Prof Craig JacksonHead of Psychology
Birmingham City University
The Biopsychosocial
Model
Has it turned medicine into holistic
feel-goodery?
George Engel George Engel
Spring 1977Spring 1977
Groundbreaking Groundbreaking
The need for a new medical model: a challenge for The need for a new medical model: a challenge for biomedicinebiomedicine
Challenged reductionist linear approach to psychiatric Challenged reductionist linear approach to psychiatric diseasedisease
George Engel George Engel
"The dominant model of disease today is "The dominant model of disease today is biomedical, with molecular science it's basic biomedical, with molecular science it's basic scientific discipline. It assumes disease to be scientific discipline. It assumes disease to be fully accounted for by deviations from the norm fully accounted for by deviations from the norm of measurable biological (somatic) variables. It of measurable biological (somatic) variables. It leaves no room within its framework for the leaves no room within its framework for the social, psychological, and behavioural social, psychological, and behavioural dimensions of illness"dimensions of illness"
Against patients as "cases"Against patients as "cases"
Medical Model Medical Model
PathogenPathogen
ModifiersModifiersLifestyleLifestyleIndividual susceptibilityIndividual susceptibility
AcceptanceAcceptance
Commonly accepted in managing ill healthCommonly accepted in managing ill health
Integrates...Integrates...psychological factors & sociological conditions psychological factors & sociological conditions
Hippocrates Hippocrates
2 Millennia onwards2 Millennia onwards
Man is more than his disease Man is more than his disease
RamazziniRamazzini
Hermann Nothnagel Hermann Nothnagel
PhysicianPhysician
18821882
Medicine is treating sick people NOT diseaseMedicine is treating sick people NOT disease
Early Adopters of BPS Early Adopters of BPS
William OslerWilliam Osler
Russell Reynolds 1869Russell Reynolds 1869
Francis Peabody 1927Francis Peabody 1927
George Robinson 1939George Robinson 1939
Franz AlexanderFranz Alexander
Roy Grinker 1954 challenged psychoanalytic Roy Grinker 1954 challenged psychoanalytic orthodoxy orthodoxy
William Osler William Osler
"The good physician treats the disease, the great "The good physician treats the disease, the great physician treats the person"physician treats the person"
Rene Descartes Rene Descartes
Cartesian DualismCartesian Dualism
Allows for placeboAllows for placebo
Therapeutic symbolTherapeutic symbol
Response determined subjectively by Dr and Response determined subjectively by Dr and PatientPatient
von Bertanlaffy's General Systems Theoryvon Bertanlaffy's General Systems Theory
General Systems Theory General Systems Theory
von Bertanlaffyvon Bertanlaffy
All levels of organisation in All levels of organisation in entities are hierarchically linkedentities are hierarchically linked
Changes in one level influence Changes in one level influence change at other levelschange at other levels
Micro level processes are nested Micro level processes are nested within macro level processwithin macro level process
Changes on micro level have Changes on micro level have macro level effects and vice versamacro level effects and vice versa
Complexity Theory Complexity Theory
BPS strong in analysing BPS strong in analysing complexitycomplexity
SmokingSmokingEducationEducationWorkingWorkingGamblingGamblingRiskRiskCommunicationCommunication
Biopsychosocial Application Biopsychosocial Application
45 yr old female checkout worker45 yr old female checkout workerOff sick with GADOff sick with GAD
Emphasis on Wellbeing Emphasis on Wellbeing
Biomed model focused on "cures" an repairing Biomed model focused on "cures" an repairing altered biologyaltered biology
BPS looks at maintaining wellbeing possibly in BPS looks at maintaining wellbeing possibly in absence of the aboveabsence of the above
Complete PHYSICAL, MENTAL & SOCIAL Complete PHYSICAL, MENTAL & SOCIAL wellbeingwellbeing
Health is not merely absence of diseaseHealth is not merely absence of disease
Empowers Physicians Empowers Physicians
Empowers doctor to explore other causes of ill Empowers doctor to explore other causes of ill health other than biomedicalhealth other than biomedical
Provide informationProvide information
Discuss treatment optionsDiscuss treatment options
Allows for the Artistry of Medicine Allows for the Artistry of Medicine
Failing of BPS Failing of BPS
Strength of BPS also it's weaknessStrength of BPS also it's weakness
Incorporating all other possible causes of Incorporating all other possible causes of disease it lends itself to more complex and disease it lends itself to more complex and circumnavigatory models of complexitycircumnavigatory models of complexity
No universal theory of everythingNo universal theory of everything
We would have found it by nowWe would have found it by now
Linear Simplicity Linear Simplicity
Is "more possible Is "more possible explanations" better?explanations" better?
More perspectives gets More perspectives gets closer to a "highly closer to a "highly complex reality"?complex reality"?
Linear simplicity of cause Linear simplicity of cause and effect is good tooand effect is good too
Helicobacter Pylori Helicobacter Pylori
Discovered 1982Discovered 1982
Implicated in peptic ulcersImplicated in peptic ulcers
Once seen as classic psychosomatic illnessOnce seen as classic psychosomatic illness
However....However....
Mesothelioma - not "just" biomed exposureMesothelioma - not "just" biomed exposure
Blame and Stigma Blame and Stigma
Implying some illness has psychological originsImplying some illness has psychological origins
Holds patients responsible for their diseasesHolds patients responsible for their diseases
Blaming leads to Labelling leads to StigmaBlaming leads to Labelling leads to Stigma
Revival of psychosomatic concept of illness or Revival of psychosomatic concept of illness or "hysterias""hysterias"
All in the MindAll in the Mind
Blaming the patient not the disease! Blaming the patient not the disease!
