Biopsychosocial model

The biopsychosocial model (abbreviated "BPS") is a general model or approach positing

that biological, psychological (which entails thoughts, emotions, and behaviors), and social(socio-
economical, socio-environmental, and cultural) factors, all play a significant role in human
functioning in the context of disease or illness. Indeed, health is best understood in terms of a
combination of biological, psychological, and social factors rather than purely in biological
terms.
[1]
This is in contrast to the biomedical model of medicine that suggests every disease process
can be explained in terms of an underlying deviation from normal function such as a virus, gene
or developmental abnormality, or injury.
[2]
The concept is used in fields such
as medicine, nursing, health psychology and sociology, and particularly in more specialist fields such
as psychiatry, health psychology, family therapy, chiropractic, clinical social work, and clinical
psychology. The biopsychosocial paradigm is also a technical term for the popular concept of the
"mindbody connection", which addresses more philosophical arguments between the
biopsychosocial and biomedical models, rather than their empirical exploration and clinical
application.
[3]

The model was theorized by psychiatrist George L. Engel at the University of Rochester, and
putatively discussed in a 1977 article in Science,
[2]
where he posited "the need for a new medical
model." He discusses his model in detail in his paper in the American Journal of Psychiatry [Engel
GL The clinical application of the biopsychosocial model, American Journal of Psychiatry
1980;137:535-544] where he discusses the fate of a hypothetical patient, a 55 year old Yoda who
has a second heart attack six months after his first. Engel elegantly indicates that Yoda's personality
helps to interpret his chest pain, that he is in some degree of denial and that it is only the
intervention of his employer that gives him permission to seek help. Whereas reductionistically his
heart attack can be understood as a clot in a coronary artery, the wider personal perspective helps
to understand that different outcomes may be possible depending on how the person responds to
his condition. Subsequently Yoda in the emergency room develops a cardiac arrest as a result of an
incompetent arterial puncture. Once again systems theory can analyse this event in wider terms than
just a cardiac arrhythmia. It sees the event as due to inadequate training and supervision of junior
staff in an emergency room. Thus while there may be "no single definitive, irreducible model has
been published,"
[4]
Engel's elegant exposition of his model in this paper gives plenty of scope for
this broader understanding of clinical practice.
The novelty, acceptance, and prevalence of the biopsychosocial model varies across cultures.
[1]
Model description and application in medicine[edit]
Some thinkers see the biopsychosocial model in terms of causation. On this understanding the
biological component of the biopsychosocial model seeks to understand how the cause of the illness
stems from the functioning of the individual's body. The psychological component of the
biopsychosocial model looks for potential psychological causes for a health problem such as lack of
self-control, emotional turmoil, and negative thinking. The social part of the biopsychosocial model
investigates how different social factors such as socioeconomic status, culture, poverty, technology,
and religion can influence health.
[1]
However a closer reading of Engel's seminal paper in the
American Journal of Psychiatry (1980) embeds the biopsychosocial model far more closely into
patient care. it is not just about causation but about how any clinical condition (medical, surgical or
psychiatric) can either be seen narrowly as just biological or more widely as a condition with
psychological and social components, which will impinge on a patient's understanding of her
condition and will affect the clinical course of that condition.
Drawing on the systems theory of Weiss and von Bertalanffy, Engel describes the commonsense
observation that nature is a "hierarchically arranged continuum with its more complex, larger units
superordinate on the less complex smaller units." He represents them schematically either as a
vertical stack or as a nest of squares, with the simplest at the centre and the most complex on the
outside. He subdivided the vertical stack into two stacks. The first starts with sub-atomic particles
and ends with the individual person. The second starts with the person and finishes with the
biosphere. The first is an organismic hierarchy, the second a social hierarchy. He then delineates
some principles: 1. Each level in the system is relatively autonomous. Thus a cell can be studies just
as a cell. 2. Each level depends on the level below. Thus a cell is composed of nuclei, mitochondria
and all sorts of other organelles. 3. Each level is a component of a higher system. Thus cells
organise together to become tissues, and organs etc. Thus, "in the continuity of natural systems
every unit is at the very same time both a whole and a part." To these principles Engel developed we
can add further that higher level properties emerge from lower level systems and cannot be
predicted from studying the lower level, We can also add the principle of top-down causation namely
that higher levels can influence lower levels.
The biopsychosocial model of health is based in part on social cognitive theory. The biopsychosocial
model implies that treatment of disease processes, for example type twodiabetes and cancer,
requires that the health care team address biological, psychological andsocial influences upon a
patient's functioning. In a philosophical sense, the biopsychosocial model states that the workings of
the body can affect the mind, and the workings of the mind can affect the body.
[5]
This means both a
direct interaction between mind and body as well as indirect effects through intermediate factors.
The biopsychosocial model presumes that it is important to handle the three together as a growing
body of empirical literature suggests that patient perceptions of health and threat of disease, as well
as barriers in a patient's social or cultural environment, appear to influence the likelihood that a
patient will engage in health-promoting or treatment behaviors, such as medication taking, proper
diet or nutrition, and engaging in physical activity.
[6]

