Domain 4: Treatment of illness
Statement: Psychiatric disorders may be (or should be) treated with biological, psychological, and social therapies.
While the BPSM is used by some clinicians as a sort of checklist that helps them to remember to consider the variety of available therapeutic options, its liabilities in this context are similar to those exposed under Domain 3. Specifically, dividing up psychiatric treatments in this way obscures potentially common mechanisms among them. Thus Baxter and colleagues,3 writing about their positron emission tomography (PET) findings in obsessive-compulsive disorder, felt the need to explain that "the possibility of both a serotonin reuptake inhibitor and behavior modification treatments having the same neural effects is not as farfetched as it might seem to some at first glance."
Further, the BPSM as applied to the conceptualization of differential therapeutics creates a false expectation of correspondence between putative causes or manifestations of illness on the one hand and components of treatment on the other. Thus, an illness thought to have a "biological" (often conflated with heritable) origin, and/or one that presents with "biological" signs or symptoms (a categorization often applied, for example, to vegetative abnormalities), warrants a "biological" (ie, pharmacologic or electroconvulsive) therapy. In contrast, a condition conceived of as resulting from a "psychological" or "social" cause (often conflated with adverse life events), and/or presenting with "psychological" symptoms (eg, identity disturbance), calls for use of a "psychosocial" intervention. Because the BPSM encourages its users to conceptualize psychopathology as resulting from a combination of biological, psychological, and social forces—which, in turn, manifest as a combination of physical and psychological symptoms—it appears to be an inescapable conclusion that essentially all patients should be managed with a combination of treatments selected from each of the categories that the BPSM comprises.
Discouragingly, this ideologic (as opposed to empiric) imperative is codified as dogma by the American Board of Psychiatry and Neurology. As Morrison and Munoz4 advise their anxious readers who are preparing for the oral portion of the psychiatry specialty board examination, "psychiatric management requires attention to these potential interventions: biological, psychological, social. This biopsychosocial framework underlies modern treatment formulation. At all costs, you must discuss each of its parts in the treatment plan of any patient you examine." Candidates for board certification in psychiatry ignore that admonition at their peril!
As I have shown, the BPSM is a linguistic and conceptual convention whose influence (on its own and via related linguistic and conceptual conventions such as the DSM multiaxial diagnostic system) is felt across a range of domains of psychiatric thinking. Although I am certainly not the first to criticize the BPSM and its uses in psychiatry (see, for example, Ghaemi5), what I have outlined (following Goodman6) is how, as a fundamentally dualist model that forces its users to employ the categories of "bio," "psycho," and "social" in various misleading ways, it is both a manifestation of and a contributor to misunderstanding. Practical consequences of that misunderstanding almost certainly include separation of psychiatry from the rest of medicine, stigmatization of patients with psychiatric illnesses, and an inequitable distribution of resources (eg, managed care "carveouts").
What I have focused on in this essay, though, are its conceptual costs, including distortions of the differential diagnostic and differential therapeutic processes and—of paramount importance—impairment of our ability to communicate modern psychiatric thinking to our students, residents, colleagues, patients, and the public. After all, it should not come as a surprise that 21st century science does not fit well into the 17th century dualist framework of the BPSM.
Into what conceptual structure, then, does modern psychiatric science fit? The answer, I believe, is a mature biological, or "holobiological," model. This is in contrast to the crude and naive biological reductionism of an earlier era that discounted the role played by the interpersonal environment in the etiopathogenesis and treatment of illness and to which the BPSM was in some ways a response. This mature or holobiological model is one that accommodates within an explicitly monist/ materialist framework the broad range of inherited and acquired phenomena that are salient to human disorders. Its mode of explanation is gene and environment action and interaction in the production of disease phenotypes (see, for example, Pezawas and colleagues7) and therapeutic responses. Guided by such a model, we can be in a position to fashion the future findings of psychiatric science into a coherent account—for ourselves, our students, our colleagues, and our patients—of the causes, manifestations, classification, and treatments of psychopathology.
Dr Waterman is associate professor of psychiatry and associate dean for student affairs at the University of Vermont College of Medicine in Burlington. He reports that he has no conflicts of interest concerning the subject matter of this article.