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진단과평가
작성자  simonshin 작성일  2016.11.20 23:46 조회수 1262 추천 0
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 신현근 박사 강의안 - 정신 역동적 진단 메뉴얼 소개  
첨부파일 : f1_20161120234617.pdf
 

과목:  진단과 평가

주제:  Introduction to PDM

내용: 강의안

교재: PDM Task Force. (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations

 

1.       OVERVIEW

1.1.     The Psychodynamic Diagnostic Manual (PDM) is a diagnostic framework that attempts to characterize an individual’s full range of functioning— the depth as well as the surface of emotional, cognitive, and social patterns.

1.1.1.  It emphasizes individual variations as well as commonalities.

1.1.2.  We hope that this framework brings about improvements in the diagnosis and treatment of mental disorders and permits a fuller understanding of the functioning of the mind and brain and their development.

1.2.     The PDM is based on current neuroscience, treatment outcome research, and other empirical investigations.

1.2.1.  Research on brain development andthe maturation of mental processes suggests that patterns of emotional, social, and behavioral functioning involve many areas working together rather than in isolation.

1.2.2.  Outcome studies point to the importance of dealing with the full complexity of emotional and social patterns.

1.2.3.  Numerous researchers (e.g., Blatt, Auerbach, Zuroff & Shahar, p. 537; Norcross, 2002; Wampold, 2001) have concluded that the nature of the psychotherapeutic relationship, reflecting interconnected aspects of mind and brain operating together in an interpersonal context, predicts outcome more robustly than any specific treatment approach per se.

1.3.     A number of recent reviews (e.g., Fonagy, p. 765, and Leichsenring, p. 819) demonstrate that in addition to alleviating symptoms, psychodynamically based therapeutic approaches improve overall emotional and social functioning.

1.4.     The PDM was created though a collaborative effort of the major organizations representing psychoanalytically oriented mental health professionals.

1.5.     The diagnostic framework formulated by the PDM work groups systematically describes: • Healthy and disordered personality functioning; • Individual profiles of mental functioning, including patterns of relating, comprehending and expressing feelings, coping with stress and anxiety, observing one’s own emotions and behaviors, and forming moral judgments; and Symptom patterns, including differences in each individual’s personal, subjective experience of symptoms.

1.6.     The PDM adds a needed perspective to existing diagnostic systems. In addition to considering symptom patterns described in existing taxonomies, it enables clinicians to describe and categorize personality patterns, related social and emotional capacities, unique mental profiles, and personal experiences of symptoms.

1.6.1.  It provides a framework for improving comprehensive treatment approaches and understanding both the biological and psychological origins of mental health and illness.

 

2.       RATIONALE FOR THE PDM

2.1.     A clinically useful classification of mental healthdisorders must begin with an understanding of healthy mental processes.

2.1.1.  Mental health comprises more than simply the absence of symptoms.

2.1.2.  Healthy mental functioning involves the full range of human cognitive, emotional, and behavioral capacities. Any attempt to describe

2.2.     Any attempt to describe and classify deficiencies in mental health must therefore take into account limitations or deficits in many different mental capacities, including ones that are not necessarily overt sources of pain.

2.3.     That a comprehensive conceptualization of health is the foundation for describing disorder may seem self-evident, yet the mental health field has not developed its diagnostic procedures accordingly.

2.3.1.  In the last two decades, there has been an increasing tendency to define mental problems primarily on the basis of observable symptoms, behaviors, and traits, with overall personality functioning and levels of adaptation noted only secondarily.

2.4.     The laudatory goal of constructing an evidence-based diagnostic system may have led to a tendency to overstep the existing evidence, to make overly narrow observations, and, in the process, to compromise the important goal of classifying mental health and mental health disorders according to their naturally occurring patterns.

2.4.1.  Only an accurate description of naturally occurring patterns can guide vital research on etiology, developmental pathways, prevention, and treatment.

2.4.2.  As the history of science attests (and, as recently emphasized by the American Psychological Association in their guidelines defining “evidence”), scientific evidence includes and often begins with sound descriptions, such as case studies.

2.5.     Insufficient attention to this foundation of scientific knowledge, under the pressure of a narrow definition of what constitutes evidence (in the service of rapid quantification and replication) would tend to repeat rather than ameliorate the problems of current systems.

2.6.     The development of the PDM reflects our concern that mental health professionals may have uncritically and prematurely adopted methods from other sciences instead of developing empirical procedures appropriate to the complexity of the data in our field.

2.7.     The PDM attempts to do this.

2.7.1.  Because the current terminology for symptoms and their groupings comes from a long and intellectually serious tradition, we employ the descriptions of symptoms and patterns of symptoms used in the currently prevailing taxonomies, the DSM-IV-TR and ICD-10, systems that represent a valuable history of careful observation and description.

2.7.2.  In the most recent versions of the DSM and ICD systems, however, some of the more subtle features of many basic symptom patterns have been lost. Most notably, despite the fact that it is usually the patient’s subjective suffering that brings him or her to treatment, a full description of the patient’s internal experience of the symptoms is often absent.

2.8.     All approaches to assessment and treatment rely at least in part on patients’ reports of their thoughts, feelings, and behaviors. (Does the patient feel depressed? anxious? Does the patient hear voices?

2.8.1.  Therefore, despite the fact that mental health professionals are inevitably dealing with the elusive world of subjectivity, we require a fuller description of the patient’s internal life to do justice to understanding his or her distinctive experience.

