Applying the Four Perspectives to Anorexia Nervosa Part 2: A Work in Progress Whose Time Has Come

By Arnold E. Andersen, M.D.
University of Iowa School of Medicine, Iowa City
Reprinted from Eating Disorders Review
May/June 2009 Volume 20, Number 3
©2009 Gürze Books

Continued from Eating Disorders Review VOL 20 / NO 2, click here for part 1

The four Perspectives classification proposed by McHugh and Slavney accords well with the previous, and too often forgotten, work by Adolf Meyer, who, decades before Engel proposed the biopsychosocial approach, advocated a detailed written investigation into every aspect of a patient’s development: social, psychological, familial, medical. Classification of AN and other disorders into one of the Four Perspectives is, as is all classification in general medicine, a work in progress, and a classification whose time has come. In the substantially politically motivated agnostic, descriptive, approach of the DSM, research progress is bound to be slower and less productive.

The argument that there is insufficient evidence to propose an etiologic classification for psychiatric disorders (as works-in-progress, as with gastric ulcer) must be rejected on scientific grounds. If it were not for the warring factions of psychiatrists whose personal philosophy, whose “politics,” whose training, whose source of income, whose comfort zone, comes from maintaining a single theoretical stance toward all psychiatric disorders, classification into one of the Four Perspectives would take place promptly, followed by quick benefits in research and treatment. The term eclectic must also be rejected as psychobabble. “Eclectic,” as used in practice, could be, but unfortunately is rarely a code word for the employment of thoughtful, integrative, layered, treatment approaches, using all of the Perspectives. Rather, the term eclectic almost always means a mish-mosh of methods that cannot be rationally described. The term “biopsychosocial” sounds good, but in practice, it, too, seldom has methodological specificity, including a differential hierarchical order of biological, psychological and social treatments according to the nature of the disorder. Finally, the term “holistic” medicine requires a methodological hierarchy and specificity, not simply use of alternative non-evidence-based approaches that are currently trendy because they have never been put to the test of empirical proof, and owe their cachet to hoped-for benefits.

Other Eating Disorders

The classification of bulimia nervosa (BN) into the Behavioral Perspective would work equally as well as AN. While the behavioral perspective is the common classificatory entry point for all eating disorders, it is not the stopping point. The behavioral perspective allows for differentiation of eating disorders from other disorders of behavior that have some similarities but are not intrinsically related to eating disorders, such as body dysmorphic disorder, and obsessive-convulsive disorder, or compulsive exercise.

I hypothesize that one of the reasons AN is at times so unyielding to clinical treatment is that it “hijacks” intrinsic self-protecting genetic fear mechanisms. If the data ever mount to support this hypothesis, then the classification of AN would continue first into the Behavioral Perspective, but the Disease Perspective might figure more prominently than current evidence allows. The Disease Perspective would be applicable if AN could be shown to involve an incorporation and redirection of evolutionarily adaptive fear mechanisms. Such evidence would support layering the Disease Perspective category next, above the foundation of the Behavioral Perspective. This hypothesis illustrates how flexibility is built into classification by the Perspectives.

A Time for Reclassification

It is time to begin reclassifying AN, all eating disorders, and all psychiatric disorders into one of the Four Perspectives of Psychiatry. Territorial competition would be minimized, patient treatment would be enhanced, and research would flourish at a much brisker pace. Psychiatry is a branch of medicine. General medicine, conversely, would also benefit by incorporating other Perspectives besides the Disease Perspective into treatment and prevention in that field. Example: While all lung cancers are in their pathology medical diseases, 85% of lung cancers arise from an acquired human behavior, tobacco smoking. We could improve medical practice by applying the Behavioral Perspective to lung cancer, to heart disease, and to Type II diabetes, with further layering on of the Dimensional and Life-Story Perspectives. The evidence exists that these other Perspectives apply to several of the most common chronic adult diseases. Not so with brain cancer, in which only the Disease Perspective is applicable.

Economic Issues Act as Roadblocks

Are economic issues involved in resistance to applying the Four Perspectives? “You betcha,” as Midwesterners say. But economic factors should not be the primary issue in practicing good psychiatry and good medicine. More important is thinking clearly, appreciating that all of our knowledge has to be understood by the strengths and limitations of our methods of acquiring knowledge, whether those methods are psychodynamic or biological or other. Only then, using however many of the Perspectives apply, will treatments grow logically out of these categories in a hierarchical manner.

Psychiatry is ready scientifically for the implementation of the Perspectives of Psychiatry. Science and the good of patients will be held back if the cost of reclassifying research subjects or reconfiguring insurance schemes become primary rather than secondary considerations in implementing the Perspectives. Ghaemi5 has come to a similar approach as the Perspectives in his lucid book, The Concepts of Psychiatry, using the term “A Pluralistic Approach to the Mind and Mental Illness,” instead of the Four Perspectives. Ghaemi’s book, along with the Perspectives of Psychiatry, and for those willing to put in some amply repaid hard work, General Psychopathology by Jaspers, are highly recommended for clinicians who are interested in thinking clearly and seriously about the origin and treatment of psychiatric disorders in general, and eating disorders, in particular. A cautionary note: these books will change your practice.


  1. Jaspers, K. General Psychopathology (Translated by J Hoenig and MWHamilton. Forward by PR McHugh. Baltimore, MD: Johns Hopkins University Press, 1997.
  2. McHugh PR, Slavney PR. The Perspectives of Psychiatry. Baltimore:Johns Hopkins University Press, 1998.
  3. Robinson RG, Price TR. Post-stroke depressive disorders: a follow-up study of 103 patients. Stroke. 1982 13(5): 635-41.
  4. McHugh PR. Striving for coherence: psychiatry’s efforts over classification. JAMA 2005; 293:2526.
  5. Ghaemi SN. The Concepts of Psychiatry. A Pluralistic Approach to the Mind and Mental Illness. Baltimore: Johns Hopkins University Press, 2003.
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