From symptom to process: Case formulation, clinical utility, and PDM-2.

Abstract

The Psychodynamic Diagnostic Manual (PDM) and its successor, the PDM-2, were developed to provide a framework for conceptualizing psychological dysfunction that is more comprehensive and clinically useful than extant symptom-focused diagnostic manuals (i.e., the International Classification of Diseases, the Diagnostic and Statistical Manual of Mental Disorders). By evaluating symptom patterns and the patient’s subjective experience (Axis S), personality patterns and disorders (Axis P), and the individual’s mental functioning in a broad array of domains (Axis M), the PDM-2 provides a contrasting, person-centered perspective to the conceptualization and classification of psychopathology. This article examines the ways in which PDM-2 can enhance case formulation, psychodynamic and otherwise. I begin by describing the evolution of the major diagnostic systems, and contemporary approaches to case formulation. I discuss the role of diagnostic manuals in case formulation, and the ways in which PDM-2 may be more helpful than other diagnostic systems in this regard. Finally, I describe the ways in which PDM-2 sets the stage for more rigorous multimethod psychological assessment to enhance case conceptualization and facilitate treatment, and offer suggestions for future work in this area.

The DSM’s Reconnection to Psychoanalytic Theory through the Alternative Model for Personality Disorders

“…By design, the PDM recognizes the dimensionality of personality health, from the healthy end, where good functioning is shown by an individual in all or most domains, to the severely disturbed end of the continuum, where individuals display a level of personality dysfunction that causes suffering or impairment. The range of case formulation afforded by this system and its dimensional framework enables a clinician to evaluate risk, identify treatment goals, select suitable interventions to meet those goals, and pinpoint potential ruptures that will interfere with the therapeutic process for patients presenting with any level of personality health (Bornstein 2018). The DSM and ICD systems, by contrast, are symptom-focused and employ taxonomic approaches to classify or categorize disorders.…”

“…The DSM and ICD systems, by contrast, are symptom-focused and employ taxonomic approaches to classify or categorize disorders. These symptom-focused diagnostic systems were originally designed to facilitate research and communication (Bornstein 2018), an objective they approach using the concept of distinct personality disorders. As diagnostic entities, these personality disorders, despite long-standing problems in clinical practice associated with their categorical classification (Acklin 1993; Clark 2007; Strack 2006; Tyrer 2012; Zimmerman, Rothschild, and Chelminski 2005), have shown fair reliability and validity (Blais and Norman 1997; Holdwick et al 1998).…”

“…As diagnostic entities, these personality disorders, despite long-standing problems in clinical practice associated with their categorical classification (Acklin 1993; Clark 2007; Strack 2006; Tyrer 2012; Zimmerman, Rothschild, and Chelminski 2005), have shown fair reliability and validity (Blais and Norman 1997; Holdwick et al 1998). Personality disorder categories have also been recognized for their value in epidemiological research and the comparison of large populations, ability to provide terminology for communication across theories and disciplines (e.g., medical, public policy, education), use in psychopharmacological decision making and insurance reimbursement, and for their systematized diagnostic criteria advantageous in the study of treatment efficacy and antecedents, correlates, and consequences of different forms of pathology (see Bornstein 2018). Despite the ever evolving debate over how “best” to conceptualize personality (a debate reviewed in the following sections), it is important to recognize the validity and utility of each of the current personality diagnostic and classification systems (for a meta-analytic review comparing the clinical utility of these systems, see Bornstein and Natoli 2019).…”

From the Manifest Motive to the Real Demand of the Patient in the Psychological Consultation [Del motivo manifiesto a la demanda real del paciente en la consulta psicológica]

“…The therapist will have to help, be flexible and with the capacity for abstraction to lead the patient to be able to manage, organize and discover the meanings about her own symptom in such a way that the subject is perceived as an integrated being. Returning to Bornstein (2018), the evaluation of symptoms is not enough for the subjective understanding of the patient; it requires a wide range of conceptual and technical domains in psychotherapy.…”

Introduction to the Special Issue on the Psychodynamic Diagnostic Manual, 2nd Edition (Pdm-2): The Pdm: Yesterday, Today, Tomorrow

“…The PDM-2 perspective on later life is reviewed in the article by Del Corno and Kiosses (2018). The authors explore the complexities of such diagnostic assessment as it relates to mental functioning, personality patterns, and the evaluation of symptoms and their effects on the subjectivities of patients and clinicians Bornstein (2018). then examines how the PDM-2 can enhance case formulation, psychodynamic and otherwise.…”