(This is a prepublication copy.

The published copy may be slightly different)

Lingiardi, V., McWilliams, N., Bornstein, R.F., Gazzillo, F. and Gordon, R.M. (2015) The Psychodynamic
Diagnostic Manual Version 2 (PDM-2): Assessing Patients for Improved Clinical Practice and
Research, Psychoanalytic Psychology, 32(1), 94-115. http://dx.doi.org/10.1037/a0038546

The Psychodynamic Diagnostic Manual Version 2 (PDM-2):  

Assessing Patients for Improved Clinical Practice and Research

Vittorio Lingiardi, Nancy McWilliams,

Robert F. Bornstein, Francesco Gazzillo, Robert M. Gordon

Abstract. This article reviews the development of the second edition of the Psychodynamic
Diagnostic Manual, the PDM-2. We begin by placing the PDM in historical context, describing the
structure and goals of the first edition of the manual, and reviewing some initial responses to the PDM
within the professional community. We then outline five guiding principles intended to maximize the
clinical utility and heuristic value of PDM-2, and we delineate strategies for implementing these
principles throughout the revision process. Following a discussion of two PDM-derived clinical tools
—The Psychodiagnostic Chart (PDC) and Psychodynamic Diagnostic Prototypes (PDP)—we review
initial research findings documenting the reliability, validity, and clinical value of these two measures.
Finally, we discuss changes proposed for implementation in PDM-2, and the potential for an updated
version of the manual to enhance clinical practice and research during the coming years.

Introduction
The first edition of the Psychodynamic Diagnostic Manual (PDM Task Force, 2006) was
published during a critical era of change in mental nosology. This period began in 1980 with the
publication of the DSM-III, which represented a shift from a psychoanalytically based, dimensional,
inferential diagnostic system to a “neo-Kraepelinian” descriptive, multiaxial classification that relied
on present-versus-absent criteria sets for identifying discrete mental disorders. This paradigm shift
was adopted deliberately, with the aim of removing the psychoanalytic bias from the manual now that
other theoretical orientations were common, including behavioral, family systems, cognitive,
humanistic, and biological. The shift was also intended to make certain kinds of outcome research
easier: Present-versus-absent traits could be identified by researchers with little clinical experience,
whereas the previous classifications (DSM-I and DSM-II) had required significant clinical training to
diagnose inferentially many of the syndromes described. Each succeeding edition of the DSM has
included more discrete disorders (see Clegg, 2012). The publication of DSM-IV (APA, 1994)

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continued the neo-Kraepelinian descriptive trend, which has been further elaborated and expanded
with the recently published DSM-5 (APA, 2013).
Although the Diagnostic and Statistical Manual of Disorders (DSM) is considered by many as
a permanent fixture in the world of mental health—a set of guidelines and diagnostic criteria that, for
better or worse, will always guide our clinical work—this belief is based more on history and habit
than anything else. The DSM-I (APA, 1952) was published just over 60 years ago.  The manual is not
a government document (although the development of DSM-I was in part a government effort), nor is
it in any way related to policies and procedures endorsed by the National Institute of Mental Health
(see Insel, 2013). The DSM is not the most widely used diagnostic system today: The International
Classification of Diseases (ICD-10; World Health Organization, 2004) takes that prize. Despite its
aura of inevitability, the current version of the diagnostic manual, the DSM-5 (APA, 2013) is a
privately published book, a product of the American Psychiatric Association, intended to guide the
professional activities of mental health professionals, but also to help shape the reimbursement
policies of managed care organizations (MCOs) and to fund various activities of the association.
This historical sidebar is not intended merely to place DSM-5 in its proper context, but also to
set the stage for a somewhat brazen prediction: 2013 might mark the beginning of the end of the DSM
series. Although early editions of the manual were applauded for systematizing what had been, prior
to World War II, a somewhat chaotic array of overlapping diagnostic systems emerging from different
theoretical traditions, more recent editions of the DSM have been increasingly controversial (see, e.g.,
Cooper, 2004; Vanheule, 2012).  Beginning in October of 2014, the Health Insurance Portability and
Accountability Act (HIPPA) will require clinicians to provide ICD-10—not DSM-5—codes for
reimbursement.  Moreover, although advances in biological and cognitive research have tended to
dominate recent discussions of diagnosis, assessment, and treatment, psychoanalytic concepts have
undergone a quiet resurgence as well, not only in clinical psychology, but in myriad other subfields
(e.g., cognitive, social, developmental, neuropsychological; see Gerber, 2013; Protopopescu, 2013;
Wilson, 2009).
Recent critiques of the DSM have touched upon its problematic political and economic
aspects, but they have not ended there.  Clinicians and clinical researchers have also questioned the
DSM emphasis on a disease model of psychopathology, which works better for some syndromes (e.g.,
schizophrenia) than others (e.g., narcissistic personality disorder).  Critics have noted the expansion in
the number of categories in DSM-5 (Batstra & Frances, 2011; Frances, 2013), and have questioned the
Kraepelinian nature of DSM diagnoses, with their continued adherence to categorical classification,
even for those disorders which may be best conceptualized as reflecting continua of functioning, with
no sharp cutoff between normality and pathology (see Craddock & Owen, 2010; Livesley, 2010).
Beyond questions regarding the overarching framework of DSM-5 (Good, 2012; Zimmerman, 2012),

