Resuscitating the Biopsychosocial Model in Psychiatry

Have we lost our way in the assessment and treatment of our patients? As we approach the 50th anniversary of George Engel’s seminal 1977 publication,¹ in which he introduced the biopsychosocial model informed by systems theory to replace the then-dominant biomedical model for psychiatry, it feels to me as if we have drifted backward. During my training in medical school and psychiatric residency, Engel’s model served as the guiding principle for good medical care. My training was truly eclectic, with wide-ranging ongoing supervision in psychopharmacology, psychodynamic psychotherapy, cognitive behavioral treatment, psychoeducation, defense mechanisms, transference/countertransference, and social factors affecting a patient’s diagnosis and treatment. Over the decades, although the length of a typical patient’s treatment note has greatly expanded with electronic health records, the amount of helpful information has decreased.

The Essentiality of a Psychosocial History

In all medical specialties, but especially in psychiatry, the patient’s chief concern is just the first letter of a paragraph that needs to be explored to create a meaningful and comprehensive treatment plan. In the middle of that paragraph should be a solid assessment of the psychological and social factors that may have contributed to the onset of the chief concern, and that will affect the likelihood of meaningful and lasting treatment. Until the publication of DSM-5 in 2013, the prior 33 years of DSMs required a psychiatric assessment that was grounded in a diagnostic multiaxial system of 5 axes, challenging the clinician to complete a comprehensive interview that assessed wide-ranging synergistic variables that defined the patient and informed the treatment plan (Table).²

Coincidentally, DSM-5’s changes to downgrade this comprehensive list of 5 axes to a single diagnosis for a patient occurred at the time that electronic health records emerged to digitalize treatment documentation.

Critics of the Biopsychosocial Model

Researching this topic, I came across a range of articles highly critical of Engel’s biopsychosocial model of assessing and treating patients.^3-5 After reading them, I think that the authors are missing Engel’s point. The biopsychosocial model is not claiming to be the new periodic table of elements for psychiatry. Rather, it serves as a reminder to inquire into the wide range of lived experience, strengths, vulnerabilities, supports, stressors, beliefs, expectations, fears, and biological factors that converge to define the patient we are assessing. This information can significantly inform our assessment and treatment plan for a unique individual, which will arguably improve our treatment alliance and patient adherence, facilitating a healing that transcends the chief concern.

Medical training in the United States may rely too strongly on the biomedical model, with the common belief by practitioners that the existing medical paradigm at any point in time reflects scientific fact. The biomedical model is not an established fact but rather an evolving hypothesis, as is all of science. A tangible example of this is the dramatic reversal of the accepted primary pathophysiological etiology of peptic ulcer disease (PUD). For decades, it was accepted as dogma that PUD was caused by stress and associated excess gastric acid, diet, and cigarettes. The accepted treatment included antacids, histamine receptor antagonists, dietary modification, and, when necessary, surgery. The ulcers healed, but almost always recurred. In 1979, after continued observation that a bacillus often colonized the gastric mucosa in biopsies of ulcers, the Australian pathologist J. Robin Warren hypothesized that the bacilli were causal of PUD. Gastroenterologist Barry Marshall joined Warren in 1981, and they published their findings in The Lancet in 1983. The medical establishment ridiculed their hypothesis, well ingrained in its long-standing PUD dogma, and continuously criticized and rejected them at conferences. Finally, in 1988, Warren and Marshall et al published a prospective, double-blind trial in The Lancet, findings of which, along with those from subsequent studies, provided unequivocal evidence that Helicobacter pylori infections were the primary etiology of PUD and that antibiotics cured the ulcers and prevented recurrence.⁶ In 2005, Warren and Marshall were awarded the Nobel Prize in Physiology or Medicine for their work.

