JournaloftheRoyalSocietyofMedicineVolume85August1992483Astructureforps - PDF document

1 JournaloftheRoyalSocietyofMedicineVolume
JournaloftheRoyalSocietyofMedicineVolume85August1992483Astructureforpsychiatryatthecentury'sturn-theviewfromJohnsHopkinsPaulRMcHughMDHenryPhippsProfessorofPsychiatry,TheJohnsHopkinsUniversitySchoolofMedicine,Baltimore,MD20205,USAKeywords:disease;personality;dimensions;behaviour;lifestoryIntroductionIhavethreespecificaims:firstly,toreviewsomeoftheconceptssupportingcontemporaryAmerican(USA)Psychiatry;secondly,toexplaintheorigins,strengths,andfrailtiesoftheseparticularfoundations;andthirdly,toprovideexamplesofactivityintheDepartmentofPsychiatryatJohnsHopkinsSchoolofMedicinethatintendstobothreviseandrestructurethesefoundationsinwaysthatenhanceteaching,practice,andresearch.TheissuesCurrently,muchofAmericanpsychiatricpracticerestsuponundertakingslaunchedinthelate1960s.Themostcelebratedachievementwasthefashioningofareliableapproachtonamingandclassifyingpsychiatricdisordersthatculminatedinthe1980editionoftheAmericanPsychiatricAssociation'sDiagnosticandStatisticalManual(DSM-III).Thisfeatencouragedpsychiatryprogrammestocommittoresearchinamorecollaborativeandprogressivespirit.Aswell,Americanpsychiatristsseemtobeabandoningallegiancestonarrowexplanatorytheoriesaboutmentaldisorders.Manyacknowledgeabreadthofinformativesourcesbyenthusiasticallysupportingtheencompassing'biopsychosocial'approachproposedbyGeorgeEngel2.DSM-IIIandthebiopsychosocialconceptsettledsomeoftheuneasinessinpsychiatryprovokedinthe1960sbygrowingappreciationoftheunexpectedandspecificpowerofpsychopharmacology,theawkwardrandomnessindiagnosticpractices,andtheembar-rassing'housedivided'characterofthedisciplinewhere'biologic'and'dynamic'factionscontended.Thesenewproposalshadmanyfeaturestorecommendthem.Eachtookacompromisingstancetowardscontemporarypracticeandopinion.DSM-lIadmitstoitscanonanyentitythatcanbe'operationally'definedbyitschampions,andthebiopsychosocialorientationseemsreadytoembraceanyexplanatoryconceptwithinitsamplehierarchicalarms.Theproblemsofthesecontemporarypositionsarenothardtofind.InattemptingtosteerclearofthedisputesthathadrivenpsychiatrytheauthorsofDSM-IIIdevisedaclassificatorysystemcommittedtoempiricism.Andempiricismforallitsadvantagesatonestageinadiscipline'sgrowthisadmittedly-andwithDSM-malmostboastfully-aformofignorance.ByposingtheexistenceofconditionsDSM-Icallsoutfortheirvalidationandexplanation.Thatcallcertainlyencouragesresearch,butDSM-Illisacataloguenotaguideandthuscannotrecommendapath.ThebiopsychosocialconceptlookslikethesourceofinformationtoanswerthiscallfromDSM-III.TheHierarchyofNaturalSystemsSYSTEMSHIERARCHY(LEVELSOFORGANIZATION)BIOSPHEREISOCIETY-NATIONCULTURE-SUBCULTUREICOMMUNITYIFAMILYTWO-PERSONiPERSONl(belavIor)NERVOUSSYSTEMtORGANS/ORGANSSYSTEMSJTISSUESICELLSJORGANELLESJMOLECULESATOMSSUBATOMICPARTICLESFigure1.Engel'shierarchy(reprintedwithpermission)systemshierarchy(Figure1)thatEngellaidout2revealahowrestrictiveanyformulationofaclinicaldisorderwouldbeifitwereconfinedtomattersbiologic,psychodynamicorsocial,hencethistermbiopsychosocial.However,thisapproachissobroadinitsscopeandsonon-specificinitsrelationtoanyparticulardisorderthatitcandonomorethanremindpsychiatriststobepreparedtolookateverything,andtheinteractionsofeverything,whenseekinganexplanationofanydisorder.Thebiopsychosocialconceptoffersnorules,nodirections,nologicalpathwaystoexplainthepatientgroupingsinDSM-III.Inthisway,itisheuristicallysterile.ItprovidesingredientsbutnorecipestospecifytheaptuseoftheseingredientsinvalidatingandexplainingthecategoricallydistinctdisordersputforwardinDSM-Infact,thebiopsychosocialideaisnotnew.ItisquitesimplyAdolfMeyer'sconceptofpsychobiologyLecturereadtoSectionofPsychiatry,11June1991BurroughsWellcomeVisitingProfessorinClinicalMedicine0141-0768/92080483-05/$02.00/0O1992TheRoyalSocietyofMedicine 