A new tool for psychotherapists

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.