive/explosive; self-defeating; depressive; somatizing; dependent; avoidant/constricted, subtype- counterphobic; anxious; obsessive-compulsive; histrionic; dysregulated; and mixed/other.
 
 Child and Adolescent Symptom Patterns: The Subjective Experience- SCA Axis

 

Finally, the PDM considers the SCA axis- child and adolescent symptom patterns and subjective experience. The SCA axis looks at symptom patterns in a developmental, dynamic context and the fact that each child’s subjective experience of his or her symptoms is unique. These include discerning healthy responses, developmental crises, situational crises, and disorders of affect. The main symptoms categories are: anxiety disorders; somatization (somatoform) disorders; affect/mood disorders (such as: prolonged mourning/grief reaction, depressive disorders, bipolar disorders and suicidality); disruptive behavior disorders; reactive disorders (such as: psychic trauma and posttraumatic stress disorder); disorders of mental functioning (such as: psychotic disorders and neuropsychological disorders); psychophysiologic disorders; developmental disorders; and other disorders. 

 

The Classification of Mental Health and Developmental Disorders in Infancy and Early Childhood

The PDM classification of infant and early childhood disorders is unique and appropriate to this age group. The primary diagnoses include the interactive disorders that involve symptom patterns such as anxiety, depression and disruptive behaviors. Secondly, the regulatory-sensory disorders which involve such symptoms regarding inattention, over and under reactivity and sensory seeking.  Thirdly are the neurodevelopmental disorders of relating and communicating including the autism spectrum disorders.

 

RESEARCH FOUNDATION FOR THE PDM

 

The PDM devotes the latter half the book to the “Conceptual and Research Foundations for a Psychodynamically based Classification System for Mental Health Disorders.” These are valuable articles and references on the concepts and research that supports the PDM’s classification system. These articles can also inform researchers to use constructs and designs based on the PDM’s formulation of the whole person that would improve external validity.

 

References

 

Clemens, N. A. (2007). The psychodynamic diagnostic manual: A review. Journal of Psychiatric Practice, 13(4), 258-260.

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Ekstrom, S. (2007). Review of Psychodynamic Diagnostic Manual. The Journal of Analytical Psychology, 52(1), 111-114.

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Gordon, R.M. (2008). Early reactions to the PDM by Psychodynamic, CBT and Other psychologists. Psychologist-Psychoanalyst, XXVI, 1, Winter, p.13.

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Migone, P. (2006). La diagnosi in psicoanalisi: Present azione del PDM (Psychodynamic Diagnostic Manual). [The psychoanalytic diagnosis: Presentation of the Psychodynamic Diagnostic Manual (PDM).]. Psicoterapia e scienze umane, 40(4), 765-774.

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PDM Task Force (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations.

 

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Silvio, J. R. (2007). Review of Psychodynamic diagnostic manual. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35(4), 681-685.

 

 

Robert M. Gordon, Ph.D., ABPP in Clinical Psychology and in Psychoanalysis in Psychology

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