While operating from a BPS framework requires that more information be gathered during a
consultation, a growing trend in US healthcare (and already well-established in Europe such as in
the U.K. & Germany) includes the integration of professional services through integrated disciplinary
teams, to provide better care and address the patient's needs at all three levels.
[7]
As seen, for
example in integrated primary care clinics, such as used in the U.K., Germany, U.S. Veteran's
Administration, U.S. military, Kaiser Permanente, integrated teams may comprise physicians,
nurses, health psychologists, social workers, and other specialties to address all three aspects of the
BPS framework, allowing the physician to focus on predominantly biological mechanisms of the
patient's complaints
[7]
See also
[8]

Psychosocial factors can cause a biological effect by predisposing the patient to risk factors. An
example is that depression by itself may not cause liver problems, but a depressed person may be
more likely to have alcohol problems, and therefore liver damage. Perhaps it is this increased risk-
taking that leads to an increased likelihood of disease. Most diseases in BPS discussion are such
behaviourally-moderated illnesses, with known high risk factors, or so-called "biopsychosocial
illnesses/disorders".
[9][10]
An example of this is type 2 diabetes, which with the growing prevalence of
obesity and physical inactivity, is on course to become a worldwide pandemic. For example,
approximately 20 million Americans are estimated to have diabetes, with 90% to 95% considered
type 2.
[11]

It is important to note that the biopsychosocial model does not provide a straightforward, testable
model to explain the interactions or causal influences (that is, amount of variance accounted for) by
each of the components (biological, psychological, or social). Rather, the model has been a general
framework to guide theoretical and empirical exploration, which has amassed a great deal of
research since Engel's 1977 article. One of the areas that has been greatly influenced is the
formulation and testing of social-cognitive models of health behavior over the past 30 years.
[12]
While
no single model has taken precedence, a large body of empirical literature has identified social-
cognitive (the psycho-social aspect of Engel's model) variables that appear to influence engagement
in healthy behaviors and adhere to prescribed medical regimens, such as self-efficacy, in chronic
diseases such as type 2 diabetes, cardiovascular disease, etc.
[13][14]
These models include
the Health Belief Model, Theory of Reasoned Action and Theory of Planned
Behavior, Transtheoretical Model, the Relapse Prevention Model, Gollwitzer's implementation-
intentions, the PrecautionAdoption Model, theHealth Action Process Approach, etc.
[12][15][16][17][18][19]

Criticism[edit]
Some critics point out this question of distinction and a question of determination of the roles of
illness and disease runs against the growing concept of the patientmedical tradesperson
partnership or patient empowerment, as "biopsychosocial" becomes one more
disingenuouseuphemism for psychosomatic illness.
[20]
This may be exploited by medical insurance
companies or government welfare departments eager to limit or deny access to medical and social
care.
[21]

Some psychiatrists see the BPS model as flawed, in either formulation or application. Epstein and
colleagues describe six conflicting interpretations of what the model might be, and proposes that
"...habits of mind may be the missing link between a biopsychosocial intent and clinical
reality."
[22]
Psychiatrist Hamid Tavakoli argues that the BPS model should be avoided because it
unintentionally promotes an artificial distinction between biology and psychology, and merely causes
confusion in psychiatric assessments and training programs, and that ultimately it has not helped the
cause of trying to destigmatize mental health.
[23]

Sociologist David Pilgrim suggests that a necessary pragmatism and a form of "mutual tolerance"
(Goldie, 1977) has forced a co-existence of perspectives, rather than a genuine "theoretical
integration as a shared BPS orthodoxy."
[24]
Pilgrim goes on to state that despite "scientific and
ethical virtues," the BPS model "...has not been properly realised. It seems to have been pushed into
the shadows by a return to medicine and the re-ascendancy of a biomedical model."
[25]

However, a vocal philosophical critic of the BPS model, psychiatrist Niall McLaren,
[26]
writes:
"Since the collapse of the 19th century models (psychoanalysis, biologism and behaviourism),
psychiatrists have been in search of a model that integrates the psyche and the soma. So keen has
been their search that they embraced the so-called 'biopsychosocial model' without ever bothering to
check its details. If, at any time over the last three decades, they had done so, they would have
found it had none. This would have forced them into the embarrassing position of having to
acknowledge that modern psychiatry is operating in a theoretical vacuum."
[27]

