Psychodynamic Diagnostic Manual: PDM-2
1078
Psychodynamic Diagnostic Manual: PDM-2
1078eBookSecond Edition (Second Edition)
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Overview
New to This Edition
*Significant revisions to all chapters, reflecting a decade of clinical, empirical, and methodological advances.
*Chapter with extended case illustrations, including complete PDM profiles.
*Separate section on older adults (the first classification system with a geriatric section).
*Extensive treatment of psychotic conditions and the psychotic level of personality organization.
*Greater attention to issues of culture and diversity, and to both the clinician's and patient's subjectivity.
*Chapter on recommended assessment instruments, plus reproducible/downloadable diagnostic tools.
*In-depth comparisons to DSM-5 and ICD-10-CM throughout.
Sponsoring associations include the International Psychoanalytical Association, Division 39 of the American Psychological Association, the American Psychoanalytic Association, the International Association for Relational Psychoanalysis & Psychotherapy, the American Association for Psychoanalysis in Clinical Social Work, and five other organizations.
Winner--American Board and Academy of Psychoanalysis Book Prize (Clinical Category)
Product Details
| ISBN-13: | 9781462530564 |
|---|---|
| Publisher: | Guilford Publications, Inc. |
| Publication date: | 05/15/2017 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 1078 |
| File size: | 10 MB |
About the Author
Nancy McWilliams, PhD, ABPP, is Visiting Professor Emerita in the Graduate School of Applied and Professional Psychology at Rutgers, The State University of New Jersey, and has a private practice in Lambertville, New Jersey. She is author of Psychoanalytic Diagnosis, Second Edition; Psychoanalytic Case Formulation; Psychoanalytic Psychotherapy; and Psychoanalytic Supervision; and is coeditor of Psychodynamic Diagnostic Manual, Second Edition. She is a past president of the Society for Psychoanalysis and Psychoanalytic Psychology, Division 39 of the American Psychological Association (APA), and is on the editorial board of Psychoanalytic Psychology. A graduate of the National Psychological Association for Psychoanalysis, Dr. McWilliams is also affiliated with the Center for Psychotherapy and Psychoanalysis of New Jersey, and serves on the Board of Trustees of the Austen Riggs Center in Stockbridge, Massachusetts. She is the recipient of honors including the Gradiva Award from the National Association for the Advancement of Psychoanalysis; the Goethe Scholarship Award from the Section on Psychoanalytic and Psychodynamic Psychology of the Canadian Psychological Association; the Rosalee Weiss Award from the Division of Independent Practitioners of the APA; the Laughlin Distinguished Teacher Award from the American Society of Psychoanalytic Physicians; the Hans H. Strupp Award from the Appalachian Psychoanalytic Society; and the International, Leadership, and Scholarship Awards from APA Division 39. Dr. McWilliams is an honorary member of the American Psychoanalytic Association, the Moscow Psychoanalytic Society, the Institute for Psychoanalytic Psychotherapy of Turin, Italy, and the Warsaw Scientific Association for Psychodynamic Psychotherapy. Her writings have been translated into 20 languages.
Read an Excerpt
CHAPTER 1
Personality Syndromes P Axis
CHAPTER EDITORS
Nancy McWilliams, PhD Jonathan Shedler, PhD
CONSULTANTS
Allan Abbass, MD John F. Clarkin, PhD Ferhan Dereboy, MD Glen O. Gabbard, MD Brin Grenyer, PhD Steven Huprich, PhD Robert Michels, MD Judith Rosenberger, PhD,
LCSW
Introduction
A model of personality is ultimately a form of map. Its purpose is to help users find their bearings, orient themselves with respect to recognizable landmarks, and navigate. Different maps serve different purposes (e.g., road maps, topographical maps, political maps). The purposes of the P-Axis "map" of PDM-2 are to deepen clinical practitioners' understanding of their patients and to help them navigate the terrain of treatment.
