The Perspectives Approach at Johns Hopkins Psychiatry
Why the Perspectives?
Short answer: Because sometimes a patient’s problem is not – or more than – simply a disease.
Longer answer: because the biomedical approach to medical problems, although extremely powerful, fails to guide a clinician through common scenarios such as:
- The middle-aged man who had a heart attack and a stent placed three months ago, but has yet to lose weight, change diet, or quit smoking.
- The adolescent with new onset diabetes who insists that she can monitor her own glucose and insulin without parental involvement, yet repeatedly is hospitalized for uncontrolled diabetes.
- The patient who is HIV-positive and forgets to take antiviral meds whenever an emotional crisis occurs, which - for this patient - happens at least once a week.
(adapted from Dean MacKinnon Brain Mind Behavior Curriculum for Johns Hopkins Medical Students)
Clinical and Research Applications
"The 3 approaches [Perspectives approach, DSM, and biopsychosocial frameworks] can complement one another and together enable richer descriptions and deeper understanding of patients' conditions. What distinguishes the Perspectives is its comprehensive, sequential, systemic approach to understanding the nature and origin of each patient's presentation and its focus on the integrative, holistic formulation of the patient and his/her treatment plan.
The Perspectives approach also provides a useful framework for developing research hypotheses regarding the nature of different conditions listed in the DSM."
What is the Perspectives?
The Perspectives Approach to Patient Presentation
| PERSPECTIVE | Disease | Dimensional | Behavior | Life Story |
|---|---|---|---|---|
| WHAT A PATIENT... | Has | Is | Does | Encounters |
| LOGIC | Categorical (Disease) | Quantitative (Dimensional) | Teleological (Behavior) | Narrative (Life Story) |
| SCHEMA | Syndrome | Response | Choice | Setting |
| Pathophysiologic process | Provocation | Conditioned Learning | Sequence | |
| Etiology | Potential | Drive | Outcome |
Take Home Points
(adapted from Systemic Psychiatric Evaluation)-
- A detailed history
- A history that is obtained and presented in a specific sequence
- A history obtained from multiple sources
- A systematic mental status exam
- A careful distinction between observations and interpretations
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- Is a personal perspective
- Is based on the reasoning of narrative with its triad of setting, sequence, and outcome. This is produced meaningfully and understandably
- Applies to psychiatric conditions arising from something an individual has encountered
- Suggests rescripting as the treatment goal
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- Focuses on individual psychological dimensions that are universal, measurable, and graded (cognition and temperament)
- Underlying conceptual triad of potential, provocation, and response
- Applies to psychiatric conditions arising from who a person is
- Suggests guidance as the treatment goal
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- Seeks to identify and explain disorders of individual choice
- Underlying conceptual triad of choice, physiologic drive, and conditioned learning
- Applies to psychiatric conditions characterized by what a person does
- Suggests interrupting as the treatment goal
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- At its essence is about an abnormality in the structure or function of the brain expressed in the development of a syndrome
- Underlying conceptual triad of clinical syndrome, pathology, and etiology
- Applies to psychiatric conditions that a patient has
- Suggests curing as the treatment goal