Source: Psychiatric Research Report, Summer 2001
Paul R. McHugh, M.D.
Director and Psychiatrist-in-Chief, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, Baltimore Md.
The crisis of psychiatry seems to be on everyone’s mind and many explanations for it are offered. Tanya Luhrmann (1), an anthropologist, sees a growing disorder as psychoanalysts and biological psychiatrists fight for domination and confuse the students. Others noting the growing influence of the drug industry in our discipline fear that we have lost our way and are committed more to cosmetic therapy than the care of the sick. Managed care seems overly oppressive in our discipline - more than any other medical specialty
The reason we are in trouble is obvious to any doctor who comes from another specialty - say neurology - and notices how we work. Such a visitor from the Mars of contemporary medicine will note how we labor under a strange classificatory system- one that insists that we define mental disorders by their symptomatic appearance. Also when such a visitor asks us how we explain these mental disorders, we mutter a strange mantra as in "We use the bio-psycho-social approach" even though the visitor will quickly see that this approach presents only the ingredients of explanation rather than offering any explanatory recipe.
At Johns Hopkins Department of Psychiatry we have long held that psychiatry needs a new conceptual structure that ties the mental disorders we treat to mental life as psychological science understands it today. Such a structure would insist on defining mental disorders by their essential natures rather than by their appearances alone. Such definition would generate hypothesis-driven research and ultimately, by establishing valid, essential constructs, promote rational treatments to replace symptomatic ones (2, 3).
In this talk I plan to present a brief history of psychiatry, document its problems, describe our approach to resolve them, and conclude with the implications of our proposed structure for practice, training , and research.
Brief History of 20th Century American Psychiatry
The American history of psychiatry in the 20th century consists of three generation-long (i.e. 30-year) epochs. The first 30 years (1910 - 1940) was led by Adolf Meyer of Johns Hopkins and thus is properly entitled Meyerian. Psychiatrists of this epoch learned from Meyer how to deploy a complete history and full mental state examination in evaluating and conceptualizing clinical problems. Meyer insisted that they identify every theme that might illuminate a mental disorder. He also emphasized the need to appreciate progress in psychological science and aspired to inform clinical judgements by these sciences. Just as the internists of his time were being taught to anticipate progress in their clinical conceptions from advances in biology, so Meyer believed, psychiatrists should become experts in Psychobiology - a term he coined to identify not biologic psychiatry but (as the term psychobiology is derived) the study of life at the psychological level (4).
Present day psychiatrists still employ aspects of the Meyerian methods such as the mental status examination but for many his thorough approach to history-taking led to an overload of information that seemed unnecessary for the understanding, care, and treatment of patients. Indeed the random noise of an individual biography seemed to drown out any pertinent message of pathology and pathogenesis.
This sense that crucial matters were obscured by Meyerian detail and that psychiatrists needed to "cut to the chase" gave rise to the second epoch, the psychoanalytic one (1940 – 1970), where motivational drives, libidinal development, and unconscious psychic conflict were seen as the primary pathogenetic forces provoking and shaping psychiatric disorders. This epoch drew out a belief in the similarity of all human beings to each other and thus enlarged one's sympathy for patients. However, the practices and conceptions of psychoanalysis led to neglecting differential diagnosis and to disregard for the seriously mentally ill unresponsive to psychoanalysis. With the discovery of specific medications such as lithium for mania and with the recognition - particularly emphasized in US-UK diagnostic study of 1968 (5) - that psychiatrists were unable to agree on diagnostic formulations, confidence in psychoanalysis as fundamental to psychiatry waned and the third epoch , the empirical one (1970 -2000), came along.
The empirical epoch emphasized a need for reliability in psychiatric diagnosis, recommitted psychiatrists to the thorough, systematic, structured evaluation methods championed by Meyer, and led to the publications by the APA of the third and subsequent editions of the Diagnostic and Statistical Manuals of Mental Disorders (DSM-III, IIIR, IV). Psychiatry advanced with the insistence on reliable, replicable psychiatric diagnoses. No one wants to return to the days when the same patient could be diagnosed with schizophrenia at one center and manic-depression at another. It is my point, however, that this emphasis on reliability (what you call a patient) has too long deferred the issue of validity (what the patient actually has) so that this era is now waning as its problems are evident.
