The Biopsychosocial Model of Health & Illness
Health is traditionally equated to the absence of disease. A lack of a fundamental pathology was thought to define one’s health as good, whereas biologically driven pathogens and conditions would render an individual with poor health and the label “diseased”. However, such a narrow scope on health limited our understanding of wellbeing, thwarted our treatments efforts, and perhaps more importantly, suppressed prevention measures.
Many institutions and medical doctors have managed to incorporate a holistic view of health in sound medical application, primarily based on the Biopsychosocial (BPS) Model of Health and Illness. The concept of wellness is particularly stressed, where the state of being in good health based on the biopsychosocial model is accompanied by good quality of life and strong relationships.
In 1977, American Psychiatrist George Engel introduced the major theory in medicine, the BPS Model. The model accounted for biological, psychological, and sociological interconnected spectrums, each as systems of the body. In fact, the model accompanied a dramatic shift in focus from disease to health, recognizing that psychosocial factors (e.g. beliefs, relationships, stress) greatly impact recovery the progression of and recuperation from illness and disease.
Engel eloquently states:
To provide a basis for understanding the determinants of disease and arriving at a rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which he lives and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system. This requires a biopsychosocial model.
Today, individuals are living with diseases that would have taken their lives in the past. We see health and wellness is a broader forum. Medical practitioners are more frequently adopting the biopsychosocial form in their clinician practice. The following outline compares the presentation, diagnosis, and treatment used by physicians who follow the biomedical and biopsychosocial model:
Biomedical Model
Reason for visit: Patient complains of chest pain.
Presentation: The focus is on physical causes of disease. The physician will ask few questions on recent diet, pain history, and familial incidence, however, empirical signs and symptoms of myocardial infarction are considered paramount.
Diagnosis: The clinician will order objective lab tests and monitor vital signs (i.e. temperature, pulse, and blood pressure) that would form the sole basis of any finding.
Therapy: The doctor will prescribe a medicinal plan for the patient based on biological etiology and pathogenesis.
Biopsychosocial Model
Reason for visit: Patient complains of chest pain.
Presentation: The aim to ascertain psychosocial and physical processes that may cause the chief complain, chest pain. The physician may ask for a history of recent life stressors and behaviors.
Diagnosis: Based on a combination of psychological factors and standard lab tests, the clinician will form a diagnosis.
Therapy: The physician discusses the available interventions with special attention to behaviors and lifestyles that could influence her pain and adherence to the treatment plan. The patient is involved in formulating and implementing the plan, and maintains a supportive relationship with the clinician.
Shaheen E Lakhan, MD, PhD, MEd, MS
Shaheen Lakhan, MD, PhD, MEd, MS, is executive director of the Global Neuroscience Initiative Foundation (GNIF). He is a published scholar in protein biomarkers, bioethics, biotechnology, education technology, and neurology. He serves on the editorial board of several scholarly publications and has been honored by the U.S. President and Congress.19 Responses
Encephalon #2
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Hmmm, nice counterbalance to the D.O. article on your site. It would be nice to know if this Engle was ever exposed to osteopathic training?
While the Biopsychosocial Model demands further discourse and exploration and debate needs to continue as to which Medical model is most beneficial to which type of patient, it is important to understand some of the changes that permitted the growth from BioMedical to BioPsychoSocial.
The first factor, and one of the most important, is the Science and medical field’s acceptance of psychology. While studies have for years touted that the mind and body are interconnected and hence, one influences the other; it was not until greater sophistication in medical tools such as imaging or scans that won skeptics over. Now, most doctors and clinicians may be inclined to admit several things. One, the brain controls most of our bodily functions. Two, intangible variables such as mood and stress affect the body and hence, the ability to fight off disease.
