Lecture on Biopsychosocial Model of Health and Disease I. Introduction: A.

Psychiatry is sometimes accused of being an unscientific and impressionistic field, which is more concerned with unprovable theories about the nature of humankind than the hard data of science. 1. Example: psychiatrists as quacks. B. This assumption is based on the biomedical model of disease 1. Definition: The concept that diseases are caused by one or a chain of biochemical or physiological changes that can ultimately be identified and measured 2. Implications: a) All diseases have strictly biological causes. So, no biological cause, not a disease b) Since no definite biological causes of psychiatric diseases have been identified, they are not really diseases and therefore need not be treated by a physician. (1) Its all in the head

3. Illustration: a) MD of diabetic patient is more interested in the patients blood sugar and insulin dosage but not his emotional state or living conditions. As a result, he may not be able to discover that the uncontrolled blood sugar was due to the patients non-compliance with medications and diet, which was triggered by a serious problem such as the loss of a job. b) The doctor treating a schizophrenic patient solely with medicines and ascribing an exacerbation to an underdosage of medicines rather than the stress caused by separation from home when the patient went off to college. 4. We do not ascribe to this model. II. Body A. The Biopsychosocial Model of Disease 1. The concept that states of health and illness are produced by the interaction between biological, psychological, and social factors. 2. The basic underpinning of the biopsychosocial model is the systems theory as described by von Bertalanfly (1968), Meninger (1963), Engel (1980), Marmor (1983), and others. This systems approach has been applied to three levels of structure: nature, health and disease in general, and to mental health and illness. B. The BPS Model in Nature 1. Engel pointed out that nature is organized as a hierarchical continuum from less complex, smaller units such as cells through intermediate units such as individuals and up to more complex, larger units such as societies. a) Each level in this hierarchy has its own identity, possesses distinct qualities, relationships, and criteria for explanation. b) At the same time, each level is also a component of a higher level 2. Engel wrote that: a) Every unit is at the very same time both a whole and a part b) An individual represents at the same time the highest level of organismic hierarchy and the lowest level of the social hierarchy c) Every system is influenced by the configuration of the system of which it is a part, that is, by its environment.

C. The BPS Model in Health and Disease 1. From Engels constructs, Molina (1983-84) further elaborated on the models application to health and disease. 2. He stated the following four premises: a) Illness is a dynamic process rather than a steady state. The process of illness changes continuously as biological, psychological and social factors interact. b) Illness is caused by the interaction of several factors. c) A person is best understood in terms of indivisibility and wholeness rather than as separate entities of body and mind. A person is a unified living system composed of subsystems that exchange inputs and outputs of information among the internal subsystems and other external systems. d) The interaction of subsystems creates the vulnerability or predisposition of the whole system, the living organism, to a disease process. 3. Illustrations: a) Psychological distress precedes the onset of a variety of physical illnesses (1) Leukaemia, lymphoma, uterine CA, lung CA are preceded by history of loss, hopelessness and depression (2) Depressed patients had lower rated of heart surgery survival (3) Mortality from heart disease increases within six months after the loss of as spouse b) Certain personality styles may predispose a patient to characteristic responses to stress or may be associated with a lifestyle which leads to illness (1) Type A Personality: anxious, pressured, impatient individual who is intensely ambitious and competitive, who is unable to relax, who has a chronic sense of urgency, and who is quick to feel anger and hostility because of a low tolerance for frustration is closely associated with coronary artery disease

c) Psychiatric illness may represent a psychological reaction to the significance of a physical illness e.g. depression D. The BPS Model in Mental Health and Illness 1. The biopsychosocial model was further applied to states of mental health and disease by Marmor (1983). a) He described the development of human personality and behaviour as the sum of the interaction of biological subsystems with environmental and relationship components. b) He forwarded that personality develops out of interactions of the human biological substrate with influences from the environment, family, school, community and so on. c) Thus, psychopathology originates not only from the psychological aspects of a persons behaviour but also from a persons total system of relationships. d) Clinical implications: (1) A systems approach to the understanding of human personality and behaviour clarifies the dynamics of change and change management. (2) Change at multiple levels within the system might have either a positive or a negative effect on the individual. (3) Sources of stress do not always come directly from within or even close to an individual. (4) Thus, the most effective interventions in any clinical situation might not necessarily entail direct involvement of the identified patient. (5) Similarly, a full appreciation of the impact of stressful situation on an individual requires an understanding of the total context within which the stressor occurs.

