Applying the Four Perspectives to Anorexia Nervosa

The classification, etiology, and treatment of anorexia nervosa (AN) have been enigmatic and controversial. AN has been variously classified as a hypothalamic abnormality, an endocrine disorder, a hidden form of obsessive-compulsive disorder (OCD) or depressive illness, a psychosocially understandable feminist protest, a strategy to regulate family functioning, a syndrome of unknown origin, and others. The DSM-IV classifies psychiatric disorders in an “agnostic” manner, without reference to etiological category, and instead emphasizes symptom description.

The time has come to move AN and other eating disorders (EDOs), as well as all psychiatric disorders, into a classification system based on etiological category. Only by this logical and timely step forward will psychiatry advance in its ability to conduct research and to offer treatment approaches that spring from a more fundamental understanding. The result will be to free psychiatry from warring denominational schools of belief that pit one set of theoretical assumptions against another, the psychodynamic vs. the biogenic categories, which have coexisted with tension for at least four decades– since psychoanalytic unquestioned dominance was shattered.

Karl Jaspers emphasized in his foundational work, General Psychopathology,1 that all knowledge is intimately connected with the methods by which knowledge is obtained. The fact that the electron is both a wave and a particle is no less true because of its frequent citation. McHugh and Slavney, in their ground-breaking book, The Perspectives of Psychiatry,2 have advanced the field of psychiatry by advocating that all psychiatric disorders be classified into etiological groups according to one of four “perspectives”: the Disease Perspective, the Dimensional Perspective, the Behavioral Perspective, and the Life-story Perspective. The “perspectives” are lenses through which to view psychiatric disorders, with each disorder falling primarily into one of the four groups. Because psychiatry is called upon to treat fundamentally different types of disorders, it is important to use different forms of reasoning for each etiological category of disorder. After correct classification into one of the four Perspectives, treatment and research strategies follow more logically.

Putting the Four Perspectives to Work

Here are some examples of how psychiatric disorders may be classified by using the Perspectives:

The Disease Perspective. Post-stroke depression falls clearly into the Disease Perspective. It had been considered a psychological reaction until the work of Robinson and colleagues.3 The evidence now is clear that a damaged brain is the source of the psychiatric symptomatology. The treatments pari passu therefore are largely somatic, primarily antidepressants.

The Dimensional Perspective. In this Perspective, extremes in one or more traits of personality along a continuum are the source of the problematic thinking and behavior of personality disorders, for example, obsessive-compulsive personality disorder.

The Behavioral Perspective. For disorders that belong in the Behavioral Perspective, the behavior shown by the patient is the cardinal abnormality, whether it is the behavior of self-starving, purging, alcohol consumption, dysfunctional sexual behavior, or other actions. A psychiatrically abnormal behavior is required. Absent the behavior, absent the disorder.

The Life Story Perspective. Finally, in the Life Story Perspective, it is the round peg individual facing the square hole of life: individuals suffer existentially and symptomatically because of the collision between who they are and the situations that they face. There is no disease state present comparable to the Disease Perspective. Table 1 summarizes the four Perspectives with examples.

General medicine has long used classification of disorders into probable etiologic groups to organize its knowledge of disease development, to plan treatment, and to advance research. The fact that gastric ulcers were transferred from disorders of excess acid production (hence the prior emphasis in treatment on h1 blockers and proton pump inhibitors) to a category of disorders of infectious origin (leading to triple antibiotic treatment) was a logical development rather than a vitiation of classification by etiology. For psychiatry to advance to the state of general medicine, it needs to move from a general description, much like a field guide to birds based on coloration, warble, etc., to grouping by origins.4

Where Does AN Fit?

AN is best viewed from the Behavioral Perspective. Without self-starving behavior, anorexia does not exist as a disorder. Many people may struggle with a desire for slimness or shape change. They may suffer from body dissatisfaction, relentlessly comparing themselves to impossibly idealized body images in the media. Without the behavior of self-starving, AN as an entity does not exist.

There are multiple advantages to viewing AN as belonging in the Behavioral Perspective. First, this classification avoids a search for a hypothesized, more fundamental, single classification, which previously had suggested AN was a forme fruste (incomplete or abnormal form) of OCD, depression, or schizophrenia. While AN may migrate amongst subtypes of EDOs, AN does not turn into another disorder. Second, it allows for acceptance of the fact that multiple paths of entry, not a single one, may lead to the abnormal behavior of sustained self-starving, avoiding the division of the field into factions promoting the onset of the disorder from single sources. Such sources include an existential stance against fears of development, a method of controlling the family, a feminist protest against male domination, a result of serotoninergic dysfunction, a defense against repeated criticism at critical points in development, or a strategy for emotional self-regulation.

When an abnormality of behavior is the defining perspective, such as self-starvation being the requisite behavior in AN, treatment strategies follow logically. Changing the abnormal behavior, whether in AN, in substance abuse, or in sexual behavior, is the first treatment goal for disorders in the Behavioral Perspective. Although treatment begins with changing the behavior, treatment does not end there. Appreciating, where applicable, the contributions of the other Perspectives allows for the individualization of the treatment of each patient according to the diversity of paths of onset into the abnormal behavior, and according to the various specific predisposing features operative for each patient, and any comorbid disorders.

