From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization

PURPOSE OF REVIEW

The concept of personality functioning (Alternative DSM-5 Model of Personality Disorders) has led to increased interest in dimensional personality disorder diagnosis. While differing markedly from the current categorical classification, it is closely related to the psychodynamic concepts of personality structure and personality organization. In this review, the three dimensional approaches, their underlying models, and common instruments are introduced, and empirical studies on similarities and differences between the concepts and the categorical classification are summarized. Additionally, a case example illustrates the clinical application.

RECENT FINDINGS

Numerous studies demonstrate the broad empirical basis, validated assessment instruments and clinical usefulness of the dimensional concepts. Their advantages compared to the categorical approach, but also the respective differences, have been demonstrated empirically, in line with clinical observations. Evidence supports the three dimensional concepts, which share conceptual overlap, but also entail unique aspects of personality pathology, respectively.

Operationalized psychodynamic diagnosis: a systematic review of the literature

INTRODUCTION

The Operationalized Psychodynamic Diagnosis (OPD-2) is an operational multiaxial diagnostic assessment and treatment planning tool. This systematic review sought to analyze empirical studies that used the OPD as an instrument. In addition to identifying the studies, we analyzed the topics covered and the results of research that used the OPD empirically.

METHOD

Articles, dissertations and empirical theses that mentioned or used the OPD instrument in the last five years (2012-2017) were included in this review. The strategy included searching with combinations of the descriptors "Operationalized and psychodynamic and diagnosis" from the Portal de Periódicos CAPES on the PubMed, Google Scholar, and ResearchGate databases for work published in English, Portuguese or Spanish in the last five years.

RESULTS

The search returned a total of 189 papers, but only 20 were included. The studies selected discussed the validity and reliability of the instrument, the therapeutic process and analysis of outcomes, assessment of different mental disorders, and also included studies comparing different instruments and techniques. Considerable scientific effort has evidently been dedicated to accumulating more consistent data on psychodynamic diagnosis.

CONCLUSION

It was demonstrated that the OPD is an essential clinical tool for dimensional comprehension of the subject and for scientific research. However, the number of publications on the subject is not yet significant and the methods employed are diverse. Nevertheless, there is a growing body of data on topics such as applicability in different contexts and to different pathologies, promoting greater visibility and with greater representativeness of professionals who have experience with the instrument.

Diagnostic Classification Systems Based on Psychoanalytical Principles

The diagnostic classification systems in psychiatry practice which are used worldwide extensively, The Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD) are far away from the psychoanalytical point of view. It is thought that this gap results in the difficulty to understand psychiatric patients in clinical practice for many years. It has also created an obstacle to scientific researches addressing the validity and reliability of the psychoanalytical principles. On the other hand, psychoanalysis has been much criticised for years due to the lack of empirical foundations. As a result of this paucity, psychiatry is led by the biomedical approach. Without enough grounds in evidence-based medicine, psychoanalytical principles could not become widespread in psychiatric practice. To survive criticism and strengthen its place in contemporary psychiatry, empirical research in psychoanalytical discipline has gained momentum in the last two decades. Development of objective psychodynamic diagnostic tools enabled the design of such studies. The aim of this review is to introduce such diagnostic tools, namely Psychodynamic Diagnostic Manual (PDM) and Operationalized Psychodynamic Diagnosis (OPD), and to discuss the possible contributions they provide for psychoanalytical perspective to take its deserved place in the psychiatry discipline.

Assessing Level of Personality Organization With the Psychodiagnostic Chart: A Validity Study

Heterogeneity within diagnostic types and comorbidity across diagnostic groups render a specific personality disorder anything but specific, leading researchers and clinicians to increasingly focus on the general severity of personality pathology. Personality pathology severity is reflected in one's level of personality organization (LPO) and research has demonstrated that LPO is a significant predictor of treatment response. This investigation examined the reliability and validity of the Psychodiagnostic Chart (PDC) in assessing the LPO dimension of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006). Among a sample of 88 urban-dwelling women seeking primary medical care, the LPO dimension of the PDC received fair to good interrater reliability among 6 psychodynamic psychologists. Convergent validity was demonstrated with contrast analysis and individual correlations that yielded statistically significant associations between LPO scores and conceptually related psychodynamic variables (e.g., defensive functioning, object relations) and self-reported personality pathology scores. Support for discriminant validity was limited by the modest power associated with the sample size. Exploratory analyses examining LPO scores and measures of physical health and intimate partner violence were conducted. Our results supported the reliability, validity, and practical use of the LPO dimension of the PDC.