2. Molina (1983 84) further elaborated that all mental illnesses are caused by the interaction of multiple factors, and an understanding of disease must take into consideration the state of vulnerability of the biological, psychological and social systems prior to the development of the disease process itself. 3. Abrams (1981, 1983) AND Lazare (1989), sought to identify which of the many factors is most important in a given clinical situation, at what level treatment should begin, what treatments should be combined and when treatments should be changed. Abrams (1983) recommends that the causes of mental illness be viewed in a hierarchy from biological to psychosocial to existential-moral and that treatment should be conducted in a similar serial fashion whenever possible. 4. Lazare (1989) advocates a multidimensional approach in which patients are viewed simultaneously and separately through alternative horizontal and vertical frames of reference. The vertical perspective involves the integration of information from various levels in an individuals system in a manner similar to Engels (1980) bioipsychosocial model. The horizontal perspective entails the interaction of explanatory models within a given level on the hierarchy, such as the various schools of thought currently employed to explain psychological phenomena and their treatment. 5. Sabelli and Carlson-Sabelli (1989) added the process theory to the biopsychosocial perspective to integrate biological, social and psychological factors in the management of mental illness. a) Process theory implies that processes are ordered in a hierarchy according to their complexity biological, psychological and social. b) Higher, more complex levels control the function of and thus have supremacy over lower, simpler levels but simpler processes have priority over more complex, higher level. c) For example, biological aspects of mental processes have priority, whereas social and psychological aspects have supremacy. d) Interventions should be designed in a manner giving priority over biological needs while at the same time recognizing the supremacy of social and psychological factors. e) Although a persons biological needs should be addressed first, once a measure of stability has occurred, social and psychological needs will quickly become more important treatment issues.

f) The process model is also inherently flexible, however, and recognizes that interventions often must focus on only one particular level at a time. g) There is no fixed formula that is applicable to every clinical situation. 6. Factors in mental health and illness a) Biological (1) Genetic (2) Neurochemical, neuroendocrine, and psychopharmacological (3) Biological rhythms b) Psychological (1) Conflicts (2) Defense mechanisms (3) Object relations (4) Self-esteem c) Social 7. Patterns of reaction to stress a) Fight-flight (1) The psychophysiologic mobilization which is a reaction to stress, real or imaginary (2) The natural reaction to a dangerous situation is to feel frightened or angry or both (3) The body prepares to either run away (flee) or to attack (flight) through a number of physiological change. (a) Activation of the sympathetic nervous system (b) Suppression of the parasympathetic nervous system (c) Pituitary-adrenal-cortical activation leading to an increase in the secretion of catecholamines (epinephrine and norepinephrine) from the adrenal medulla (d) Mobilization of the reticular activating system (4) The end result:

(a) Increase energy mobilization (through an increase in blood glucose and free fatty acids) (b) Increased heart rate and cardiac output (through an increase in circulating catecholamines (c) Increase in the capacity for physical activity (through an increase in blood flow to the skeletal musculature) (5) In the healthy individual, the flight-fight activation has few consequences. (6) In the vulnerable person or who is exposed to chronic or unrelieved activation, there may be adverse consequences (a) Hypertension (b) Coronary artery disease b) Conservation-withdrawal (1) Definition: A psychophysiologic state characterized by decreased interaction with the environment, decreased energy mobilization, and decreased activation of bodily systems. (2) Through: (a) Activation of the parasympathetic nervous system (b) Suppression of the sympathetic nervous system (3) End-result: (a) Decreased heart rate, blood pressure and body temperature (b) Decreased muscle tone and general lack of motor activity (4) Examples: (a) Institutionalised babies (b) Monkeys separated from their mothers III. Summary A. The BPS is the prevailing orientation in psychiatry. B. All forthcoming lectures shall apply the biopsychosocial model to its analytic framework.