The Psychodynamic Diagnostic Manual, 3rd edition (PDM‐3)

The DSM‐III and its successors have been intended to increase diagnostic reliability and validity without embedded assumptions about the meanings and etiologies of symptoms, thereby providing researchers and clinicians, irrespective of their theoretical orientation, with present‐versus‐absent criteria for diagnosing psychiatric disorders. However, this primary focus on the symptomatic manifestations of disorders left out critical aspects of the patients’ presentation that are essential for good clinical care. The Psychodynamic Diagnostic Manual (PDM) is intended to compensate for this weakness in descriptive taxonomies.

The effort to highlight individuals’ full range of functioning (i.e., the implicit as well as the observable components of their emotional, behavioral, cognitive, interpersonal and social patterns), rather than simply label their disorders, is central to the psychodynamic and humanistic clinical traditions. The PDM outlines a diagnostic framework that is symptom‐oriented like the DSM and ICD approaches, but also considers individuals’ idiographic characteristics and psychological functioning across different life stages.

The first edition of the PDM ¹ , spearheaded by S. Greenspan and co‐edited by N. McWilliams and R. Wallerstein, was published in 2006. Given its positive reception, and in response to feedback about its strengths and weaknesses, a comprehensively revised second edition was published in 2017 ² .

Improving the framework of the previous editions, the PDM‐3 ³ reorganizes its sections in accordance with developmental chronology. The first three sections are devoted to the diagnostic process in infancy and early childhood, childhood, and adolescence, while sections 4 and 5 concern adulthood and later life. Each section, over and above the DSM/ICD development‐based reorganization of disorders, presents the same diagnostic entities in the context of the clinical specificities of each age group. For example, depressive disorders are listed in childhood, adolescence, adulthood and later life sections, because their clinical manifestations, and related subjective experiences, may present crucial variations across the lifespan that need to be acknowledged in a diagnostic formulation. A final section describes assessment using the Psychodiagnostic Chart (PDC), a PDM‐derived tool ⁴ , and provides several case descriptions to enhance the clinical utility of the manual.

In each section/age group, the PDM‐3 adopts a “prototypic” diagnostic approach, which provides descriptions for each style/disorder that can be considered an “ideal” to which an individual can more or less approximate (rather than distinct categories to which a given person belongs or does not belong) ⁵ . Within this framework, clinicians can describe individuals’ functioning dimensionally in each age range along three axes: Personality (P Axis), Mental Functioning (M Axis), and Symptoms (S Axis) (with the exception of the “Infancy and Early Childhood” section, which follows a specific multiaxial system). Each Axis provides a nuanced perspective on individual functioning to assist clinicians in creating a multifaceted diagnostic profile to determine the best possible treatment plan.

The P Axis considers both levels of personality organization (i.e., a spectrum of functioning ranging from healthy to psychotic) and personality styles/disorders – i.e., clinically familiar personality configurations (such as narcissistic, obsessive‐compulsive, dependent, paranoid) as well as other patterns that have been empirically confirmed (e.g., emotionally dysregulated personalities).

The M Axis considers individual profiles of mental functioning across 13 maturational capacities (e.g., affect regulation and expression, mentalization, bodily experiences and representations, impulse regulation, defensive functioning, adaptation and resilience). Clinicians rate each mental capacity on a 5‐point scale, in which higher scores reflect more adaptive levels of functioning.

The S Axis considers symptom patterns. They are mostly labeled according to the DSM‐5‐TR, but with a specific focus on individual differences in the subjective experience of symptoms and disorders (i.e., the affective states, cognitive processes, somatic experiences, and relational patterns most often associated with each listed condition) and the related emotional experiences of clinicians.

Finally, each section concludes with a chapter focusing on the subjective experience of non‐pathological conditions that might warrant specialized intervention – such as individual responses to climate change, the recent pandemic, actual or threatened war, and the experiences of patients (and therapists) who are racially, ethnically, culturally, linguistically, politically, or gender and sexually minoritized.

Studies that have been conducted to establish the reliability and clinical utility of the PDC ⁴ , the PDM‐derived tool, have shown not only adequate to good interrater reliability in samples of adults ⁶ , but also good sensitivity in placing children into common diagnoses of developmental vs. behavioral disorders with respect to specific mental functioning patterns, global mental functioning, and levels of personality organization ⁷ .

Recent studies involving different clinical populations have supported the relevance of PDM‐related dimensions for planning of personalized clinical interventions and for prediction of therapeutic outcomes. For example, a naturalistic study on a sample of patients with feeding and eating disorders (EDs), evaluated with both the Structured Clinical Interview for DSM‐5 ‐ Clinical Version (SCID‐5‐CV) and the PDC, showed that higher levels of personality organization and lower personality pathology severity predicted lower ED‐specific psychopathology at treatment termination, even when controlling for baseline ED symptoms. Moreover, higher levels of overall mental functioning, identity integration, mentalizing capacity, and self‐coherence were related to better therapeutic outcomes, whereas DSM‐5 categories did not have an impact on symptom change ⁸ . Further on, single case studies have exemplified the clinical utility of in‐depth assessment of individual characteristics (i.e., personality style and level of organization, mental functions, subjective experience of symptoms) in children, adolescents and adults with diverse mental health conditions ⁹ .

Unlike the DSM and ICD frameworks, the PDM diagnostic approach provides information for developing a case formulation that is sufficiently psychologically rich to guide effective treatment planning, especially when psychotherapy is the recommended intervention. Even though it is based mainly on psychodynamic research and clinical experience, the PDM‐3 case formulation can be also useful in non‐psychodynamically oriented practice settings, given that it provides a careful and jargon‐free description of the patient, informed by neuroscience and always in dialogue with cognitive‐behavioral perspectives.

The PDM reconciles the diagnostic process with its clinical implications, clearly supporting what practitioners have long realized – that every treatment should be tailored to the individuality of the patient and the patient's unique context. The PDM‐3 provides updated clinical implications for treatment focus that may be familiar to clinicians trained in psychodynamic approaches, but are also applicable to those with other therapeutic backgrounds. For each condition, clinical guidelines are offered to enhance relevant dimensions of the therapeutic relationship, including the therapist's emotional responses and the therapeutic alliance, both of which have been shown to relate to treatment outcomes.

In summary, the PDM aims at representing a “taxonomy of people”, rather than a “taxonomy of disorders”, highlighting the clinical value of considering who one is, rather than what one has. Although the approach may appear more complex and time‐consuming than that of the DSM/ICD, and despite the fact that PDM‐based empirical research is still in its infancy, we strongly believe that the diagnostic process has no simple, easily applied formula. The PDM aspires to constructively bridge the gaps between descriptive psychiatry, psychodynamic research, clinical experience, and the psychometric/empirical traditions that shape diagnostic reasoning. It adds a much‐needed perspective on existing taxonomies, enabling clinicians to describe and evaluate personality patterns, related social and emotional capacities, unique mental profiles, and patients’ subjective experiences of symptoms.