Have you ever wondered how mental health clinicians arrive at a psychiatric diagnosis? You may have heard of the Diagnostic and Statistical Manual (DSM), which is often referred to as "the bible of psychiatry." First published in 1952, the DSM was the first comprehensive guide to mental disorders, with a focus on clinical diagnosis. The DSM has since evolved and is currently in its fifth edition, known as DSM-5-TR, and remains the primary source used to diagnose psychiatric disorders. While the DSM is widely used, it has received constructive criticism over the years, leading to the development of alternative approaches to supplement its use. Today, we'll be discussing the Perspectives approach to psychiatry.
As a psychiatric nurse practitioner (PMHNP), I often question the use of the DSM alone to arrive at a diagnosis. It begs the question, am I truly considering the individual and their unique experiences and circumstances? A categorical approach to diagnosis (which is commonly accepted as a means of medical diagnosis) may not always be the best tactic for complex psychiatric disorders, which can be influenced by ever-changing symptoms and external factors. Mental health disorders are distinct from medical diseases. That’s certainly not to say that mental disorders are not diseases with demonstrated biological, physiologic, and genetic underpinnings, because they certainly are. However, they have additional factors at play, such as social and personality influences. That is why I have turned to the Perspectives approach to psychiatry, which considers the holistic picture of an individual's diagnosis.
What is the Perspectives approach to psychiatry?
The Perspectives approach emphasizes that a patient’s problem is more than a disease. Building upon the pioneering work of Adolph Meyer and Karl Jaspers, it was first described in The Perspectives of Psychiatry (1998) by Dr. Paul McHugh and Dr. Phillip Slavney and was developed at Johns Hopkins University, where I received my training. It acknowledges that while psychiatric disorders have a biological and physiological basis, there are also social, behavioral, and personal factors that contribute to each patient's unique diagnosis. By addressing all of these perspectives, clinicians can gain a more comprehensive understanding of the patient's mental health and develop more effective treatment plans.
It outlines four perspectives from which to view and treat a patient:
- Disease – what the patient has
- Dimensional – what the patient is
- Behavior – what the patient does
- Life story – what the patient encounters
The disease perspective
The disease perspective can best be described as what the person has. It focuses on identifying the structural or functional, biological or physiological problems that underlie an individual’s symptoms. This perspective is in line with traditional biomedical models and diagnoses. For example, in the case of psychosis, excess dopaminergic activity is believed to be partially responsible for symptoms. In schizophrenia, dysregulation between communication pathways in the brain and inflammatory and genetic factors is known to be contributory. In anorexia nervosa, anxiety can activate the dopamine food intake control circuitry, and weight loss itself can trigger neuroendocrine changes that decrease the desire to eat. These are biological aspects of a person’s body that contribute to the disease they have. Treatment from this perspective involves evaluating how best to treat the structural issues or biochemistry of the disease. This may include medication management, medical diagnostic testing, or the involvement of other medical specialists, if necessary.
The dimensional perspective
The dimensional perspective can best be described as what the person is, taking into account their inherent personality traits or dispositions. For example, some people naturally have higher levels of neuroticism, perfectionism, or extraversion, to name a few. Neuroticism is characterized by perceiving normal events as threatening, emotional instability, increased reactivity, negative thought patterns, and self-consciousness. By understanding that a person has neuroticism as a trait, treatment can be directed toward addressing these issues. In the case of neuroticism, psychotherapy would be a suitable intervention aimed at challenging negative beliefs and distorted thinking patterns.
The behavior perspective
The behavior perspective can best be described as what the patient does. This perspective considers what is driving a person to behave a certain way or make certain choices. It recognizes that some behaviors may be learned or conditioned, and seeks to understand what factors initiated and maintain the behavior. This is where the provider needs to think about what may have initiated a maladaptive behavior and what is continuing to drive or motivate it. For instance, with anorexia nervosa, one would consider various factors that may have contributed to the desire to restrict food intake, such as poor body image, societal pressure to be thin, or perhaps even a desire to be “healthier.” These are just some factors that can initiate restrictive food intake, but one then needs to consider what maintains the behavior once it starts. In the case of anorexia nervosa, weight loss itself can maintain the desire to restrict. Again, there may be outside considerations, such as peers or family commenting on weight loss, perhaps in a positive light initially. These factors can reinforce and motivate the behavior.
Life story perspectives
Lastly, the life story perspective can best be described as what the individual encounters. I like to have a grasp on what a person’s life has looked like up until the point they met me. Not only because it’s part of this model, but because it’s a great way for me to get to know them and build a level of comfort and trust. It can give a provider insight into a person that may otherwise be missed. This life story approach involves looking back into childhood, development, home life, family structure, traumatic events, significant relationships or losses, jobs, etc. Where have they been? What have they seen? These conversations paint a picture of what a person’s life looks like according to them. As a provider, it’s helpful to gain insight into how this person views their life until now, awhichallows me to be more sensitive to each unique picture. If an individual’s view of their story is largely negative, psychotherapeutic work can be done to reframe or rewrite their story.
After outlining each of these perspectives, it is evident that the Perspectives approach differs greatly from traditional biomedical or categorical approaches to mental health. This approach questions the very use of the term diagnosis in mental health care. Instead, the Perspectives approach encourages the use of a formulation that summarizes the whole person, not just their diagnosis, and highlights each perspective of their care and treatment. A formulation can change over time, just as the person does. Life happens, circumstances change, and all of this is taken into account when providing compassionate care to individuals with mental health concerns. As a psychiatric nurse practitioner, I aim to approach each person with empathy and understanding, and the Perspectives approach provides an invaluable model for achieving that goal.