Customer Reviews

Psychodynamic Diagnostic Manual: (PDM)

5 star:		(13)
4 star:		(3)
3 star:		(0)
2 star:		(0)
1 star:		(0)

 

 

Finally the psychoanalytic world has produced a diagnostic manual that describes people in a way that is true to life since it incorporates symptoms, inner experiences and the person's strengths and weaknesses. This book at long last puts into black and white the diagnostic map that analysts have used for the past 30 years, though never as an authorized nosology. The result of the long delay is the sad truth that the DSM has had no competition. Wisely the authors--essentially everyone in field of note who has been interested in questions of diagnosis including Kernberg, Wallerstein, McWilliams and Drew Westen -- present the PDM as complementary to the DSM rather than as a replacement since the DSM is unfortunately too firmly entrenched to be dislodged. However the PDM really boils down to an alternative diagnostic system, which corrects the over-simplifications, some of the omissions and a lot of the implicit biological bias of the DSM. In the correcting-omissions-department the PDM restores some traditional personality types that are very common in office practice - like depressive and masochistic - that were left out of the DSM because politically important factions lobbied against their inclusion. The PDM also has restored 'borderline' to its more usual usage as a level of severity. Still, there are suprises in the PDM. Three new "personality types" are introduced, and without full explanation why. These are the the anxious, the dissociative and the somatizing personalities. Usually anxiety, somatization and dissociation are included as symptoms (which the PDM does as well) but here these pathologies are listed as defining personality types. Since no research data is presented to support these additions, the impression is left that one or more members of the Committee prevailed and had to be assuaged in order to hammer out the final compromise document. But what will be most suprising to people who buy this book -- expecting a diagnostic manual -- is that about half of this 800 page book is not a manual at all but a collection of supportive research articles that are not specifically explications of the PDM's diagnostic system. The articles amount to a high level conversation between the analytic researchers and the makers of the DSM, particularly the Axis II committee. It remains to be seen if the audience for this kind of manual - clinicians overwhelmingly - will be put off by so much of the book being devoted to learned articles not obviously related to "The Manual." I myself would have preferred that these pages had been devoted to a fuller explication of the diagnostic system of the PDM (sometimes described too briefly) and with more case examples, since that would help ensure that different readers apply the criteria in the same way (i.e. the reliability issue). Nonetheless the PDM towers over the DSM and no quibble about shortcomings should obscure that fact. The overall schema is more true to life and more clinically on target and the personality types are better described and in fewer words than those of the DSM. Unlike the DSM you won't need a tool kit from Home Depot to fit someone into a diagnostic category.

When I first learned about the PDM, I was so intrigued about this much needed and exciting alternative to the DSM that I decided to develop a continuing education online course for psychotherapists, which provides a historical context and a systematized summary of the clinically most relevant part of the new manual. In this process I learned to appreciate that, unlike the DSM or the ICD, which focus exclusively on pathology, the PDM includes descriptions of healthy functional patterns and healthy personality. The new manual insists that personality be evaluated first, and symptoms considered as secondary, because symptoms cannot be understood, assessed, or treated in the absence of an understanding of the personality structure of the person who has the symptoms. While the PDM sees it as important to differentiate "personality disorder" from personality per se, the manual does not present a hard-and-fast dividing line between the two, but suggests a continuum of severity. In contrast to the DSM, the psychodynamic manual considers subjective experiences, typical relationship patterns, and ways of engaging in the therapeutic process in the description of a person's overall functioning. For each personality disorder, clinicians learn what transference and countertransference reactions to expect in the clinical hour and what treatment approach to consider. For many diagnoses the possible psychological roots of the client's problems are mentioned. The manual emphasizes that, depending on their evaluation of a client's location on this severity dimension, therapists need to behave with important differences in emphasis, level of activity, explicitness of boundary-setting, frequency of sessions, and other features of technique. It becomes clear that there is a continuum from exploratory to supportive treatment that correlates roughly with the level-of-organization dimension. I believe that the PDM is a useful and invaluable resource for psychotherapists of most clinical orientations.

This is a bold and accomplished attempt by the psychoanalytic collaborative to produce a diagnostic manual that respects the phenomenological astuteness of the DSM-IV-TR, whilst asssertively departing from it and offering a personality centred nosology for categorising psychological difficulties.

