Are we using the wrong criteria to diagnose mental illness? The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the gold standard used by healthcare professionals as the authoritative guide to diagnose mental health conditions. But is it the best tool for clinicians to use? Were you even aware there are other options?
Today’s guest, Dr. Margaret Chisolm, a professor at Johns Hopkins University School of Medicine, tells us all about the “Perspectives Approach,” a method of evaluating a patient using multiple perspectives of their lives and experiences.
This method has existed for over 40 years and is taught and researched at the world-renowned Johns Hopkins University. Dr. Chisholm will explain how this method is superior, and some limitations and flaws of the DSM.
Dr. Margaret S. Chisolm, MD, FAMEE, FACP, FAAP, is vice chair for education, psychiatry, and behavioral sciences; professor of psychiatry and behavioral sciences; and professor of medicine, at Johns Hopkins University School of Medicine. She directs the Paul McHugh Program for Human Flourishing, which fosters a humanistic clinical approach to patient care. Find out more at MargaretChisolmMD.com.
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.
Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without. To learn more about Gabe, please visit his website, gabehoward.com.
Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.
Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.
Gabe Howard: I’m your host Gabe Howard, and I want to thank our sponsor, Better Help. You can grab a week free just by visiting BetterHelp.com/PsychCentral. And calling into our show today we have Dr. Margaret S. Chisolm. Dr. Chisolm is Vice Chair for Education, Psychiatry and Behavioral Sciences, a professor of psychiatry and behavioral sciences and a professor of medicine at Johns Hopkins University School of Medicine. And her latest book, “From Survive to Thrive” is available right now. Dr. Chisolm, welcome to the show.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Thank you. I’m really happy to be here, excited to have a conversation.
Gabe Howard: Well, we are excited to have a conversation with you as well, because anyone who lives with mental illness or knows someone living with mental illness has probably heard of the DSM, the Diagnostic and Statistical Manual, which is used to aid in the diagnosis of mental health disorders. It’s arguably the gold standard and is currently on version five. I was surprised to learn that there is another method and you literally wrote the book on the subject. The book is called “Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The Perspectives of Psychiatry,” and it is a textbook meant for clinicians. But you’re going to help all of us understand. So let’s start at the very beginning. What is the perspectives approach?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Ok, so I trained at Hopkins in ’88 – ’92 as a psychiatrist. And that was the first time I learned about the perspectives approach because at that time it was mainly being taught at Johns Hopkins, and it’s a way of understanding patients as whole persons. You don’t just think about patients as having a disease. You want to look at people from different perspectives to get a complete understanding of who they are as a person and if they are experiencing a disease, how that fits into their lives and what it means to them.
Gabe Howard: Now, I know that it’s called the perspectives approach, which of course, is plural, and I understand that there are actually four perspectives?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: That’s right four.
Gabe Howard: And what are the four perspectives?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: The one that we’re most familiar with, of course, is the disease perspective, because that is what the DSM sort of leads us to think about. But there are three other perspectives that are equally important, two of which everybody experiences. One is a life story. The second perspective is the dimensional perspective, which really has to do with personality, not only your cognitive capabilities, but your temperament, your personality traits. And then the third is the behavior perspective, which is about things that you might be doing that are causing you difficulties. And then the fourth is the disease perspective. So those are the four perspectives. Everybody has a life story. Everybody has a personality. Not everybody is engaging in problematic behaviors, and not everybody has a disease. So when we see patients, we usually start with that life story perspective and getting to understand who someone is to understand whatever is going on with the patient now, how that fits into their life story, the context of their life.
