A Conceptual Structure for Diagnoses

Paul R. McHugh, M.D., of Johns Hopkins University has proposed a conceptual structure for psychiatry that seeks to identify the essence of mental disorders as expressions of psychological life in a context of pathology and misdirection. This would replace the current focus on symptoms found in the DSM-IV, which McHugh claims has led to an unwieldy and outmoded system with overlapping conditions and confusing diagnoses. McHugh's criticism and proposed solution appeared in the summer issue of Psychiatric Research Report, a quarterly publication from the American Psychiatric Association's division of research. His discussion can be found on the Internet at <www.hopkinsmedicine.org/press/2001/august/McHugh.htm>.

McHugh, Henry Phipps Professor and chair of the department of psychiatry and behavioral sciences at Johns Hopkins, proffers an approach based on four explanatory methods or perspectives used at Johns Hopkins for over 20 years. While these methods may be used implicitly by many practicing psychiatrists, by making them explicit, McHugh and colleagues hope to bring forth a new structure for psychiatry. The four perspectives are disease, dimension or psychological variation, behavior, and life story.

The disease perspective identifies psychiatric disorders that are neuropathic. It explains clinical presentations by tying symptoms to disrupted functional or structural body parts. Examples given by McHugh include delirium (disruption of consciousness), bipolar and panic disorders (disruption of affective control), and schizophrenia (disruption of executive and psychointegrative brain functions). Research on the disease perspective works to tie pathologic disruptions to clear etiologies.

Patients' cognitive and affective constitutions are the focus of the dimension perspective. Rather than originating from a disease, according to McHugh, emotional distress may be the outcome of the combination of cognitive or affective potential and provocative situations that attack this vulnerable potential. Laying at an extreme of a dimension (for example, scoring low on cognitive capability or high on neuroticism) could lead to strong emotional responses requiring psychiatric attention.

The behavior perspective identifies troubles resulting from patients' own goal-directed activities. According to McHugh, some behavior disorders are related to problems with control and choice, particularly when tied to innate motivated drives like eating, drinking, sleeping and sexuality. Other behavior disorders, such as anorexia nervosa, false memory syndrome and adult gender identity disorder, are related to the personal viewpoint that emerges from meaningful experience, which McHugh calls the assumptive world of an individual. Treatment of behavior disorders must include confronting and ending the patient's reluctance to change.

Disorders that represent a meaningful response to life's encounters call for the life-story perspective. This perspective, McHugh notes, "forges a narrative that illuminates the troubled outcome and suggests some role of the self in it." The life-story perspective reveals a common presentation in patients who have been demoralized and overmastered by circumstances. Treatment calls for the reinterpretation of a distressful setting, sequence and outcome.

While quick to say this format is not a final solution, McHugh told the press, "What I am saying is that solutions of this sort should be the subject of psychiatric attention and academic work."