Thus the development of operational criteria and formulaic diagnostic practices based on symptomatic appearances led to claims for the existence of dubious conditions such Multiple Personality Disorder and Chronic Post Traumatic Stress Disorder that often seem to exist only in the minds of their champions. Likewise the emphasis on appearances has generated categories beyond measure. DSM-IV claims to identify over 2000 subcategories of depression by adding specifiers and subtypes to major and minor depression. Fabulism and ontologic incontinence are predictable consequences of a total commitment to appearance-based reliability at the expense of validity in psychiatric thought.
Internal Medicine gave up appearance-driven diagnoses after a long and unhappy experience a hundred years ago. A telling example was the classification of illnesses around fever patterns as promoted by Carl August Wunderlich in the 1870s (6). These diagnostic conceptions were quite reliable in that they rested upon a systematic assessment of the fever chart. But they were not valid and following the work of Pasteur and Koch were replaced by diagnoses resting upon the essential provocations of these fevers by infection.
In fact when one leaves the psychiatric wards to talk with medical students about how they grasp diagnostic issues for medical and surgical patients, one learns they are often taught simple, effective, essential, rather than appearance-driven diagnostic concepts. They may refer to their VITAMIN C mnemonic as a way of identifying the primary problems of their patients: V for vascular; I for infectious; T for toxic-traumatic; A for Autoimmune; M for metabolic; I for idiopathic-genetic; N for neoplastic; and C for congenital. Such a rubric can only be a beginner’s method to address classificatory issues in internal medicine, but it does offer an approach to physical disorders that appreciates them as life under the altered circumstances of some specific process that can produce many different symptom clusters or appearances even as it remains essentially the same from case to case. If most American psychiatric students today are asked similar questions they can not respond so pertinently. Their only recourse is to turn to DSM even though they are baffled as to how its distinct categories are tied to more fundamental psychological issues.
For these reasons I hold the empirical epoch is coming to an end. Now is the time to propose a structure for psychiatry that identifies disorders according to their distinct and essential natures - a structure that can offer coherent links between mental disorders and psychological life itself as Adolf Meyer at our beginnings tried to encourage. The challenge for leadership in psychiatry today is to offer just such a structure and to demonstrate how it enhances practice, teaching and research. Our book The Perspectives of Psychiatry is our response, the essentials of which I will briefly summarize.
Our approach was to identify the methods of explanation psychiatrists employ in making sense of mental and behavioral disorders. We held that for many psychiatrists these methods were implicit in their practice and we intended to make them explicit. We thought that a structure for psychiatry - one that took into account the essential natures of mental disorders as well as the basic substrate for them - would emerge as a consequence of making explicit these explanations. These intentions and suppositions led us to four explanatory methods or "perspectives": the Disease perspective, the Dimensional perspective, the Behavior perspective, and the Life-Story perspective.
As shown in figure 1 these perspectives can be identified by name, by implication, and by common sense. The perspective of disease works by categories and asks " what the patient has." .The perspective of dimensions works by the logic of gradation and quantification and asks "what the patient is." The perspective of behavior works by the logic of teleology and goals and asks "what the patient is doing." The perspectives of the life story works by the logic of narrative and asks "what the patient has encountered."
Psychiatric diseases affect the brain in the same way as cardiac diseases affect the heart and therefore the disruptions, their causes, and the explanations will follow the same pathway of reasoning. Psychiatric diseases represent injuries to fundamental brain faculties: delirium is a disruption of consciousness, dementia of cognition, Korsakoff’s syndrome of memory and learning, aphasia of language, bipolar disorder and panic anxiety of affective control, and frontal lobe syndromes and schizophrenia of the executive and psycho-integrative functions of the brain.