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and its choice of syndrome and symptom descriptors (Huprich, 2011), much of the current opposition
to DSM-5 is a product of the process used to create it (Bornstein, 2011).
Any classification system that is based on the work of a committee (or set of committees) will
never be completely free of politics and personal preference.  Nonetheless, as a number of writers
have pointed out—including some who were involved in earlier DSM revisions (e.g., Frances, 2011;
Livesley, 2010; Widiger, 2011) —the DSM-5 revision process differed from earlier efforts in
fundamental ways. In particular, three stand out.
First, the DSM-5 is a product of secretive deliberations. Members of the DSM-5 work groups
were asked not to reveal details of their deliberations to other mental health professionals, the media,
or members of the public, presumably in an effort to avoid being unduly influenced by those who
might have a vested interest in the outcome of work group decisions.  Although such a strategy has the
advantage of minimizing the potential biasing effects of outside forces [e.g., representatives from
Managed Care Organizations (MCOs) and pharmaceutical companies], it also fosters group-think,
increasing the possibility that decisions will be driven by interpersonal dynamics within the group
(e.g., the persuasive power of individual committee members; see Turner & Pratkanis, 1998). Even if
the process of creating DSM-5 has been periodically updated online, sometime giving the public a
chance to submit comments and observations, the priceless opportunity to have a real open dialogue
with the clinical and scientific communities was partially lost. In the absence of such a conversation,
faux pas such as the proposed deletion of the narcissistic personality disorder were perhaps inevitable
(about the controversy over the proposed elimination of some personality disorders in the DSM-5, see
Shedler et al., 2010)
Second, as several critics noted (e.g., Ronningstam, 2011; Widiger, 2011, Bornstein, 2011),
the DSM-5 work groups conducted selective reviews of the literature, excluding large swaths of
empirical evidence, and providing minimal rationale for their decisions.
Finally, the DSM-5 in based on an overreliance on self-report data. A plethora of evidence
from cognitive and social research confirms that people are, at best, flawed perceivers of their traits,
behaviors, and internal states; our inherent introspective limitations are magnified when psychological
symptoms (e.g., anxiety, personality pathology, situational variations in mood) are present (Huprich,
Bornstein & Schmitt, 2011).  Although, when used in combination with self-report instruments,
performance-based measures have proven useful in illuminating underlying dynamics and in
documenting meaningful divergences between patients’ inner experience and the outward expression
of that experience (see Bornstein, 2010; Ganellen, 2007), studies involving multi-method assessment
strategies played virtually no role in the DSM-5 revision process.
For all these reasons, we think that the Psychodynamic Diagnostic Manual (PDM; PDM Task
Force, 2006) 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

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personality patterns, related social and emotional capacities, unique mental profiles, and personal
experiences of symptoms. It provides a framework for improving comprehensive treatment
approaches and for understanding the biological and psychological origins of both mental health and
mental illness. In focusing on the full range of mental functioning, the PDM complements the DSM
and ICD efforts to catalogue symptoms and syndromes. In contrast to the DSM, the PDM has aspired
to be a taxonomy of people rather than diseases, and has conceptualized its main purpose as helping
clinicians to diagnose complex psychopathologies, formulate individual cases, and plan the best
possible treatment for each patient.
With these observations as context, a brief description of the PDM-1 structure and “philosophy”
follows.
The PDM uses a multidimensional approach to describe the intricacies of each patient's
functioning and ways of engaging in the therapeutic process. In this way, it attempts to provide a
comprehensive profile of an individual's mental life.
The first edition covered adults, children and adolescents, and infants, emphasizing individual
variations as well as commonalities. It included four major sections: Classification of Adult Mental
Disorders, Classification of Child and Adolescent Mental Health Syndromes, Classification of Infant
and Early Childhood Disorders, and Conceptual and Empirical Foundations for a Psychodynamically
Based Classification System for Mental Health Disorders.  
Part I—the adult section—opened with the Personality Patterns and Disorders (P) axis,
followed by the Profile of Mental Functioning (M) axis.  The patients’ symptoms (and syndromes and
their subjective experience of them) (S axis) was intended to capture the phenomenology of mental
illness—the personal, private experience of suffering—from the perspective of the patient.  These
three subsections were followed by illustrative case formulations demonstrating this more holistic,
biopsychosocial kind of diagnosis.
Part II—the child and adolescent section—reordered things a bit, on the basis of respect for
the developing nature of children’s psychologies, and opened with the Profile of Mental Functioning
(MCA) axis, followed by the Emerging Personality Patterns and Disorders (PCA) axis, then the
Subjective Experiences (SCA) axis. A special Section on Infancy and Early Childhood (IEC) Mental
Health Disorders followed.
Part III contained a selection of relevant empirical papers by noted scholars on
psychodynamic diagnosis and psychotherapy research.
Schematically, according to this structure, the clinician should assess the following in all
patients (except infants, assessed with IEC):
 level of personality organization and the prevalent personality styles or disorders (Axis P for
adults and PCA for adolescents and children);

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  level of overall mental functioning, on the basis of the evaluation of 9 different but partly
overlapping capacities ([1] capacity for regulation, attention and learning; [2] capacity for
relationships; [3] quality of internal experience, and level of confidence and self-regard; [4]
affective experience, expression and communication; [5] defensive patterns and capacities;
[6] capacity to form internal representations; [7] capacity for differentiation and integration;
[8] self-observing capacity, or psychological-mindedness; [9] capacity for internal standards
and ideals), each assessed along a continuum with 4 possible levels (Axis M for adults and
Axis MCA for adolescents and children); after having assessed the level of these capacities,
the clinician has to asses on a continuum of 8 possible levels the overall health/sickness of the
mental functioning of the patient;
 symptoms and syndromes and the patient’s subjective experience of them (Axis S for adult
and SCA for adolescents).
PDM diagnoses are prototypic because this manual, unlike the DSM, is not based on the
addition of symptoms within a category; that is, it is not based on polythetic diagnosis. The PDM
considers each disorder as a constellation of signs, symptoms, or personality traits that constitute a
unity of meaning. It attempts to capture the gestalt of human complexity while combining the
precision of dimensional systems and the ease of categorical applications (Gazzillo, Lingiardi, & Del
Corno, 2012).