2.8.2.  We are hoping that with more elaborated depictions, we can make more progress on understanding naturally occurring patterns.

2.9.     A scientifically based system begins with accurate recognition and description of complex clinical phenomena and builds gradually toward empirical validation.

2.9.1.   Reliance on oversimplification and favoring what is measurable over what is meaningful do not operate in the service of good science.

2.10. A recent meta-analysis of outcomes of manualized treatments for targeted symptoms found that symptomatic improvement often did not persist and that fundamental psychological capacities involving the depth and range of relationships, feelings, and coping strategies did not show evidence of long-term change.

2.11. Process-oriented research has demonstrated that essential characteristics of the psychotherapeutic relationship as conceptualized by psychodynamic models (the working alliance, transference phenomena, and stable characteristics of patient and therapist) are more predictive of outcome than any designated treatment approach per se.

2.11.1.      Most dynamically oriented clinicians pay careful attention to the therapeutic relationship, noting interpersonal patterns, feelings, coping strategies, and other indicators of mental processes.

2.11.2.      Although underresearched for decades, psychodynamically based treatments have been the subject of several recent meta-analyses and reviews that reveal evidence of their efficacy.

2.12. The importance of focusing on an individual’s full range of feelings and thoughts (personal experience) in the context of his or her unique history cannot be underestimated.

2.12.1.      The study also revealed that both the physical and mental health disorders were associated with complex feelings and thoughts employed to deal with the adverse childhood experiences.

2.13. Although the psychoanalytic tradition, or depth psychology, has a long history of examining overall human functioning in a searching and comprehensive way, the diagnostic precision and usefulness of psychodynamic approaches have been compromised by at least two problems.

2.13.1.      First, untilfairly recently, in attempts to capture the range and subtlety of human experience, psychoanalytic accounts of mental processes have been expressed in competing theories and metaphors that have, at times, inspired more disagreement and controversy than consensus.

2.13.2.      Second, there has been difficulty distinguishing between speculative constructs on the one hand, and phenomena that can be observed or reasonably inferred on the other. Where the tradition of descriptive psychiatry has had a tendency to reify “disorder” categories, the psychoanalytic tradition has tended to reify theoretical constructs.

2.14. Psychodynamic models have moved toward functional understanding of psychopathologies, with the expectation that such understanding will eventually lead to the identification of etiological patterns.

2.15. The PDM uses a multidimensional approach to describe the intricacies of the patient’s overall functioning and ways of engaging in the therapeutic process.

2.15.1.      It begins with a classification of the spectrum of personality patterns and disorders, then offers a profile of mental functioning” covering in more detail the patient’s capacities, and finally considers symptom patterns, with emphasis on the patient’s subjective experience.

 

3.       DIMENSION I: PERSONALITY PATTERNS AND DISORDERS— P AXIS

3.1.     The PDM classification of personality patterns takes into account two areas: the person’s general location on a continuum from healthier to more disordered functioning, and the nature of the characteristic ways the individual organizes mental functioning and engages the world.

3.2.     This dimension has been placed first in the PDM system because of the accumulating evidence that symptoms or problems cannot be understood, assessed, or treated in the absence of an understanding of the mental life of the person who has the symptoms.

3.3.     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. There is not just one clinical presentation of the artificially isolated phenomenon known as depression.

 

4.       DIMENSION II: MENTAL FUNCTIONING— M AXIS

4.1.     The second PDM dimension offers a more detailed description of emotional functioning— the capacities that contribute to an individual’s personality and overall level of psychological health or pathology.

4.2.     It takes a more microscopic look at mental life, systematizing such capacities as information processing and self-regulation; the forming and maintaining of relationships; experiencing, organizing, and expressing different levels of affects or emotions; representing, differentiating, and integrating experience; using coping strategies and defenses; observing self and others; and forming internal standards.

 

5.       DIMENSION III: MANIFEST SYMPTOMS AND CONCERNS— S AXIS

5.1.     Dimension III begins with the DSM-IV-TR categories and goes on to describe the affective states, cognitive processes, somatic experiences, and relational patterns most often associated clinically with each one.

5.2.     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. In other words, we are taking care not to overstep our knowledge base.

5.2.1.  Thus, Dimension III presents symptom patterns in terms of the patient’s personal experience of his or her prevailing difficulties.

5.2.2.  The patient may evidence a few or many patterns, which may or may not be related, and which should be seen in the context of the person’s personality and mental functioning.

5.2.3.  The multidimensional approach depicted in the following sections provides a systematic way to describe patients that is faithful to their complexity and helpful in planning appropriate treatments.

5.3.     As the title of this manual makes clear, we have looked at mental health disorders from a frankly psychodynamic point of view.

5.3.1.  Because we consider it impossible to be unbiased or genuinely atheoretical, we have simply tried to be explicit about our biases insofar as we are conscious of them.

5.3.2.  We hope that our explication of a psychodynamically influenced diagnosis will be useful to therapists trained in other traditions, including biological, cognitive-behavioral, family systems, and humanistic approaches.

5.3.3.  A more thorough diagnostic formulation has the potential to inform any treatment plan that seeks to take the whole person into account.

5.3.4.  We also believe that even fondly held ideas must be subject to potential disconfirmation by empirical investigation. Hence, we hope that this manual will be tested and improved in later editions, as empirical researchers continue to investigate our assumptions.


 
 
 
 
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