Biopsychosocial Model: Helpful or Hindering?

The points made by Dr G. Scott Waterman in his article, "Does the Biopsychosocial Model Help or Hinder Our Efforts to Understand and Teach Psychiatry?" (Psychiatric Times, December 2006) are right on target. Unfortunately, the biopsychosocial model of psychiatry is not merely conceptual; it is woven into the delivery of care at every level. Institutions of government, insurance, and hospital and outpatient services separate "behavioral" medicine from all other medicine and further separate substance abuse disorders from those deemed "psychiatric."

Emergency department doctors commonly regard any kind of cognitive or behavioral dysfunction as "nonmedical" and turn over decision making to barely trained mental health workers who are often simply not interested in the medical significance of differences, let's say, between hallucinations caused by alcohol withdrawal and those caused by a discontinuation of antipsychotic medication of a patient with schizophrenia or by a brain lesion.

State and county governments oversee and provide for treatment of psychiatric and substance abuse disorders separately from medical care and from each other. This applies not only to the hopelessly fractionated delivery of day-to-day service but to the bizarre legal tangle relating to the treatment of patients not able to make rational decisions about their own care. In the name of freedom, we restrict involuntary treatment only to those cases in which the patient represents an imminent threat to himself or herself or others, and even then we make exceptions for cases in which the threat is caused by substance abuse.

In other words, if you are suicidal with schizophrenia, you can be held involuntarily. If you are suicidal with alcoholism, you are out of luck. If you are merely killing yourself with neglect because "the voices tell you" to lie on subway vents and stare at the moon, you don't even come into the concern of the law.

Insurers welcome the medical-behavioral dichotomy because it allows them to shave treatment costs. They are able to bundle behavioral services separately from others in a way that gives the appearance of cost cutting. Implicit in the structuring of these services is the idea that behavioral illness is not really illness, or worse, that behavioral illness is essentially a life choice of the patient.

Psychiatry is as responsible for this dichotomy as are other institutions. As psychoanalytic domination of the field was waning, biological understanding of mental illness was expanding exponentially. The last few decades could have been a time in which the distinction between psychiatric and medical (or "real") illness faded into history.

Instead, along came DSM, a classification system only a committee could love. It not only reified the distinction between medical and psychiatric illness but separated psychiatric illness into 2 "axes" that defy any consistent rational definition.

Fortunately, 2 forces are poised to converge on this mess and cause an implosion that will resolve the dichotomy. The first is economics. It is likely that Congress will soon mandate equity for mental health coverage. This will have an impact that will ripple through the health insurance industry and create changes in the delivery of care at every level.

The second is the simple progression of science. The meeting of the DSM committee is reminiscent of those of the high priests in the Middle Ages who debated the relevance of bodily humors and divine forces in various medical conditions. The 5 axes, numerous qualifiers, and hundreds of diagnoses now listed will give way to diagnoses with etiologies, markers, and definitions as specific or general as type 1 or 2 diabetes or idiopathic hypertension.

How is schizophrenia different from type 1 diabetes? Each is a chronic condition that is inherited and has a lifetime progression that can be improved with medication. How is alcoholism different from type 2 diabetes? Each is caused by a combination of inherited, behavioral, and environmental factors that can be modified with medication and environmental management. How is anxiety different from hypertension? Each is clearly an identifiable entity that may be either idiopathic or symptomatic of another condition. Why should any of these conditions not be part of the same axis?

If I understand Dr Waterman's use of the "holobiological" model, it means that good medical assessment and treatment is based on the recognition that the biological condition occurs within a context that includes heredity, social and psychological history, and physical environmental forces. Good psychiatric assessment and treatment is no more or less than its "medical" counterpart. The holobiological model, then, is an improvement and unification forming from 2 perspectives toward a common goal.

William S. Greenfield, MD
Philadelphia

Dr Greenfield is medical director of the Lenape Crisis Center at Lower Bucks Hospital and serves on the alumni board of Temple University School of Medicine in Philadelphia.