The PDM’s Fortunes So Far

The first edition of the PDM in the United States and in Europe met with considerable
commercial success and has influenced many practitioners and researchers. The New York Times
reviewed the PDM on January 24, 2006, with a headline entitled “For Therapy, a New Guide with a
Touch of Personality,” and in the United States the manual has received an adequate welcome also in
the clinical literature, as demonstrated by the 2011 monographic issue of the Journal of Personality
Assessment titled: “Can the Psychodynamic Diagnostic Manual (PDM) Put the Complex Person Back
at the Center-Stage of Personality Assessment?”.
Shortly after its publication, Nancy McWilliams (2008) wrote an article on the PDM for
Psychiatric Times, outlining its background, explicating Greenspan’s approach to diagnosis, and
describing each section, including the one on infancy (which has received the most positive reaction
from the community of practitioners). Finally, she provided a clinical example intended to
demonstrate how the PDM can capture the entire functioning of a patient’s personality. In the
monographic issue of the Journal of Personality Assessment, McWilliams (2011) describes the PDM,
whose explicit purpose is to help clinicians to become more therapeutically effective, as a worthy first
effort to compensate for the limitations of descriptive psychiatric diagnosis. In Hansell and Damour’s
book on Abnormal Psychology (2008), the PDM is also presented as “an alternate classification

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system” to the DSM, which clinicians can use instead of, or as a supplement to, its descriptive
classification.  Reviewing the PDM in the Journal of the American Psychoanalytic Association, Peter
Dunn (2008) states that the manual conforms with the basic framework of the DSM and its coding
system, but adds essential content from the psychoanalytic and psychodynamic tradition.
An interesting study by Robert Gordon (2008; 2009) examined how psychologists with
different training and theoretical orientations (psychodynamic, cognitive-behavioral, and other non-
psychodynamic preferences, respectively) judged the PDM. Results showed that the manual received
a highly favorable evaluation by all psychologists, irrespective of theoretical orientation. Participants
in the study emphasized the value of the PDM’s jargon-free language and commented on its
usefulness in helping non-psychodynamic clinicians to formulate a clinically relevant diagnosis.
According to Paul Stepansky (2009), the PDM’s exposure in the USA has been quite
extensive. “To achieve commercial success of this order, the ‘psychoanalytic’ appellation must be
diluted to ‘psychodynamic," and the psychodynamic ‘terms’ and ‘concepts’ offered in a user-friendly
format intended to broaden rather than supplant other diagnostic frameworks. This is the very formula
that has made the recently self-published Psychodynamic Diagnostic Manual, collectively authored by
an ‘Alliance of Psychoanalytic Organizations,’ a stunning success, with sales, as of March, 2008, of
over 20,000 copies.” Stepansky further notes that the PDM was not intended to replace existing
diagnostic manuals, but to be integrated with them.
The PDM has also aroused interest in other countries, as shown by the interview with Nancy
McWilliams conducted by George Halasz (2008) and published in the Australasian Psychiatry
journal. The emphasis in the interview is on how the manual can be usefully implemented for clinical
purpose and teaching.
In Europe, the PDM’s diffusion and reception have been investigated by Franco Del Corno
and Vittorio Lingiardi (2012), who noted that: a) in the German professional literature, references to
the manual are mostly linked to the PDM’s chapter on the Operationalized Psychodynamic Diagnosis
(OPD Task Force, 2001); b) in Spanish and Portuguese-speaking countries (Ferrari, 2006, 2008) a
group of psychoanalysts proposed a “Reportes de investigation” about the PDM and announced a
Spanish version of the manual, while Rosenthal (2008) characterized the PDM as a way to reconcile
the psychoanalytic therapies with scientific inquiry; c) in Turkey, Dereboy (2013, personal
communication) is striving to introduce the PDM to training programs for medical residents and
graduate students; d) in France, Widlocher (2007) wrote a very favorable review of the manual with
the subtitle “From nosographic to psychopathologic,” in which he argued that the psychoanalytic
tradition is the best context for the development of new and more complex classifications of
psychiatric disorders that may be complementary to the DSM; more recently, Widlocher and Thurin
(2011) cited the PDM as an effort to integrate a dynamic perspective about psychopathology with a
symptom-behavior-oriented diagnosis; e) in Italy, the PDM was translated and published in 2008. The

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clinical value of the manual is mentioned in many Italian papers, research projects, books, seminars,
academic courses, and training programs. Appreciation of its utility is beginning to spread in clinical
settings as well.
Despite these instances of international appreciation of the PDM, there are many areas – both
in the United States, where it was originally published, and in other countries – where the manual is
virtually unknown. We believe that this unevenness of visibility is a result of the decision that Stanley
Greenspan initially made to self-publish the PDM, so that he could keep its price as low as possible,
making it affordable especially to the students he hoped it would influence. To avoid the problem of
uneven impact in the future, we have decided to contract from now on with an established publishing
company, whose marketing practices will ensure far greater exposure for PDM-2 and any later
versions of the manual.

Principles for the Development of the Second Edition of the PDM (PDM-2)
As members of the Steering and Scientific Committees for PDM-2, we have devised a
preliminary set of guidelines for the PDM revision process that are straightforward, easy to
implement, and designed to increase substantially the likelihood that the product of our efforts will be
empirically rigorous, clinically useful, and viewed positively by clinicians of varying theoretical
orientations.  Five principles guide the work.
1. Transparency.  All aspects of the PDM-2 revision process will be transparent and
periodically accessible to professional colleagues.  New instruments for assessing
PDM-2 related constructs are available to the professional community at no cost.  
2. Inclusiveness. We invite colleagues to contribute to the PDM-2 revision effort by
offering input and critical feedback. We invite colleagues to contact any of us if
questions or concerns arise and to send us papers or works in progress that they think
might be useful in shaping our discussions and debates.
3. Flexibility. Although members of the PDM-2 Steering and Scientific Committees are
of one mind in assuming that psychodynamic processes play a role in all forms of
psychopathology, there is also a clear recognition that some symptoms and syndromes
are more strongly influenced than others by psychodynamic elements.  For example,
certain forms of personality pathology (e.g., narcissistic, histrionic) seem to be driven
primarily by psychodynamic processes; in others (e.g., avoidant, schizotypal)
psychodynamic processes may play a less prominent role.
4. Empirical Rigor. In order for PDM-2 to have a firm empirical foundation, we will
conduct comprehensive surveys of the literature, including studies from outside
psychoanalysis, to obtain as complete a picture as possible of what we know about
normal and pathological functioning.  

