Saveanu, Radu V. MD
Professor and Vice Chair for Education Department of Psychiatry and Behavioral Sciences University of Miami/Leonard M. Miller School of Medicine, Florida
The Perspectives of Psychiatry by Drs McHugh and Slavney, first published in 1986 and revised in 1998, was written to provide psychiatrists with a coherent framework for better understanding mental disorders and helping patients. The authors envisioned it as a kind of manifesto against what they perceived as “the problematic state of American Psychiatry” at the time (p. ix). Looking beyond the “reductionism” of the biopsychosocial model and the Diagnostic and Statistical Manual of Mental Disorders, the book’s central thesis was that psychiatric presentations and disorders cannot be understood by using only one standard investigative and diagnostic method. McHugh and Slavney firmly believed that clinicians, to gain the comprehensive, balanced, systematic understanding of their patients, need to consider all psychiatric presentations from four points of view or perspectives—disease, dimensional, behavior, and life story. This conceptual framework for understanding psychiatric patients was adopted over the years by a number of departments of psychiatry, including Johns Hopkins, where it originated.
More than 20 years later, Margaret Chisolm, MD, and Constantine Lyketsos, MD, MHS, both seasoned faculty members in the department of psychiatry at Johns Hopkins University, published Systematic Psychiatric Evaluation, a casebook that provides a practical framework for conducting a psychiatric clinical evaluation and developing a comprehensive treatment plan. In the words of its authors, this volume was “an attempt to distill the detailed instructions of the Perspectives of Psychiatry into a practical ‘recipe’ for trainees” (p. xiii).
The book is divided into two sections. Part 1, titled “The Concepts Behind the Approach,” provides a very clear, concise description of the four perspectives. The life story perspective is usually compelling to clinicians. We all live both surrounded by stories and telling stories. Stories define our culture, our family origins, and our place in the world. We use stories to explain who we are and what we do. Being able to construct a meaningful narrative to explain life events makes us feel less fragmented, more secure, and whole. The life story perspective focuses on the fact that an individual’s psychiatric condition arises, in part, from understandable psychological reactions to life’s events.
The dimensional perspective focuses on personality (which is composed of enduring cognitive and temperament dimensions). This perspective informs the psychiatrist about the role played by personality traits on a patient’s psychiatric condition. As (McHugh 1992) aptly described it, “it grapples with patients who cannot be placed in clear and distinct categories, but can sometimes be comprehended in their vulnerability to mental distress from their individual position on psychological dimensions that are analogous to physical dimensions such as height or weight.”
The disease perspective, most familiar to physicians, rests on “disease reasoning”—in other words, categorical logic. It assumes that a patient’s presentation can be explained by the presence of a clinical syndrome. This clinical syndrome emerges from an underlying pathology as a result of one or more etiologies. Fundamentally, the disease perspective emphasizes what the patient has.
The behavior perspective, on the other hand, emphasizes what the patient is doing. It can explain repetitive, maladaptive behaviors involving the satisfaction of common drives (eating, drinking, and sexuality) or strong, acquired, desired goals (gambling and substance abuse). Behavior is viewed as a function of physiological drive, learning, and personal choice. The therapeutic goal, from a behavioral perspective and based on conditioned learning theory, is to interrupt the maladaptive behavior (stopping the behavior to gradually extinguish the drive and limiting exposure).
Each perspective sheds a particular light on a different aspect of psychopathology. Not surprisingly, certain psychiatric conditions are more easily “explained” by some perspectives than others. For instance, given our current state of knowledge, the disease model, a model that applies to psychiatric conditions that a patient has, seems to provide the most “natural fit” when evaluating a patient with schizophrenia. Several short clinical cases are introduced in part 1 to illustrate each perspective. I particularly enjoyed one of these cases based on Edgar Allan Poe’s history.
Part 2, titled “The Approach in Action,” consists of nine clinical cases. It provides the reader with a practical, effective roadmap to evaluate and better understand patients with psychiatric conditions having multiple etiologies. Each chapter starts out with excerpts from an actual patient interview, followed by a systematic discussion of the case. Each patient’s history is seen through the prism of the four perspectives, regardless of the clinical presentation. The authors firmly believe that “applying such a systematic approach to complex cases … is necessary to reach a full formulation and comprehensive treatment recommendation” (p. 197).
The book ends with two very useful appendices—the Psychiatric Evaluation and the Mental Status Examination, presented in a format that can be used at the bedside.
I believe that this book will be a useful companion to psychiatric residents and other mental health practitioners who struggle to better understand, diagnose, and treat patients with complex psychiatric and medical conditions.
Radu V. Saveanu, MD
Professor and Vice Chair for Education
Department of Psychiatry and Behavioral
University of Miami/Leonard M. Miller
School of Medicine, Florida
McHugh PR. (1992); A structure for psychiatry at the century’s turn—The view from Johns Hopkins. J R Soc Med. 85: 483–487.