Economy in terrible stateEconomy in terrible state
Unemployed with 3 childrenUnemployed with 3 children
Female in a prejudiced communityFemale in a prejudiced community
Becomes depressedBecomes depressed
Eventually suicidalEventually suicidal
BPS still places locus of problem with patientBPS still places locus of problem with patient
"Physician-Endorsed Malingering" "Physician-Endorsed Malingering"
Stress epidemic 1995 - Present dayStress epidemic 1995 - Present day
Biopsychosocial Model Biopsychosocial Model
HazardHazard IllnessIllness (wellbeing) (wellbeing)
Psychoscial FactorsPsychoscial Factors AttitudesAttitudesBehaviourBehaviourQoLQoL
Rise of the patient Rise of the patient as a “psychological as a “psychological entity”entity”
Psychosocial Triparte of Ill-Health Psychosocial Triparte of Ill-Health
Individual vulnerabilityIndividual vulnerability
Personality typePersonality type
ExperienceExperience
Learned behavioursLearned behaviours
Biopsychosocial Effects of StressBiopsychosocial Effects of Stress
Weakness of Eclecticism Weakness of Eclecticism
Hypertensive PatientHypertensive Patient
Excessive saltExcessive salt
Stressful jobStressful job
Poor social supportPoor social support
Over-responsible personality Over-responsible personality
Reduce dietary saltReduce dietary salt
Stress reduction courseStress reduction course
MedicationMedication
Psychotherapy Psychotherapy
Irritable Bowel Syndrome Irritable Bowel Syndrome
Common digestive disorderCommon digestive disorder
Functional syndromeFunctional syndrome
Traumatic life events, Personality Traumatic life events, Personality disorders, Stress, Anxiety, Depression disorders, Stress, Anxiety, Depression SomatizationSomatization
Not a psychological disorderNot a psychological disorder
Night-workersNight-workers
LonersLoners
Psychology important :Psychology important :how symptoms are perceived and reacted tohow symptoms are perceived and reacted to
Irritable Bowel Syndrome Irritable Bowel Syndrome
Chronic Fatigue Syndrome Chronic Fatigue Syndrome
Non-specific subjective symptom Non-specific subjective symptom
Overlap with psychiatric diagnoses (66%)Overlap with psychiatric diagnoses (66%)
Chronic long-term inability and tirednessChronic long-term inability and tiredness
Both Physical and Psychological fatigueBoth Physical and Psychological fatigue
Most prevalent in white, middle class 30s femalesMost prevalent in white, middle class 30s females
Fatigue dominates activities and lifeFatigue dominates activities and life
Chronic Fatigue Syndrome Chronic Fatigue Syndrome
Chronic Fatigue Syndrome Chronic Fatigue Syndrome
Iatrogenic Harm Iatrogenic Harm
Professional Meddling Professional Meddling
The Cope not Cure Industry The Cope not Cure Industry
Spurious Practices Spurious Practices
Legacy of the Biopsychosocial Model Legacy of the Biopsychosocial Model
Displaced traditional medicine from dominant role Displaced traditional medicine from dominant role
Made "consultations" a thing of the pastMade "consultations" a thing of the past
Empowered patients - not always a good thingEmpowered patients - not always a good thing
Made space for quackery, frauds and crystalsMade space for quackery, frauds and crystals
Has it been best for the patient?Has it been best for the patient?
Will trad-med make a comeback?Will trad-med make a comeback?
References References
Engel, GL. (1977) The need for a new medical model: a challenge for Engel, GL. (1977) The need for a new medical model: a challenge for biomedicine. Science. biomedicine. Science. 196(4286):196(4286):129-36. 129-36.
Jackson CA. (2005). Review of "Biopsychosocial Medicine: An Jackson CA. (2005). Review of "Biopsychosocial Medicine: An Integrated Approach to Understanding Illness" by Peter White. Occup Integrated Approach to Understanding Illness" by Peter White. Occup Medicine; Medicine; 55(7):55(7): 582. 582.
Jackson CA. (2007). Psychosocial Hazards. In Smedley, J et al. (eds) Oxford Handbook of Occupational Health. Oxford. Oxford University Press; 167-179.
Karasek R. (1979). Jobs demands, job decision latitude and mental strain : implication for job redesign, Administrative Science Quarterly, 285-308.
References References
Kivimäki M, Leino-Arjas P, Luukkonen R, Riihimäki H, Vahtera J, and Kirjonen J. (2002). Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. BMJ; 325: 857
Lees, R., and Laundry, B.R. (1989). Comparison of reported workplace morbidity in 8-hour and 12-hour shifts in one plant. Journal of the Society of Occupational Medicine 39.
Premchand P, Paraskeva K., Jackson CA, Isaacs P. Fibre, Bran and Premchand P, Paraskeva K., Jackson CA, Isaacs P. Fibre, Bran and Irritable Bowel Syndrome: role in primary care setting. British Society Irritable Bowel Syndrome: role in primary care setting. British Society of Gastroenterology Annual Meeting, March 21-23 2000, of Gastroenterology Annual Meeting, March 21-23 2000, Birmingham, UKBirmingham, UK
White, P. (2005) Biopsychosocial Medicine: An Integrated Approach White, P. (2005) Biopsychosocial Medicine: An Integrated Approach to Understanding Illness. Oxford University Press, Oxford.to Understanding Illness. Oxford University Press, Oxford.