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 5. Clinical Utility. The raison d’etre of any diagnostic system is its usefulness in clinical
settings. No matter how empirically rigorous and precise they may be, diagnostic
criteria and syndrome descriptions are only helpful if they enhance the work of the
practicing clinician and thereby improve the lives of patients. We seek to find a better
balance between empiricism and clinical utility.

Strategies
To turn our vision into reality, we have inaugurated a four-step process for implementing
these principles.
First, we are developing ways to collaborate across groups. By creating a mechanism through
which different PDM-2 work groups communicate with each other about their initial proposals, we
hope that active exchange of information can take place as new proposals are developed and refined.
Not only will this cross-communication provide a broader clinical and empirical context for each work
group’s discussions, but it also affords the possibility of collaborative work on syndromes that have
implications for more than one part of the manual.
We believe that no theoretical framework—psychoanalysis included—can provide a complete
picture of the intra- and interpersonal dynamics that characterize a particular syndrome or set of
syndromes. Accordingly, we seek input from clinicians of various theoretical orientations. As a
number of writers have pointed out, most disorders are best understood as reflecting a combination of
factors—investigated in psychodynamic, cognitive, biological, and cultural studies —and it is only
when these perspectives are integrated that a nuanced understanding of a given syndrome can emerge.
The PDM-2 will seek feedback from researchers in other specialty areas. Although ongoing
discussions with clinicians and clinical researchers of varied backgrounds and theoretical allegiances
can go a long way toward ensuring that diagnostic categories and descriptors are consistent with
prevailing evidence from within and outside psychoanalysis, we must also ensure that PDM-2 is
consistent with current research in neuroscience, developmental psychology, memory, social
cognition, and other areas.
We aim to engage constituents and stakeholders. A decade ago Sadler and Fulford (2004)
raised the question of whether patients and their families should play a role in the DSM-5 revision
process.  This is a worthwhile question for PDM-2 as well. Beyond the advantages and disadvantages
of soliciting feedback from consumers of psychological services, it raises a broader issue—the degree
to which input from various stakeholders (e.g., patients, policymakers, other health care professionals)
would enhance future versions of the PDM.  To be sure, there are tradeoffs (e.g., it is important to
guard against bias from powerful, economically motivated groups), but to the degree that constituents
and stakeholders are engaged in the development of PDM-2 the manual can benefit from their

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experience and expertise. In turn, these constituents and stakeholders may ultimately feel an increased
ownership of, and commitment to, the manual.

PDM-Derived Empirical Tools

Although the PDM has earned respect from both psychodynamic and non-psychodynamic
practitioners (Gordon, 2008, 2009), it is in danger of being underutilized because it lacks easily usable
assessment instruments. To help remedy this, we developed two user-friendly tools:  the
Psychodiagnostic Chart (PDC) and the Psychodynamic Diagnostic Prototypes (PDP).

The Psychodiagnostic Chart (PDC)

The two forms of the Psychodiagnostic Chart (PDC) (Gordon & Bornstein, 2012) would
operationalize the entire adult and children/adolescent sections of the PDM. The chart has been
developed to be idiographic, flexible, and useful for practitioners of various theoretical orientations, to
have a distinct dimension of personality structure, and to integrate the PDM with the symptom
classifications of the DSM or ICD.
The PDC is both a categorical and a dimensional chart. All dimensional ratings range from
“most disturbed” (1) to “healthy” (10). It comprises five sections:
1. Personality Organization. The PDC uses the seven mental capacities of the PDM (identity,
object relations, affect tolerance, affect regulation, superego integration, reality testing, ego
resilience) to assess level of severity. In the first step, the clinician rates each of the 7
capacities from 1 (severe) to 10 (healthy). Then, considering the 7 ratings, the clinician rates
the person’s overall personality structure from 1 (psychotic) to 10 (healthy);
2. Personality patterns. This section reviews the personality patterns described in the P and PCA
axis of the PDM. The clinician begins by checking off as many descriptors as may apply to
the client. He or she then infers the most dominant personality pattern or disorder and rates
the level of severity (1-10);
3. Mental functioning. The clinician rates from 1 to 10 the nine descriptions of a person’s core
mental functions. Then he or she rates the patient’s overall mental functioning using a similar
scale, ranging from 1 (severe defects) to 10 (optimal);
4. Symptoms. The clinician lists as many as 4 symptoms or subjective complaints and rates their
degree of severity (from 1 = severe to 10 = mild);
5. Cultural-contextual issues. This is a qualitative section where the practitioner may consider
how cultural or contextual factors may contribute to the symptoms.
We initially assessed the utility of the PDC by surveying practitioners from various
psychology listservs and websites who considered themselves expert in diagnostics. We asked them to
complete an online survey after using the PDC with at least one client. We looked at the data when we