Cultural Factors as Essential

The inclusion of cultural factors in a psychiatric diagnostic formulation occurred incrementally from 1977, building on Engel’s biopsychosocial model. It was first formally introduced in 1994 with the Outline for Cultural Formulation (OCF) in an appendix in DSM-IV. This provided clinicians with a structured approach to assess and document a patient’s cultural identity, cultural explanations of an illness, and cultural factors that are present in the patient’s psychosocial environment during the initial assessment. To the American Psychiatric Association’s credit, the DSM-5 in 2013 expanded the OCF to the Cultural Formulation Interview (CFI), which is a set of 16 standardized questions recommended for use in an initial patient evaluation, which remains in the DSM-5-TR today. However, from 2013 to the present, CFI and other culture-specific information remain in the DSM’s Section III, entitled “Emerging Measures and Models,” a section not frequently read.

Let’s Not Forget the Spiritual

Incorporating a patient’s religious/spiritual beliefs into a diagnostic formulation often conjures anxiety and conflict in the clinician, except in the most extreme circumstances. Severe psychotic, manic, depressive, and anxiety symptoms can include content with strong religious or spiritual overtones. In my opinion, an individual’s religious/spiritual beliefs significantly affect complex human emotions, relationships, community supports, and identity, which can all play a vital role in treatment planning. I prefer the term spiritual, which, although not standardized by any medical organization or nomenclature, can be a proxy to describe a person’s belief system that provides for them a personal understanding of the meaning and purpose of their existence. Used in this way, belief in any religion, atheism, agnosticism, or another belief system can characterize a person’s spirituality.

Researching the PubMed literature, in 1992, Lukoff et al proposed a new diagnostic category for “psychoreligious and psychospiritual problems.”⁷ The publication of DSM-IV in 1994 added criteria for attributing a patient’s spiritual or religious beliefs to some aspect of their assessment. These include the V code (V62.89) for a “Religious or Spiritual Problem,”⁸ the OCF and CFI sections, as well as frequent reminders in the main diagnostic criteria section to interpret beliefs and experiences within the patient’s religious/cultural context to avoid a misdiagnosis. Daniel Sulmasy’s publication in 2002 is credited with formally introducing the expanded biopsychosocial/spiritual model, proposing that a patient cannot be fully understood without knowledge of their spiritual beliefs.⁹

A Biopsychosocial/Cultural/Spiritual Model

In conclusion, I opine that humans are complicated and that good medicine incorporates many dimensions that weave together and create our patients and their experience. In an 1899 address to students at Albany Medical College, Sir William Osler, considered the father of modern medicine, famously stated, "Care more particularly for the individual patient than for the special features of the disease."¹⁰

I often wonder how Osler would feel spending the day at a major medical center and observing our current approach to treating patients. As a biochemist by training, I am awestruck at the progress that has been made during the past century in the biomedical arena. But the implementation of the biomedical model becomes meaningful only when delivered as part of comprehensive treatment of a patient that includes the biological, psychological, social, cultural, and spiritual domains (Figure).¹¹

References

1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136.

2. DSM-IV-TR. American Psychiatric Association; 2000.

3. McLaren N. A critical review of the biopsychosocial model. Aust N Z J Psychiatry. 1998;32(1):86-92.

4. Ghaemi SN. The rise and fall of the biopsychosocial model. Br J Psychiatry. 2009;195(1):3-4.

5. McLaren N. The biopsychosocial model: reality check. Aust N Z J Psychiatry. 2021;55(7):644-645.

6. Marshall BJ, Goodwin CS, Warren JR, et al. Prospective double-blind trial of duodenal ulcer relapse after eradication of Campylobacter pylori. Lancet. 1988;2(8626-8627):1437-1442.

7. Lukoff D, Lu F, Turner R. Toward a more culturally sensitive DSM-IV: psychoreligious and psychospiritual problems. J Nerv Ment Dis. 1992;180(11):673-682.

8. Turner RP, Lukoff D, Barnhouse RT, Lu FG. Religious or spiritual problem: a culturally sensitive diagnostic category in the DSM-IV. J Nerv Ment Dis. 1995;183(7):435-444.

9. Sulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist. 2002;42(suppl 3):24-33.

10. Cordova J. The "good" physician: Oslerian aphorisms in the 21st century. Proc (Bayl Univ Med Cent). 2020;34(2):325-326.

11. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137(5):535-544.