From Symptom to Process: How the PDM Alters Goals and Strategies in Psychological Assessment

Abstract

In many respects the Psychodynamic Diagnostic Manual (PDM) P and M Axes represent psychoanalytic versions of Diagnostic and Statistical Manual of Mental Disorders (DSM) Axes II and V: Whereas the DSM axes focus on surface behaviors and their associated mental states (e.g., thought patterns, affective responses), the PDM axes emphasize underlying psychodynamic processes (e.g., implicit motives, conflicts, defenses), with more modest attention to expressed behavior. The paradigmatic shift envisioned by the PDM creates tremendous opportunities for clinicians and researchers, and significant assessment challenges as well. This article discusses those opportunities and challenges. After briefly contrasting the DSM and PDM conceptualizations of personality pathology and global psychological functioning, I discuss the implications of these contrasting perspectives for diagnosis and psychological assessment, outline strategies for documenting the construct validity of DSM and PDM symptom criteria using symptom-focused and process-focused methods, and offer suggestions for how DSM symptom-focused data can be integrated with PDM process-focused data to facilitate case conceptualization and treatment planning.

Notes

One might argue that PD screening questionnaires and diagnostic interviews are in fact assessment tools—and technically they might be—but in this context there is an important distinction to be made between the structure of an instrument and the goals of that instrument. Structurally PD screening questionnaires do indeed resemble psychological assessment tools like the Personality Assessment Inventory (PAI; Morey, 1991) and MMPI–2 (Butcher & Megargee, 1989) and like these assessment tools PD questionnaires and interviews must meet acceptable criteria for retest reliability, interrater reliability, and convergent and discriminant validity (Widiger & Samuel, 2005). Despite these similarities, these two types of instruments differ with respect to their central purpose: PD questionnaires and interviews are designed to quantify symptoms and syndromes, whereas assessment tools like the Rorschach Inkblot Method (RIM; Rorschach, 1921) and MMPI–2 are designed to tap implicit and self-attributed needs, motives, attitudes, and affect states (see Bornstein, 2007a).

Other categories of assessment instruments within a process-based framework include constructive tests (e.g., the Draw-a-Person test) that require the testee to create a novel image or written description within parameters defined by the tester; observational tests (e.g., Spot Sampling) wherein test scores are derived from observers’ ratings of a person's behavior in vivo, or in a controlled setting, and informant-report tests (e.g., the Informant Report version of the NEO Personality Inventory) wherein scores are based on knowledgeable informants’ judgments of a person's characteristic patterns of behavior and responding. A detailed discussion of these test categories is provided by Bornstein (2007b).

There are also a number of variables that are not indexes of validity in its strictest sense, but are nonetheless germane in this context. For example, retest reliability also has implications for validity: When a predictor is designed to quantify a construct that is presumed to be stable over time (e.g., Axis II symptomatology), inadequate retest reliability is prima facie evidence of a problem with construct validity.

Although a defining feature of personality pathology is limited insight and self-awareness, it is important to note that many patients with Axis I disorders also show modest insight into inter- and intrapersonal processes that characterize their current difficulties. For example, panic disorder patients are often unaware of the triggers that precipitate panic episodes, and anorexic patients characteristically misperceive extreme emaciation as optimal slimness, exacerbating their avoidance of food.