484JournaloftheRoyalSocietyofMedicineVolume85August1992renamedandreanimatedforthecontemporaryera.Itretainsallthestrengthsandlimitationsofthatpreviousversion.Meyeralsoembeddedthepersoninahierarchyofstratifiedsystems('interactivelevelsofintegration'washisterm)fromtheatomtothesociety(Figure2)3.Inproposinganexplanationforanydisorder,heencouragedacompletestudyofeachpatient'sbody,brainandbiography.Everymentaldisorder,hebelieved,stemmedfromtheresponsesofthepersonencounteringtheissuesofalifetime.Hepersuadedpsychiatriststoseekwithintheir'criticalcommonsense',amplyenhancedthroughthisconceptofintegrativelevels,theexplanationsandtreatmentsofmentaldisorders.Meyer'senergiesderivedfromhisoppositiontosimplicitiesandfatalisticimplicationsthathediscernedwithinthediagnosticandconceptualframeworkthatcamefromEmilKraepelin.Hedebunkedthemethodoffixedentitydiagnosisemphasizinginsteadindividualizedformulationsforpatientswithmentalillnesses.Itcertainlywasnoco

2 incidencethatEngel'sbio-psychosocialconc
incidencethatEngel'sbio-psychosocialconcept,arestatementofMeyer'sposition,emergedintoprominenceinthesamedecadeasDSM-III.Itmetandsatisfiedthesamefeltneedashaditspredecessor.AmericanPsychiatryisreplayingasetofthemesfromearlierinthiscentury.Itisbothneo-Kraepelinianandneo-Meyerian.But,howthesereappropriationsofthepastcansteerourpresentactivitiesintoamoresatisfactoryfutureisnotobvious.Amorethoroughgoingreappraisalofpsychiatricexplanationsisrequiredinthe1990stoanswerthecallfromtheneo-KraepelinianDSM-IIIandyetsustaintheecumenicaltenoroftheneo-MeyerianPHILOSOPHYMATHEMATICSETHICSANTHROPOLOGYLINGUISTICSLOGICETHNOLOGYHISTORYSOCIOLOGYINDIVIDUATIONPHYSICSCHEMISTRYMASSANDMOTIONSPECIFICUNITFORMATIONFigure2.Meyer'shierarchy'(reprintedwithpermission)biopsychosocialapproach.Specificallyweneedaconceptualstructureonwhichtorestanilluminatingsequenceofpropositionsaboutmentaldisordersandfromwhichtoderiveacorrespondingsetofexamplesembodyingandinvestigatingthesepropositions.AstructureforexplanationsWeatJohnsHopkinsholdthatfourstandardmethodsforelucidatingmentaldisorderareimplicit(andshouldbemadeexplicit)incontemporarypsychiatricthought.Theyare:thediseaseconcept,thedimen-sionalconcept,thebehaviourconceptandthelifestoryconcept.Wehavecalledtheseconceptsfour'perspectives'4.Wechoseavisualmetaphorbecausewewishedtoemphasizehoweachofthesemethodsisadistinctviewpointfromwhichcertainaspectsofpsychiatricdisordersareclearlyseenandothersareobscured.Incombination,theyprovideabasicstructureforpsychiatricexplanationsandilluminatewhatispathologicinpsychopathology(Table1).Eachperspectiveisrulegoverned.Eachisuniqueinitsinitiatingpremises,operationalguidelines,logicalsequencesandvalidatingimplications.Each,therefore,mustbeseparatelytaughteventhoughitmaybeemployedwiththeothers,invaryingsalience,intheelucidationofaparticularclinicalproblem.Eachperspective,becauseitrevealshowwearethinkingaboutcertaindisorders,enlargeswhatweknowaboutallthepatientsinourcareandenhancesourgraspofwhatwearedoingforthem.Thediseaseperspectiverestsonacategoricallogic.Itattemptstoclusterpatientsintoseparategroups,eachgroupdefinedbythedistinctfeaturesthatarethedefiningcharacteristicsofthedisease.Embeddedinthetermdiseaseistheimplicationthattheultimateandconfirmingcharacteristicendowingapatientwithmembershipinagivencategoryanddistinguishingthatpatientfromthoseinothercategorieswillbeanidentifiableabnormalityinstructureorfunctionofabodilypart.Thedimensionalperspectiveappliesthelogicofquantitativegradationandindividualvariationtopsychiatricdisorder.Itgrappleswithpatientswhocannotbeplacedinclearanddistinctcategoriesbutcansometimesbecomprehendedintheirvulnerabilitytomentaldistressfromtheirindividualpositiononpsychologicaldimensionsthatareanalogoustophysicaldimensionssuchasheightorweight.Thebehaviourperspectiveemphasizesthegoal-directed,oftengoal-driven,teleologicaspectofhumanactivities.Itnotesthatdisorderscanemergeeitherbecauseoftheabnormalgoalssomepeoplecancometocrave(asindrugaddiction)orbecauseofanexcessintheirattemptstosatisfydrivescommontoall(asineatingtoobesity).Finally,thelife-storyperspectiverestsonthelogicofnarrative.Itdrawsontheoccurrenceofeventsinthepatient'spasttounderstandhiscurrentdistress,andmorespecifically,itpositstheexistenceofapilotingselfwhosechoicessomehowbringaboutTable1.Thefourperspectives1.Diseaseperspective(thelogicofcategories)2.Dimensionalperspective(thelogicofquantitationandindividualvariation)3.Behaviourperspective(thelogicofteleology)4.LifeStoryperspective(thelogicofnarrative)WITHSYMBOLIZATIONANDMOREORLESSCONSCIOUSNESSSEGREGATIONOFSTIMULUSANDRESPONSEVEGETATIVEBRANCHZOOLOGICALBRANCH(BASEDONOSMOSIS)(INCLUDINGMOTION)(GROWTH,METABOLISM,REPRODUCTION)BIOLOGY JournaloftheRoyalSocietyofMedicineVolume85August1992485unintendedconsequences,allilluminatedbythepersuasivepowerofnarrative.Noticethatwedonotdescribea'biologic'ora'dynamic'perspective.Biologicanddynamicissuesfigureineachofourperspectivesbutvaryinsaliencefromthediseasetothelifestoryperspectiveinanalmostreciprocalfashion.Also,justaswedonotfindithelpfulinteachingthisstructureforpsychiatricexplanationstospecifyaseparateneurophysiologicperspective,orasociologicperspective,orapsycho-pharmacologicperspective,sowedonotputforwardaseparatedevelopmentalperspective.Developmentlikephysiologyandlikecultureiseverywhere.Thusinourproposalitformsaningredient(animportantingredient,admittedly)foreachoftheseperspectivesratherthanaperspectiveitself.DiseaseperspectiveThelogicofthisperspectiveisacategoricalone.ItrestsupondisorderssyndromeielucidatinthiscohespatientsMbegintouinstructurbeprovoktheselatt4theclinicadiseasenaturere.Psychiatr:(dementiawhethert]Bothco:magneticbrainsof'implying(workaretschizophridistinctioxs

3 ubjectsaAtJohnonlyevidegyrusbuttheseveri
ubjectsaAtJohnonlyevidegyrusbuttheseveripatientsuevidenceepilepsy,E4'E200-~151�D-�u,tu5-5E-O10-1cc1500.0o-0ma2-25u-30C.-33540Figure3.I1temporalgtomatchedetal.8)thatitsparticularsymptoms,ofwhichhallucinatoryexperiencesarebutone,maybelinkedtodistinctsitesofdamageinthebrain.Thisworkisbutbeginning.Iadmireitbecauseitneatlyexemplifieswhatisexpectedwhenemployingthediseaseperspectivetoelucidateamentaldisorder.Symptomsarelinkedtopathologyandasearchforaetiologies-which,forschizophrenia,maybeofseveralkinds(birthinjury,anoxia,geneticvulner-abilityetc.)