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had 50 completed surveys. Half of the respondents identified themselves as not psychodynamic. Sixty-
eight percent of the practitioners rated the PDM Personality Organization as “helpful to very helpful,”
58% rated PDM Mental Functioning as “helpful to very helpful, ”44% rated PDM Dominant
Personality Patterns or Disorders as “helpful to very helpful.” In contrast, only 18% of the
practitioners rated DSM GAF scores as “helpful to very helpful,” and just 14% rated ICD or DSM
symptoms as “helpful to very helpful.” These preliminary results lend strong support for the PDC
among experts (Bornstein & Gordon, 2012). After considering them, we dropped the GAF section and
added a qualitative cultural/contextual dimension to the PDC. These survey results were recently
replicated with a sample of 511 mental health practitioners with very similar findings, i.e personality
organization rated the highest, and the ICD or DSM symptom classification rated the least helpful in
understanding their clients (Gordon, et al. 2013)
We then worked to test the stability and construct validity of the PDC. We asked 38
psychologists who had frequently used the MMPI-2 during the last 12 months with psychotherapy
patients, disability, or forensic clients to participate in a study on diagnoses. They were asked to rate
their last ten clients with both the PDC and MMPI. Of the 38 psychologists, 15 sent in a total of 98
PDCs and MMPI-2s. The PDC had very good two-week retest stability. Test-retest reliability for the
Overall Personality Organization scale was .92 (p<.001); for Overall Severity of Personality Disorder
was .89 (p<.001); for the 9 Mental Functioning ranged from .77 to .89 (p<.001); and for Severity of
Symptoms was .87 (p<.001).
All the PDC constructs had good correlations with the MMPI-2 scores in the predicted
direction (Gordon & Stoffey, in press). The MMPI-2 scales of Schizophrenia (Sc), Hysteria (Hy) and
Ego Strength (Es) indicated good construct validity for the distinct categorical components of
psychotic, borderline, and neurotic levels of Personality Organization.
The categories were derived by dividing the 10-point Overall Personality Organization scale
into psychotic (ratings 1-3, n = 13), borderline (4-6, n = 52), and neurotic (7-10, n = 33) levels. We
predicted that the Sc scale mean at the psychotic level should be significantly larger than both the Hy
and Es scale means for the psychotic level.  Pairwise comparisons supported that prediction: Sc was
significantly larger than Es (M = 85.77, SD = 19.55 vs. 34.31, SD = 6.78, p = .001) and significantly
larger than Hy (M = 85.77, SD = 19.55 vs. 72.69, SD = 18.46, p = .017).
For the borderline level, we predicted that both the Sc scale mean and the Hy scale mean
should not be significantly different, but they both should be significantly larger than the Es scale
mean. That prediction was supported: Sc and Hy were not significantly different, but Sc was
significantly larger than Es (M = 62.21, SD = 12.31, vs. 43.58, SD = 10.25, p = .001) and Hy was also
significantly larger than Es (64.21, SD = 12.31 vs. 43.58, SD = 10.25, p = .001).

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 Finally, for the neurotic level, we predicted that the Es, Sc and Hy scales should all be in the
normal-moderate range. Hy and Sc were in the moderate range, and ego strength moved up to the
average range, showing support for the prediction.
Taken together, the analyses lend strong support to the construct validity of the Overall
Personality Organization scale of the PDC. They specifically support the conclusion that personality
patterns can exist on a continuum from neurotic to psychotic levels (see figure 1).

INSERT FIGURE 1

These analyses support Kernberg’s (1984) and McWilliams’s (2011b) positions that
personality organization is an important (arguably the most important) dimension by which to
understand overall psychopathology and mental suffering. This position was recently empirically
supported by the meta-analysis by Koelen et al. (2012). We found also that expert practitioners of
various theoretical orientations (most of whom were not psychodynamically oriented) felt that
personality organization is a very important dimension in understanding their patients, and that
personality patterns express themselves across the range of personality structure.  The conviction of
the members of the Personality Task Force of the original PDM that personality should be assessed as
a first step in diagnoses has thus received considerable empirical support and therefore will be a
primary, distinct dimension or axis in PDM-2.

The Psychodynamic Diagnostic Prototypes (PDP)

The Psychodynamic Diagnostic Prototypes (PDP) (Gazzillo, Lingiardi & Del Corno, 2012),
consists of 19 prototypic descriptions of personality disorders, one for each disorder included on the P
Axis of the PDM. The aim of the PDP is to help clinicians and researchers use the P Axis even
without a previous knowledge of the PDM. For this reason, the authors have taken the PDM
descriptions of all the Axis P disorders, deleted the reference to articles and books presented in
manual, and reformulated those parts of the PDM personality descriptions that were too theoretically
laden or too inferential. In order to operationalize these theoretical concepts, the authors then took into
account well validated dynamic assessment tools such as the Defense Mechanisms Rating Scale
(DMRS; Perry, 1990) and the Analytic Process Scales (APS) (Waldron et al., 2004).
The clinician/rater who uses the PDP assesses on a 1-5 rater scale the degree to which the
patient resembles one or more PDP prototypes. A score of 1 means no resemblance, while a score of 5
means a complete match between the patient’s clinical presentation and the prototypical description of
that personality disorder; thus, with a score of 4 or 5 it is possible to make a categorical diagnosis of
the disorder (see also Spitzer et al., 2008).