Other personality maps, such as those included in the Diagnostic and Statistical Manual of Mental Disorders (currently DSM-5; American Psychiatric Association, 2013) and the International Classification of Diseases (currently ICD-10; World Health Organization, 2000), serve different purposes. They have advantages and disadvantages, but clinical practitioners generally do not feel that they provide a level of psychological understanding sufficient to guide clinical treatment (e.g., Spitzer, First, Shedler, Westen, & Skodal, 2008). The P-Axis map is intended expressly for this purpose.
A fundamental difference between the DSM and ICD maps and the P-Axis map is that the former are taxonomies of disorders, whereas the latter is an effort to represent kinds of people (for further discussion of differences and of the rationale for the PDM-2 system, see Appendix 1.1 at the end of this chapter). It aims to promote clinical case formulation — that is, to help clinicians understand an individual's difficulties in the larger context of personality functioning. Such an understanding can inform decisions about whether and when psychotherapy may be helpful, and how to conduct it most effectively for a particular person. Case formulation is also clinically helpful for patients who are not in psychotherapy — for example, in helping clinicians understand and address treatment nonadherence, manage trauma or grief, or work effectively in rehabilitation settings. Although the concepts we present here may be most familiar to clinicians with psychodynamic backgrounds, our goal is to provide information that can deepen the understanding and enhance the effectiveness of clinicians of any theoretical orientation (Lingiardi & McWilliams, 2015).
The major organizing principles of the P Axis are (1) level of personality organization and (2) personality style or type. The former is a spectrum describing severity of personality dysfunction that ranges from healthy, through neurotic and borderline, to psychotic levels of personality organization. The latter represents clinically familiar personality styles or types that cross-cut levels of personality organization. The concept of personality style does not inherently connote either health or pathology, but rather core psychological themes and organizing principles. By locating an individual patient with respect to level of organization and personality style, a clinician can begin to develop a case formulation psychologically rich enough to guide effective treatment.
Conceptualizing Personality
Personality is more about who one is than about what disorder one has. It Comprises considerably more than what is readily observable via behavior alone; it subsumes a range of internal psychological processes (motives, fantasies, characteristic patterns of thought and feeling, ways of experiencing self and others, ways of coping and defending, etc.). Irrespective of overt "presenting problems," many patients come to realize, as they participate in therapy, that their difficulties are inextricably tied up with who they are. They need their clinicians to comprehend something psychologically systemic that helps them understand why they are repeatedly vulnerable to certain kinds of suffering. Psychological problems are often complexly intertwined with personality, may be the flip side of a person's strengths, and need to be appreciated in the context of the whole person, as well as the larger relational and cultural contexts in which the person is embedded. (Note that our use of the term "personality" subsumes what has historically been termed "character." See Appendix 1.2 at the end of this chapter for definitions of "personality," "character," "temperament," "traits," "type," "style," and "defense.") For purposes of psychotherapy aimed at shifting something psychologically fundamental, understanding a person's overall psychological makeup and developmental trajectories may ultimately be more important than classifying symptoms or mastering specific techniques (American Psychological Association, 2012; Norcross, 2011).
Consequently, a skilled therapist conducting a clinical interview not only assesses the patient's current symptoms and mental status, and evaluates the sociocultural context of the immediate problem, but also tries to get a feel for the patient's personality, including strengths, weaknesses, and major organizing themes. In psychotherapy outcome studies, investigators are starting to attend to the role of personality differences (e.g., Blatt, 1990, 1992, 1993, 2008; Duncan, Miller, Wampold, & Hubble, 2010; Gabbard, 2009a, 2009b; Horowitz et al., 1996; Roth & Fonagy, 2005; Westen, Novotny, & Thompson-Brenner, 2004) — an emphasis that is crucial to clinical practitioners, but notably absent from most empirical research.
Personality Styles versus Personality Disorders
There is no hard and fast distinction between a personality type or style and a personality disorder. All people have personality styles. The term "disorder" is a linguistic convenience for clinicians, denoting a degree of extremity or rigidity that causes significant dysfunction, suffering, or impairment. One can have, for example, a narcissistic personality style without having narcissistic personality disorder.
