Diagnosing Mental Illness with the Perspectives Approach

Dr. Turck:
The Diagnostic and Statistical Manual of Mental Disorders, or DSM for short, is the handbook traditionally used by healthcare professionals to guide the diagnosis of psychiatric conditions, but a number of psychiatrists advocate for the perspectives approach, which extends beyond the DSM model.  So how exactly do these two models differ?  And how might this newer approach impact our patients? 

Welcome to NeuroFrontiers on ReachMD.  I'm Dr. Charles Turck.  And joining me to talk about the perspectives approach is Dr. Margaret Chisolm, Professor of Psychiatry and Behavioral Sciences as well as the Vice-Chair of Education, Psychiatry, and Behavioral Sciences at Johns Hopkins School of Medicine.  She's also the author of From Survive to Thrive: Living your Best Life with Mental Illness. 

Dr. Chisolm, welcome to the program. 

Dr. Chisolm:
Oh, thank you for having me.  I'm really excited to be here. 

Dr. Turck:
Well to start us off, Dr. Chisolm, can you give us some background on the DSM model and some of the challenges it presents when we're diagnosing psychiatric conditions? 

Dr. Chisolm:
Yeah, so the DSM has many merits, but it's really limited when used to formulate patients and to understand patients and all their complexity because the DSM is really a categorical approach to understanding mental illness or psychiatric problems. The limitation of a categorical approach to understanding patients is that it really lends itself to thinking about these syndromes within these categories as diseases; but as we know, psychiatric problems can have a variety of origins, and they are not all because of a broken part or a broken function in the brain or the body. 

Dr. Turck:
With that in mind, what is the perspectives model, and how is it different from other approaches? 

Dr. Chisolm:
Yeah, so the perspectives of psychiatry is really just making explicit what we clinicians know implicitly that not all psychiatric problems are diseases, and so not all can be explained using disease reasoning.  And so the perspectives approach is really a visual metaphor for thinking about patients.  So you would look at a patient and their problems from four different perspectives, and you'd consider, “Is this something that the person has?  Is it something like a disease like schizophrenia or manic-depressive illness that has come upon them unbidden?” Or the second perspective: “Is this problem arising? Does it have its origin in something that the person is doing, like an eating disorder or a substance use disorder?” Or the third perspective: “Is this psychiatric problem, originating in who the person is? Is it an expression of their personality, their affective temperament, or their cognitive capabilities?” And the fourth perspective asks us to consider, “Is this psychiatric problem originating because of something the person has encountered? Is it part of their life story?” And obviously’’, there’s overlap among all these perspectives, but it’s different from thinking of someone only as having a disease. 

Dr. Turck:
Can you tell us how the perspectives approach empowers patients to flourish? 

Dr. Chisolm:
So the perspectives approach is something that clinicians can use not only to formulate a patient and understand what is the goal of treatment and what priorities need to be set for their treatment, but it’s also a way of helping patients understand their own experiences.  It gives a framework. Often when I meet with patients, I’ll ask them, “You’re coming to me with these problems or this problem. How much of this do you think can be explained because of something that you’re doing or something that you have or who you are as a person or something that you’ve encountered in your life?”  And it really does open people up to be able to understand the various origins of their problems and how they might be interacting and what needs to be done to help them feel better.  However, ’’’my job I think as a psychiatrist, I think as a physician in general, is to help people reach their greatest potential. 

Dr. Turck:
For those just tuning in, you're listening to NeuroFrontiers on ReachMD.  I'm Dr. Charles Turck, and I'm speaking with Dr. Margaret Chisolm about the perspectives approach to treating patients with mental illness. 

So Dr. Chisolm, are there any other ways that you help your patients work through their diagnosis and empower them to live a healthy life? 

Dr. Chisolm:
So I would look at the four pathways to flourishing that have been described by the epidemiologist at Harvard, Tyler VanderWeele, which are family, work, education, and community, and look at those aspects of someone's life and whether or not there are ways that those aspects of their life can be strengthened that would allow them to flourish in life and be able to really thrive.  As an example, I worked for 10 years at the Center for Addiction and Pregnancy, and we saw pregnant women often addicted to heroin.  And it was relatively easy to help them stop using drugs during their pregnancy because they wanted to have a healthy baby, they wanted to be able to have custody of the baby after it was delivered, but it was often a challenge to help them stay in recovery after they had the baby, and so we would look at these pathways to flourishing and think, Do they need to reconnect with their family and get that support?  Many of them had burned bridges with their family because of their drug use.  Do we want them to get a job or to go back to school to further their education, so that that brings meaning and purpose in their life and gives them a sense of responsibility and that somebody is depending on them?  And obviously in addiction treatment, you really want to help people rebuild their community, so the recommendations to go to AA or NA or reconnect with their faith community are fairly common recommendations for treatment in somebody with addiction. 

So those are the ways that I would think about helping my patients reach their greatest potential is by looking at these four pathways to flourishing (family, work, education, and community) and figure out ways that we could strengthen those pathways for the patient. 

Dr. Turck:
Before we close, Dr. Chisolm, is there anything else you'd like to share with our audience today, be it about some of the perspectives or models we discussed or even just more globally about mental health? 

Dr. Chisolm:
Well, you know, one of my goals in writing the book was to demystify psychiatry. I don't think that there's as much mystery around psychiatry as one might think. So people can have diseases. The brain can have an alteration in its functioning or its structure that can cause problems.  People can have problems that arise because of their temperament.  People can have problems that arise because of things that they are doing, like restricting their food intake or using a substance, or people can have problems because they have had a life event that's thrown them off course. 

Most people come to treatment because their life isn't where they want it to be, but the reasons really can vary, and so demystifying that I think is really one of my goals.  And the other goal is to destigmatize these psychiatric problems.  Everybody has problems at some time in their life with their feelings or their thoughts or their behaviors, and normalizing those times when things aren't going the way that you had hoped is really I think an important role for a clinician. 

For this book, I thought as part of the goal of decreasing stigma around psychiatric problems I'd use my own story. So I talk about when I was a college student having a suicide attempt in the setting of severe depression, and then I also share my story many years later of having a postpartum depression.  In addition, I've lost two family members to suicide, a first cousin as well as my brother who passed away in 2012.  So I share those stories to make a couple of points: one, that these are nothing to be ashamed of, these problems happen to everyone; and two, to show that even with these problems people can flourish and go on to lead a good life, as I think I am.  Not only did I want to illustrate the points in the book, but I also wanted to destigmatize these problems and give people hope that they could go on and lead full lives despite and sometimes even because of their mental illness.

Dr. Turck:
Well this has been such an interesting look at a different approach to the evaluation of mental illness.  And I want to thank my guest, Dr. Margaret Chisolm, for sharing her insights on the perspectives model.  Dr. Chisolm, it was a pleasure speaking with you today. 

Dr. Chisolm:
Oh, thank you. Thanks for having me. 

Dr. Turck:
For ReachMD, I'm Dr. Charles Turck. To access this and other episodes in our series, visit ReachMD.com/NeuroFrontiers, where you can Be Part of the Knowledge. Thanks for listening.