Gabe Howard: Now, the DSM, as I understand it, and again, fully admitting not a practitioner, but the DSM as I understand it, it just has a list of symptoms and a patient comes in and sits down, you know, and if they check off enough boxes, boom, there it is. Is that how the DSM works?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: That is definitely how the DSM works, it’s a checklist approach, and that’s how it was designed. It was designed not as a clinical tool. It was designed for researchers so that somebody say in England who was studying schizophrenia and somebody in the U.S. who was studying schizophrenia could at least say that they were studying an illness that looked similar. So it really just is based on appearances and doesn’t talk about the origins of the illness and is very limited. So it really helped with research, what scientists call reliability. It helped with people making these diagnoses, but it didn’t really talk about the validity of those diagnoses and has now expanded. It was a slim volume. Now it’s just grown in the number of pages with every edition. There are many overlapping symptoms on these checklists, and frankly, it’s not even that reliable. So when they tested the DSM-5, the latest edition in community practice settings, they actually found low reliability for the classification of major depressive disorder. It also had very little reliability in the personality disorders. The DSM couldn’t reliably distinguish between borderline personality disorder, histrionic personality disorder, narcissistic personality disorder, for example. So it’s a very limited tool clinically.
Gabe Howard: And you feel that these limitations are hurting psychiatry as a whole. Can you discuss that more? Because again, we hear the gold standard is hurting psychiatry as a whole, and I know I, for one, am cocking my head to the side saying, Huh? What does that mean?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: So when somebody comes for help with a problem, their life’s not where they want it to be. It’s the job of a psychiatrist to figure out what the problem is and how best to treat it. And if we only have an incomplete picture of what the problem is, say we see that they meet the criteria for the checklist of symptoms and signs in the DSM for major depressive disorder. But we don’t put that in the context of the person’s life and who they are as a person and what behaviors they might be engaging in. We might be inclined to prescribe an antidepressant which may or may not be indicated, but we might not really take into consideration other aspects of their life that would help them get better. For instance, somebody could have had a major loss recently in their life. They could be experiencing grief, extended grief. They could be drinking heavily. They could be someone who just feels things very intensely. And understanding all those aspects of a person’s life will help us better treat the person. If medication is indicated, we may be able to help them get off the medication sooner, or we may be able to help them do even better. But you need to understand somebody as a person. You can’t just ask a checklist of symptoms and think that you’re going to have the ideal treatment for that patient.
Gabe Howard: Is that why it’s so important to discuss a detailed history rather than just what’s happening in the moment or even what’s happening over the past two weeks?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: I definitely start with the family history and move forward in time, I tell every patient I see, look, you know, I do want to know why you’re here and we’re going to get to that, but I really want to understand you as a person and how what you’re experiencing now fits into your life. I do think it’s very important to ask these questions. I’ll tell you a story. I worked for about 10 years at the Center for Addiction and Pregnancy, and I saw this patient who had, I think she was one of eight children and all seven of her brothers and sisters had substance use disorder. Her parents had substance use disorder, and this lovely young woman had graduated from high school, had gone to college and gotten a job, had gotten her own apartment. This patient had totally avoided having any substance use disorder. So that was so fantastic. Then she got in a car accident and was prescribed opioids and developed an opioid use disorder, which was no surprise. Nobody had taken her family history. If you had taken a family history, you would have known what high risk she was for a substance use disorder, and she had a good prognosis because she did have a lot going for her and a lot of accomplishments, a lot of positive aspects of her life that she could draw on in her recovery, but that could have been avoided by a family history.
Gabe Howard: And along those same lines, you believe that patients should allow their friends, their family members and others to talk to their clinicians, which is controversial in so many different ways. Some practitioners, they don’t want that. They don’t want to talk to friends and family. Some patients don’t want their friends and family involved because maybe they’re hiding that they’re seeking help, etc. And then, you know, we get into stigma and it just we can really fall down the rabbit hole on this. But the bottom line is you believe that it’s important for patients to allow friends and family members and others to talk to their clinicians and that the clinician should welcome it.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Definitely, so I always invite a family member to come to the initial appointment. They obviously don’t sit in for the entire two hour evaluation, but I do like to have family members’ perspectives and I’ll share another story and I have permission to share these stories I’m sharing about some of my patients. But I had a patient who was in psychotherapy for a year because he believed he had had an extramarital affair and was feeling incredibly guilty about it. It wasn’t until a year later when his wife intervened and said, Look, he has not had an affair. What he’s talking about never happened. We work together, we live together. Nothing has happened. This is a delusion. It’s a false belief that’s grown out of this severe depression that he’s had. I think it’s really important to get the family members’ perspectives. Some of the illnesses that our patients come to us for interfere with their ability to think clearly and they might have false beliefs or they might have distortions. They have distorted views of themselves. And sometimes that’s because of their personality. Sometimes it’s because of diseases like depression, but we really need to hear from other people to get their perspective. That’s not to say that I don’t take some of these with a grain of salt, but it is helpful to hear other people’s perspective.
