Practical application of the biopsychosocial model to medical care—Are we nearly there yet?

Abstract

The paper in this issue by Fava and colleagues¹ highlights features of the Diagnostic Criteria for Psychosomatic Research (DCPR) and stresses how the DCPR was inspired by Engel's biopsychosocial model.²

Engel wrote that his ‘proposed biopsychosocial model provides a blueprint for research, a framework for teaching, and a design for action in the real world of healthcare’.² Since then, the biopsychosocial model has been widely adopted, particularly by clinicians and clinical teachers. However, it has also attracted criticism. Some have argued that it says nothing about the subjective experience of the patient.³ Others have gone further in their criticism, claiming that individualising treatment to each patient, as the model implies, gives rise to eclectic freedom which ‘borders on anarchy’ and merely replaces the dogmas which the model was intended to protect against (notably the reductionism of the biomedical model) with other dogmas.⁴ Responding to criticisms that Engel's model lacks a sound theoretical basis, Bolton⁵ noted that the original model needs to be understood as of its time and that despite its limitations, the model anticipated the crucial role in health and illness of ‘concepts such as regulation and dysregulation, information and communication and function and dysfunction’. It has been argued that the main problem with the model as Engel proposed it is that it is too general. One proposed solution to this is to elaborate specific, evidence-based, models for different diagnoses or conditions.⁶ The DCPR represents a different but effective solution to the same problem. Instead of elaborating the details of the biopsychosocial model separately for different conditions (a monumental undertaking), the DCPR aims to describe particular transdiagnostic states (termed ‘syndromes’) which can occur as features of the experience of illness.

Fava et al.¹ illustrate the DCPR by characterising some of its syndromes. These are all patterns of responses to life situations involving illness, reflecting dysregulation and/or dysfunction. They are termed syndromes to distinguish them from disorders or diseases which form the basis of standard diagnostic classifications.⁷ The syndromes were intended to be descriptive and without any pathogenic implications, although with progress in research and understanding, this assumption might now be challenged. The original syndromes were not intended to be exhaustive and indeed the original DCPR has been revised to include two additional syndromes.⁸ An important feature of the syndromes is that they each include (or overlay) biological, psychological and social components. Allostatic overload is a prime example, manifestly showing biological, psychological and social factors in its aetiology as well as in its consequences. The key purpose of the DCPR is to provide a richer description of the experience of illness than is possible using standard diagnostic classifications alone. Supporting this, a 2015 review⁹ highlighted that in a variety of clinical samples, the prevalence of DCPR syndromes was substantially higher than that of formal psychiatric diagnoses. The same has been found among patients in primary care.¹⁰

One criticism which has been made of Engel's biopsychosocial model, already noted above,³ which could also be levelled at the DCPR, is that the model does not explicitly incorporate the patient's perspective but focuses on the patient's illness experience as seen by the clinician or researcher. While both the biopsychosocial model and the DCPR focus on the tasks of the clinician or researcher, both acknowledge the importance of the clinician-patient relationship, which Engel regarded as integral to the biopsychosocial model.² The DCPR affords the clinician and the researcher a more comprehensive understanding of the patient's experience of illness which can contribute to discussion shared in the clinical encounter.¹¹

A more important criticism is that as it stands, the DCPR covers only negative aspects of the illness experience whereas biopsychosocial influences on illness can be positive as well as negative. In his original paper, Engel also made no explicit reference to positive biopsychosocial influences² although there were implicit references to this, for example: ‘the behaviour of the physician and the relationship between patient and physician powerfully influence therapeutic outcome for better or for worse’.² Just as health is not merely the absence of disease, so biopsychosocial factors are more than the presence or absence of (negative) DCPR criteria. A clear example of a positive biopsychosocial factor is the concept of sense of coherence, which Antonovsky intentionally developed as a measure of what he termed ‘salutogenesis’ (as opposed to ‘pathogenesis’).¹² Someone with a high sense of coherence views life as comprehensible, manageable and meaningful. In epidemiological studies, a high sense of coherence has been associated with reduced all-cause, cardiovascular and cancer mortalities.¹³ There are measures available of other ‘non-negative’ mental states like euthymia.¹⁴ However, some positive psychosocial effects may be more difficult to characterise than negative ones. One possible example is wellbeing, for which 99 different self-rating scales have been identified.¹⁵ Perhaps another barrier to extending the DCPR to cover such states lies in their title, specifically the term ‘diagnostic’. Although ‘diagnosis’ strictly means only to ‘distinguish apart’, the term is applied specifically to recognising features of illness. If this is a potential problem to extending the DCPR, perhaps ‘diagnostic’ might be replaced by ‘clinimetric’ or even ‘biopsychosocial’? However, adding further syndromes, whether positive or negative, risks making unwieldy the current use of the DCPR as a unitary instrument, that is, screening all patients for all syndromes. This would be a particular problem for researchers. For clinicians and their patients, particular biopsychosocial syndromes could be selected from an extended ‘toolkit’ to contribute to or enhance (biopsychosocial) formulations of the person's illness experience.

Richer descriptions of the illness experience have an important purpose. As Fava et al.¹ indicate, the DCPR may help ‘to demarcate major prognostic and therapeutic differences among patients who are otherwise deceptively similar’. There is already evidence, some cited in their paper, that when present, the syndromes of the DCPR have an adverse effect on illness outcomes. In addition, in most instances, the presence of a DCPR syndrome is expected to increase the patient's psychosocial burden. Alleviating such burdens should be one focus for intervention. Once characterised and recognised, the psychological aspects of these syndromes should be amenable to effective intervention.¹⁶ Given that the DCPR syndromes turn out to be prevalent in people with physical illnesses, developing and testing interventions tailored to individual DCPR syndromes is the logical next step.

The author declares no conflict of interest.