KELLIE NEWSOME: The DSM is not the only way to assess patients, and today, we speak with Margaret Chisolm about another model, one that developed at the same time as DSM-III and takes the famous manual a few steps further. Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of The Carlat Report.

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: Psychiatrists used to pride themselves on rich personal history of documentaries, the kind that wove together a complex pattern of development, life events, inner conflicts, and outer symptoms. But somewhere along the line, we traded all that for a list of DSM diagnoses. Maybe it was in the 1980s when insurers threatened to withhold coverage if we didn't submit a medicalized list of diagnoses. Or the 1990s, when industry-sponsored talks started crowding out the rest of the dialogue with their focus on the diagnoses for which their drugs were approved. Or maybe it was when we stopped using psychotherapy as our primary treatment.

KELLIE NEWSOME:  But even if you’re not practicing psychotherapy, your patients demand a little more. The psychopharmacology revolution has left many empty-handed. Only 1 in 3 recover fully on an antidepressant. Negative symptoms keep people with schizophrenia from leading full lives, even when they “respond” to an antipsychotic. And 30-60% of people with bipolar disorder continue to suffer disabling cognitive problems even after their mood symptoms resolve. Most patients want us to consider all angles of their problem before jumping to medication – they deserve a full account, and taking one builds trust. Today, we’re going to introduce you to a method of assessment that does just that. It’s called Perspectives in Psychiatry, and it was developed by two psychiatrists at Johns Hopkins – Paul McHugh and Phillip Slavney. Other authors have fleshed it out further, like Nassir Ghaemi and Margaret Chisolm, whom we’re going to hear from in today’s interview.

CHRIS AIKEN: The Perspectives came together in the 1970s and early 1980s, a time when psychiatry was splintered in many directions. There was the biological, the behavioral, existential, humanistic, social, cognitive, and the psychoanalytic. DSM tried to reshape these into a categorical medical model, while McHugh and Slavney sorted them into four different lenses, which we can use to gather a history and find pragmatic solutions for our patients. You have a way of understanding mental illness at Johns Hopkins that is different from the biopsychosocial model; tell us about that. 

MARGARET CHISOLM: Yeah, so, Paul McHugh and Phillip Slavney, when they came to Hopkins in the mid-70s, were really thinking about what the field of psychiatry needed to move forward, to move the field forward. And they developed this model called “The Perspectives of Psychiatry”, which really just makes explicit what psychiatrists are doing implicitly. Their model was used not only for the teaching of psychiatry but also for the practice of psychiatry, and it really provides a framework for a way of understanding how to think about the origins of patients’ problems. And it’s not so much focused on diagnosis, but more on formulation of patients. So, understanding the origin of the problems, prioritizing the treatments, and then hoping people live their fullest life possible.

CHRIS AIKEN: And what are the four perspectives in that model?

MARGARET CHISOLM: Sure, so for the four perspectives – there’s a pneumonic called HIDE. This is something a person Has (a disease perspective). Is this problem emerging from who the person Is (the dimensional perspective; it’s about personality)? Is this problem or set of problems the patient is bringing; is this emerging from something the patient is doing, like restricting their food intake or using substances (that’s the behavioral perspective). And then, the fourth perspective asks the question, “Is this problem emerging from something the patient has encountered (and that’s the life story perspective). So, HIDE: Is it something the patient has a disease? Is it coming from who the person is (dimensional)? Is it because of something the patient is doing (behavioral)? Or is it because of something the patient has encountered, and that is the (life story perspective). So those are the four perspectives.

CHRIS AIKEN: So, a problem that a patient presents with could fit under all or some of these perspectives. 

MARGARET CHISOLM: Yes, that’s a really important point. These perspectives interact with one another, so, obviously, how someone reacts to something that they encounter is influenced by their personality, by the dimensional perspective. If somebody has a disease, that’s a life event that they’ve encountered, and they are going to need to make meaning of that naturally, and so that’s an interaction between the disease and the life story perspective. So, yes, they all interact with one another. When we teach the Perspectives, we separate them out, but in actual practice of the Perspectives, we need to integrate that with every patient.

