Describing her condition in DSM terms would require several "comorbid" diagnoses and rule-outs, perhaps including generalized anxiety disorder, bulimia nervosa, cannabis abuse, and posttraumatic stress disorder or amnestic disorder not otherwise specified. The general impression might be of someone with somatization disorder, but the patient reports only 3 pain syndromes, not the 4 required for this diagnosis.
This collection of labels captures little that a therapist needs to know to help such a patient. Via the PDM framework, a more holistic picture might emerge. In terms of personality P Axis , this woman would be seen as organized psychologically at the borderline level discriminated from the DSM's borderline personality disorder , with notable problems in affect regulation, self and object constancy, and self-esteem that she has handled with compulsive and addictive behaviors, dissociation, and a characterological tendency to somatize.
In the personality section, characteristics of persons in the borderline range are summarized, and therapeutic implications are discussed eg, clear contracts, structure, here-and-now focus, weathering affect storms. The manual suggests the importance of such dimensions in psychotherapy. The patient's profile of mental functioning M Axis might reveal her as someone with strengths in regulation, attention, and learning, but with notable deficits in quality of internal experience; capacity for relationships and intimacy; and affective experience, expression, and communication.
Such an assessment orients a therapist to certain areas of treatment emphasis. Finally, the therapist could hone his or her empathic attunement to the patient's problems by consulting the section on the subjective experience of symptoms S Axis in the areas of anxiety, eating disorders, substance abuse, and trauma.
For example, with respect to eating disorders, affective states noted in the PDM include feelings of being starved for care; feelings of failure, shame, and ineffectiveness; and fear of abandonment, aggression, and loss of control. Cognitive patterns include a sense of being inadequate, incompetent, and unloved, as well as a preoccupation with being young.
Somatic states include numbness, confusion about bodily sensations, inability to judge the stomach's fullness, and a sense of physical emptiness that may express a more inchoate psychological emp-tiness. Issues of control and perfectionism, secrecy about the eating disorder, compliance, and ingratiation may affect relationships. Conclusion The PDM deals very little with etiology but deals extensively with the phenomenology of psychopathology.
Its language is accessible; jargon is minimal. Although the authors felt they should acknowledge their collective bias by titling the manual "psychodynamic," they tried to make it readable by and useful to practitioners of other orientations, such as biological, cognitive-behavioral, and family systems perspectives.
The PDM is available online at www. Through self-publishing, the steering committee was able to make it affordable for students and beginning therapists. The authors invite criticisms and suggestions from the mental health community. The manual is a work in progress that will be only as valuable as it is clinically and pedagogically useful. PDM Task Force. Psychodynamic Diagnostic Manual.
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