Manual's Breadth May Aid Diagnosis

Article excerpt

The DSM-IV-TR and the ICD-10 are no longer the only handbooks for psychiatric diagnosis.

After 2-plus years of preparation, a consortium of psychoanalytic groups has published its own guide to the full spectrum of disorders: the Psychodynamic Diagnostic Manual (PDM).

The idea was not to supplant the DSM series, but to complement it or "to add breadth and depth" to a diagnostic system that has moved too far toward a reductionist view of human nature and experience, said Dr. Stanley Greenspan, chair of the task force that produced the manual.

The impetus for the creation of the PDM, he said, was the concern among clinicians that the DSM approach, which is based on symptoms and surface phenomena rather than on a fuller range of feelings, beliefs, and thoughts, falls short as a foundation for clinical and research work, and has fueled the trend in mental health care toward short-term, medication-based treatment.

It is hoped that the PDM will affect reimbursement policies by documenting the need for longer-term psychodynamic approaches, said Dr. Greenspan, also a professor of psychiatry and pediatric medicine at George Washington University in Washington.

The volume was assembled by work groups organized by a steering committee of leaders within the American Psychoanalytic Association, the International Psychoanalytical Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, the division of psychoanalysis of the American Psychological Association, and the National Membership Committee on Psychoanalysis in Clinical Social Work.

The work groups produced a guide with separate sections for adult and child/adolescent mental health disorders, with a third section that elaborates on the foundations of the manual's classification system.

Parts I and II of the text, devoted to adult and pediatric disorders, offer templates that use three axes for case formulation and treatment planning: personality patterns and disorders, profile of mental functioning, and symptom patterns and related internal experiences.

The PDM takes a dimensional, rather than a categorical, approach. "When someone's personality is so rigid or so marked by deficit that he or she has persistent problems in living, we may call it a personality disorder," says the introduction to the adult section on personality patterns and disorders. "In fact, there is no hard and fast dividing line between personality type and personality disorder. Human function falls along a continuum.... It is important to recognize that individuals with well-functioning, stable personalities have many features of the pathological personality types described here."

The personality disorders, which roughly parallel the axis II diagnoses in the DSM-IV-TR (with additional subtypes and several diagnoses excluded from the older manual), are described in terms of characteristic feelings, thoughts, and behaviors, and often refer to the subjective experience of the therapist as well as that of the patient. …