As they think along disease lines doctors expect to find some structurally or functionally "broken part" in the body as the essence of the disorder. Psychiatrists also, when employing the disease perspective, expect to find some "broken part" (or better "pathologic entity) in the brain producing symptoms and signs. The etiology, pathology and syndrome connection is diagramed in figure 2. Pathogenesis links etiology and pathology and pathophysiology links pathology and syndrome. A complete understanding of a clinical disease entity in psychiatry will rest upon developing research into all these issues.
Examples of psychiatrists studying pathogenesis include those who have discerned some of the molecular disarray tied to Huntington’s disease and Fragile X syndrome by recognizing that in these conditions a local "trinucleotide repeat" in the genome expands and disrupts the synthesis of some crucial protein (7). Examples of psychiatrists approaching pathophysiology include the demonstration by Barta and Pearlson of a correlation in schizophrenic patients between the degree of atrophy in the left superior temporal gyrus ( the brain site for audition) and the severity of their auditory hallucinations (8).
The disease perspective thus identifies those psychiatric disorders that are essentially neuropathic and encourages research to validate that identification. It aims to explain the clinical presentations by tying symptoms to disrupted functional or structural bodily parts and then tying these pathologic disruptions to clear etiologies in a medically traditional bio-scientific fashion.
Dimensions. Many psychiatric problems depend not on some disease the patients have but upon their cognitive and affective constitution. IQ is a dimension of human psychological variation on which everyone has a position. Those individuals at the lower end of this dimension are vulnerable to emotional distress - anxiety or depression - when faced with analytic problems that stress their limited cognitive capacities. Likewise Hans Eysenck identified affective dimensions such as introversion/extraversion, and "neuroticism" as also universal graded variables in the human population (9). Again if an individual lies at some extreme along these dimensions he or she can be vulnerable to emotional distress. In particular, a high score on "neuroticism" (the stable/unstable dimension of Eysenck) is most frequently a substrate for strong emotional responses that lead to psychiatric attention.
The central concept of the dimensional perspective is that emotional distress needing psychiatric help can often be understood as the outcome of a combination of an individual’ cognitive or affective "potential" and provocative situations that strike at this vulnerable potential (See figure 3). Particular problematic dispositions are sub-optimal cognitive capacity (IQ less than 85) and an affective constitution that reflects high neuroticism, low conscientiousness and immaturity. The research of Gerald Nestadt in the Epidemiologic Catchment Area study of the 1980s demonstrated that affective dimensions underlie and better explain the typologies and categories of Axis II In DSM-III and as well define the goals of therapy for these vulnerable people (10).
Behaviors. The perspective of behavior identifies troubles people have because of what they are doing. We emphasize that the term behavior refers to something more than activity. It is goal-directed activity. Neurologists study activity - seeking whether a person can walk, grasp, run, or reach. Psychiatrists study behavior - how people employ these capacities. The psychiatric question is not "can you move?" it is "What are you doing?"
The behavior perspective thus identifies those conditions that represent problems of choice and control particularly those tied to innate motivated drives such as eating, drinking, sleep, and sexuality. Some drives are acquired and problematic by nature such as drug dependency. In all of these conditions research has identified brain mechanisms for drive and social contingencies related to learning and conditioning. (see figure 4).
Certain behavior disorders derive from the unique human capacity for self-consciousness - that is how one sees one’s place and purposes in the world. This personal viewpoint emerges from meaningful experience influenced by social structures, language, and symbol. We refer to this as the individual’s assumptive world and point out that some common behavioral disorders rest upon it. They include anorexia nervosa, hysteria - both in its pseudo-neurologic (conversion) form and its pseudo-psychologic (dissociative) form - the false memory syndrome, and adult gender identity disorder.
Because behavior disorders are expressed through willful actions, choices, and decisions, a conflict of wills between patients and therapists is an ever present obstacle to recovery. Treatment involves confronting the patient’s reluctance to change and striving to end it. The issue of conversion, rather than cure, demonstrates most clearly how behavior disorders differ from diseases in their essential nature, treatment, and prognostic implications. This is a fundamental issue that psychiatrists know well but it gets lost in catalogues of disorder that fail to differentiate psychiatric conditions in essential terms.
