The Perspectives of Psychiatry, second edition
Drs. McHugh and Slavney have revised an earlier edition of their book first published in 1986 to provide a coherent framework for the research, practice, and teaching of modern psychiatry; the authors are well-respected faculty members of the Johns Hopkins University School of Medicine. The Perspectives of Psychiatry delineates, clearly and concisely, how the lack of a demonstrable path between brain and mind has led both to difficulty in understanding psychiatry as a medical discipline and to what the authors call "factionalism," or the tendency for psychiatrists to try to apply one theory to all patients.
McHugh and Slavney feel that the term "biopsychosocial" is reductionistic. They develop four "perspectives": diseases, dimensions, behaviors, and life stories, the last one being the idea that, given a patient's experiences, his or her current distress makes sense. They then develop the history and characteristics of each perspective and apply it to the psychiatric disorders it best explains.
The section on the concept of diseases uses analogy to physical medicine to explain the concept and then applies it to bipolar disorder and schizophrenia. The next section, on dimensions, focuses on the quantitative measurement of cognition and temperament and applies it to mental retardation and personality disorder. The authors use Eysenck's classic scheme of unstable-stable and introverted-extroverted as an example of thinking along a dimensional perspective, and they explain neurosis as a combination of individual vulnerability, which occurs along a continuum, and stressful circumstances.
The next, and longest, section covers the behavioral perspective, which views behavior as a function of physiological drive, learning, and ultimately personal choice. McHugh and Slavney examine eating disorders, suicide, and, most controversially, "hysteria." Some readers may disagree strongly with their approach to dissociative disorders, in particular "multiple personality," which they view as dysfunctional behavior. Although in general, I agree with the authors, I feel this example distracts from the overall theme of the book.
Lastly, they consider the power of the life story to link the individual with what he or she does and feels and, just as important, to suggest a treatment for the patient. This method in particular lends itself to combination with the other perspectives. The authors view psychotherapy as appropriate for treating the distress our patients feel, regardless of its source.
One quibble I have with The Perspectives of Psychiatry is that it tends to return to the neurochemical or behavioral perspective, somewhat slighting psychological explanation; psychodynamic theory is given short shrift. Overall, though, it is a coherent, scientifically oriented, clearly elucidated, and historically informed integration of psychiatric thought. It makes the case that not all patients or problems are the same and that they deserve differing explanations and a variety of approaches.
I believe this book will appeal mostly to mental health practitioners with a more scientific or medical background; however, I think anyone interested could profit from reading it. Most of all, I believe the book should be incorporated into the curriculum of every psychiatric residency program, to help residents struggling to keep a perspective on the disparate, sometimes emotionally draining problems they are expected to understand and treat.
Dr. Szeeley is associate professor of psychiatry at the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey in New Brunswick.