Gabe Howard: And if I understand correctly, this all happens in a mental status exam, and MSE. What constitutes a good mental status exam?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Yeah, so there’s two parts to the evaluation, one is the history, and one is the mental status exam. You know, we don’t have a way of examining our patients in psychiatry other than talking to them. We don’t have a stethoscope for their mental life. And so it’s really important to understand what a patient’s experiencing, what their mental experience is. And in order to do that, we have to ask questions about their mental life. What is their mood like? What is their energy like? And you have to ask all the questions because you can’t assume, Oh, this person doesn’t look like they are experiencing hallucinations. So I’m not going to ask that or this person doesn’t look like someone who is feeling really guilty. So I’m not going to ask that question, but you really need to ask every question of every patient. And it’s important to ask them in the same way so that we don’t forget one question or overlook a question because we have a bias of thinking that that’s not going to apply to this patient. You never know unless you ask.
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Gabe Howard: And we’re back with Dr. Margaret S. Chisholm discussing the perspectives approach. Now, if I were cynical, I would say, look, we’re diagnosing illnesses. The DSM exists, it’s been around for decades. Why do we need another method? And isn’t your method wrong? Because it’s newer?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Actually, our method is very old, our method predates the DSM, it really is based in the work of Karl Jaspers, who was someone who contributed to the ideas around psychiatry in the early 20th century. Basically, Jaspers described mental illnesses as having different ways of being explained. And so we’re just making explicit what really is implicit in psychiatric practice, which is that we know that not everybody who comes to a psychiatrist is experiencing a disease. And the DSM, the way it’s organized, this checklist of symptoms, really limits our thinking and makes things sound more like diseases than they really are sometimes.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: You know, it’s focused on acute treatment of psychiatric illness, it doesn’t speak at all about what a good life looks like and how to get to a good life despite or because of your psychiatric illness. So it’s very limited. I often think about this in medicine in general. So many problems in medicine outside of psychiatry are also related to behaviors, right? A patient might not be taking their medication for their diabetes, or they might not be coming to their appointments, they might not be getting preventive care. And you have to ask yourself what their life looks like? Because if they have no meaning and purpose in their life, if they have no happiness or life satisfaction, if their mental health is compromised, if they really don’t have any close social relationships, what is the reason that they would want to take their medication or come to their appointments and have better physical health if none of these other aspects of a good life are there?
Gabe Howard: One of the disconnects that I see between the patient community and the provider community is the reason for taking psychiatric medication. If you ask many prescribers, they say well, the reason that they need to take it is for stability. And if you ask many patients, the reason that they want to take it is so they can go to Hawaii, so they can get married, so they can buy a house. It’s such a slight difference, right? I mean, stability will get you, you know, a job, Hawaii, marriage, in a house, etc. But the patient community doesn’t see it that way, and we don’t understand it that way. Do you think that the perspectives approach helps bridge that gap between some of the, I’m going to say, misunderstandings, because at its core, that’s what it is, right? It’s just a different way of looking at the same thing. Do you think the perspectives approach helps bridge that gap?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Yeah, I mean, the thing I like about the perspectives approach is it’s a very systematic way of looking at patients and understanding patients, and it’s a way that because it’s systematic, it’s used with every patient and it allows us to understand patients from all these different perspectives. We never overlook one of these perspectives and gives us a sense of really who a patient is as a person, what they’ve experienced in their life, what their hopes and dreams are. We don’t want people just to be symptom-free. We want them to lead a good life. I want this for myself. I too was a patient and had had a very serious post-partum depression, and getting over those symptoms was only the first step of getting better. You know, I had to make meaning of this in my life. I had to understand how my personality played into this, what habitual behaviors when I was depressed I had been engaging in that I wanted to overcome and what my goals were for myself. And that’s really important for everyone. I think just looking at eradication or alleviation of symptoms is so limited. We are embodied selves. We are not just bodies where things can break down and go awry. We have a sense of self. And I think the perspectives approach is one that doesn’t allow just looking at patients as diseases and doesn’t look at the endpoint of treatment as just alleviation or eradication of symptoms.