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 After having completed the construction of the PDP, the authors asked 7 raters, clinical
psychologists who had completed a 12-hour training on the PDM, to assess on a 1-5 Likert scale in
what measure each of the PDP prototypes resembled the description of the same disorder given in the
PDM. In 90% of the cases the, PDP prototypes were assessed as good or very good descriptions of
PDM Axis P disorders. The PDP thus seems to have good face validity.
The second step of the validation of the PDP was the assessment of inter-rater reliability
(IRR) with respect to both dimensional (1 to 5) and categorical (diagnosis given/not given)
assessment. In order to assess these IRR values, the authors collected the PDP assessments of 200
Italian patients. All were independently assessed with PDP by their treating clinicians and by one of
our 7 PDM-trained raters. Clinicians had been following the patients assessed for an average 67.9
sessions (SD = 86.5; ranging from 2 to 576 sessions), while the raters assessed the personalities of
these patients via the Clinical Diagnostic Interview (CDI; Westen & Muderrisoglu, 2003), a
systematic interview for personality assessment. The average Cohen’s kappa for the PDP prototypes
categorically assessed (4 and 5 = presence of the disorder, 1, 2 or 3 = no disorder) was .61. The
average ICC of the PDP prototypes dimensionally assessed was .74. Thus, the IRR of PDP ranges
from good to excellent.
For assessing the concurrent and discriminant validity of the PDP, we have used as criterion
measures the DSM-IV Axis II personality diagnoses of our patients as assessed by the raters with the
Axis II checklist. This checklist, developed by Drew Westen (2002), is a clinician report instrument
that combines a categorical and dimensional assessment of each of the Axis II criteria and disorders.
For the categorical DSM diagnoses, we have followed the diagnostic thresholds of DSM-IV Axis II,
and we have averaged the PDP assessment of clinicians and raters before comparing them with DSM
diagnoses. Given that in Axis II we have only 9 disorders analogous to the PDM Axis P diagnoses, we
have concurrent and discriminant validity data only on 9 of our PDP prototypes. The average
correlation between the PDP and the analogous DSM disorder is .62, while the average correlation
between the PDP prototype and a different DSM disorder is .05. On this basis as well, we can say that
the concurrent and discriminant validity of our PDP is generally good.
To assess the construct validity of the PDP, we have used a stepwise model of linear
regression to capture the relationships between the different PDM Axis P disorders and their specific
core preoccupations and pathogenic beliefs. To this end, we developed two different clinician report
instruments: the Core Preoccupation Questionnaire (CPQ; Gazzillo & Lingiardi, 2010) and the
Pathogenic Belief Questionnaire (PBQ; Lingiardi & Gazzillo, 2010). These instruments ask the
raters/clinicians to assess on a 1-7 Likert scale the degree to which the motivations, cognitions,
emotions and behaviors of a patient reflect each of the 16 preoccupations and 36 beliefs about self and
others described in the PDM Axis P. Our data show that 14 of the 16 core preoccupations and 21 of
the 36 pathogenic beliefs are specifically connected with the disorder predicted by the PDM.

12
Consequently, we have added to our PDP descriptions the core preoccupations and pathogenic beliefs
described in the manual.
Finally, we have assessed the concurrent validity of the PDP with respect to some life history
information collected by our raters with the Clinical Data Form (CDF; Westen & Shedler, 1999a). In
this case as well, we have used a stepwise model of linear regression and we have chosen only
objective data as predictors. We have found, for example, that the number of arrests and violent
crimes committed by adolescents are predicted by their level of psychopathy; health problems are
correlated with somatizing personality features, physical abuse in childhood correlates with
masochistic personality patterns, and quality of social relationships is inversely correlated with the
schizoid features.
On the basis of these data, we can say that PDP is a reliable and valid instrument for the
assessment of personality with the PDM Axis P categories. Given that it needs no more than 30
minutes to be scored, we think that it is user-friendly enough to be utilized in real clinical practice,
including public settings.
There follows one of the PDP prototypes:

PDP Psychopathic Personality Disorder Prototype

    Psychopathic individuals manipulate others and are afraid of being manipulated by them. They tend

to feel rage and envy, think they can do anything they want, and believe that everyone is selfish,
manipulative, and dishonorable. For these reasons, they tend to control other people in a persistent and
pervasive way and to use their power for their own sake. Psychopathic people seem to care more about
themselves than other people, and tend to feel anxiety less frequently or intensely than others. In addition,
they need constant stimulation. They seem to lack a moral center of gravity, but may be charming and
charismatic and able to read others’ emotional states with great accuracy, being hyperacute to their
surroundings. However, their emotional life tends to be impoverished, and their expressed affect often is
insincere and intended to manipulate other people. They lack the capacity to describe their own emotional
reactions with any depth or nuance, and they frequently somatize. Their emotional connection to others is
minimal, typically they lose interest in people they see as no longer useful to them, and they tend to be
self-centered and manipulative. Individuals who match this prototype lack remorse and tend to devalue
love and kindness, considering these feelings childish and illusory. Some are actively aggressive,
explosive and predatory; others seem passive, more dependent, non-aggressive and relatively non-violent,
but in any case they are manipulative and ready to exploit others.

We are currently completing an international research project with a large sample of

practitioners aimed at investigating the relationships between the PDC and the PDP categories,
defense mechanisms (with the Defense Functioning Scale; APA, 2000), and countertransference

13
patterns (with the Countertransference Questionnaire, (CTQ) (Betan, Heim, Zittel & Westen, 2005;
see also Colli, Tanzilli, Dimaggio & Lingiardi, 2013). We are particularly interested in the
implications of each of these diagnostic elements on the structuring of the therapeutic setting.

The Construction of PDM-2

The PDM-2 project would never have been achieved without its conceptual father, Stanley
Greenspan (1941-2010), whom we view as “our Magellan who has given us the road map,” and
Nancy Greenspan, a responsive and devoted caretaker of her late husband’s legacy.
The first steps toward the new edition required a steering committee representing both
continuity and change. Robert Wallerstein (Honorary Chair), Nancy McWilliams, and Vittorio
Lingiardi have agreed to comprise that group.
Currently, the sponsoring organizations for the second edition are: the American
Psychoanalytic Association, the International Psychoanalytical Association, the Division of
Psychoanalysis (39) of the American Psychological Association, the American Association for
Psychoanalysis in Clinical Social Work, the American Academy of Psychoanalysis and Dynamic
Psychiatry, the International Association for Relational Psychoanalysis and Psychotherapy, and the
Italian Group for the Advancement of Psychodynamic Diagnosis and Research.
For the drafting of the different sections of the manual, five specific Task Forces have been
considered: [1]Adults, [2] Children and Adolescents, [3] Infancy and Early Childhood, [4] Elderly,
and [5] PDM-2 Empirical Tools. Many contributors to the first edition are involved, with the
collaboration of some new scholars.