CHRIS AIKEN: Now the DSM, I believe, views all 300-something disorders through one of those perspectives – the medical model - is that right?

MARGARET CHISOLM: Well, you know, I don’t think that was what was intended. I think the DSM was intended to be atheoretical and not really talk about the origins of these syndromes, but by classifying them or categorizing them in the way that they are with these checklists of signs and symptoms, there is an implication that these are diseases. And so that has, I think, really has limited our ability to care for patients in a holistic way because we frequently go the disease perspective, see if somebody meets the signs and symptoms within that checklist, and if they do, we stop there. Now, we also use the DSM at Hopkins; we can use that with the Perspectives Model, but we just don’t stop at the disease reasoning; we don’t stop at giving somebody you know a DSM diagnosis. We say, “Okay, is there another perspective from which we could look at this patient’s problems. You know, maybe it’s not all disease, or maybe none of is disease, or maybe it’s all disease. But regardless, this disease is happening in a person who has a certain personality. This disease is happening in a human being who naturally is going to make meaning of what they’ve encountered. And so, it is always important to look at the patient from all four perspectives even if you know the primary problem that’s bringing them in is best explained as a disease – a clinical syndrome that runs a course together that has some underlying pathophysiology and ultimately an etiology.

CHRIS AIKEN: That makes sense because I've never understood the physiology of adjustment disorder. So, on that note, are there conditions or diseases in the DSM that you think are better suited to the other lenses? I mean, clearly, maybe schizophrenia is well understood through the medical model, but are there other perspectives that are better suited for some of the conditions in the DSM?

MARGARET CHISOLM: So, there are some conditions in the DSM that are clearly not meant to be diseases like adjustment disorder, for instance. So that’s one point I’d just like to make, even though most of them are what we think of diseases, not all of them are. Certainly, in the older versions of the DSM, the personality disorders weren’t thought of as necessarily diseases. But I would say that there are two distinctions: one is as I said, we’re not really looking at diagnosing people as much as formulating and understanding the origin of their problem or problems. That’s always at work even when we’re thinking about somebody as having a disease. And clearly, there are some diseases in the DSM: schizophrenia, you know, traumatic brain injury – those kinds of things are pretty well-agreed upon; you know, clear manic episodes agreed upon that these are diseases. But there’s a lot of grey area. Depression is a huge grey area. And now we have, I hear, that prolonged grief disorder diagnosis. So, I would say there are conditions or problems that are better explained as having emerged from something that somebody has encountered or their personality or something that someone is doing. So, I know that a lot of psychiatrists look at addiction as a disease. We actually make a distinction, and we’re not saying that there are not biological bases, but we’re saying that there’s something qualitatively different from schizophrenia that comes upon someone and opioid use disorder that, if somebody is on a desert island they’re not going to express. You know there is an element, and I’m not gonna win any popularity contests. I am addiction medicine certified; I’m not gonna win any popularity contests among the addiction community when I say this, but I think people know this that experience addiction that there is an element of choice involved, and AA recognizes that there’s an element of choice involved. Now, that choice is very, very diminished over time as people are conditioned and their drive increases, it makes it much harder to make a different choice. It’s not a trivial choice at all to use drugs, but there is an element of choice that is different from schizophrenia or mania. And so, we look at this family of behavioral disorders, substance use disorders, or eating disorders, for instance, and we look at what they have in common, and they do have a conceptual triad that unites them of choice, conditioned learning, and drive.

CHRIS AIKEN: Okay, so you mentioned those are perhaps better understood in the behavioral lens.

MARGARET CHISOLM: Well, yeah, I think we’ll say that I think this problem is best understood from the behavior perspective, but that doesn’t mean it’s not a medical perspective; we’re just saying it’s not a disease in the same way that schizophrenia or mania is, and rather than searching for the pathophysiologic process and the etiology and offering in cure in that sense, maybe it would be better to intervene in diminishing drive with medication which we can do, or offering a way of conditioning away from that behavior or helping to support people in their choice. So, it’s not that we don’t see it as medical, and we certainly recognize the biological forces and might even offer medications, but those medications aren’t sort of targeted to a broken part necessarily, but to interrupt the behavior in some way by interrupting some part of that cycle.