The second factor is inter-related to the first. In the last twenty years or so, social scientists, psychologists and other researchers have turned their attention to not just illness but wellness as well. There was a hallmark study, completed in the mid 1990′s .It was entitled “The Macarthur Study on Successful Aging” (Rowe, JW. MD., Kahn, RL., MD). What made this research so remarkable was that it was the first time researchers thought to ask about what gave people pleasure. We know now that social interaction, friendships and even religiosity contribute to personal happiness and satisfaction which, in turn, helps to maintain physical well-being.
Third, doctors are being proactive about the eternal problem of the patient’s medicinal non-compliance. Literature in many peer journals have for years explored and found the reasons why people do not take their medication as prescribed. While in the past noncompliance may not have bothered the doctor as much as vexed him or her, times have changed. The population is aging which means that some medications are integral to daily functioning and also, health insurance is tightening the belt.
Research, such as that found in the Journal of Antimicrobial Chemotherapy (2002, (49): Kardas, P), has shown that while cost is a reason, it is not the only one. While the above study is limited in scope, an important point is that if non-compliance occurs in short term, respiratory illness, then imagine the rate for long term physical and/or psychiatric use.
Some of these factors plus others may have coalesced into creating an atmosphere that allowed the Biopsychosocial Model to be born. What each component shares is greater understanding. There is greater understanding of how the brain functions, both on a physical and emotional basis, about the effect of external influences on the body and of course, a better understanding of patient behavior.
I bring this up because they are as important as the Model itself and therefore, deserve some attention.
I hope you will forgive my rambles. At times, I get curious not just about the new destination but also about the path that was tread.
An overly garrulous,
Always Learning
The models do not have to be mutually exclusive. Most health organizations espouse a multidisciplinary approach. Doctors can have this approach by allowing another healthcare provider to do the patient interview (for instance, a nurse, CRNP, PA, etc) and then the doctor coming in later and working collaboratively with the other HCP to reach a treatment plan (in conjunction with the patient, of course). If doctors really wanted to, they could have such services available in their offices.
“In 1977, American Psychiatrist George Engel introduced the major theory in medicine, the BPS Model. The model accounted for biological, psychological, and sociological interconnected spectrums, each as systems of the body.”
A common misunderstanding. Engels produced nothing that could be remotely described as a standard scientific model. What he did do was argue cogently for the necessity and importance of a biopsychosocial model. May seem like nitpicking, but it is important to get these basic facts right.
As to the model itself. I, like most, do not have any in principle problem with such a model, and believe it is an advance in medical thinking.
But the way it is often used is troubling. Far too much is simply ascribed to primary psychosocial causation (in particular somatisation, in all its guises) simply because the clinician can’t find any immediate primary physical cause. Yet even a cursory glance at the history of such diagnostic reasonings reveals a disturbingly persistent pattern of serious error. Just about every major disease has been ‘somatised’ at some point by medical science (well, the psychiatric branch of it), and yet they turned out to be primarily (or even entirely) physical disorders. The latest and perhaps most infamous major example being stomach ulcers, which were supposedly (indeed, undisputedly) the archetypal conversion disorder. Except they were not.
Lack of clear primary physical causation (even when coupled with the presence serious emotional distress) is not solid evidence of somatisation, it could just as easily be evidence of the current limitation of biophysical medical science or the particular clinician, or both.
/rant
Agreed, there may not be a “standard scientific model for Dr Engel’s BPS theory. Mind-body-social-psychological axis is on-going in real people. We create models to try to explain real, natrual phenomena, the patient lives or dies, gets bettor or worse. Nothing happens in standard pressure or temperature.
I have held the hand of a patient having a myocardial infarction and watched her ST segments normalize without mediciation. Did her coronaries dilate from empathy? Was it just a fluke? Some other factor? My energy field? No way of knowing. It just happened in real time, no model.
The ulcer is for real, but so much mind-body-behavior is involved in worsening/healing. We have gotten much better at fixing than preventing (fixing is more profitable).
JP MD
Well;the article is good but it would have been better if Engel elaborated more on the bio-psychosocial model.