Presumably as a consequence of the complex and varied nature of our subject matter, psychiatry has had a more difficult time than the rest of medicine agreeing upon a conceptual framework. The closest the field has come to a consensus on this score is George Engel's biopsychosocial model (BPSM), whose explicit and implicit influences extend throughout psychiatric education, training, and practice.1 The question that needs to be examined is how those influences manifest and whether they aid or hinder understanding and teaching in psychiatry.
In this essay, I approach the question about the BPSM from the perspective of a teacher of psychiatry, medical school dean responsible for (among other matters) student career advising, and clinician. In those capacities, my duties include fostering an understanding of psychiatric disorders among medical students and residents, instilling confidence in and respect for the discipline of psychiatry among students as well as nonpsychiatric colleagues, and explaining psychiatric diagnosis and treatment to patients and their families. Why are those tasks so difficult? The obvious answer is that psychiatry is a complicated field. I also argue, however, that psychiatry's de facto philosophical structure—of which the BPSM is currently a prominent component--impedes rather than facilitates our ability to grasp, describe, and teach our complex topic and incorporate its expanding database in valid and useful ways.
The components of my argument are:
- Psychiatry is in conceptual disarray.
- Several of our linguistic and conceptual conventions both instantiate and perpetuate misunderstanding of psychiatric concepts.
- Mind-body dualism tends to underlie those linguistic and conceptual conventions.
- The BPSM is one of those (closely related) linguistic and conceptual conventions.
We need, therefore, to scrutinize this nexus of modes of thinking and speaking that reflect dualistic misconceptions and that, in turn, impair our capacity to conceptualize and communicate the complexities of our specialty.
Let us first examine the assertion that the theoretical structure of psychiatry is in disarray. One need not look hard to see evidence of its validity. On as basic a question as whether psychiatric disorders are a subset of medical disorders, or whether psychiatric explanations are a subset of medical explanations, psychiatrists' opinions appear incoherent. Thus, while statements such as "depression is a serious medical disorder" or "mental illnesses are brain diseases" are routinely mouthed as articles of faith, any psychiatrist who peruses his mail will see on a daily basis phrases such as "psychiatric care of the medically ill," "treatment of depression with coexisting medical illness," or "evaluation of medically unexplained symptoms." Any hope that the resurgent and anachronistically named subspecialty of "psychosomatic medicine" will bring coherence to this matter appears misplaced. With its dualistic talk of the "mind-body connection," one wonders whether psychosomatic medicine is simply Descartes without the pineal gland hypothesis.
In order to determine the effects that the BPSM (and related conceptual and linguistic conventions) has on our thinking in psychiatry, we must examine the arenas where it is typically applied and held to be valid and/or useful. I have identified 4 such domains:
- Causes of illness
- Manifestations of illness
- Classification of illness
- Treatment of illness
For each of these domains of psychiatric thinking, I have tried to condense into a single statement the approach to it that is reflected in or dictated by the BPSM and/or the linguistic and conceptual conventions that are related to it. After presenting each statement, I analyze each statement's content, validity, and consequences.
Domain 1: Causes of illness
Statement: Diseases result from a summation or interaction of biological, psychological, and social influences.
Since people commonly but erroneously conflate "biological" with "heritable" and "psychological" or "social" with "environmental," the above statement can be misunderstood as being equivalent to, "diseases result from the summation or interaction of genes and environments." If the BPSM entailed the latter statement, there would be no need to quarrel with it. The fact that it does not, however, can be confirmed by considering into which of the 3 categories of the BPSM (ie, biological, psychological, or social) the influence of radiation exposure on the development of disease, for example, would fall. Although radiation exposure is clearly an environmental factor, the BPSM would place it into its "biological" box. Thus, the BPSM separates some environmental influences on disease causation (eg, radiation and diet into the "biological" compartment) from other environmental influences (eg, neglect and witnessing violence) into the "psychological" or "social" compartments, thereby obscuring the point that different environments may simply be salient to different human structures and functions.
Specifically, the fact that some brain functions are exquisitely sensitive to events in the social environment to which the brain has access via the sense organs—one of the most important truths in all of psychiatry—is inconsistent with the framework provided by the BPSM. The imperative of the BPSM to dichotomize the various ways that environments affect brains (eg, toxic chemical agents: biological; sense organ input: psychological) is spurious and misleading and interferes with our ability to understand and talk coherently about the etiology and pathogenesis of psychiatric disorders.
The way the BPSM would have us conceptualize the causes of depression reveals how it fosters confusion of etiology and pathogenesis. Experience leads me to believe that most psychiatrists would agree with the statement, "some people are depressed because of abnormalities of neurotransmission in certain brain circuits, some people are depressed because of adverse events in their lives, and some people are depressed because of a combination of those factors." Yet, a sentence of identical logical structure, "some people have myocardial infarctions because of insufficient oxygen supply to their hearts, some people have myocardial infarctions because of shoveling snow, and some people have myocardial infarctions because of a combination of those factors," is readily seen as nonsensical. The fact that myocardial infarction necessarily entails insufficient oxygen supply to the heart, and that there is a variety of routes—including increasing the oxygen requirement of the heart by shoveling snow--by which that may occur, is well known and understood.
In psychiatry, however, the impulse, which is both reflected in and fostered by the BPSM, to see some environmental influences as somehow nonbiological obscures the crucial point (if one rejects mind-body dualism in favor of monism) that events in the social environment can be transduced into
disease only to the extent that they affect the structure and function of the body. Far from being helpful in our attempts to understand and communicate information about the causes of
psychiatric illness, the BPSM is, at least in this effort, a millstone around our collective neck.
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