When the blind men examined the elephant, they came to a wide variety of conclusions by examining only part of the animal’s anatomy. The approach of the Perspectives avoids this fractionalization into mutually exclusive categories by recognizing the primacy of one Perspective for each disorder, a perspective that proposes an etiological rather than a descriptive classification, but does not exclude other information. Multiple research efforts are currently tunneling into the clinical mountain of AN symptomatology from different sides of the mountain, different theoretical orientations, hoping to meet in the center. In fact, because they are using methods that are orthogonal to each other in the interpretation of the results produced (abnormal serotoninergic functioning vs. close-binding families are not mutually convertible), they are, in reality, moving further and further away from each other in coming to a fundamental understanding of AN. No, Virginia, there is no single path into AN. It is a disorder of abnormal eating behavior with a variety of paths.

A Logical Path for Treatment

Treatments grow logically from the particular Perspective into which a psychiatric disorder is classified. For example, Huntington’s disease is best classified within the Disease Perspective. This devastating illness results from a genetic abnormality of brain functioning, one of the few where a single specific cause is known. Research logically focuses on explicating the sequence of biochemical abnormalities resulting from the single gene abnormality. The other Perspectives are not applicable. Schizophrenia and bipolar disorder are also disorders that are best categorized by the Disease Perspective, even though the disease processes are not yet understandable at the level of specific gene abnormalities or exact biochemistry. Probably multiple genetic abnormalities apply. The focus of treatment must begin, but not end, with medical, pharmacologic, approaches. In contrast to Huntington’s disease, where other Perspectives do not add understanding, additional, secondary application of the other Perspectives may be helpful in schizophrenia and bipolar disorder.

Some gnashing of teeth may occur in sincere folks holding the view that alcohol abuse is a disease when it becomes clear that alcohol abuse/dependence is better understood within the Behavioral Perspective, not within the Disease Perspective. Excess alcohol ingestion is a behavior, not a disease, although in some patients a disease process may predispose to alcohol abuse. In others afflicted with the ills of alcohol abuse, the disordered behavior may be appreciated from a dimensional vulnerability, such as social shyness, or may be a short-term but ultimately ineffective strategy of coping with life’s vicissitudes, conflicts, and disappointments, and is best approached by the Life Story Perspective.

These examples illustrate the advantage of assigning each disorder to one of the four primary Perspectives. In addition to avoiding intrafamilial conflicts within psychiatry according to one’s theoretical orientation, it leads to the supplementary application of the other three Perspectives in a logical, hierarchical order of contribution, resulting in the fullest appreciation of the case, if there is evidence that these other Perspectives apply. The primary assignment of a disorder to one Perspective is a statement about which method of reasoning helps us to best understand the disorder, not a sterile categorization with a ceiling effect of further understanding. Figure 1 schematically outlines an approach to a global view of AN, classifying it into the Behavioral Perspective as a foundational statement, but then adding, from evidence-based studies, additional etiological contributions. The result is a logical multidisciplinary approach to treatment beginning with the Behavioral Perspective, but not stopping there. Contrast how the very different treatments of Huntington’s disease vs. AN both are logical outgrowths of the initial classification by the most useful Perspective.

The Dimensional Perspective and the Life-Story Perspective both give supplemental understanding to the origin and treatment of AN. Both add, in appropriate proportion according to the individual case, to planning the most effective treatment strategies for AN. Even in the small percentage of cases of AN that begin inadvertently by non-dieting sources of weight loss, and certainly in the large majority of typical AN cases, a Life Story Perspective is involved.

Eating disorders always have psychosocial precipitants, most commonly criticism by a parent, peer, significant other, or authority figures. Every case of AN requires a Life Story perspective after the primary assignment into the category of abnormal behaviors. Decades ago Hilde Bruch warned about letting patients “eat their way out of hospital.” Treatment of the weight loss by threats, or purely behavioral strategies, is rarely successful. Treatment without any behavioral strategy, as in prolonged psychotherapy without any attempt to change the behavior, has led to voluminous charts documenting ineffective therapy sessions.

An appreciation of the vulnerabilities of an AN patient from the Dimensional Perspective is also almost always applicable. A patient probably cannot develop classical self-starving AN (no binge-purging) without an extreme endowment of perseverance, perfectionism, and inflexibility. Recognizing these features of temperament as being extreme from the Dimensional Perspective, allows the clinician to help the patient to focus on the strengths and not the vulnerabilities of the double-edged sword of temperamental extremes. Essentially, we are helping the patient to hook the engine of perseverance onto the chain of railroad cars carrying healthy behaviors rather than pulling the train of illness behaviors, while at the same time moderating the inflexibility and perfectionism using CBT.

For Patients with AN: Disease Perspective Is Least Helpful

The Disease Perspective in the etiological understanding of AN has been the least helpful of the Perspectives. Historically, AN was classified around 1900 and for several decades has been viewed as a disorder of endocrine function. Only in the sense that individual differences in genetics and brain development underlie every word we speak and every action we take, are physical mechanisms involved in AN. In the sense that there is evidence for a primary disorder of brain function as a necessary and sufficient cause for AN, the evidence for the Disease Perspective is absent and unpersuasive. In contrast, evidence of disease consequences from the self-starving behaviors of AN abound. There is no evidence for the Disease Perspective being useful in understanding predisposing factors to AN, except, as noted above, that genetic differences underlie differences in choice of beer or shoes or music.

Continued, click here for part 2 “work in progress whose time has come.”)
Note: All references will appear at the end of Part 2.