Gabe Howard: When we talk about the perspectives approach and how often it’s used out in the community. Why is it having trouble getting buy in? Because as you pointed out, it’s been around for 40 years. This isn’t some rogue concept. Honestly, I just keep thinking, why is this not catching on? It was developed by Johns Hopkins.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Yeah, so it was it was actually, you know, a book was written called “The Perspectives of Psychiatry” by Paul McHugh and Phillip Slavney. Paul McHugh was the director of psychiatry at Johns Hopkins, and Phillip Slavney was the residency program director for many, many years. And they wrote this book, which is very dense. It’s not, I would say, accessible to the average reader. And so that was one of the reasons we wrote “Systematic Psychiatric Evaluation,” to make it more accessible to clinicians who wanted to apply some of these concepts. And so I think part of it has been that it’s takes some work to really understand this approach. I mean, I had to read the book five times to understand the nuances of this approach. So I think that’s one reason is that it’s just the leading book about it is a challenge to read. I think the second reason is that this approach takes a little more time. It’s easy to ask people to fill out a checklist or to ask them, you know, a checklist of questions. But it’s harder to, as I said, I spend two hours with a patient the first time I see a patient to go through all the questions that are necessary, I think, for a full history and evaluation.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: So I think it can be time consuming. A lot of providers don’t have time or aren’t willing to take the time to do that. Personally, I think it saves time down the road. And patients get better more quickly because I understand them from the get go. You know, in this day of managed care and that kind of thing, people are more concerned with seeing a higher volume of patients. But I’m more concerned, and I think at Hopkins in general, we’re more concerned about getting it right.
Gabe Howard: I understand that you have an ambivalence about the labels that are applied by the DSM to psychiatric disorders. Can you explain that and do you feel that those labels contribute to the stigma that surrounds mental illness?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: You know, that’s a great question, I do think there are some labels in the DSM that are more problematic than others. I think historically the personality disorder labels are extremely problematic. We call some of those labels at Hopkins as sophisticated name-calling because, you know, again, there’s no validity from the DSM. Among the personality disorders, there’s limited reliability, so somebody could call somebody with borderline personality disorder. Somebody else could say histrionic personality disorder. Another person could be labeled antisocial personality disorder, and those can’t be distinguished reliably from one provider to another based on the DSM criteria, because people get labeled with these names of antisocial or borderline personality disorder, and they might not think that they’re highly stigmatized, but they are within the medical profession. You know, somebody comes into an emergency room with a legitimate physical complaint, and if they’ve got histrionic personality disorder, borderline personality disorder in their record, I assure you, they’re going to be treated in a biased way. So I think those are highly stigmatizing and again, literally just sophisticated name calling. Now some of the other illnesses are less problematic. I think there’s less stigma attached to, say, having a postpartum depression than there is a psychotic depression. But I just think they’re so limiting and they come with judgments. I mean, I have had patients with schizophrenia who go to the emergency room with legitimate physical concerns and they just get written off as figments of their imagination.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: So, yeah, I think that some of these illnesses are highly stigmatized still. I think rushing to those labels is a problem. You know, the DSM is so authoritative because of the huge compendium that it is, it carries like not only literal weight, I mean, heavy book, but it has figurative weight in the field. And so putting down these categorical labels makes them have more validity, I think, than they warrant. We still can’t reliably distinguish some of these illnesses from one another. You know, what’s a major depression versus bipolar disorder? What’s a bipolar disorder versus a personality disorder? I still think there’s so much we don’t know about these illnesses, and having these firm categories written down make them sound like that much more is known about them than there is.