The rationale for this theoretical vacuum is outlined in his 1998 paper
[28]
and more recently in his
books, most notably Humanizing Psychiatrists.
[29]
Simply put, the purpose of a scientific model is to
see if a scientific theory works and to actualize its logical consequences. In this sense, models are
real and their material consequences can be measured, whereas theories are ideas and can no
more be measured than daydreams. Model-building separates theories with a future from those that
always remain dreams. An example of a true scientific model is longer necked giraffes reach more
food, survive at higher rates, and pass on this longer neck trait to their progeny. This is a model
(natural selection) of the theory of evolution. Therefore, from an epistemological stance there can be
no model of mental disorder without first establishing a theory of the mind. Dr. McLaren does not say
that the biopsychosocial model is devoid of merit, just that it does not fit the definition of a scientific
model (or theory) and does not "reveal anything that would not be known (implicitly, if not explicitly)
to any practitioner of reasonable sensitivity." He states that the biopsychosocial model should be
seen in a historical context as bucking against the trend of biological reductionism, which was (and
still is) overtaking psychiatry. Engel "has done a very great service to orthodox psychiatry in that he
legitimised the concept of talking to people as people." In short, even though it is correct to say that
sociology, psychology, and biology are factors in mental illness, simply stating this obvious fact does
not make it a model in the scientific sense of the word.
[26][28][29][30]

The Tufts psychiatry professor and author S. Nassir Ghaemi considers Engel's model to be anti-
humanistic and advocates the use of less eclectic, less generic, and less vague alternatives, such
as William Oslers medical humanism or Karl Jaspers method-based psychiatry.
[31][32]

See also[edit]
Activities of daily living
Bodymind
Brain Blogger
Diathesisstress model
Health psychology
Psychoneuroimmunology
Psychosomatic medicine
References[edit]
1. ^ Jump up to:
a

b

c
Santrock, J. W. (2007). A Topical Approach to Human Life-span
Development (3rd ed.). St. Louis, MO: McGraw-Hill.
2. ^ Jump up to:
a

b
Engel, George L. (1977). "The need for a new medical model: A challenge for
biomedicine". Science 196:129136. ISSN 0036-8075 (print) / ISSN 1095-9203
(web) doi:10.1126/science.847460
3. Jump up^ Sarno, John E. MD "The Mindbody Prescription: Healing the Body, Healing the Pain."
1998 [1].
4. Jump up^ McLaren N (2002). "The myth of the biopsychosocial model". Australian and New
Zealand Journal of Psychiatry 36 (5): 701703. doi:10.1046/j.1440-1614.2002.01076.x.
5. Jump up^ Halligan, P.W., & Aylward, M. (Eds.) (2006). "The Power of Belief: Psychosocial
influence on illness, disability and medicine". Oxford University Press, UK
6. Jump up^ DiMatteo M.R., Haskard K.B., Williams S. L. (2007). "Health beliefs, disease severity,
and patient adherence: A meta-analysis". Medical Care 45: 521
528.doi:10.1097/mlr.0b013e318032937e.
7. ^ Jump up to:
a

b
Gatchel, R. J. & Oordt, M. S. (2003) Clinical health psychology and primary
care: Practical advice and clinical guidance for successful collaboration. American Psychological
Association: Washington, D.C.
8. Jump up^ Society of Behavioral Medicine
9. Jump up^ Bruns D, Disorbio JM, "Chronic Pain and Biopsychosocial Disorders". Practical Pain
Management, March 2006, volume 6, issue 2 [2]
10. Jump up^ An Overview Of Biopsychosocial Disorders: Conceptualization, Assessment And
Treatment
11. Jump up^ Wild S., Roglic G., Green A., Sicree R., King H. (2004). "Global prevalence of
diabetes: Estimates for the year 2000 and projections for 2030". Diabetes Care 27: 1047
1053.doi:10.2337/diacare.27.5.1047.
12. ^ Jump up to:
a