An essential consideration in diagnosing personality disorder is evidence that the person's psychology causes significant distress to self or others, is of long duration, and is so much a part of the person's experience that he or she cannot remember, or easily imagine, being different. Some individuals with personality pathology are unaware of, or unconcerned with, their problematic patterns and come to treatment at the urging of others. Some come on their own, often seeking treatment not for personality patterns but for some more specific, circumscribed distress: anxiety, depression, eating disorders, somatic symptoms, addictions, phobias, self-harm, trauma, and relationship problems, among others.
It is crucial to differentiate personality from symptom syndromes, organic brain syndromes, and psychotic spectrum disorders. Ritualized behavior, for example, may indicate an obsessive–compulsive disorder unrelated to personality, or may be one piece of evidence for a pervasive obsessive–compulsive personality disorder, or may express a psychotic delusion, or may be the result of an organic brain syndrome.
It is also vital to evaluate whether what appears to be a personality disorder is a response to ongoing situational stress. For example, a man who had no notable psychological problems before leaving his homeland, but who has moved into a society whose language he does not speak, may appear paranoid, dependent, or otherwise disturbed in personality functioning (Akhtar, 2011). Under sufficient strain or trauma, any of us can look borderline or even psychotic. Hence it is not possible to diagnose a personality disorder without considering other possibilities that might explain the patient's behavior.
Finally, individuals from cultures unfamiliar to the interviewer can be misunderstood as having personality disorders. Boundaries between normality and pathology are not fixed and universal; they vary, depending on cultural systems (Alarcón & Foulks, 1995a, 1995b; Kakar, 2008; Kitayama & Markus, 1999; Lewis-Fernández et al., 2014; Tummala-Narra, 2016).
Level of Personality Organization (Severity of Disturbance)
The Continuum of Personality Health
The recognition that personality health–disturbance is a dimension or continuum has evolved over decades of clinical observation and research. At the healthy end of the continuum are people who show good functioning in all or most domains. They usually can engage in satisfying relationships, experience and understand a relatively full range of age-expected feelings and thoughts, function relatively flexibly when stressed by external events or internal conflict, maintain a relatively coherent sense of personal identity, express impulses in a manner appropriate to the situation, conduct themselves in accordance with internalized moral values, and neither suffer undue distress nor impose it on others.
At the severely disturbed end of the continuum are people who respond to distress in rigidly inflexible ways, for example, by relying on a restricted range of costly or maladaptive defenses, or have major and severe deficits in many of the domains described in the Summary of Basic Mental Functioning: M Axis (e.g., self–object differentiation, affect regulation, attention, and learning; see Chapter 2, Table 2.1, pp. 118–119).
Historical Context of Levels of Personality Organization
By the end of the 19th century, psychiatric classification distinguished between two general types of problems: (1) "neurosis," a term that may refer to either minor or major psychopathology in which the capacity to perceive reality is intact; and (2) "psychosis," in which there is significant impairment in reality testing. In the ensuing decades, as clinicians slowly appreciated that many people suffer not from isolated symptoms but from issues that pervade their lives more totally, they also began to distinguish between "neurotic symptoms" and "neurotic character," or what we now call "personality disorder."
Throughout the 20th century, clinical writers began describing individuals who seemed too disturbed to be considered neurotic and yet too anchored in reality to be considered psychotic. Slowly, a "borderline" group was identified (Frosch, 1964; Knight, 1953; Main, 1957; Stern, 1938). The concept of a disturbance on the "border" between psychosis and neurosis was subsequently investigated empirically (e.g., Grinker, Werble, & Drye, 1968; Gunderson & Singer, 1975) and elaborated theoretically (e.g., Adler, 1985; Hartocollis, 1977; Kernberg, 1975, 1983, 1984; Masterson, 1972, 1976; Stone, 1980, 1986).
