By Venkat Srinivasan, MD

The Need for a Biopsychosocial Model of Health

By Venkat Srinivasan, MD

Introduction

The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1 This definition, which was adopted in 1948, created a seat for social and psychological well-being at the table of health care. One could state that being happy, having a family and having a comfortable job were conceived to be as relevant to health as having healthy cholesterol levels. Translating this definition into an actionable plan has, however, proven elusive.

Limitations of the Biomedical Model

Health care is dominated by a biomedical model, where diseases are primarily defined by underlying biochemical abnormalities; interventions are directed at reversing them. One of the critics of this biomedical model was George L. Engel (1913-1999), who was a major figure in the field of psychosomatic medicine in the United States. He felt that medicine was bound by a seventeenth-century worldview of a body-mind divide that was erroneous.2 This artificial dichotomy had resulted in a hierarchical organization in the treating physician’s estimate that continues to this day. Physical processes that can be measured and easily manipulated alone are “real” and considered as worth treating, while the more subtle psychological processes are relegated as much less relevant. He stated that: 1. A biochemical alteration does not translate directly into an illness.

The appearance of illness results from the interaction of diverse causal factors, including those at the molecular, individual and social levels. And the converse, psychological alterations may, under certain circumstances, manifest as illnesses or forms of suffering that constitute health problems, including, at times, biochemical correlates. 2. The presence of a biological derangement does not shed light on the meaning of the symptoms to the patient, nor does it necessarily infer the attitudes and skills that the clinician must have to gather information and process it well. 3. Psychosocial variables are more important determinants of susceptibility, severity and course of illness than had been previously appreciated by those who maintain a biomedical view of illness. 4. Adopting a sick role is not necessarily associated with the presence of a biological derangement. 5. The success of the most biological of treatments is influenced by psychosocial factors, for example, the so-called placebo effect. 6. The patient-clinician relationship influences medical outcomes, even if only because of its influence on adherence to a chosen treatment. 7. Unlike inanimate subjects of scientific scrutiny, patients are profoundly influenced by the way in which they are studied, and the scientists engaged in the study are influenced by their subjects.2

Biopsychosocial Model of Engel

In 1977, George Engel proposed his biopsychosocial model of health as an alternative to the generally accepted biomedical model of health.3 His model takes into consideration a hierarchy of systems ranging from the molecular and biochemical processes all the way to societal, geopolitical and environmental forces that collide to contribute to health or disease. The biopsychosocial model is both a theoretical framework to understand health and illness and also a treatment guide. The construct recognizes that different clinical scenarios necessitate the understanding of illness at more than one level of the natural systems continuum. It also restores primacy to the unique subjective experience of the patient, thus redirecting the treatment plan to address the elements affecting it.

Mr. T. is a 70-year-old widower with coronary heart disease. His dyspnea limits his ability to get out of the house resulting in social isolation, which in turn makes him feel depressed. His depression affects his motivation to exercise or get out of his house. He, therefore, does not want to participate in any rehabilitation program, whereby his dyspnea does not improve. He feels lonely at home and this perpetuates his depression. All three dimensions of his personality — the physical, emotional and social — have been affected by his illness and contribute to his experience of illness and suffering.

The risk factors for his illness can also be viewed through the biopsychosocial model. The universally accepted risk factors include age, smoking status, family history, physical activity, diabetes, hypertension and hyperlipidemia. If, however, we lift our gaze and look beyond the obvious, we can recognize multiple elements in the biopsychosocial spheres contributing to and affected by the patient’s illness — food preferences of parents during development, financial status, work hours, the extent of social support available, quality of marriage, perception of self-esteem, sense of optimism, stress at work and at home, availability of healthy food choices at work, the sociocultural norms for activity, sleep, religious inclination, etc. Medicine is more easily understood through linear causations; however, and in our eagerness to simplify, we should not run the risk of oversimplification.4

Biopsychosocial Model in Clinical Practice

The astute clinician, using the biopsychosocial perspective, can tailor the treatment plan to fit the unique needs of the individual patient. According to Engel, to apply the biopsychosocial approach in clinical practice, the clinician should: • Recognize that relationships are central to providing health care, • Use self-awareness as a diagnostic and therapeutic tool, • Elicit the patient’s history in the context of life circumstances, • Decide which aspects of biological, psychological and social domains are most important to understanding and promoting the patient’s health, • Provide multidimensional treatment.

Thus, the biopsychosocial model enables the treating physician to develop a construct to understand the various factors contributing to the health/illness of the patient and also an insight into their belief and value systems. It also offers multiple targets to intervene in, which could potentially help improve the health of the patient.

Conclusion

The past two years have acutely brought into focus the psychosocial factors and belief systems that influence choices made by patients in matters of life and death. These elements are even more important in the management of noncommunicable diseases. We, as health care providers, are only too aware that stemming the relentless tide of diabetes, obesity and metabolic disorders is not going to be from better diagnostic tools or a magic pill. The need for a biopsychosocial approach to health has never been more imperative than today.

References 1. "WHO Definition of Health." WHO Definition of Health. World

Health Organization, 2003. Web. 31 July 2016. 2. Engel, George L. "How Much Longer Must Medicine's Science Be

Bound by a Seventeenth Century World View?" Family Systems

Medicine 10.3 (1992): 333-46. Web. 31 July 2016. 3. Borrell-Carrio, F. "The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry." The Annals of Family Medicine 2.6 (2004): 576-82. Web. 31 July 2016. 4. Engel, G. "The Need for a New Medical Model: A Challenge for

Biomedicine. “Science 196.4286 (1977): 129-36. Web. 31 July 2016. 5. Srinivasan, Venkat. Principles of Mind Body Medicine. Norton

Publishing, 2017. 6. Engel, G. "biopsychosocial model approach definition - University of Rochester ..." 2014. <https://www.urmc.rochester.edu/education/md/documents/biopsychosocial-model-approach.pdf>

Venkat Srinivasan, MD is a member of the Bexar County Medical Society.