Wednesday, October 24, 2012

Guest Blogger Dr. Meg Chisolm on Systematic Psychiatric Evaluation

Over on our Clinical Psychiatric News blog, I've written a review of a new book, just published by Johns Hopkins University Press, Systematic Psychiatric Evaluation,  A Step-by-Step Guide in Applying The Perspectives of Psychiatry, by Margaret S. Chisolm, M.D. and Constantine G. Lyketsos, M.D., M.H.S.  Do check out my review over on CPN (it should be up later today), along with ClinkShrink's article on "Debunking The Mad Artistic Genius Myth" and Roy's piece on World Mental Health Day which lists some great resources. 

Dr. Chisolm was kind enough to write a Shrink guest post for us on her inspiration for writing the book, with just a little about French cooking.  Sorry no recipes here.  Meg writes:

I did my psychiatry residency training at Johns Hopkins University in the late 1980s, under department chair Paul McHugh and residency director Phillip Slavney.  These leaders also are the authors of the textbook The Perspectives of Psychiatry, whose principles informed the way I and a generation of Hopkins psychiatrists since have been trained.  The basic idea of The Perspectives is that by conducting an evaluation that considers a patient’s psychiatric presentation from each of four perspectives, the clinician can better understand the nature(s) and origin(s) of the patient’s problems, and develop a more comprehensive and personalized formulation and treatment.  (The four perspectives are: disease, dimensional, behavior, and life-story.) 

The most frequent question raised about the Perspectives model by trainees and clinicians unfamiliar with the approach is “How are the Perspectives any different from Engel’s biopsychosocial model?”  In response, McHugh and Slavney are fond of saying that the biopsychosocial model provides the ingredients (atoms to biosphere) for understanding patients with psychiatric illness, but the Perspectives provides the recipe.  I like this analogy (or is it a metaphor?) because, in addition to enjoying my work as a psychiatrist, I like to cook.  But, more about that later. 

As a Hopkins-trained psychiatrist, I had probably read The Perspectives of Psychiatry about five times, beginning with my stint as a medical student during my sub-internship at Hopkins.  Let me tell you, The Perspectives is a good, but hard read.  As a student, I don’t think I understood much of it.  Reading it again as a psychiatry intern, having seen many more patients with psychiatric conditions, it started to make some sense.  As a junior resident, I began to understand it a little better, which was a good thing since – by then – I was expected to be teaching the book to medical students.  By the time I was a chief resident teaching junior psychiatry residents how to apply the Perspectives approach to patients, I thought I had it down.  Well, I was wrong.  It wasn’t until I began writing a casebook companion to The Perspectives of Psychiatry that I finally figured it out.  So, if the biopsychosocial method provides the ingredients and The Perspectives of Psychiatry the recipe, that’s one highfalutin’ cookbook!  And that’s where our new book Systematic Psychiatric Evaluation: A Step-by-Guide to Applying ‘The Perspectives of Psychiatry’ (Chisolm & Lyketsos) comes in.

So, back to French cooking.  If any of you are into cooking, reading cookbooks, or just watching the Food Network, you may have heard of Auguste Escoffier’s 1903 Guide Culinaire.  Escoffier wrote his book for professionally trained and experienced European chefs (working in restaurants, hotels, ocean liners, private estates, etc).  Escoffier’s book outlined recipes and discussed methods of professional food preparation and kitchen management.  Escoffier did not offer his reader detailed recipes with instruction on basic cooking techniques, as he assumed the reader would already have this set of knowledge and skills.  His book’s target reader was not the average home cook looking for advice on how to keep a soufflé from falling.  Enter Julia Child and friends.  In Mastering the Art of French Cooking Julia Child et al translated a selection of Guide Culinaire recipes into simple steps and added detailed instruction on the basic techniques (How do you keep a soufflé from falling?  Ask Julia).  Julia Child’s goal was to start someone off in French cooking with the hope that someday they would be ready to go deeper and perhaps read the master himself. 

And so it is with Systematic Psychiatric Evaluation.  If you’re a clinician who already conducts a systematic psychiatric evaluation and are adept with applying the Perspectives approach to patients, there’s no need to read our book.  But, if you are new to the Perspectives and/or want to familiarize yourself with the model, we’ve got you covered.  Systematic Psychiatric Evaluation walks the reader through the basic concepts of The Perspective of Psychiatry and shows, step-by-step, how to apply these concepts to evaluate, formulate and develop individualized treatment plans for patients with psychiatric conditions.

Bon appétit!


Plain Anon said...

So I have a question. Paul R. McHugh is a controversial figure in the transgender community. If he has cultivated his stance based on these 4 perspectives and a majority of the psychiatric community has the opposite stance, wouldn't this method be as fraught with ambiguities as the the DSM?

Margaret Chisolm said...

DSM-III was designed to function as an a-theoretical (to sidestep the differences between various psychiatric factions like psychoanalysts and "biological" psychiatrists)research tool to enable reliable diagnoses (so researcher in UK, for instance, and researcher in US would know that they were both researching patients with same syndrome, which would advance scientific research). DSM says nothing about validity of diagnoses or their origins. This is very different from the Perspectives model, which is based on what is known empirically from sciences of biology and psychology, and was elaborated to help understand origins of psychiatric conditions.

Plain Anon said...

Umm...Dinah...can you translate Margaret's response? I'm not understanding how this is an answer to my question. Sorry!

Dinah said...

plain anon: I think the simple answer to your question is No. Dr. McHugh is controversial because of some specific stands he takes. The concept that one should look at problems with an in-depth focus and consider them from the perspective of disease (is this an illness?), dimension (personality, intelligence, etc), motivation (food, sex, drugs), or, of life story, is a bit "different" but the method is not controversial, per se. It makes a whole lot more sense then saying "You have these six symptoms so you have this DSM diagnosis" in a vacuum without considering other factors. I'm sure someone can pick at anything and find ambiguities, but the majority of the psychiatric community doesn't have the opposite stance. The Hopkins department of psychiatry is consistently rated #1 in the country.
I don't share his views on everything, but I certainly agree that patient care is something that should be approached in a thoughtful way and that it takes time, and something more than a checklist. And the 4 perspectives are not directly at odds with the DSM, Hopkins people certainly use DSM diagnoses and talk about the criteria, they aren't mutually exclusive. I hope that helps. More my answer to your question then a direct translation of what Meg said.

Anonymous said...

McHugh does take a saner approach to child sex (re)assignment surgery than Money by encouraging parents to wait until their children can make informed decisions about what they want to do with their bodies. He did try to shut down Hopkin's Gender Identity Clinic during a time when it was without consent doing intensive surgeries and lying to children about their identities.

He has also said some really ignorant stuff about transwomen, saying all transwomen are not women, but either guilt-ridden gay men who are too guilty about being gay or pathologically paraphilic straight men who find extreme sexual pleasure in cross-dressing. Both of these concepts are offensive to transwomen (and to cisgender gay men and cisgender straight men who like to wear traditionally "women's" clothing.) Also made some blanket statements about how women are interested in babies/children and transwomen seem not to be (what!?) and other messed up comments.

Makes me nervous that Hopkins is considered to have the top Psychiatry program when its most (in)famous Professors are who they are. As a queer, makes me angry that I sought psychiatric help in the first place, when I should have known better that psychiatrists seem so clueless about queer lives, but have so much power to define and pathologize them.

DSM or Perspectives, still someone without a clue with the force of law and medicine behind them making subjective claims about your character, possibilities, health, and history and be damned if you disagree.