Monday, May 15, 2006

New psycho-diagnostic manual

$23.10 at Amazon
A coalition from various psychodynamic associations has produced a new diagnostic manual as an alternative to the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), the main one currently used by psychiatrists and therapists to give patients a code number for purposes of treatment, research, and prognosis — but mostly health insurance reimbursement.

The new group's manual is the Psychodynamic Diagnostic Manual (PDM), which allegedly “attempts to characterize the whole person — the depth as well as the surface of emotional, cognitive, and social functioning.”

In contrast to the DSM's total focus on dysfunction, the PDM claims that its basis is the belief that “a comprehensive conceptualization of health is the foundation for describing disorder”. I'm actually not impressed by that philosophy. It still assumes a (socially) normative range of behavior as “healthy”, human, and approved.

The PDM editors also claim to “require a fuller description of the patient's internal life to do justice to understanding his or her distinctive experience.”

Yeah, well, okay. Beautiful thought. But how it actually executed?

Dimension I: Personality Patterns and Disorders

All patients get assigned to personality categories, because, “for example, a depressed mood may be manifested in markedly different ways in a person who fears relationships and avoids experiencing and expressing most feelings and in an individual who is fully engaged in all of life's relationships and emotions.”

But what is the real basis for assigning the person in front of you to one specific category of or another? Is “personality” so perfectly cut-and-dried? What if you start seeing the patient through your initial diagnosis, but she actually has more variation in her responses? Won't her assigned code number blind you to her complexity? No? If it doesn't affect your ongoing interaction with her, why assign it in the first place?

The new PDM supposedly improves on the DSM because where the DSM only had one narcissistic disorder, the PDM includes two  subcategories:
P104 – Narcissistic Personality Disorder
    • P104.1 – Arrogant / Entitled
    • P104.2 – Depressed / Depleted
Those poor Arrogant / Depleted folks are still out in the cold.

I would say the main problems of the DSM are rampant in this system. I prefer an idea I've read at Psycho-Babble: personality disorders are code numbers for judgments of personal distaste.

The new approach also includes “PCA109 – Histrionic Personality Disorder”! Oh my god. Aren't they embarrassed to be using that word in the 21st century??

The main outline list of PDM diagnoses is here.
Dimension III: Manifest Symptoms and Concerns begins with the DSM-IV-TR categories…. We approach symptom clusters as useful descriptors. Unless there is compelling evidence in a particular case for such an assumption, we do not regard them as highly demarcated biopsychosocial phenomena.
Well, if they're not real phenomena, how are they “useful”? What on earth is going in these friggin’ shrinks’ heads!!

And if this 600-page book just adopts the DSM's lists and clusters, how is it an improvement? Or even a change?

According to Garry Cooper's Clinician's Digest column in the current Psychotherapy Networker,  the PDM editors “have no illusions that the PDM will replace the DSM as insurance companies' coding manual of choice.” That's good. I think we'd have to label them MCA207 (Major Defects in Basic Mental Functions) if they thought otherwise.

But their stated hope that the PDM will “encourage the next generation of therapists to start thinking about clients as something more than a collection of symptoms” is groundless. In fact, they're further contributing to the arbitrary, authoritarian, dehumanizing process of diagnostic bullying; they've just put a barely different cover on it.

Personally, I think effective  diagnostic categories — ones that point to specifically effective treatments — might someday be based on brain scans and genetic testing, in addition to in-life observations (like in the home) and today's history-style interviews. But we're not there yet.


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