Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The Perspectives of PsychiatryRichard Balon, MD
Wayne State University, Detroit, MI, USA
By Margaret S. Chisolm and Constantine G. Lyketsos. Baltimore, MD: The Johns Hopkins University Press; 2012; ISBN 978-1-421-407012; pp 264; $60 (paperback).
Over the last several decades there has been a continuous effort to make psychiatric diagnosis and evaluation more and more simple or, as many would say, more simplistic. The DSM approach to psychiatric diagnosis has, rightfully or not, been criticized from many angles. One of the main criticisms has been the disappearance of individual aspects and experience of our patients from their diagnosis and of what underlies their presentations. As Paul R. McHugh and Phillip R. Slavney write in their Foreword, “…psychiatric practice has devolved from a thoughtful professional art to a technical, instrumentalist routine where, with what exists being officially presumed, what is done both diagnostically and therapeutically is mechanical and generic rather than devised, individuated, challenging, and progressive” (p x). They also warn of the fact that today’s psychiatrists “…display a complacent satisfaction in refusing to go beyond the securities of diagnostic consistency given to them by the DSM diagnostic categories—a complacency often expressed in discussion-ending statements such as ‘he meets criteria’” (p x). There have been some attempts to address these concerns within the world of even American psychiatry. One of the attempts or approaches addressing these concerns has been McHugh and Slavney’s book, The Perspectives of Psychiatry.1 They introduced a conceptual framework using 4 perspectives: disease, dimensional, behavior, and life story, for understanding patients who present with psychiatric condition. As they state, “With The Perspectives of Psychiatry we did not offer some new theory to psychiatrists but rather drew attention to causal ideas long implicit within the discipline and in need of re-emphasis at this time and place in the discipline’s history: specifically ideas that provide psychiatrists power to ‘know about’ the disorders that they ‘know of’ by name. The Perspectives of Psychiatry strives to offer a view of what psychiatry today ought to become” (p xi).
Some of McHugh and Slavney’s students and colleagues have expanded the ideas of “perspectives of psychiatry” into further volumes. This book is another contribution to this list sparked by McHugh and Slavney’s work. It attempts to “distill that book’s [The Perspectives of Psychiatry] concepts into an easier-to-digest and easier-to-use format”… “to distill the detailed instructions of The Perspectives of Psychiatry into a practical ‘recipe’ for trainees” (p xiii) and apply it into a systematic psychiatric evaluation.
The book is divided into 2 parts: “I. The concept behind the approach” and “II. The approach in action.” The purpose of the 6 chapters of Part I: “An introduction”; “The psychiatric evaluation”; “The life-story perspective”; “The dimensional perspective”; “The behavior perspective”; and “The disease perspective,” is to explain and illustrate the key concepts of “perspectives of psychiatry.” In the Introduction that the authors point out that “The central tenet of The Perspectives is that one single method cannot explain all psychiatric conditions” (p 5). According to this tenet, clinicians should consider every psychiatric patient from 4 points of view: disease, dimensional, behavior, and life story—”each with a unique way of understanding the emergence of various psychiatric conditions” (p 5). The authors add that The Perspectives introduce “perspectival” thinking and are “less concerned with the differentiation and classification of psychiatric conditions (nosology) than with helping clinicians become aware how they think about each patient presentation” (p 6). The rest of the Introduction explains each perspective in more detail. The disease perspective focuses on disease (what one has) and reasoning, with key features being clinical syndrome, pathology, and etiology. The dimensional perspective “considers whether a patient’s psychiatric condition is arising from aspects of personality that make her vulnerable to developing distress in specific situations,” (p 8) as personality is composed of enduring cognitive and temperament dimensions (what one is). The key concepts of this perspective are potentials, provocations, and responses. According to the authors, “understanding a patient’s dimensional characteristics help the clinician guide the patient in psychotherapy” (p 9). The behavior perspective focuses on what a patient is doing, with key concepts being choice, physiological drive, and conditioned learning (what one does). Finally, the life-story perspective deals with what one encounters, as “Every individual goes through life as an agent with needs, desires, goals, and hopes. When someone encounters life circumstances that disrupt these, distress and demoralization may arise” (p 11). The conclusion of this chapter suggests that the entire approach could be summarized in what a patient has, is, does, and/or encounters, in mnemonic: HIDE (Has, Is, Does, Encounters).
