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.