Patients construed as psychologically organized on that border often fared badly in the kinds of treatments that were usually helpful to healthier patients. They would unexpectedly develop intense, problematic, and often rapidly shifting attitudes toward their therapists. Some who did not show psychotic tendencies outside therapy developed intractable "psychotic transferences" (e.g., they might experience their clinicians as omnipotently good or malevolently evil, or as exactly like persons from their past, and could not be persuaded otherwise).
A consensus gradually evolved that personality syndromes exist on a continuum of severity, from a comparatively healthy to a severely disturbed level. This continuum has been conventionally, if somewhat arbitrarily, divided into "healthy," "neurotic," "borderline," and "psychotic" levels of personality organization.
Note that the term "borderline," when used by psychodynamic clinicians to denote a level of personality organization, has a different meaning from the term "borderline" as it used in the DSMs, in which only one specific variant of borderline personality organization has been labeled borderline personality disorder (for a discussion of subtypes and differences from complex trauma, see Lewis, Caputi, & Grenyer, 2012; Lewis & Grenyer, 2009). Our use of the term "borderline" is thus broader than that of the DSMs and more consistent with the clinical observations that gave rise to the term and its widespread professional adoption.
Although each personality style can, in principle, exist at any level of organization, some personality styles are more likely to be found at the healthier (e.g., neurotic) end of the severity spectrum, and some at the sicker (e.g., borderline, psychotic) end. For example, patients with hysterical or obsessional personality styles are more likely to be organized at a neurotic level of severity; those with paranoid or psychopathic styles are more likely to be organized at a borderline level.
The distinction between level of organization and personality style permits, for example, the identification of "quiet borderline" patients (Sherwood & Cohen, 1994), such as schizoid individuals who are psychologically organized at the borderline level of severity. In contrast, the DSM diagnosis of borderline personality disorder essentially conflates borderline organization with histrionic personality disorder (and in the process renders the diagnostic categories of borderline personality disorder and histrionic personality disorder essentially empirically indistinguishable; see Shedler & Westen, 2004). We do refer, however, to research on borderline personality disorder that is based on the DSMs' definitions, given the extensive empirical literature on the DSM-defined syndrome that has accrued since its inclusion in DSM-III in 1980.
Kernberg addressed the problem of discrepant uses of the term "borderline" by distinguishing between borderline personality disorder (the DSMs' concept) and borderline personality organization (the psychoanalytic concept). We adopt his solution here by describing a borderline level of personality organization, and additionally including borderline personality as a diagnosable P-Axis personality style or type. We recognize that the inclusion of borderline personality as a P-Axis personality style is an imperfect and inelegant solution, and is not fully consistent with the conceptual framework that we lay out in this chapter. However, given the extensive literature that exists on the DSMs' construct of borderline personality disorder and its widespread clinical acceptance, we also felt it was necessary to include it.
Recent Findings on Level of Organization
Research indicates that some problems of patients in the borderline range have a genetic component. Twin studies suggest that in both men and women, genetic influences account for about 40% of the variance in the severity of borderline traits (e.g., Distel et al., 2008; Leichsenring, Leibing, Kruse, New, & Leweke, 2011; Torgersen et al., 2008). Indeed, genetic interpersonal hypersensitivity has been put forward as an endophenotype marker (Gunderson, 2007). Neuroimaging studies have revealed the functional neuroanatomy of borderline disorders that are associated with the hypersensitivity, intolerance for aloneness, and attachment fears typical of patients in this broad diagnostic group (Buchheim et al., 2008; Fertuck et al., 2009; King-Casas et al., 2008).
Whereas past generations of psychoanalytic thinkers tended to view level of severity with fixation at, or regression to, a particular developmental challenge or stage, contemporary theorists understand personality pathology as reflecting a confluence of factors, including genetic heritability, temperament, early life experiences (e.g., trauma, neglect), and early attachments, among other factors. For a discussion of "biopsychosocial" models of personality, see, for example, Leichsenring and colleagues (2011) or Paris (1993).
