Summary of the books "The Perspeceives of Psychiatry" and "Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The Perspectives of Psychiatry"

1. Systematic Psychiatric Evaluation
2013
Yuma Yokoi, MD

2. Conflict of Interest
• A member of Japanese translation team of
“Systematic Psychiatric Evaluation”

3. Why diagnose?
1) Usefulness for treatment planning
2) Implications for prognosis
3) Contribution to protecting consumers of
mental services
4) Value in enabling the therapist to convey
empathy
5) Role in reducing the probability that certain
easily frightened people will flee from
treatment
McWilliams N (2011)

4. Has psych diagnosis labeled rather
than enabled patients?
Pros of diagnosis
• Provides boundary and
enables psychiatrists
maintaining its integrity
• Framework to disseminate
the knowledge gained
Cons of diagnosis
• Overmedicalization
• Diagnostic overshadowing
(physical symptoms
misattributed to mental
illness)
• Ticket to long-term
institutionalization
• Patients may be deprived of
their legal capacity
Callard F et al. BMJ 2013;347:f4312

5. Three questions for psychiatrists
1. What is psychiatry’s domain of study?
2. How can one make reliable and valid
observation in that domain?
3. How is the domain generated by the brain?

6. How diagnose?
Individual
Biological + Psychological + Social = Biopsychosocial
Psychodynamic
DSM
ICD
Descriptive
(Operational)

7. Descriptive vs. operational in Japan
Descriptive Operational p
Alzheimer’s disease 16 (9.9%) 15 (9.1%) n.p.
Schizophrenia 79 (49.1%) 39 (23.8%) <0.001
Personality disorder 61 (37.9%) 42 (25.6%) <0.01
Social anxiety disorder 4 (2.8%) 16 (9.8%) <0.01
Egawa J et al. (2010)

8. Momentary assessment with the
Experience Sampling Method
van Os J et al. (2013)

9. Contextual precision diagnosis
van Os J et al. (2013)

10. The Perspectives of Psychiatry

11. Systematic Psychiatric Evaluation
1. A detailed history
2. A history obtained and presented in a specific
sequence
3. A history obtained from multiple sources
(including collateral informants)
4. A systematic mental state exam
5. A careful differentiation between
observations and interpretations

12. Mental state exam
1. Appearance/behavior
2. Speech
1. Volume
2. Rate
3. Rhythm
4. Fluidity
5. Spontaneity
6. Latency
7. Thought disorder
3. Mood and affect
(observed and
reported)
1. Stability, reactivity,
appropriateness
2. Vital sense
3. Self-attitude
4. Thoughts of death,
suicide, homicide

13. Mental state exam (ctnd.)
4. Abnormal Perceptions
1. Illusions
2. Hallucinations
5. Content of Thought
1. Delusions
2. Obsessions
3. Compulsions
4. Phobias
6. Insight and Judgment
7. Cognition
1. Level of consciousness
2. Orientation
3. Memory
4. Praxis
5. Language
6. Abstraction
7. Fund of knowledge
8. Attention
9. Calculation
10. Executive function

14. Perspectives of Psychiatry
Perspective Triad What a patient…
Disease Clinical Syndrome 
Pathological Process  Etiology
Has
Dimensional Potentials  Provocations 
Responses
Is
Behavior Does
Life story Setting  Sequence  Outcome Encounters
Physiological
Drive
Conditioned
Learning
Choice

15. The Life-story perspective:
1. Is a personal perspective
2. Is based on the logic of narrative with its
triad of setting, sequence, and outcome,
which is produced meaningfully and
understandably
3. It applies to psychiatric conditions that arise
from something an individual has
encountered
4. It suggests rescripting as the treatment goal

16. The life-story perspective
A recently widowed patient may seek treatment
for feelings of loneliness and sadness following
the loss of her husband.
Her clinician understands her symptoms as
arising from loss and uses psychotherapy to help
the patient “rescript” her life story and regain a
feeling of mastery over her circumstances.
Type of story told may be less important than
the therapeutic relationship and other factors.
Peters ME et al. 2011

17. Life story
Pros
• Vivid way to capture a part
of reality
• Best way to enhance our
natural sympathy
• Whole / holistic
appreciation
Cons
• Bias
• Causation contrived
• Difficult to refute
• Must deal with fiction