Perspectives
There are two key purposes for the next edition. First, we need to enhance dialogue between
PDM diagnosis and other diagnostic systems, in particular the DSM and the ICD. Like the original
PDM, PDM-2 is not intended to replace these descriptive nosologies, but to provide an overarching
framework of personality structure and mental functioning within which the neoKraepelinian
symptom classifications can be understood and more effectively treated. Furthermore, PDM-2 will
involve more systematic and empirical research than the first edition included, especially as such
research informs more operationalized descriptions of the different disorders.
Although the second edition will conserve the main structure of the first PDM, it will be
characterized by several important changes.
In the P Axis of the Adult section, Blatt’s (2008) conceptualization of two key configurations
of psychopathology, anaclitic and introjective, will be examined in greater depth with relevance to
difference personality types. According to Blatt, introjective issues, centered on problems about the
definition of one’s identity, seem mainly present in schizoid, schizotypal, paranoid, narcissistic,

14
antisocial and obsessive personality disorders, while anaclitic issues, related to the need to develop
more stable and mutual object relations, seem more prevalent in borderline, histrionic and dependent
personality disorders (Blatt, 1990; 1995). The first PDM incorporated Blatt’s work in noting
introjective (self-definition) and anaclitic (self-in-relation) subtypes of personality types, but since its
publication, more research has been done on these core polarities of personality. This
conceptualization seems highly relevant to which kinds of psychotherapy may be most effective in
relation to the specific difficulties of different patients.
In order to connect PDM-2 more closely with empirical research, the section on “Level of
Personality Organizations” will be integrated and reformulated according to the empirical results from
measures such as the Inventory of Personality Organization (IPO) (Kernberg & Clarkin, 1995), the
Structured Interview of Personality Organization (STIPO) (Clarkin, Caligor, Stern & Kernberg, 2004)
and the Karolinska Psychodynamic Profile (KAPP) (Weinryb, Rossel, & Asberg, 1991).
Careful readers may have noticed that in the original PDM, there is a significant omission.
Despite some authors’ arguments for the presence of a psychotic level of personality organization
(e.g., Kernberg, 1984; McWilliams, 2011b; Wallerstein (2006), the authors of the PDM considered
that this formulation could lead to a terminological confusion with other syndromes, such as
schizophrenia. This problem is not particular to the PDM; the same confusion inheres in the
interesting fact that whereas the DSM-5 characterizes schizotypal personality as a personality
disorder, the ICD-10 classifies it as a psychotic disorder. Gordon (menninger), in support of
McWilliams’s argument that personality organization exists along a continuum from psychotic
through borderline to neurotic and healthy structures, has empirically demonstrated that even
histrionic personality patterns can be expressed at the psychotic level of functioning (see figure 1). It
appears that schizophrenia and psychotic affective illnesses should not to be confused with a severe
level of personality organization that can be present with any particular personality pattern. A
separate axis of personality organization would also resolve the “schizotypal controversy” in that it
would be classified a schizoid pattern at the psychotic level of personality organization. Such
conceptualizations may demonstrate the PDM’s superiority to the DSM and ICD in the domain of
personality taxonomy.
The PDM-2’s P and PCA Axis will also integrate and revise the section on “Types of
Personality Disorders” according to theoretical, clinical and empirical indications from the clinical
literature and according to clinically and empirically sound measures such as the Shedler-Westen
Assessment Procedure-200 (SWAP-200) (Westen & Shedler, 1999a, b) and its new versions and
applications (SWAP-II) (Blagov, Shedler & Westen, 2012; SWAP-200-Adolescents (Westen, Shedler
& Durrett, et al., 2003); see also Lingiardi, Shedler & Gazzillo, 2006; Gazzillo, Lingiardi, Peloso et
al., 2013), and the Psychodynamic Diagnostic Prototypes (Gazzillo, Lingiardi & Del Corno, 2010).
Moreover, we are considering the possibility of including an “Emotionally Dysregulated Personality

15
Disorder,” corresponding in part to the DSM’s description of “Borderline Personality Disorder”
(which is not included in the current list of PDM personality disorders, as the concept of “borderline”
has been retained there in the meaning that original arose from clinical experience: as a level rather
than a type of personality organization).
With respect to the M and MCA Axis of the Adult section, a better coordination is needed
among the PDM labels of the nine mental capacities and other descriptions of the elements of mental
functioning, possibly already operationalized in literature. For example, we could use items or scales
from empirically sound instruments such as the SWAP-200, the Defense Mechanism Rating Scale
(DMRS) (Perry, 1990), the Social Cognition and Object Relations Scale (SCORS) (Westen, 1995), or
the Object Relations Inventory (ORI) (Blatt & Auerbach, 2001).
Moreover, we will revise and reformulate the “illustrative descriptions of the range and
adequacy of functioning” in a way that is more clinician-friendly, empirically grounded, and
assessment-relevant, by introducing an assessment procedure with a Likert-style scale (i.e., indicating
in a quantitative way the level at which any single mental function is articulated).  
Regarding the S Axis of the Adult section, we will enhance its integration with the more
symptom-syndrome oriented diagnostic manuals such as the DSM and the ICD. We will try not to
exclude any relevant syndrome or psychopathological condition (e.g., panic disorder or
hypochondriasis, which are not included in the PDM current list of symptom’s patterns). Finally, we
will give a more exhaustive explanation of the rationale for the description of “affective states,”
“cognitive patterns,” “somatic states,” and “relationship patterns,” and we will reference related
clinical and empirical studies.
The section dedicated to the Classification of Child and Adolescent Mental Health Disorders
will also be subject to some changes. First, we intend to separate the Adolescent section (age 12-18)
from the Child section (4-12), because it seems clinically naive to use the same levels and patterns for
describing the mental functioning of, say, a 4-year old child and a 14-year old adolescent.
About the SCA Axis, however, we know that it is organized in a way that can be reliable for
both the populations; it might be useful to differentiate by age only the descriptions of the subjective
patterns connected to the various syndromes outlined. We intend to maintain the idea of assessing first
Mental Functioning (MCA Axis) and then Personality patterns (PCA Axis).
Regarding the Special Section on Infancy and Early Childhood (IEC) Mental Health
Disorders, we are considering the possibility of adding a specific section on developmental lines and
homotypic/heterotypic continuities of early infancy, childhood, adolescent and adult psychopathology,
which are objects of investigation in the clinical and empirical literature (see, e.g., Costello et al.,
2003; Speranza & Fortunato, 2012). We will give better definitions of the quality of primary
relationships (between the child and his or her caregivers), adding contributions from theoretical,
clinical and empirical investigations into infant research and attachment theory (see Cassidy &