As suggested by the findings of Clarkin, Kernberg, and their colleagues (e.g., Clarkin et al., 2001; Clarkin, Levy, Lenzenweger, & Kernberg, 2004, 2007; Clarkin, Yeomans, & Kernberg, 1999), and Greenspan and his colleagues (e.g., Greenspan & Shanker, 2004), we recommend evaluating where an individual's personality lies on the severity dimension by assessing the following domains, elaborated in Chapter 2:
1. Capacity for regulation, attention, and learning
2. Capacity for affective range, communication, and understanding
3. Capacity for mentalization and reflective functioning
4. Capacity for differentiation and integration (identity)
5. Capacity for relationships and intimacy
6. Capacity for self-esteem regulation and quality of internal experience
7. Capacity for impulse control and regulation
8. Capacity for defensive functioning
9. Capacity for adaptation, resiliency, and strength
10. Self-observing capacities (psychological mindedness)
11. Capacity to construct and use internal standards and ideals
12. Capacity for meaning and purpose
Chapter 2 describes a way of evaluating an individual's mental functioning that is helpful for locating his or her personality in the healthy, neurotic, borderline, or psychotic range.
Healthy Level of Organization
Psychopathology expresses the interaction of stressors and individual psychology. Some people who become symptomatic under stress have overall healthy personalities, as assessed by the Summary of Basic Mental Functioning: M Axis (see Chapter 2, Table 2.1, pp. 118–119). They may have certain favored ways of coping, but they have enough flexibility to accommodate adequately to challenging realities (though not necessarily to severe trauma, which can damage even people who may seem quite resilient; see Boulanger, 2007). We all have a characteristic style or flavor or type of personality, or a stable mixture of styles. For example, the fact that one has a consistently pessimistic outlook is not a sufficient criterion for diagnosing depressive personality disorder.
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Table of Contents
Introduction, Vittorio Lingiardi & Nancy McWilliamsI. Adulthood
1. Personality Syndromes—P Axis, Nancy McWilliams & Jonathan Shedler
2. Profile of Mental Functioning--M Axis, Vittorio Lingiardi & Robert F. Bornstein
3. Symptom Patterns: The Subjective Experience—S Axis, Emanuela Mundo & John Allison O’Neil
II. Adolescence
4. Profile of Mental Functioning for Adolescents—MA Axis, Mario Speranza & Nick Midgley
5. Emerging Personality Patterns and Syndromes in Adolescence—PA Axis, Johanna C. Malone & Norka Malberg
6. Adolescent Symptom Patterns: The Subjective Experience—SA Axis, Mario Speranza
III. Childhood
7. Profile of Mental Functioning for Children—MC Axis, Norka Malberg & Larry Rosenberg
8. Emerging Personality Patterns and Difficulties in Childhood—PC Axis, Norka Malberg, Larry Rosenberg, & Johanna C. Malone
9. Child Symptom Patterns: The Subjective Experience—SC Axis, Norka Malberg & Larry Rosenberg
IV. Infancy and Early Childhood
10. Mental Health and Developmental Disorders in Infancy and Early Childhood—IEC 0–3, Anna Maria Speranza & Linda Mayes
V. Later Life
11. Introduction to Part V, Franco Del Corno & Daniel Plotkin
12. Profile of Mental Functioning for the Elderly—ME Axis, Franco Del Corno & Daniel Plotkin
13. Personality Patterns and Syndromes in the Elderly—PE Axis, Franco Del Corno & Daniel Plotkin
14. Symptom Patterns in the Elderly: The Subjective Experience—SE Axis, Franco Del Corno & Daniel Plotkin
VI. Assessment and Clinical Illustrations
15. Assessment within the PDM-2 Framework, Sherwood Waldron, Robert M. Gordon, & Francesco Gazzillo
16. Clinical Illustrations and PDM-2 Profiles, Franco Del Corno, Vittorio Lingiardi, & Nancy McWilliams
Appendix. Psychodiagnostic Charts (PDCs)
Interviews
Clinical psychologists, psychiatrists, psychoanalysts, clinical social workers, psychiatric nurses, and mental health counselors. May serve as a supplemental text in graduate-level courses.