The Contribution of Sidney Blatt's Two-Polarities Model to the Psychodynamic Diagnostic Manual

This article reviews the theoretical and empirical contributions of Blatt's two-polarities model of personality development and psychopathology to the second edition of the Psychodynamic Diagnostic Manual (PDM-2). First, we briefly provide an overview of the manual's main features and describe the guiding principles of the revision process. We then discuss in more detail how Blatt's model, which is focused on the dialectic interaction between anaclitic-introjective and relatedness vs self-definition dimensions in both normal and disrupted personality development, increases the PDM-2's theoretical and empirical comprehensiveness and clinical utility, especially concerning the classification and assessment of personality and overall mental functioning in adult populations. Finally, we address the implications for the therapeutic process, showing how anaclitic and introjective patients may be differentially responsive to different psychodynamic techniques (e.g., supportive or expressive interventions). Taken together, these considerations demonstrate the importance of a more theory-driven and empirically informed diagnostic system that embraces, in accordance with Sidney Blatt's empirically supported and psychoanalytically-oriented ideas, the complexities of human experience (both normal and pathological) and captures the subjective and underlying dynamics of psychological symptoms and syndromes.

The Relationship between Theoretical Orientation and Countertransference Expectations: Implications for Ethical Dilemmas and Risk Management

Countertransference (CT) awareness is widely considered valuable for differential diagnosis and the proactive management of ethical dilemmas. We predicted that the more practitioners' theoretical orientation (TO) emphasizes insight into the dynamics of subjective mental life, the better they will be at using their CT expectations in differential diagnosis with high-risk patients. To test this hypothesis, we compared psychodynamic therapy (PDT) practitioners who emphasize insight into subjective mental life with practitioners who do not emphasize this epistemology. Results indicated that PDT practitioners expected significantly more CT than practitioners of cognitive-behavioural therapy (CBT) and other practitioners (e.g., family systems, humanistic/existential and eclectic) to patients with borderline personality organization overall. PDT practitioners had significantly more CT expectations to patients with borderline-level pathologies as compared with neurotic-level patients than both CBT and other practitioners. PDT practitioners were significantly more expectant of CT issues than CBT practitioners with respect to the personality disorders most associated with acting out and risk management problems (e.g., paranoid, psychopathic, narcissistic, sadistic, sadomasochistic, masochistic, hypomanic, passive-aggressive, counterdependent and counterphobic). The other practitioners generally had CT expectations between PDT and CBT. These findings suggest that clinical training into CT may be useful in differential diagnoses and in helping to avoid ethical dilemmas regardless of one's theoretical preference. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Insight into countertransference can be used to help with differential diagnoses and to help prevent possible management problems with acting out patients. The Psychodynamic Diagnostic Manual is a useful taxonomy in that it includes countertransference as a diagnostic aid.

Patient personality and therapist countertransference

PURPOSE OF REVIEW

The purpose of this review is to provide a comprehensive and critical examination of the empirical literature about the relation between patient personality and therapist countertransference.

RECENT FINDINGS

The therapist's countertransference can play a crucial role in psychotherapy outcomes, especially in the treatment of personality disorders. The therapist's emotional responses to patients can accomplish the following: inform the clinician about the patient's personality, impact therapy outcome, influence patient resistance and elaboration, mediate the influence of the therapist's interventions and influence therapeutic alliance.

SUMMARY

In the last years, several studies have empirically demonstrated the presence of a specific pattern of therapist responses that are related to different patient personality disorders. Other works showed how the effects of the therapist's technique depend on the emotional context in which they are delivered and in particular countertransference experiences. Moreover, researchers suggest that the therapist's emotional responses occur across all kinds of therapy and are independent of the therapist's theoretical preferences.