-canbelaunched.Ifthisresearchprogrammeissuccessfulinitssearchforcauses,thenrationaltreatmentandpreventionbecomepossible.Yeteveryoneknowsthatdiseaseisnotanappropriatetermforalldistressordifflculty.Toteachthatalldisordersarekindsofdiseasewillmisconstruemattersofimportanceinpracticeandresearch,implyingasitdoesthatneurosciencewillprovideananomalousneuronforeveryanomalousthought.ithefactthatsignsandsymptomsofsomeDimensionalperspectivetendtocohereinrecognizableclustersorPsychologicaldimensionswiththeirlogicofgradationsthatprogressincharacteristicways.Theandquantitationprovideacontrasttodisease.ThereLgchoreisdrivenbytheneedtoexplainareseveralpsychologicalfeaturesacrosswhich;ion.Oncephysiciansrecognizea-groupofhumansvaryinagradedfashionmuchastheyvaryvithadistinctiveclusterofsymptoms,theyinsuchphysicalcharacteristicsasheightandweight.vonderwhetherabodilypathology(eitherAnindividualwhodeviatestoanextremealongsuchreorfunction)andabiologicaetiologymightadimensioncan,undercertaincircumstances,sufferingthecondition.Successfuldiscoveriesofbecauseofit.erelementsconfirmboththeopinionthatIndividualvariationisasapparentinaffectivealcategoryisappropriatelyconsideredcharacteristicsasitisincognitivecharacteristicssuchandtheembeddedimplicationthatitsasintelligence.AxisIIofDSM-Iattemptstocapturestsonadisruptionofbodilymechanisms.thisvariationwithincategoriesortypologiesiststreatmanyconfirmeddiseases(histrionic,narcissistic,compulsive,etc.)andthusL,deliriumetc.)withoutquarrellingaboutfollowsapatternofreasoningsimilartothatusedheconceptisappropriatelyappliedtothem.wIithdisease.AtJohnsHopkins,weagreedthatthemputerizedaxialtomography(CAT)andfeaturesdefimingthesetypesinDSM-llIareunlikeresonanceimaging(Ml)haveshownthatthesymptomsofdiseaseintheir.allbeinggradedschizophrenicpatientsoftenhaveatrophyphenomena.Weproposedanapproachthatassesseddamage.Amongthebestexamplesofsuchsuchfeaturesinadimensionalfashionaswiththestudiesofidentical-twinsdiscordantforintelligenceassessment.WebelievedthattheresultseniaofSuddathetaL5wheretheseclearwoulddisplaythenatureofcertainclinicalconditionsnsbetweenthenormalandtheabnormalmoreclearlythandoesthecategoricalapproach.Ireevidentintheirbrainimages.If,aswithintelligence,thedistressedindividualsLsHopkins,BartaetaaL6demonstratednotseenaspatientsinhospitalsandclinicsrepresent,nceofatrophyintheleftsuperiortemporalthosepeopletowardsoneextremeonadimensionofalsoaclearcorrelationofthisatrophywithvariation,thenapopulation-basedsurveywouldlbetyofthehallucinatoryexperiencesintheirneededasthesourceofbasicdatafordimensionalvithschizophrenia(Figure3).Thisissomereasoning.WetackledthistaskinthelocalBaltimoreconfirmingthatschizophreniawill,likepopulation,amongstourcontributionstotheNationalemergeasaproductofbrainpathologyandEpidemiologicCatchmentArea(ECA)study.HereIshalldiscussthefindingsforthecompulsivepersonalitydisorder7.Fivefeatures,saysDSM-IU,comprisethecharacteristicsofthatdisorder:inon,stubbornness,workdevotion,perfectionism,andemotionalconstriction.Thestrikingaspectofthe0~\**resultsofthisresearchishowmanypeoplein-\*BaltimorehavesomecompulsivefeaturesandhowI|---:theindividualswhosatisfytheDSM-Ilcriteriafor;*\;;thecompulsivepersonalitydisorderaretheminorityattheextremeonthedimension(Figure4).�^^--~~~~~~~~Thisobservationcouldbeanoutcomeofthemethodst__________________________.