The discussion of “The psychiatric evaluation” presents 2 versions of the same case evaluation; the first illustrating a typical approach to a psychiatric history and the second presenting a more comprehensive evaluation embedded in The Perspectives (this usually takes >1 hour and should be done in >1 session). The chapter summary emphasizes that the essential features of the systematic psychiatric evaluation are a detailed history; a history obtained and presented in a specific sequence; a history obtained from multiple sources; a systematic mental status examination; and a careful differentiation between observations and interpretations.
The following 4 chapters present cases illustrating in more detail the life-story perspective, the dimensional perspective, the behavior perspective, and the disease perspective. Each chapter is written in a dialogue format between the clinician and the patient, followed by a structured discussion and key summary points. The authors explain that they changed the order and started with the life-story perspective “because the life story is the most natural, and personal, way of explaining someone’s thoughts, feelings, and behaviors” (p 35). Although these chapters generally explain the concepts, they are not always clearly written (eg, the chapter on dimensional perspective written on the background of an intellectual disability case).
The second part consists of 9 cases: bipolar disorder (maintaining personhood in the face of a disease); a young man with psychosis (the role of life story and behavior in disease); a mother’s overdose (life story and dimension); a man with depression amidst multiple life stressors (life story or disease?); a matriarch with memory and mood problems (managing diagnostic dilemmas); an executive with health worries (dimension or disease); a young woman’s fear of fat (an aberration in feeding behavior); a lawyer who lies and cuts (synthesis of a complex case); and a case of bereavement (why psychotherapy matters). Cases (again in a dialogue format) are followed with discussion that applies a stepwise approach to psychiatric evaluation (step 1: role induction; step 2: history; step 3: mental status examination; step 4: collateral information; step 5: consideration from each perspective in sequence: life story, dimensional, behavior, disease; step 6: collaborative formulation; step 7: collaborative treatment plan). In my opinion, these cases are interesting not only in the way they are presented, but also in what they present (eg, the case of the executive with health worries considers both dimension and disease). They may make an interested clinician think.
Appendices A, “The psychiatric evaluation” (table format to be used), and B, “The mental status examination” (discussion and table to be used) accompany this book.
This book left me with mixed feelings. Although I understand and agree we need to perform and teach more complex and refined psychiatric evaluation, I am not sure The Perspectives and this book will be able to accomplish that. This book is not clear in explaining some issues. I felt that I was able to understand the entire concept better when I read Peter Fagan’s book on applying the perspectives in the area of sexual disorders.2 The idea of the 4 perspectives is intriguing (although some may envision that the dimensional perspective presents something different in terms of psychopathology dimensions) and on the right track…maybe. However, I am not sure how practical this approach is, and how to teach it to clinicians. To spread this gospel would probably require a long-term combination of the passion of Johns Hopkins trainees with training seminars at meetings around the country. Nevertheless, an interested clinician disappointed with the current state of affairs of psychiatric diagnosis and/or a teacher interested in teaching more than just what is in the DSM and how to prescribe medications will find this book thought provoking and useful.
- McHugh PR, Slavney PR. The perspectives of psychiatry. Baltimore MD: The Johns Hopkins University Press; 1983.
- Fagan PJ. Sexual disorders. Perspectives on diagnosis and treatment. Baltimore MD: The Johns Hopkins University Press; 2004.
Annals of Clinical Psychiatry ©2013 Frontline Medical Communications Inc.