16
Shaver, 2008), and we will make references to empirically grounded instruments useful for their
assessment.
Starting from this perspective, we will also emphasize more strongly the evaluation of family
systems and their characteristic relational patterns, including a paragraph about attachment patterns
and their possible relationship to psychopathology and normative development.
An important change in the incoming new version of the manual will be the inclusion of a
section on Mental Health Disorders of the Elderly, which was not in the first edition. As McWilliams
(2011a) pointed out: “One of the first serious criticisms of the PDM embarrassed us: Daniel Plotkin
(personal communication, December 2006) at UCLA Medical Center wondered why, in this avowedly
developmental document, we included sections on infancy, childhood, and adulthood, but none on the
elderly. In view of the average age of the steering committee members (late 60s and early 70s, by my
calculation), one can only infer massive denial: Including a section on elderly patients never occurred
to us!”.
Finally, PDM-2 will contain a special section dedicated to Clinical Exemplifications, which
will help the reader to have a better and deeper understanding of the manual’s contents.  Our aim is to
provide clinical illustrations that exemplify how the PDM assessment procedures can help therapists
to understand and describe the mental functioning of real patients, both their positive resources and
their pathological dimensions. Together with the PDM (Axis P, Axis M and Axis S) and the ICD and
DSM-5 diagnoses, PDM-2 clinical presentations should articulate what are the more relevant affects,
defense mechanisms and conflicts of the patients, their specific core preoccupations and pathogenic
beliefs, and the affective reactions experienced by the assessor while interacting with them. Case
presentations deriving from PDM-2 should specify the more and less compromised mental processes
of the patient and in what circumstances the person functions at higher and lower levels, respectively.

Conclusion: A Historic Opportunity

As McWilliams (2011a) has noted, the primary goals for the PDM were to create a diagnostic
system that embraced the complexities of human experience (both normal and pathological) and to
conceptualize the major psychological disorders in ways that went beyond external description to
capture the subjective phenomenology and underlying dynamics that shape psychological symptoms
and syndromes.  
As we have noted, 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. There is increasing evidence,
however, that both mental health and psychopathology involve many subtle features of human
functioning, including affect tolerance, regulation, and expression; coping strategies and defenses;
capacities for understanding self and others; and quality of relationships. Mounting evidence from

17
neuroscience and developmental studies supports the position that mental functioning, whether
optimal or compromised, is highly complex. To ignore mental complexity is to ignore the very
phenomena of concern to therapists and students of human psychology. After all, our mental
complexity defines our most human qualities.
Greenspan thought that the PDM could serve as a holistic diagnostic tool. He believed it
could help not only psychodynamically oriented, but also behavioral, cognitive, humanistic, emotion-
focused, family, systems, and biologically oriented therapists "understand their patients more fully.
[…] We've seen interest from people in anthropology, sociology, educators, legal scholars and people
in the justice system," he noted. "It's broadened the purview of psychology to reach into all the related
disciplines that deal with human beings" (Packard, 2007).
The PDM has a historic opportunity to expand beyond the doctor’s office and the symptom
checklist into the deeper complexities of the human being. To be trapped between the anonymity of
rating scales and the challenges of self-referential jargon language not only mortifies the clinician’s
professional identity, but also dims or distorts practitioners’ abilities to detect and describe their
patients’ characteristic mental experience – and therefore the capacity to relieve their psychological
distress. Without a counterpoint to the current tendency to focus more and more narrowly and
discretely on disorder categories, the clinical relationship may be jeopardized and even damaged
beyond repair.
This danger is the main reason we feel we need a biopsychosocial classification system such
as the Psychodynamic Diagnostic Manual. It also is the main reason we are committed to improving
its clinical value with a new edition. With it, we hope to fulfill Robert Wallerstein’s wish: “that PDM
will have an enduring life.”

18
s

Figure 1: MMPI-2 Hysteria-Hy, Schizophrenia-Sc, and Ego Strength-Es Scales within the Psychotic, Borderline, and
Neurotic Categories of the Personality Organization Scale.
Note: Solid line at MMPI-2 score of T50 is average. Dotted line at T65 indicates clinically significant scores.
Psychotic (ratings 1-3, n = 13), Borderline (4-6, n = 52), and Neurotic (7-10, n = 33). Psychotic: Sc >> Hy > Es;
Borderline: (Sc ~ Hy) > Es; Neurotic: (Sc ~ Hy) > Es all in the average to moderate range. Hy: Psychotic >Neurotic.
Sc: Psychotic >> (Borderline ~ Neurotic). Es: Neurotic >>Psychotic; Neurotic >Borderline; Borderline > Psychotic.

19
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