The PDM corrects what has long been the bain of psychologists and psychotherapists, namely, the DSM's prioritising of discreet Axis I disorders over an understanding of how these form a part of a person's overall orientation to self, others and the world. The PDM recognises the personality, both healthy and disordered, (the P Axis) as the basis for understanding psychological problems. It further offers the M Axis, that begins to provide measurable psychodynamic criteria for mental functioning that cuts across personality style. This axis introduces a way of thinking about the developmental (maturational) aspects of our psychology as pivotal to an understanding of psychological disorders. Finally, the PDM in its 3rd S Axis, outlines the Subjective Experience that characterises the typical DSM Axis I-like difficulties. Here the PDM explores affective, cognitive, somatic, and relationship patterns associated with psychological difficulties in a manner evocative of a CBT formulation. In fact, I hope that in future editions, more of the fine cross-sectional formulations that CBT is famous for will find its way into this manual.

Being versed in psychodynamic theory is not a pre-requisite for the use of this manual, although it could help. The PDM has attempted to move beyond and integrate and systematise the divergent streams of knowledge that make up psychodynamic theory today. In addition it has employed understanding from the cognitive and neuropsychological traditions to provide a more descriptive view of the person-in-suffering than the compartmentalised DSM could. That said, the PDM does not attempt to replace the DSM, but functions as a complimentary adjunct, by providing the DSM equivalents of its own categories.

One of the strengths of this manual is that it is full of rich case illustrations. Half the book is also dedicated to the research base for the nosology that opens up and attempts to engage with the fissures in diagnostic thinking that are usually whitewashed in everyday practice.

The true test of the PDM will reside in its application, to find its way into psychological reports and formulations, and for its editorial team to continue its integrative psychological spirit that may stretch beyond specifically psychoanalytically/dynamically derived knowledge. I urge you to take this one on for size. Diagnostic systems are here to stay, we ignore them at our peril, and the PDM is a courageous first attempt to tame the diagnositc beast with the tempering of meaning and astute psychological science.

I agree Dunn and Wolz have said it all regarding the PDM. I have only one criticism of this excellent diagnostic volume, that the descriptions of the disorders are too brief. However, its brevity in that regard is instantaneously forgotten when considering it presents mental health from a truly holistic perspective. Any clinician working in the field should have this book!

Dr. Peter B. Dunn summarized this book fantastically in his review. Even upon first skimming the book, I was shocked at how clearly and realistically diagnostic categories are presented (the key word being REALISTICALLY). If you are even simply interested in therapy, this is a book that you must own.

This is a long over due alternative to the DSMlV-R. The joint effort of six of the countries dynamically oriented professional organizations have led to a fully referenced and well thought out manual using a psychodynamic/psychoanalytical oreintation to understanding the patient.
Using a three axis model including Personality Patterns and Disorders,Mental Functioning axis and Subjective Experience to help the clinician organize the elements of the dynamic presentation of the patient Each axis has usefull subsets and using them the clinician can deveolpe a dynamic picture of the whole patient. This is a wonderful tool and teaching device. Kit Erskine M.S.Ed., M.S.W., L.I.C.S.W.

If you're anything like me (by like "me" I mean you're not necessarily fond of the DSMs) chances are you'd like this alternate classification. All of the heavyweight psychoanalysis organizations joined together to produce a diagnostic manual that takes into account the subjective experience of the patient, beyond the description of a general diagnosis. The reason I'm not giving it 5 stars is because I'd like it to have important information on transference and countertransference. Being created by the psychoanalytic organizations you'd expect it to include some notes on the Transference/Countertransferece experience in general for each pathology. But the truth is that this manual is actually useful even for therapists outside the psychoanalytic field, so the transferences/countertransference would have probably narrowed the group of psychotherapists it can reach being written the way it is.

I am not essentially a psychodynamicist (though I have written extensively on the Karpman Drama Triangle, codependence, and family of origin issues in the addictions.) I am fundamentally a cognitivist, and a rational-emotive one at that. Yet I found the PDM extremely enlightening and worthwhile, at least through the first 650 pages.

Rather than approach the topic as "better or worse than the DSM or ICD," I'm just going to touch upon some of the book's specific strong points:

Why else does the patient turn up in front of us? Because he is in pain. And he wants, first and foremost, to feel that he is -understood-. We could all use a little more empathy here. Odd, perhaps, that a "client-centered" notion seems to underly the principally psychodynamic creative effort here. But I'm gratefull that it does.