The Life Story. Finally, the perspective of the life story attempts to make sense of those disorders that represent meaningful responses to life encounters - responses of a universal kind that one would expect from anyone faced with such circumstances. The expectations of psychiatrists working with life stories are that they can forge a narrative that illuminates the troubled outcome and suggests some role of the self in it.
They turn, for example, to the life story to explain anxiety produced in threatening work settings, grief or shame from losses, home-sickness associated with problems of acculturation, jealousy or hostility provoked in threatened personal relationships, as well as the conditioned emotional responses, such as phobias or post traumatic states that derive from frightening experience. Contemporary understanding of the life-story perspective has evolved from the efforts of two people, Jerome Frank at Johns Hopkins and Aaron T. (Tim) Beck of the University of Pennsylvania.
While investigating psychotherapy patients Frank discovered that in contrast to psychoanalytic prediction patients did not resemble one another in their stories. They did not have similar unconscious conflicts, and did not have similar early life experiences. Rather they shared a common presentation in that they were demoralized and over-mastered by a whole variety of circumstances. Indeed Frank emphasized the word, demoralization, to conceptualize their common state of mind and its nature (11).
Tim Beck took this concept and began to treat all the different cognitive assumptions and attitudes that were provoking it. He designed treatment protocols that offered patients alternative ways of thinking about their life situation thus reframing it in a fashion that brought hope and psychological skill (12). Beck’s Cognitive Behavioral Therapy fits the life-story perspective because it identifies a need in therapy to re-interpret for the patient a distressful setting, sequence, and outcome (See Figure 5).
A structure for psychiatry.
As mentioned at the start we have an ambitious goal for rendering explicit the explanatory methods of psychiatrists We want to identify how mental and behavioral disorders are essetially the expressions of psychological life under the altered conditions of brain pathology, powerful motivations, personal misdirection and the like. In this way we intend to demonstrate how the fundamental conceptions psychiatrists use for mental disorders can take on the character of the advanced and contemporary explanations for medical disorders where disorders are seen, not as alien entities, but as physical life under altered conditions susceptible to illumination by research and treatment. With the perspectives we likewise propose to derive our explanations of mental and behavioral disorders from our fundamental understanding of human psychological life.
We hold that human psychological life can be organized hierarchically into four distinct but interrelated levels of expression from the most neurologically basic to the most psychologically highly developed. Each of these levels has domain specific expressions in the psychology of the individual and each has its particular way of going awry, as defined by the four perspectives. Figure 6 displays this hierarchy and relates each level to a perspective of psychiatry and a treatment plan.
The most fundamental level in this hierarchy is that of the cerebral faculties that provide for many basic psychological functions from consciousness to executive capacity. Next is that of the motivational rhythms for eating, thirst, sexuality, sleep. Next higher is that of the constitutional dimensions of cognition and affective temperament. The highest level is the personal life chronicle from whence we note the sequence of individuation, character development, role assumptions, and overall social attitude.
Separating these levels or domains draws them and their disorders out for study even as they obviously interrelate and interact in the integrated psychology of patients and non-patients alike. As well though it becomes clear exactly how this conception of psychology and psychiatry promotes both basic and applied research. The Perspectives of Psychiatry recaptures the endeavor of Adolf Meyer to found psychiatry upon psychobiology by identifying the essential natures of psychiatric disorders in ways that elude our contemporary catalogue, DSM-IV.
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2. McHugh, P.R. A structure for psychiatry at the century’s turn - the view from Johns Hopkins. J Royal Society Medicine 85: 483-487, August 1992.
3. McHugh, P.R. and Slavney, P.R. The Perspectives of Psychiatry, second edition. Baltimore: The Johns Hopkins University Press, 1998.
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11. Frank, JD and Frank, JB. Persuasion and Healing: A Comparative Study of Psychotherapy, 3rd edition. Baltimore, MD: The Johns Hopkins University Press, 1991.
12. Beck, A.T. Cognitive Therapy and the Emotional Disorders. New York: International Universities Press, 1976.