The DSM-IV, widely considered the foremost authority for providing diagnostic criteria for mental disorders, provides a managed-care-friendly classification system that simplifies and categorizes mental illness into clean and quantifiable categories. This limited categorical approach to psychological diagnosis overlooks important psychodynamic elements crucial to a comprehensive understanding of pathology.
Take depression, for example. The DSM-IV emphasizes somatic, behavioral, and some limited mood components that manifest themselves as observable and overt symptom components. Defensive processes remain entirely unexplored. This oversight accounts for the central distinction between psychodynamic diagnostic conceptualization and the parochial medical model endorsed by the DSM-IV.
The evaluation of defensive styles, whether ego-alien or ego-syntonic, primitive or mature, offers clinicians a wealth of information about a patient’s particular pathology—information about the patient’s attachment style, early object relations, and general ego strength. As a result, clinicians will approach treatment with greater sensitivity and precision. A clinician who does not exclusively base his diagnosis on the DSM-IV criteria can differentiate, for instance, between someone who is experiencing a depressive episode and someone who has a depressive personality. In other words, if a patient generally relies on the defenses of introjection and idealization, he likely has a depressive characterological organization, although he may not necessarily endorse any of the items on the DSM-IV because he is not experiencing clinical depression per se.
Differentiating characterological from situational defensive reactions is a critical aspect of any informed diagnostic decision. The limited approach of the DSM-IV fails entirely to account for those psychodynamic elements necessary to make this distinction, severely limiting the ability of clinicians to fully and comprehensively address their patients’ needs.