I found "The Internal Experience of Psychic Trauma and Posttraumatic Stress" on pages 100-106 to be some of the most accurately descriptive material I have run across on PTSD from the patient's perspective. I can assert that because I've spent quite a bit of time on both sides of the nursing station counter with this particular diagnosis. The PTSD sufferer really -suffers-; this section may help the practitioner understand precisely -how-.

In fact, the adaptation of the organizing principle of "The Internal Experience of..." to a range of diagnoses has lead to descriptions from pages 93-148 that struck me as some of the most-empathy-inducing I have encountered in the professional literature. I did not expect this from a "manual," and was very pleasantly surprised to find it.

While the section on "Infancy and Early Childhood" (pp. 320-375) is neither Brazelton & Cramer, Perry, Seigel, or Stern in terms of depth, detail or turn of phrase, I again found it to be surprisingly empathic for this format. The child is in front of us because he either hurts himself, causes his caregivers to hurt, or both. The descriptions of pretty much all that we have recognized thus far are effective, as well as discerning and discriminative.

The material on pp. 345-351 concerning the "Sensory Modulation Difficulties" will be an eye-opener for those who are not deeply grounded in early life research. Do parents over-stimulate their children into the doctor's office nowadays as much parents of two generations ago under-stimulated them? That is what I see in the real world, and it is well-addressed here.

Greenspan and Shanker's "Developmental Framework for Depth Psychology and a Definition of Healthy Emotional Functioning" on pp. 431-473 provides sufficient data for the psychodynamically-oriented therapist to understand at depth what he is seeing in front of him, and what needs to be done about it from a "re-developmental" perspective.

In it, I found myself able to construct a simple forumlation of remediation as a process of working back through the defense mechanisms of the psychotic-level demonstrations -- or truly "infantile" assessment of the environment -- then rebuilding through what may be developmentally incomplete, but hopefully temporary, borderline defenses, onto more developmentally complete, "societally normal neurotic" defenses... and even onto (if the patient is willing to foot the bill) -very- developmentally complete, reality-based, rational and empirical defenses.

Shevrin's "...Neurophysiological Frames of Reference to a Psychodynamic Nosology..." (pp. 483-506) helped me clarify the notion of specific "paths of dissociation" I have seen in so many adults molested as children, and other traumatees. I think van der Kolk, for one, would see the sensibility of Shevrin's "neuropsychological" theses here.

And for those looking for in-depth material on the increasingly popular SWAP diagnostic asssessment tool, there are 38 pages of it here (pp. 573-610) from Shedler and Westin themselves. Much of the article is a defense of the validity and reliability of the SWAP. But I was particularly taken with the adaptation of the SWAP concepts to a case history of borderline personality on page 591-592 in which BPD is effectively presented as a "defensive process" rather than as a set of traits.

This is, after all, what any of the personality disorders really are when we take a diagnostic snapshot over the course of an hour or two. Are we seeing any more than the lab results of the state of being at that particular moment? I think not, and that is vital for those who work with borderlines (and -any- of the other personality disorders, really) to understand.

In my view, the behavioral adaptations of the moment represent a point along an unfolding process of continuing, corrupted, Eriksonian development. No single assessment -- or diagnosis -- ever be cast in bronze. A "working hypothesis on this particular date" is more like it. I'm gratified, I suppose, to see that others understand this, as well.

I am not so taken with all the material that follows in the final 200 pages. But understanding the need to lay some empirical bedrock for the afforementioned theoretical constructs, I accept that it has to be there... even if it may do as much to put the afforementioned in question (for some readers) as it does to back it up.

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Yes it is a masterpiece in nosology, but it is not just for professionals who need to diagnose for a living. ANYONE who wants to understand personality- I mean the FULL range of personality should read as least pages 1 to 31! You will read the non-dogmatic culmination of over 100 years of research, case study and wisdom that is applicable to all theoretic orienations. I have taught the PDM to non and even anti-psychodynamic psychologists. What happens? Except for very few defensive types, the all loved it. [...]

I found this manual a useful resource for the evaluation and treatment of our consultants.
It's also an invaluable aid for teaching psychotherapy.
As it presents personality traits as a continuum, with emphasis in healthy functional patterns and healthy personality, the comprehension of psychopatology results a dynamic process, not a cold list of symtoms.