-employedinthestudy,butavalidatingsetofassess-0123456mentswereavailabletotestwhethertheactualscoreHALLUCINATIONSonthisscaleofcompulsivity-couldidentifyeitherariskfocertainconditionsoraprotectionfromothers.screasingauditoryhallucinationsasleftsuperiorThisisexactlywhatemerged,whenthe.DSM-IIIvrusshrinksinschwzophrenicsubjectswuithrespectconditions,generalizedanxietydisorder(GAD)andcontrols(reprintedWithpermissionfromBartaalcohol.disorders,werecorrelatedwiththecompulsivityscore.Therewasaclearenhancementof 486JournaloftheRoyalSocietyofMedicineVolume85August1992502018161412co'U.&1086-42002468CompulsivityscoreFigure4.Prevalence(o)ofcompulsivefeaturesintheBaltimorepopulationand(shaded)theprevalenceandpositiononthiscompulsivityscaleofsubjectswhosatisfiedDSM-IIIcriteriaforcompulsiveperso

4 nalitydisorder(reprintedwithpermissionfr
nalitydisorder(reprintedwithpermissionfromNestadtetal.9)riskforGADasthescoreincreasedandaclearprotectionagainstalcoholismasthescoredecreased,inanalmost'dose-response'fashion.Mymajorpointhereissimple.Adimensionalperspectiveilluminatessomepsychiatricdisordersbetterthandoesthemorestrictlycategoricallogictiedtodiseasereasoning.Itiscompatiblewiththesenseofindividualvariationindispositionthatisfamiliartoeverypsychiatristmakingapersonalitydiagnosis.Finally,itbringsintofocusasubstrateofriskandprotectionthatiscomprehensibleforelucidatingotherpsychiatricdisorders.BehaviourperspectiveTheideaIwishtocommunicatewiththetermbehaviouristhesignificanceofthegoal-directedaspectofmanyhumanactions.Disordersofhumanbehaviourmayresteitherondisruptedbodilymechanisms-asinhypothalamicobesity-oruponculturallyinducedgoalssuchasthe'sick'rolesoughtinhysteria.Manyclinicallysignificantbehavioursprobablyderivefrombothlifeexperienceandembodiedmechanisms.Drugaddictionsorvarioussexualabnormalitiesareexampleswhereboththeinducementsandenticementsofapersuasivepublicmayprovokethefirstactofwhatthenbecomesabehaviouralpatternself-sustainedbyacravingderivedfrombothpharmacophysiologyandconditioning.Oncetheconceptofthebehaviourperspectiveisappreciated,anapproachradicallydifferentfromthediseaseperspectiverecommendsitselfforthetreatmentofthesedisorders.Theinitialfocusoftreatmentistouseeverymeasuretostopthebehaviour-akindof'symptomatic'approachthatwouldbescornedassuperficialinthemanagementofdisease.Behaviourstendtobeselfsustainingformanyreasons:thebodilytoxicitiesassociatedwithdrugabusepromptrepetitionofdrug-takingbehaviour;changesinthesocialnetworkprovokedbyillness-imitatinghystericalbehaviourmayencourageit;starvation'sdisruptiontobodilyandpsychologicalintegrityinanorexianervosarendersthepatientinaccessibletocounsel.Theseissuesaremagnifiedbythehabitaspectthatderivesfromsimplerecurrenceofbehaviourandencouragesit.Alltheprogrammesforbehaviourdisorders(anorexianervosa,alcoholism,sexualdisorder)atJohnsHopkinssharetheopinionderivedfromthisperspectivethattreatmentsforsuchconditionsmustbestaged.Thestartingpointisalwaysamajorefforttostopthebehaviourandifpharmacologicmeasurescanhelptheyareemployed.Throughoutthecourseoftreatmenteffortsaremadetoensurethatthebehaviourdoesnotrecur.Onlyasthebehaviourisstoppedcantherapysuccessfullymoveontothelaterstepssuchastreatingcomorbiddisorders(depression,anxiety,etc.),elucidatingvulnerabilitiesoftemperament,deconditioningandaddressinghabitsustainingsocialattitudes.Finally,itisasbehavioursthatlinkagestobasicsciencewillemergefortheseconditions.Forexample,atJohnsHopkinswehavebeenactiveinattemptingtocurtailthecravingfordrugsthatsustainsthebehaviourofaddiction.TheinvestigatorsinourBehaviouralPharmacologyResearchUnit(BPRU)havecombinedapproachesthatattempttocombattheoperantconditioningfeaturessustainingdrugabuse8withresearchontheclinicalapplicationofnewmedicationstosuppresstherewardsofdrugseekinganddrugtakingactivities.RecentworkattheBPRUhasfocusedonbuprenorphine9",0,acompoundwithbothopiateagonistandantagonistfeatures,thuscombiningaspectsfoundinmethadoneandnaloxone.Itmayprovetobeanidealcompoundtohelppatientsstopopiateabuse,particularlyifitisintegratedintoaprogrammeofbehaviouralmanagementasadvocatedbytheBPRU8.LifestoryperspectiveThefinalperspective-andforsometheonemostidentifiedwithpsychiatrists-isthatofthelifestory.Itpresumesthatdistressingmentalstatescanbetheoutcomeofaseriesofself-involvedlifeeventsandtheseeventsarebestdepictedwhenpresentedinanarrativeform.Thefundamentalcomponentoftheclinicalstory,likeanypersonalnarrativedepictingaresult,ishowsetting,sequenceandaself'sintentionalinteractionscanmakeaseeminglychaoticmentalstatetheunderstandableoutcomeofthewishesandwantsoftheindividual.Thelifestoryperspectivecanbeapartofanyformulationincludingthosethatrestonthedisease,dimensional,orbehaviouralperspectives.Infact,itcouldbesaidthatinalldistressordisorder,someaspectoftheindividual'slifestoryprovidesunderstandingtoelementsoftheclinicalpresentation.Butastorycanbetheprimarywayofcomprehendingastateofdistress.Thismethodofelucidatingamentaldisorderbydescribingacoherentroleforthepatientinitsgeneration(addingingredientsfromthedynamic JournaloftheRoyalSocietyofMedicineVolume85August1992487unconsciousifneeded)canpromotetherapeuticoptimismandconfidenceinboththepatientandthepsychiatrist.Iftheconditionisinpartderivedfromtheself'sintentionsandmotives-especiallyonesthatneedunearthing-thenreconstructed,consciousintentionscansetinmotionnewlifeplans,sequencesandmoresatisfactoryoutcomes.Thestoryisthemajorbasisofpsychotherapyandtransmitsanexcitementencouragingpatientcare.Amissionaryfervor,however,maydeveloparoundthestorymethodandisoftenatthehea

5 rtoftheconflictbetweenvariousschoolsofdy
rtoftheconflictbetweenvariousschoolsofdynamicpsychiatry.ThusFreudiansproposethathiddenlibidinalconflictsshouldbesoughttoilluminatemanifestdisorder,whileAdleriansclaimthatpowerdrivesareattherootofthingsandneedtobebroughttolightandrescripted.Eachschoolofpsychotherapytendstoproduceversionafterversionofthesamestorydespitethedifferentingredientsofperson,placeandtimeintheirpatients.Theinsistenceuponretellingthesamestorysuggestsadogmaticcommitmentorgnosticzeal('weknowthesecret')thattransformsteachingintoinitiation.Asubliminalawarenessofthisfeatureisanissueformostyoungpsychiatrists.Itrepelssomeanddrawsothersintosegregatedtraininginstitutes.Inall,itproducesanuneasinessovertheireducationalpathwaythatcanonlybedispelledbyrecognizingitssourcewithinthelifestoryperspective.AtJohnsHopkins,theresearchofJeromeFrankhasdonemuchtorelievethisproblembyturningthecustomarytherapeuticandelucidatoryaspectsofthelifestoryperspectivearound.Hedemonstrated,fromlookingatthepatientstreatedbypsychotherapists,thatwhattheyshareisnottheirstoriesbuttheirstates.Thisstatehedescribedwellas'demoralization'.Itcanderivefrommanydifferentcircumstancesandlifesequencess.ThisviewofFrank'sdirectedhisresearchintothecommonalitiesofpsychotherapiesratherthantheirdifferences.Inthemostrecenteditionofhisimiyebook,PersuasionandHealing11,heandhis-author,JuliaFrank,repeatedlydisplayhowtheilluminationfromquitedistinct'stoylines'canbringrecoverytodemoralizedindividuals.ThekeytoWpsychotherapyisnottheelucidationofthe'coect'story.Helpemergesfromthepatient'ssensethathbisunderstoodbysomeauthoritywhoisprepaed-toprovideassistanceinrestructuri8histhandintentionsintoastorywitl.uoepisingk;meanings.Thiscanrestoreases-,at.OflifcriticallyabsentfromtheinitiatalThus,thelifestorieswhichhaveeoandyetsodivisiveinpsychitrychaemphasizedinaradicallydientwp.Kcommonalitiesinoutcomemoreitothestorylines.Weapp*ttheoristshaveprovidedacollecioconsideration.Wecanseleclhe4themesforthenarrationsweripa-tonesthatfittheparticular-ii~ioi~dot'dependuponsomeesoteric,?staraowJrgofsomethinghiddeninhua1~ure.--':-^Rlesolution%0;,Ihaveattemptedthree.thnsFit,Idis;;-ee?contemporaryfoundatiolisofAmrianphiIyoshowtheirmeritsbutalsohowtheyarerecurrentnotionsthatnow,asintheirpreviousappearances,leavemuchunresolved.Second,Iwishedtoproposeasetofelucidatingandencompassingperspectivesthatcan,whenmadeexplicit,restructureourthought.Eachperspectivehasitsownlogic,grappleswithcertainpsychiatricissuesmostnaturally,andyetcanbecoordinatedwiththeotherperspectivesinpractice.Finally,ItriedtoreviewbrieflyacurrentapplicationofeachperspectiveatJohnsHopkinssoastoshowhoweveryoneofthemcanbeembodiedinteaching,practiceorresearch.Weareallchallengedtofindwaystoassimilatetheamorphousbodyofpsychiatricfactandopinion.ThisistheresponsefromHopkins.Theeffortistoentrenchourprofessionalclaimsandcompetencesonwhatweknowandhowweknowit,dispellingboththecapricethatemboldenspoppsychologyandthemysterythatkindlesfaction.WeshoulddemonstratenotonlythatweareapartofMedicine,buthowweareavitalanddistinctivepartwithastructuredbodyofknowledgeuniquetousasspecialists.Acknowledgments:ThelecturewasdedicatedtoSirAubreyLewis,inthehappymemoryofmydaysasaResearhFellowattheInstituteofPsychiatryunderhissupervisionin1960/61.IthankPatrickBarta,GeorgeBigelow,JeromeFrank,GeraldNestadt,GodfreyPearlson,AlanRomanoski,andMaxineStitzerforhelpingmeseemoredeeplyintotheirwork.IthankMarieKillilea,TimothyMoran,andPhillipSlavneyfortheirhelpfulsuggestionsonthemanuscript.ThisworkwassupportedbytheLorraineandLeonardLevinResearchFundandgrants#DK19302and#MH15330fromNIH.NoneofitwouldevenhavebeenthoughtbutforconversationsheldonWardSevenwithJamesGibbons,GeraldRussellandTedSmithallthoseyearsago.References1EngelGL.Theneedforanewmedicalmodel:achallengeforbiomedicine.Science1977;196:129-362EngelGL.Theclinicalapplicationofthebiopsychosocialmodel.AmJPsychiatry1980;137:535-443MeyerAT-&WintersEE,BowersAMKeds.Psychobiology.-prinfleldIm:CharlesCThomas,19574.McflugPb,S1avneyPR.Teperspectivesofpsychiry.Baltimore,MD:TheJohnsHopkinsUniversityPress,1983,5S;9uddalL,ChristisonGW,TorreyE,CasanvaMF,-eXAtanalitieinthebainsofmiagoticwinsdantorschizophrenia.NEnglJMed1990S06,BartaPE,PearlnGD,^rsRE,RichardsSS,TuneLE.AihadsmallersuperiorenpolXgyrale-schiophiaAmJPsy(*iatry19S0;1:1467--62'7~ta4~7~mano~AJ,Bro*n:CH-etaLDSM-IlXep~td*r:*edemiological^;8erOlgeIowO,~r~sJ&bav4matment$44tag-^.ofpsycie2ric4iAorders,-''9',i~KStitkQ..,x-glGE,iIsmIA,-JaiskiiDR,Joaeu4AIiu4clt~iafbpeo-ffpher&_a44*Parmnce1~'he410.1kelWK^it*IL,XgloiOe^4nIA,0k.bloof;j~~j'odahdepenidet024ke-alinunore&#x- Tj;&#x /F1;&#x 11.; T; 65;&#x.38 ;&#xTz 0;&#x.00 ;&#xTs 0;&#x.24 ;� Td;&#x 000;''~halekuUtiy"P'ress,^1991'(Accepted7January1992)