To address these issues of diagnosis and explanation we organized our teaching at Johns Hopkins around four methods of reasoning or 'perspectives' about psychiatric disorders.(34) These methods bring forth an appreciation of psychiatric conditions as differing in their fundamental natures in ways critical to treatment, prevention, and research. Our views are derived in part from the methodological approach to psychiatry taken by Karl Jaspers in his classic General Psychopathology .(5)
We teach our students that four different classes of mental disorders exist and that an understanding of these classes—in particular, how they call for different explanatory methods with different treatment implications—offers a comprehensive conceptual structure for psychiatry. Any given patient may suffer simultaneously from disorders in several classes, even as each class of disorders is distinct in its causes, mechanisms, and apt treatments. For example, someone with a disease such as bipolar affective disorder can become entrapped in an abnormal behaviour such as the alcohol dependency syndrome and become demoralized by the disruption to his life produced by both of these conditions. These several aspects of his clinical presentation will call for different treatments co-ordinated within a comprehensive treatment plan.
We identify these methods of explanation and reasoning as 'perspectives' to emphasize, in a visual metaphor, how each method can illuminate some presentations of psychiatric disorder but obscure others. These four perspectives are the disease perspective, the dimensional perspective, the behaviour perspective, and the life-story perspective. Each generates different definitions of psychopathology and therefore what is normal and abnormal in mental life.
Disease is a great word in medicine and has a long history of development as a concept. We hold that psychiatrists employ the disease perspective in the traditional medical way, which begins by clustering patients into separate groups defined by symptoms, signs, and course, and thus differentiate patients with dementia, schizophrenia, and bipolar disorder from each other and from people free of disease. The ultimate validation of any clinical disease category is the demonstration of an abnormality in structure or function of a bodily part on which the clinical phenomena depend. The correction of this abnormality—in the form of either cure or palliation—is the ultimate object of treatment.
Disease reasoning follows a standard path in medicine and psychiatry. This path logically starts with the recognition of symptoms of distress or disorder, followed by a recognition that some symptoms cluster together in patient after patient and are suitably construed as forming a clinical disease entity or syndrome. This recognition then generates a search for an abnormality in brain or body underlying this categorical disorder with the impetus to search for an aetiological agency—genes, traumas, infections, nutritional deficiencies, etc.—to explain this bodily abnormality.
For psychiatrists the brain is the major organ where injuries produce mental disorders and logically we can expect to find mental disorders afflicting any of the separate mental functions tied to brain. Thus consciousness itself is the function disordered in delirium, cognition in dementia, memory in Korsakoff's syndrome, language in aphasia, affective control in major depression, and aspects of executive control in schizophrenia. Disease reasoning opens all of these brain disorders to research and practice in palliation and cure. Careful study of those psychiatric disorders most suitably approached as diseases advances our knowledge of the forces of nature that can injure the brain and also demonstrates—through these 'experiments of nature'—just how the brain is organized so as to produce normal mental life.
As is well known in medicine, not all disorders can be construed as diseases; some can be appreciated as derived from an aspect of human variation. The classic example is hypertension, where people are identified as being at risk for later physical illness simply because their blood pressures run at higher levels than average. Similarly in psychiatry we employ a dimensional perspective to grapple with the fact that some patients are vulnerable to mental distress because they occupy an extreme position on the 'bell curve' of human variation in cognitive capacities (the intellectually subnormal) or affective responsiveness (the emotionally unstable). These people differ psychologically from others only in degree, and treatment addresses means for strengthening and guiding them so they can manage their affairs more successfully in the future.
The Axis II categories in DSM-IV (narcissistic, histrionic, antisocial personality, etc.) fail to bring out this sense that the individuals identified as disordered are but examples of those who deviate to an extreme along human affective and cognitive dimensions. The dimensional perspective proposes that many troubling emotional responses derive from an interaction between a person's psychological potentials (cognitive or affective) colliding with specially provocative life circumstances. Treatment programmes are not aimed at a cure—as though these emotional responses were symptoms of disease—but at strengthening and guiding the individuals whose vulnerability to these responses derives from their deviation in cognitive ability and affective temperament. The purpose of treatment is to help these patients deal with difficulties in life which strike at their special weaknesses.
Psychiatrists work to help a large and diverse group of people who are suffering not because of something they 'have', as with a disease, but rather from what they are 'doing'. A maladaptive behaviour—such as addiction, anorexia nervosa, alcoholism—has become a way of life for these people and they seek psychiatric help because of it. We employ the behaviour perspective to identify such patients and represent their problem as due to the unusual and destructive goals that they have come to seek. Some of these people have abnormal physiological drives provoking a craving, as in drug addiction. Others have disorders resting upon social circumstances provoking destructive responses, such as suicide and hysteria. Psychiatrists employ cognitive, behavioural, and pharmacological means to interrupt these behavioural activities, but, given that an aspect of choice is always found in human behaviours, the psychiatrist's task becomes the redirection of a way of life—conversion, not cure. Help in these matters depends upon persuasion and is greatly augmented if group treatment is included. Psychiatrists who treat these patients must be prepared for what is often a remitting and relapsing course of disorder. The behaviour perspective may well be the most challenging to comprehend and employ.
A distressed state of mind can be the natural, quite understandable, result of a disturbing experience in which a person's hopes and plans are thwarted by what life delivers—hence the life-story perspective. Thus grief is a universal emotional response to loss, anger or fear regularly follow a traumatic misadventure, and a dispirited sense of lost opportunities can provoke demoralization and discouragement over the future in anyone. A narrative—a chronological recounting of setting, sequence, and outcome—can make the evolution of these emotional states comprehensible to patient and physician alike. Indeed, a story is the most natural way of making sense of many of life's problems and offers the kinds of truths that can be found in histories of any type. For patients a meaningful story has a unique power to generate hope. They can easily appreciate that if the distress they are feeling is just what a story might predict from their life circumstances, then they can expect to overcome the distress if they can better understand how to manage their lives and avoid such encounters in the future. The psychotherapeutic implications of this perspective include comforting patients through a natural course of recovery, providing them with rescripted interpretations of their life circumstances that provide more optimism and a sense of control, and assisting them to avoid similar encounters in the future.
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