CHRIS AIKEN: For clarity, is drive synonymous with cravings?

MARGARET CHISOLM: I mean, it could be, yes.

CHRIS AIKEN: I think of drive as a good thing; you want them to have drive.

MARGARET CHISOLM: Yeah, well you know it depends on what the object of the drive is; if it’s pedophilia you don’t want them to have drive, right? You want to lower the sex drive.

KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes.

1. Which of these is not among the four perspectives in psychiatry as described by Dr. Chisolm:

A. Disease perspective

B. Dimensional perspective

C. Cognitive perspective

D. Behavioral perspective

CHRIS AIKEN: So, I'm imagining this like four levers, and as you listen to the client and understand them, the different levers may be going up or down. Like, if they made a suicide attempt during a manic episode, the disease model is going to be high. Otherwise, suicide attempts might be understood as behaviors with a life story that culminated in a series of events. 

MARGARET CHISOLM: Right. Well, I mean the Perspectives is used because it is this visual metaphor looking at people’s problems from these different perspectives. And when somebody is telling me their history, I am kind of always in the back of my mind thinking, “Okay, this is making it seem more like a disease; this is sounding more like a behavior; they are interacting this way.” So yeah, they’re not mutually exclusive; they’re interacting, and different perspectives may be more relevant in different stages of an illness. I use the term “illness” broadly by the way; it doesn’t just mean disease.

CHRIS AIKEN: I understand, and maybe this is no coincidence, that this developed at Johns Hopkins, where Adolph Meyer taught, and I believe a strong element of his perspective was atheoretical but looking at the multiple ways that life, and environment, and biology intersect and interact with each other. Can you speak to that and give us a background thereon that history and how this evolved?

MARGARET CHISOLM: Yeah, so Adolph Meyer, was very interested in understanding the patient’s life course, and we have some of the drawings that he did of people’s life histories. There are these torpedo drawings, these longitudinal, very detailed histories. So, that’s our biggest legacy from Adolph Meyer at Hopkins, is we take a very, very detailed thorough history starting with the family history and then moving forward in time to the presenting problem. It usually takes me at least an hour to go through the history with a patient, and then sometimes it has taken much longer, but usually just an hour, but it’s very complete, and at the end of the hour, I usually have a pretty good sense of who the patient is as a person, what they’ve been doing, and what they’ve encountered in their life so that I could put the present problem in that context of who they are.

KELLIE NEWSOME: Adolf Meyer was the first chair of psychiatry at Johns Hopkins and is one of the most influential psychiatrists of the twentieth century. He believed that no single theory held the truth for a patient, and instead took a pragmatic approach, mapping all the biological, social, and psychological influence in a timeline of the patient’s history. He viewed mental illness as a reaction to these influences, and you can see his influence in the early editions of the DSM, where every disorder is classified as a “reaction."

CHRIS AIKEN: It sounds like you take a psych history somewhat historically, looking at how these different perspectives play out in different eras of life; is that accurate?

MARGARET CHISOLM: Well, you know what I’m trying to do with taking that history is really get a sense of who this person is, what they’ve experienced, what their risk factors might be for diseases obviously with the family history and things like that. But the main goal is to understand them as a person and to understand their illness. So the main goal is to understand them as a person and to understand the nature of the problems that they are bringing to us so that then we can figure out how best to treat those problems.

CHRIS AIKEN: And it sounds like, indeed, you use this model with every patient, is that right?

