Eating pathology and Psychodynamic Diagnostic Manual (PDM-2) diagnostic assessment: Implications for treatment outcomes in a psychodynamic-oriented residential setting.

Abstract

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) categorical classification of eating disorders (ED) has faced substantial criticism due to its limited ability to assess patients’ individual characteristics and thereby evaluate the most appropriate treatment options. The current study aimed at exploring the validity of the Psychodynamic Diagnostic Manual (PDM-2) diagnostic approach to ED by evaluating the treatment outcomes of a psychodynamic-oriented residential intervention. At the start of treatment, a national sample of 73 female ED patients was evaluated using both the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Psychodiagnostic Chart-2 (PDC-2)—a PDM-2 derived clinician-rated tool. Participants were also asked to complete a self-report questionnaire on ED symptomatic impairment at treatment intake and discharge. Results showed the overall effectiveness of the psychodynamic residential treatment in terms of therapeutic change in ED-specific psychopathology. Even when controlling for baseline ED symptoms, higher levels of personality organization and a lower severity of personality pathology were found to predict lower levels of ED-specific psychopathology at discharge. Similarly, higher levels of overall mental functioning, as well as higher mentalizing capacity, identity integration, and self-coherence, were found to relate to better therapeutic outcomes. DSM-5 categories did not impact either pre–post change or symptomatic change at treatment termination. Results suggest that the PDM-2 diagnostic approach could promote a better conceptualization of potential maintenance factors to target in psychotherapy, generating a comprehensive perspective with maximal clinical utility.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

“…Thus, the S Axis provides only one of three crucial perspectives and assists clinicians in creating a multifaceted diagnostic profile of the patient, to determine the best treatment options [41]. With respect to personality features in EDs, the manual highlights the relevance of three empirically-based personality configurations that broadly correspond to: (a) an underregulated subtype, characterized by patterns of impulsive behavior and affective lability/instability, borderline and bulimic features, and feelings of emptiness and emotional hunger [42]; (b) an overregulated subtype, characterized by inhibition and a restricted behavioral/affective presentation; schizoid, avoidant, and obsessive-compulsive features; and anorexic symptoms [43]; and (c) a high-functioning/perfectionistic subtype, characterized by normative levels of personality functioning and less severe ED psychopathology [44]. These personality profiles have been confirmed by a substantial body of research using different assessment tools with both single diagnostic and mixed ED samples [45][46][47][48][49].…”

The Mediator Effect of Personality on the Relationship Between Symptomatic Impairment and Treatment Outcome in Eating Disorders

“…The average length of clinical psychotherapy practice was 10.1 years (SD = 3.07; range = 7-15) and the average time spent per week practicing psychotherapy was 22.7 h (SD = 5.14; range = 15-35). All of the present study data were added to those of the patients and clinicians who participated in previous investigations using the same assessment tools (Muzi et al, 2020(Muzi et al, , 2021.…”

“…Although research on personality as a predictor of ED outcome is sparse, some relevant studies, drawing on the pathoplasty model, have found that PDs are commonly associated with poorer response to treatment (Steinhausen, 2002(Steinhausen, , 2009Thompson-Brenner and Westen, 2005;Wildes et al, 2011;Muzi et al, 2020Muzi et al, , 2021. Further research has suggested that high attrition, low compliance, dropout, symptom chronicity, low recovery rates, and low efficacy of therapeutic interventions relate to the personality characteristics of individual patients (Pham-Scottez et al, 2012;Martinez and Craighead, 2015;Levallius et al, 2016).…”

“…In this vein, some authors have outlined that the investigation of personality within the categorical boundaries of ED diagnoses, as proposed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), could be limited by the high rates of residual diagnoses (Fairweather-Schmidt and Wade, 2014), the common "diagnostic cross-over" between the main ED diagnoses, the low temporal stability of the main ED diagnoses, and their lack of discriminant validity in terms of severity of symptomatic impairment (Eddy et al, 2008). More specifically, with respect to treatment outcomes, some studies have found that categorical DSM-5 ED diagnoses do not predict patients' responses to therapeutic interventions or future clinical courses (Westen and Harnden-Fischer, 2001;Raykos et al, 2018;Muzi et al, 2021), and that DSM-5 severity specifiers are not related to ED psychopathology, overall impairment, health status, comorbid conditions (e.g., depressive symptoms), or therapy outcomes (Gianini et al, 2017;Machado et al, 2017;Dalle Grave et al, 2018). Conversely, studies employing more dimensional and empirically derived approaches, such as the Shedler-Westen Assessment Procedure-200 (SWAP-200;Westen and Shedler, 1999a,b), have shown promising results in the identification of personality constellations in ED patients (Westen and Harnden-Fischer, 2001;Thompson-Brenner and Westen, 2005;Gazzillo et al, 2013), including healthy personality features and psychological resources (e.g., Muzi et al, 2020), as well as their predictive value in determining therapeutic outcomes (Thompson-Brenner et al, 2008a,b).…”

In-Session-Reflective-Functioning in Anorexia Nervosa: An Analysis of Psychotherapeutic Sessions of the ANTOP Study

“…Previous findings also point to a reduced capacity to mentalize ( 16 – 19 ), which is supported by clinical contributions and qualitative empirical work ( 20 , 21 ). Additionally, in one study, a relationship between a higher capacity to mentalize and better outcomes was found ( 22 ). Difficulties in self-related information processing and perspective taking were also supported by findings from neuroimaging studies [see e.g., ( 23 )].…”