Another reader weighs in:

I was initially quite pleased to see the commentary by Dr Waterman discussing the biopsychosocial model (BPSM) developed by Dr George Engel. As I read the article, however, I felt increasing dismay. There is nothing in the commentary that demonstrates that Dr Waterman has read anything about this concept, and he makes reference to only 1 article by Engel, which it seems possible that he has not actually read.

Dr Waterman seems to believe that the BPSM suggests that for any event, one must provide either a biological, psychological, or sociological explanation. For example, Waterman states that in the case of a patient who is exposed to radiation and is becoming ill, the "BPSM would place it into its 'biological box.'" He claims, "Thus, the BPSM separates some environmental influences on disease causation (eg, radiation and diet into the 'biological' compartment) from other environmental influences." I am not certain which BPSM rule book he is using to draw these conclusions.

If one actually reads the lovely Engel paper¹ to which Waterman makes reference, it is quite clear that Engel is doing precisely the opposite of what Waterman accuses him. Engel examines the scenario of a man with chest pain who is deciding whether to seek medical help and explores this event as a contemporaneous joining of cardiac physiology, individual psychology, and the patient's social context. Engel artfully examines the interaction of these issues and events and is precisely trying to warn against the dangers of oversimplifying and ignoring the complex systems in which all medical or psychiatric events occur.

Waterman suggests that much of what is wrong with the DSM approach is a result of following Engel's model. There is no question that the multi- axial approach of DSM has led to much simpleminded thinking and confusion about psychopathology and causation. The editors of DSM have attempted to dispel some of this trouble in their (not carefully enough read) introduction, but ultimately, it is probably not possible for DSM to be atheoretical. However, to pin any of the trouble with DSM on Dr Engel is simply inaccurate and unfair. He was, in fact, arguing for a flexible, thorough combining of multiple levels of perspective and explanation in our theoretical and clinical approach to our work. Our field (both psychiatry and medicine) would do better to actually return to a careful study and consideration of his ideas.

Victor Schwartz, MD
New York City

Dr Schwartz is university dean of students at Yeshiva University in New York.

Reference1. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544.

Dr Waterman responds:

The examples in Dr Greenfield's letter point out that the ramifications of taxonomic systems are many and that the consequences of bad nosologies can be adverse in a variety of ways. The antiquated, dualist underpinnings of the linguistic and conceptual conventions that I discussed in my article-specifically, the biopsychosocial model and the DSM multiaxial diagnostic system-are reflected not only in the confused way in which we think about and teach psychiatry but also in much of the nonsense (which varies from annoying to dangerous) of day-to-day clinical practice. And while overcoming what seems to be the nearly hardwired propensity of humans to think dualistically is an ambitious project, organized psychiatry has only reified and thereby exacerbated the problem. I only hope that Dr Greenfield is not overly optimistic that the "progression of science" will contribute to the undoing of the DSM system as it is currently conceived. After all, the philosophical and scientific untenability of its conceptual foundations is hardly new.

Dr Schwartz's questioning of whether I have read Engel's paper is a consequence of his having misread mine. He mistakenly believes that I assert that the BPSM insists that events have biological, psychological, or social explanations. I make no such claim. Instead, I address the fact that the BPSM categorizes influences relevant to disease causation or course as biological, psychological, or social. In this vein, Engel discusses the importance of "processes at the psychological and interpersonal [in addition to biological] levels of organization."¹ Engel thus apparently sees these different "levels of organization" as entailing different species of effects that interact with one another in the determination of health and disease.

Dr Schwartz's failure to see that formulation as entailing mind-body dualism (and, in fact, his believing it to be "precisely the opposite") reflects the common misconception that dualism is avoided by invoking interaction among the "levels of organization" of which Engel writes. In fact, mind-body interaction has been a central feature of dualism since Descartes. Engel provided a great service to medicine by broadening the scope of what physicians count as relevant data. We must, however, move beyond the BPSM if we are to make philosophically and scientifically coherent sense of those data.

G. Scott Waterman, MD
Burlington, Vt

Dr Waterman is associate professor of psychiatry and associate dean of student affairs at the University of Vermont College of Medicine.

Reference1. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544.