MARGARET CHISOLM: Absolutely. And sometimes, I’m very explicit about the model and say at the beginning of the session when somebody comes with this problem, “You know, this is how I think about things. This is something you have. Is this because of who you are? Is this because of something you’re doing? Is this because of something you’ve encountered? How do you explain what’s going on, or how do you understand what’s going on? And often, they’ll say, “Oh, it’s all of the above.” So sometimes we are very explicit; not with every patient do I do that, but you know, often it’s helpful at the beginning to hear what the patient’s perspective is on their problems and the origins of their problems.

CHRIS AIKEN: And it sounds like regardless of the problem they bring to you, this approach might empower them to be more of a partner in change.

MARGARET CHISOLM: Definitely, it’s a collaborative process. I mean, after the hour of questions, I always ask… Well, first of all, I give a role induction before the hour of questions. I’ll ask them if they’ve ever been to a psychiatrist before, and then I’ll say, “You know this may be different from what you’ve experienced before because I’m gonna ask you a bunch of questions. It’s gonna take about an hour. And then, after that, I will tell you what my thoughts are, and we can go from there.” And so, at the end of the hour of questions, I usually ask, “Is there anything I didn’t ask or you didn’t tell me that you think is important for me to know?” Usually, they are so exhausted by that time they say, “No, you know everything about me.” But then I will say what I think. I will share my formulation using the Perspectives. I’ll say, “Well, you know, I think this is a clinical syndrome that you have. There are some risk factors you have for that,” if I think they have a disease. But I’ll never stop there. I’ll also say what I think is their affective temperament and how that might be playing a role. I will talk about if they are doing something in a maladaptive way the role of that in their problems. And we’ll talk about the relevance of the life story to their problems. Obviously, if somebody is coming in with grief after a death, that could be hugely important. And I’ll say, “This is how I’m understanding things. What do you think about that?” And I’ll get their feedback on that. And then I’ll say, “Okay, so we agree that this is a disease, here are some possible ways that it can be treated”, and have a discussion, and I’ll do that with all the perspectives if it’s relevant.

KELLIE NEWSOME: Margaret Chisolm is a professor of psychiatry at Johns Hopkins University. She has authored over 150 scientific papers and two books that explore the perspectives of psychiatry, one for professionals, Systematic Psychiatric Evaluation, and one for patients, From Survive to Thrive: Living Your Best Life with Mental Illness. A shortened version of this interview appeared in the March 2022 edition of the Carlat Report and is available online.

CHRIS AIKEN: Send us your feedback to asktheeditor@thecarlatreport.com, and a special thanks to Daniel Zigman of McGill University, who sent us a correction on last week's episode. When listing medications with strong anticholinergic effects, we mentioned hydroxyzine – also known as Vistaril. We were wrong. Hydroxyzine is only weakly anticholinergic. This mistake is an important one, and it points to a cycle farm paradox. Both hydroxyzine and diphenhydramine are antihistamines. But in the U. S., hydroxyzine is prescription only, while diphenhydramine is available over the counter, as Benadryl. So, the paradox here is that the prescription version, hydroxyzine, is arguably safer than its over-the-counter cousin. Diphenhydramine. Diphenhydramine is strongly anticholinergic, while hydroxyzine is only weakly anticholinergic. Here's how you can use this in practice. When you see a patient taking over-the-counter diphenhydramine for sleep or any over-the-counter sleep aid, they usually have them in there, and offer to trade it out for the safer prescription hydroxyzine, if that approach is appropriate.  Also, a lot of patients take this diphenhydramine for sleep in the form of a pain med combo like Tylenol PM or Advil PM, even when they don't have any pain. It's terrible marketing, and this is another opportunity for education. Tell your patient that the extra pain medicine is not helping them sleep at all, and may be harming their liver, stomach, or kidneys. Better to skip the Tylenol or Ibuprofen and take Diphenhydramine by itself. Or better yet, switch to hydroxyzine. 

KELLIE NEWSOME: Next week, we’ll talk with Dr. Chisolm about the questions she uses to get at the four perspectives in psychiatry. Read the full articles and earn CME credits at thecarlatreport.com, where we have a special offer for our podcast listeners – you can get $30 off your first year’s subscription with the promo code PODCAST.