b
Armitage C. J., Conner M. (2000). "Social cognition models and health
behaviour: A structured review".Psychology and Health 15: 173
189.doi:10.1080/08870440008400299.
13. Jump up^ Allen N. A. (2004). "Social cognitive theory in diabetes exercise research: An
integrative literature review". The Diabetes Educator 30: 805
819.doi:10.1177/014572170403000516.
14. Jump up^ Carlson J. J., Norman G. J., Feltz D. L., Franklin B. A., Johnson J. A., Locke S. K.
(2001). "Self-efficacy, psychosocial factors, and exercise behavior in traditional verses modified
cardiac rehabilitation".Journal of Cardiopulmonary Rehabilitation21: 363
373. doi:10.1097/00008483-200111000-00004.
15. Jump up^ Schwarzer, R. (1992). Self-efficacy in the adoption and maintenance of health
behaviors: theoretical approaches and a new model. In R. Schwarzer (Ed.), Self-efficacy:
Thought control of action. London, England: Hemisphere Publishing Corporation.
16. Jump up^ Garcia K., Mann T. (2003). "From 'I wish' to 'I will': Social-cognitive predictors of
behavioral intentions". Journal of Health Psychology 8: 347
360.doi:10.1177/13591053030083005.
17. Jump up^ Carels R. A., Douglass O. M., Cacciapaglia H. M., O'Brien W. H. (2004). "An
ecological momentary assessment of relapse crises in dieting". Journal of Consulting and Clinical
Psychology 72: 341348. doi:10.1037/0022-006x.72.2.341.
18. Jump up^ Carels R. A., Darby L. A. Rydin, Douglass O. M., Cacciapaglia H. M., O'Brien W. H.
(2005). "The relationship between self-monitoring, outcome expectancies, difficulties with eating
and exercise, and physical activity and weight loss treatment outcomes". Annals of Behavioral
Medicine 30 (3): 182190.doi:10.1207/s15324796abm3003_2.
19. Jump up^ Blanchard C. M., Courneya K. S., Rodgers W. M., Frasier S. N., Murray T., Daub B.,
Black B. (2003). "Is the theory of planned behavior a useful framework for understanding
exercise adherence during phase II cardiac rehabilitation?". Journal of Cardiopulmonary
Rehabilitation 23: 2939.doi:10.1097/00008483-200301000-00007.
20. Jump up^ McLaren N. "The Biopsychosocial Model and Scientific Fraud". {Paper presented to
RANZCP Congress, Christchurch NZ May 2004. Revised version: "When does Self-Deception
become Culpable?" Chap.8 in McLaren N. "Humanizing Madness: Psychiatry and the cognitive
neurosciences" ISBN 978-1-932690-39-2
21. Jump up^ Rutherford J. New Labour and the end of welfare Compass Online April 25, 2007
22. Jump up^ Epstein RM, Borrell-Carrio F, "The biopsychosocial model: exploring six impossible
things". Families, Systems & Health 22 Dec 2005
23. Jump up^ Hamid R. Tavakoli, MD (February 2009)."A Closer Evaluation of Current Methods in
Psychiatric Assessments: A Challenge for the Biopsychosocial Model". Psychiatry
(Edgmont) 6 (2): 2530. PMC 2719450.PMID 19724745.
24. Jump up^ Pilgrim D. "The biopsychosocial model in Anglo-American psychiatry: Past, present
and future" Journal of Mental Health, Volume 11, Issue 6 December 2002 , pages 585 -
594doi:10.1080/09638230020023930
25. Jump up^ The biopsychosocial model in Anglo-American psychiatry: Past, present and
future" Journal of Mental Health, Volume 11, Issue 6, pages 585 -
594doi:10.1080/09638230020023930
26. ^ Jump up to:
a

b
McLaren, Niall (2007). Humanizing Madness. Ann Arbor, MI: Loving Healing
Press. ISBN 1-932690-39-5.
[page needed]

27. Jump up^ McLaren N (2006). "Interactive dualism as a partial solution to the mind-brain problem
for psychiatry". Med Hypotheses66 (6): 116573.doi:10.1016/j.mehy.2005.12.023.
28. ^ Jump up to:
a

b
McLaren N (February 1998). "A critical review of the biopsychosocial
model". The Australian and New Zealand Journal of Psychiatry 32 (1): 8692; discussion 93
6. doi:10.1046/j.1440-1614.1998.00343.x. PMID 9565189.
29. ^ Jump up to:
a

b
McLaren, Niall (2010). Humanizing Psychiatrists. Ann Arbor, MI: Loving Healing
Press. pp. 135154. ISBN 978-1-61599-060-3.
30. Jump up^ McLaren, Niall (2009). Humanizing Psychiatry. Ann Arbor, MI: Loving Healing
Press. ISBN 1-61599-011-9.
[page needed]

31. Jump up^ Ghaemi S.N. (2009) The rise and fall of the biopsychosocial model The British
Journal of Psychiatry 195: 3-4doi:10.1192/bjp.bp.109.063859
32. Jump up^ Ghaemi S.N. (2011) The Biopsychosocial Model in Psychiatry: A Critique Existenz
6(1), Spring 2011