The Psychodynamic Diagnostic Manual: An Effort to Compensate for the Limitations of Descriptive Psychiatric Diagnosis

Abstract

This article describes, from the perspective of a participant in the process, the background of and rationale for the development of the Psychodynamic Diagnostic Manual (PDM), a classification system based on both long-standing clinical observation and recent empirical research. It was hoped that the PDM would compensate for some of the unintended negative consequences to practitioners and their clients of uncritical reliance on descriptive psychiatric taxonomies such as the Diagnostic and Statistical Manual of the American Psychiatric Association. A shared and motivating experience of the contributors to the PDM was dismay at how the dominance of a narrow, descriptive-psychiatry model has promoted the decline of the empirically sound and clinically valuable idiographic tradition, in which clients’ difficulties are conceptualized in the context of their unique personalities, developmental challenges, and life contexts. Strengths and limitations of the new manual are discussed, as are ideas about its clinical utility.

Acknowledgments

I am grateful to Jonathan Shedler for his considerable contributions to this article (and to the PDM) and to Kerry Gordon for his thoughtful critique.

Notes

This critique applies equally to the International Classification of Disease (ICD) system, which is seldom used in the United States and is less familiar to me and most contributors to the PDM.

In at least one instance, a drug company tried to create a disorder category: When Prozac's patent expired, Eli Lilly repackaged its product as Sarafem, a cure for the new disease entity “premenstrual dysphoric disorder” (Kaplan & Congrove, 2004; Shedler, 2001).

Although not dimensional, the multiaxial structure of the DSM does invite the examination of several coexisting, interwoven aspects of a client's suffering. However, the taxonomic segregation of personality disorders from other categorically construed problems permitted some unanticipated assaults on practice. Insurance companies have exploited the categorical separation by deciding not to include coverage of Axis II diagnoses in the “comprehensive mental health care” they had promised when marketing their plans to employers. This concern might soon be dated, as the next edition of the DSM will reportedly be more dimensional—although it is hard to know yet what kind of dimensionality is intended (see, e.g., Brown & Barlow, 2005, on several different possibilities).

I cannot cite data to support this contention, but I frequently comment to audiences of psychotherapists that the nonforensic clinical community diagnoses by the rule of “What is the least stigmatizing label for this person's suffering that would be covered by insurance?” and the observation has always evoked confirming nods and smiles.

More specifically, the personality style was called hysterical, and its borderline versions were called either histrionic or hysteroid.

It is noteworthy that this label itself, unlike psychopathy, reflects a sociological interest in phenomena that deviate from conventional norms, in contrast to the therapist's concern with inner experience such as wishes and motives, defenses and coping strategies, perceptions of self and others, and so on.

Interestingly, in an empirical investigation of a parallel problem in psychopharmacology, Wisniewski et al. (2009) concluded that “representative treatment-seeking patients” are not included in Phase III drug trials.

On the other hand, the fact that psychiatrists, social workers, and others contributed to the PDM means that it cannot be claimed by psychology as a discipline. A title that could have been interpreted that way would be misleading.