Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying the Perspectives of Psychiatry

The transition from seminal conceptual works in psychiatry to the practical aspects of their clinical applications and use for an overwhelming variety of patients is not always an easy journey. It requires first and foremost an essential interpretation of the original ideas and then the translation of such scholarly coined notions to the simple, everyday language of the busy clinicians who in turn must also convey them to the troubled patient. In toto, this type of endeavor entails many layers of knowledge, experience, didactic skills, and clinical acumen; it also reflects many personal, subjective features on the side of its conductors (identification with the theoretical roots, loyalty to their principles, persuasive communication style, and a continuous search for improvement) that may be as decisive for its success as those of a purely academic kind.

This has been, undoubtedly, the pathway followed by the authors of Systematic Psychiatric Evaluation, a book that represents, as stated in the preface, “an attempt to distill the detailed instructions of The Perspectives of Psychiatry into a practical ‘recipe’ for trainees” (p. xiii). Perspectives is, indeed, a classic because it pursued innovative routes toward a truly comprehensive consideration of the patient’s experience and because it brought up the polemical ingredients that are the guarantee of genuine advancements. McHugh and Slavney championed their cause in a true Hopkins-style rebellious and constructive, fierce and sincere, direct and elegant manner. Their book in the late 1990s intended, like they state in the foreword of the manual under review, to “correct the problematic state of American psychiatry” characterized by “a technical, instrumentalist routine….mechanical and generic rather than devised, individuated, challenging, and progressive” (pp. ix, x).

In this context, Systematic Psychiatric Evaluation can be considered a useful contribution to the transition process alluded to above. Not surprisingly, part I, titled “the Concepts Behind the Approach,” is a well-presented, compact summation of McHugh and Slavney’s four perspectives. Faithful and concise, the descriptions are intended to formulate practical, diagram-based steps in the conceptualization of each perspective and cannot, for obvious reasons, report on more recent contributions to, for instance, the research on dimensional diagnostic approaches or on neurobiological correlates of mental disorders. Each perspective is explored and explained with the use of clinical cases, the very first of which is a presentation of two versions of Edgar Allan Poe’s history. This is also a natural start of a list of new terms (shall we call them jargon?) aimed at the characterization of each perspective (i.e., setting, sequence, and outcome [plus encounters] for the life story; potentials [personality], provocations [life circumstances], and responses [neurotic symptoms] for the dimensional, etc.). Like in any other effort of this nature, some definitions may be right on target, whereas others may sound arbitrary, incomplete, or outdated (i.e., neurotic symptoms).

After describing the foundation of the systematic psychiatric evaluation, part II, “the Approach in Action,” presents nine clinical cases in which the tools and concepts are applied with a discussion of the value and weight of each perspective, leading to a “collaborative” diagnostic formulation and treatment plan. Every clinician knows that each and every case he or she faces has its unique, intriguing seal of complexity and inherent management difficulties. The results of the exercises in this section of the book are, expectedly, uneven: some are lucidly elucidated; others entail the proverbial ambiguity of clinical events in psychiatry; a number of them will certainly generate illuminating discussions (not necessarily clinical); others may lead to more questions of an epistemological and a pragmatic nature. Each case has a provoking title and an explanatory or illustrative subtitle, reproduces schematic interview vignettes, and proceeds to a discussion considering each perspective and deciding on which one will provide the most solid understanding of the case. The conclusion is an apt comment, followed by the summary points pertinent to the overall approach, perhaps the most substantial component of the volume. This reviewer would have liked a more pointed mention of the cultural ingredients of psychiatric diagnosis and treatment.

The cases focus on different clinical occurrences, diagnoses, and intricate etiopathogenic possibilities. The reaffirmation of emblematic clinical truths is evident throughout. From bereavement to cognitive decline, from bipolarity to eating disorders, from personality (the book uses more the term “temperament” for theoretical reasons) to hypochondriasis, from suicidal behavior to psychosis, the cases attempt to combine theoretical cogency with clinical clarity. Those who will use this manual will have to familiarize themselves with the former to achieve the latter. Well-conceived graphics, tables, scales, and clinical forms throughout the book, and particularly the appendices at the end, will assist in the effort to reach the levels of competence and satisfaction that the use of the eclectic Perspectives of Psychiatry has yielded to generations of clinicians.