From Surface to Depth: Toward a More Psychodynamically Informed DSM-6

Abstract

Although early editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; Alliance of Psychoanalytic Organizations, 2006) incorporated a broad array of psychodynamic concepts, the influence of psychoanalysis in the DSM series has waned with each successive revision. The depsychoanalyzing of the DSM had a number of negative effects (e.g., increased syndrome comorbidity, diminished clinical utility). This article discusses how psychoanalytic concepts—once central but now marginalized—have much to contribute to DSM-6. I examine several ways in which a psychodynamic perspective can enhance the diagnostic manual, and challenges that may arise when psychodynamic concepts are reintroduced. I then present a psychodynamically informed framework for diagnosis in DSM-6 and beyond, which incorporates information in 4 domains: (a) overall level of functioning, (b) symptoms and syndromes, (c) underlying dynamics (i.e., ego strength, defense style, object relations), and (d) contextualizing factors (i.e., culture, stress, resilience and adaptation). I note how key constructs can be operationalized by clinicians and clinical researchers, and how dynamic assessment data can be integrated with descriptive, symptom focused information to enhance diagnosis and facilitate treatment planning.

Notes

¹ Although the GAF has been omitted from the DSM-5, it continues to be examined by clinical researchers, and can be reintroduced in DSM-6 if needed.

² The DSM-5 Personality and Personality Disorders (PPD) work group proposed a somewhat different method for assessing overall level of personality functioning, involving clinician ratings of self-concept and interpersonal functioning. The former emphasized patients’ identity (e.g., clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal), and self-direction (e.g., pursuit of meaningful life goals, ability to self-reflect productively); the latter emphasized empathy (e.g., comprehension and appreciation of others’ experiences and motivations), and intimacy (e.g., depth and duration of positive connection with others, desire and capacity for closeness). This approach holds considerable promise, and has been included in Section 3 of DSM-5 to encourage continued study (see APA, 2013).

³ Although a skeptic might argue that the need for a psychodynamically informed DSM-6 is obviated by the existence of the PDM, there are fundamental differences between the two systems. For example, the PDM specifically avoids listing symptoms so that diagnoses may be rendered holistically, incorporating whatever information regarding the patient’s intra- and interpersonal functioning seems most relevant to the clinician. In contrast to DSM diagnoses, PDM category descriptions are deliberately written to capture the patient’s private, subjective experience, and to emphasize the idiographic nature of psychopathology. Detailed reviews of the PDM, and discussions of contrasting features of DSM and PDM are provided by McWilliams (2011), Huprich et al. (2015; this issue), and Lingiardi et al. (in press).

Additional information

Notes on contributors

Robert F. Bornstein

Robert F. Bornstein, Ph.D., is with the Derner Institute of Advanced Psychological Studies at Adelphi University.