The Psychodynamic Diagnostic Manual: A Clinically Useful Complement to DSM

The Psychodynamic Diagnostic Manual¹ (PDM) was created by a task force chaired by child psychiatrist Stanley Greenspan, MD, in cooperation with the American Psychoanalytic Association, the International Psychoanalytical Association, the Division of Psychoanalysis of the American Psychological Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, and the National Membership Committee on Psychoanalysis in Clinical Social Work. Guided by a steering committee chaired by Robert Wallerstein, MD, the PDM summarizes issues not covered in the DSM that are critical to psychotherapists. In brief, it redirects our attention from a proliferation of syndromes to the whole patient.

Background
Over the past few decades, Green-span became concerned about the gradual diminishment in professional discourse of in-depth, biopsychosocial case formulation and individual treatment planning. He noted that notwithstanding their laudable efforts to create a more reliable and less theoretically biased classification system than previous taxonomies, the creators of DSM-III and its successors had inadvertently contributed to a mental health culture in which complex, interrelated clinical problems have been reduced to a string of descriptions of behaviors and symptoms (represented ultimately as comorbid diagnoses) that make it difficult to conceptualize integrated and comprehensive therapies for many kinds of problems.

Although the authors of DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR explicitly disavowed the aim of guiding psychotherapy, the descriptive, noninferential language of those manuals (see Klerman and associates² for the prototypical debate on the paradigm shift) has come to define the categories in which therapists think and talk, as well as the categories by which outsiders, such as third parties, construe the clinical process. Our understanding of psychotherapy has tilted toward the observable and readily quantifiable. Therapy results have come to be measured almost solely in terms of symptom relief rather than in terms of the patient's growth toward over-all mental health (as defined by such concepts as ego strength, affect tolerance, resilience, and related concepts, all of which have been subject to a long history of disciplined clinical observation and well-designed research).

In the present climate, the claim that there is no empirical evidence supporting psychoanalytical concepts and treatments has been frequently made, most stridently by insurers reluctant to support long-term care. It is true that there are very few randomized controlled trials (RCTs) of more complex and open-ended treatments compared with the number of RCTs of more short-term, symptom-focused therapies. This reflects both cost factors and the complacency of the psychoanalytical community in its long heyday. Despite the scarcity of relevant RCTs, there are abundant scientific data supporting traditional psychodynamic and humanistic treatments^3-6 and their underlying assumptions about defense,^7-10 personality,^9,10 affect,^11,12 attachment,^13,14 and other areas relevant to treatment.

Contemporary neuroscientists^15,16 are also weighing in on the biology of the traditional "talking" cures. Empirical studies repeatedly dem-onstrate that individual personality factors and the quality of the therapeutic relationship account for the lion's share of variance in psychotherapy outcome.^17-20 The strengths of the psychodynamic tradition have been its appreciation for individual differences (often framed as neurotic, borderline, and psychotic organizations interacting with defensive patterns and personality styles) and its explication of relationship factors (working alliance, resistance, transference). In other words, psychodynamic formulations and treatments have emphasized precisely the domains that empirical studies have concluded are critical to outcome.

A tradition that has stimulated, responded to, and benefited from a vast body of research in areas critical to clinical process cannot reasonably be said to be without empirical foundation. Greenspan wanted to make this point and to keep alive in the mental health disciplines the psychodynamic appreciation of individual differences, subjective experience, maturational issues, complexity, and inferences about meaning. While he acknowledged that recent editions of the DSM have greatly facilitated certain kinds of research, he felt that clinical reliance on this manual, in the absence of more inferential, dimensional, and contextual biopsychosocial assessment, has skewed our field in disturbing and even countertherapeutic ways, and he concluded that a more practitioner-oriented classification system might compensate for this effect.

Accordingly, with help from leaders of the sponsoring organizations, he established task forces on adult personality structure and pathology, adult symptom syndromes, childhood and adolescent syndromes, assessment of capacities that comprise mental health, and outcome research. He also solicited original papers from noted psychoanalytical scholars and researchers. Despite considerable theoretical diversity among task force members, Greenspan set a collaborative tone and produced the PDM in just 2 years.