18. The dimensional perspective:
1. Focuses on individual psychological
dimensions that are universal, measurable,
and graded (cognition and temperament)
2. Has an underlying conceptual triad of
potential, provocation, and response
3. Applies to psychiatric conditions that arise
from who a person is
4. Suggests guidance as the treatment goal

19. Quantitative dimensions
• Intelligence (mental retardation / ASD)
– Defining a psychological disposition
– Is a potential to change
• Personality type (personality disorders)

20. Eysenck circle
Eysenck HJ (1970)

21. The behavior perspective:
1. Seeks to identify and explain disorders of
individual choice
2. Has an underlying conceptual triad of choice,
physiologic drive, and conditioned learning
3. Applies to psychiatric conditions
characterized by what a person does
4. Suggests interrupting as the treatment goal,
prompting choice of recovery.

22. • Dependence / abuse
• Anorexia / bulimia nervosa

23. Stage
• Precomtemplative stage
– No thoughts of changing behavior
• Contemplative stage
– Considering change but they were not ready to
accept the implications for the way of life
• Action stage
– Ready to act against the behavior

24. Therapies considered
Treatments of drive
• Satisfaction replacements
– Methadone, nicotine patch
• Drive reduction
– Medroxyprogesterone
acetate
• Response punishment
– Disulfiram [antabuse]
• Reinforcement blockage
– Naltrexone
• Harm reduction
Treatments of social learning
• Redirection with
psychotherapy to better
consequences
• Rewards for appropriate
choices and responses
(token economies)
• Social restructuring and
rehabilitation
(family therapy)

25. The disease perspective:
1. At its essence is about an abnormality in the
structure or function of the brain expressed
in the development of a syndrome
2. Has an underlying conceptual triad of clinical
syndrome, pathology, and etiology
3. Applies to psychiatric conditions that a
patient has
4. Suggest curing as the treatment goal

26. Disease reasoning
• Documenting a patient’s clinical history
• Conducting a physical and psychological exam
• Observing the progress of symptoms over time
 You just assess how closely the pt resembles
other pts
• Identifying symptoms
• Linking the symptoms to a pathology
• Arriving at a cause

27. Strengths and weakness
• Strengths
– Familiar to most students of medicine
– Produces testable models
– Encourages research
– Supportive of collaborative efforts btw physicians and
basic scientists
• Weakness
– May neglect to consider the individual and his or her
unique vulnerabilities to distress
– A disease model can be endlessly refined
– Provokes the temptation to presume a brain source for all
matters of mental distress

28. • Relatively-known neuropathologies
– Dementia
– Delirium
– …
• “Original madness” or “Psychosis”
– Manic-depression
– Schizophrenia

29. Perspectives of Psychiatry
Perspective Triad What a
patient…
Treatment
goal
Disease Clinical Syndrome
Pathological Process
Etiology
Has Curing
Dimensional Potentials
Provocations
Responses
Is Guidance
Behavior Choice
Physiological Drive
Conditioned Learning
Does Interrupting
Life story Setting
Sequence
Outcome
Encounters Rescripting
All Medications Are Toxic
All Guidance Are Paternalistic
All Stopping Is Stigmatizing
All Interpretations Are Hostile

31. References
• McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding
personality structure in the clinical process, Guilford Press.
• Callard F, Bracken P, David AS, Sartorius N. Has psychiatric diagnosis
labelled rather than enabled patients? BMJ. 2013 Jul 25;347:f4312.
• 江川, 純, 遠藤, 太郎, 染矢, 俊幸, 下田, 和孝, 塩入, 俊樹, 山田, 尚
登, & 高橋, 三郎. (2010). 精神科疾患の診断をめぐる諸問題 精
神科医327名のアンケート調査から. 精神医学, 52(9), 891-898.
• van Os J, Delespaul P, Wigman J, Myin-Germeys I, Wichers M.
Beyond DSM andICD: introducing "precision diagnosis" for
psychiatry using momentary assessment technology. World
Psychiatry. 2013 Jun;12(2):113-7.
• Peters ME, Taylor J, Lyketsos CG, Chisolm MS. Beyond the DSM: the
perspectives of psychiatry approach to patients. Prim Care
Companion CNS Disord. 2012;14(1).