Gabe Howard: And does the perspectives approach resolve that in any way, or does it suffer from sort of the same issues that the DSM suffers from as far as these labels are concerned?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Well, you know, the perspectives approach isn’t really about diagnosis, I use that term, but it’s really about formulation of a patient. It’s really about understanding a patient and how best to prioritize their treatment. We don’t think about patients as having adjustment disorders so much as having had a life event to which they’ve given meaning that may be maladaptive, the story that they’re telling themselves. It may be that they’re giving that event more weight because of their personality, because they feel things very strongly and are more reactive to events. So we’re really just trying to understand the patient and how to get them better. We’re not especially interested in labeling a patient. So, you know, obviously if they have a disease, we want to detect that and find a remedy for that. But that’s not viewed in isolation at all. We’re really much more interested in understanding, understanding the origin of the concerns that are bringing a patient to care and then finding the best way to treat that including medication if indicated, but not solely medication. Any disease isn’t just treated with medication. All the studies suggest that psychotherapy and medication in conjunction lead to a better prognosis in psychiatric illnesses like mood disorder. So we always know that the combination of psychotherapy and medication is what gets people better. And we just want to make sure that medication is not the only treatment for somebody who comes seeking help from a psychiatrist.
Gabe Howard: Now, if somebody’s listening to this and they think, well, I don’t know if my practitioner uses the DSM or the perspectives approach or honestly, I don’t know how I was diagnosed. How can they go about raising this question to their practitioner?
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: So you could ask people if they’re familiar with that approach. I think the approach that most people use is the DSM approach, and it’s not incompatible with the perspectives approach. It’s just, I think you want to make sure that your practitioner is asking you questions about your life, your family history, your personal experiences, your hopes, your dreams, is asking you about your personality. How do you usually react to things? Are you somebody who tends to be more introverted or extroverted? Or do you tend to feel things really strongly? Are you open to new experiences? If you feel like your practitioner really is asking you about yourself then I think that whether they’re trained in the perspectives approach or not, they’re getting to know you as a person. And that’s the most important part of being, I think, a good psychiatrist.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: What you want is a psychiatrist or clinician who’s on your side, who really is open to understanding things that are important to you. If it makes sense to think about what you’re experiencing as, is this something I have, like a disease? Is this part of who I am? Is this part of my life story? Is this because of something I’ve encountered, or is this because of something I’m doing? If your psychiatrist is curious about those questions, again, this is what all good psychiatrists do is they want to understand their patient as a whole person. And so if you have a psychiatrist that is interested in understanding you as a whole person, then I think that’s the first indicator that you’re in good hands.
Gabe Howard: Dr. Chisolm, thank you so much, where can folks find you online? Where can they get your book? Tell us everything that our listeners need to know to find you.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: So the book is called “From Survive to Thrive: Living Your Best Life with Mental Illness.” Available at all bookstores, Amazon, things like that. We also have links to sites where you can buy the book, including Amazon, on my website, which is MargaretChisolmMD.com.
Gabe Howard: Thank you so much for being here.
Margaret S. Chisolm MD, FAMEE, FACP, FAAP: Oh, thank you for having me. It was a delight.
Gabe Howard: Oh, you’re very, very welcome.And a big thank you to all of our listeners, my name is Gabe Howard and I’m the author of “Mental Illness Is an Asshole and Other Observations,” as well as a nationally recognized public speaker who would love to be at your next event. You can grab my book on Amazon, or you can get a signed copy with free swag or learn more about me just by heading over to gabehoward.com. Wherever you downloaded the podcast, please follow or subscribe to the show. It’s absolutely free. And hey, refer us. You can put us on social media. You can email a friend or, hey, word of mouth is still a thing. I will see everybody next Thursday on Inside Mental Health.
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