“Engel’s original intent for development of the biopsychosocial model was to alleviate emphasis on “biomedicine” and to provide a more holistic approach to patients” (Tavakoli, 2009).
Engel (Cited in Farre & Rapley, 2017) critiqued tradition biomedical approaches by expressing that the model only focuses physiological causes for disease and illness. The patients themselves are being cared for and being eliminated from disease physically, but psychological and social influences towards a disease is being ignored. This therefore can result in patients feeling healthy but given treatment, on the contrary side it can also result in patients feeling unwell but are told they are healthy. He argued that all three factors need to be looked at and evaluated. He provided a good basis to help us understand the relationship between the mind and body and ultimately the concept of separating of illness and disease (Brown, Bonello & Pollard, 2005).
Pain management techniques such as physical and occupational therapies, psychological interventions, and medical services can be used to deal with chronic pain and it is a great way of using psychological and social ways to deal with the illness. The pain is managed rather than to cure the actual illness. The use of both traditional biomedical treatments and psychological pain management strategies could help the patient feel more at ease (Roth, Geisser, & Williams, 2011). Looking at this from a psychology perspective self-awareness is a key factor to help emotional regulation with furthermore helps facilitate through hardship (lane, 2014). The study conducted by (Seminowicz, Shpaner, Keaser, Krauthamer, Mantegna, Dumas, & Naylor, 2013). looked at the amount of grey matter volume in the brain after CBT treatment, this was specific to patients suffering from chronic pain. The study found that the grey matter in those who completed CBD had increased significantly and those suffering from chronic pain, grey matter in the PFC and PPC results in better control over pain and pain reappraisal. This study used scientific methods like brain scans to find evidence to support the biopsychosocial model which shows biomedical practices and psychology can work well combined.
(Tanaka & Kanazawa & Fukudo & Drossman 2011) Irritable bowel syndrome is a common bowel disease, “it is characterised as recurrent abdominal pain associated with altered bowel habits without obvious structural abnormalities seen on endoscopy or X-ray”. There are different contributing factors which increases the chance of developing IBS. Firstly, IBS is known to be associated with psychosocial distress. Psychological factors such as major loss, abuse, physio social trauma all can contribute to developing and the severity of IBS. Australian twin study identified that IBS could be passed down through genetics. “concordance rate for IBS between monozygotic twins was significantly higher than that between dizygotic twins”. When looking at the brain. Neurotransmitters regulate gastrointestinal activities providing a strong link between biological factors and psychological (Mach, 2004). Furthermore, when looking at patients suffering with IBS the most common mental health conditions are Anxiety disorders, Depression and phobia disorders. This is due to the pain threshold being lowered by somatic symptoms which is caused by distress. A study conducted by (Prxekop, Hayiland, Yan Zhao, Oda, Morton & Fraser, 2012). looked at four different types of groups and identified any links between irritable bowel syndrome (IBS) and fibromyalgia (FM). The four groups included females with IBS, FM, IBS AND FM and there was a control group with healthy females. Those who were part of the control group has significantly less traumatic and major life stressors in contrast to those in the other groups. They additionally identified those individuals who had both FM and IBS reported to have the worst stressors and mental health. This is strong evidence supporting psychological factors having an influence on IBS. There has been evidence that patients with a history of abuse report more severe symptoms and psychological stress compared to those who do not. this was measured by the amount of physician visits and the amount of time spent in bed which was significantly higher thus providing evidence for social and psychological factors influences IBS (Tanaka & Kanazawa & Fukudo & Drossman 2011). The Author expressed the lack of research that is conducted on IBS, Although the significant link the lack of research can be seen as a limitation as further studies would generate stronger results which thus would result in a stronger basis for evidence. Furthermore, as the theory develops and more research is attained it would ultimately catch the idea of other physicians.
One phenomenon which shows the importance of the biopsychological model is phantom limb pain. Phantom limb pain occurs when a limb has been amputated, yet the patient can still feel immense pain in the limb. This sensation has been known to be influenced by many factors. Firstly, by Proprioceptive memories. The patient may recall the pain of a disease they had with furthermore resulted in the amputation. Katz and Melzack (cited in Fuchs & Flor & Bodmann 2018) explained that the pain the felt prior to the limb getting amputated is encoded in the brain and later is sparked. Angrilli and Köster (cited in Fuchs & Flor & Bodmann 2018) looked at stress being a factor of PLP. Two groups were observed one with PLP and one without, stress was induced to the amputees, patients who suffered with PLP were recorded to show stronger psychophysiological stress reactions. A treatment for phantom limb is a psychological therapy treatment. The patient suffering from phantom limb is told to put the intact arm in a box. From the view of the patient the reflection of the arm gives an illusion that there are two intact arms. This is done alongside movement exercises. This mental illusion\sensation has proven to reduce phantom pain (MacLachlan, McDonald & Waloch, 2004). PLP is strong evidence to support the need for the Biopsychosocial model as it shows the influence of cognitive and emotional factors resulting in physical problems. The use of the mirror box is strong evidence of cognitive methods being used to help relieve the pain rather than treating the symptoms. On the other hand, further research needs to be conducted on the role of cognitive factors as mediators of the pain experience. There is not enough conclusive evidence on the significance of these factors.
Type 2 diabetes (T2D) is one of the most psychologically demanding chronic medical illness in adult (Habtewold, Islam & Tegegne, 2016). When looking at type two diabetes the link between the disease and depression is commonly observed. Carried out a study to find a pattern between depression and diabetes. They identified that studies conducted on biopsychosocial factors were only limited to developed country’s they subsequently decided to conduct the study in Ethiopia. Negative life events within 6 months, marital status, occupation, complications with diabetes are all Biopsychosocial factors which significantly increased the depressive score (Habtewold, Islam & Tegegne, 2016). This study not only is a good study to support the need of the biopsychosocial model but additionally it explores different cultures in a world different from developed countries which increases the sample size and ecological validity.
“Emerging prospective work suggests that individuals with social anxiety disorder (SAD) may be at particular risk for developing substance use disorders (SUD)” when looking at patients that were seeking treatment for alcohol, those who had the social anxiety were found to have more severe alcohol dependency. This therefore suggests a link between the two variables. This is important to discuss when discussing the biopsychosocial model because this particular illness features all three factors (Biological, social and psychological factors) (Buckner, Heimberg, Ecker & Vinci, 2013). A limitation highlighted was the effectiveness of the treatment for both SAD disorder and substance abuse, the author expressed that although people may receive treatment for SAD it may be harder to get patients to complete the substance abuse treatment as the substance may provide the patient a positive feeling and may lead the patient to believing the substance is providing relief.
To start off with a limitation is suggested by (Tavakoli, 2009). He believes that poor behaviour would be implied as a disease and that would furthermore impact the way society looks at psychiatry and the wellbeing of society. An example they spoke about was schizophrenia, you can overlook it and include it in the psychosocial category however poor behaviour that is conducted by an individual cannot be perceived as a disease and treated in a medical environment. He carried on to talking about the distinction between biology and psychology. The two different fields are different to each other and he believes that the model could suggest biology being separate from psychology. In a working setting how is the biopsychosocial model taught? How do we explain to medical students what is psychological and what is biological? This can furthermore create a confusion, and a frustration for medical studies to try and diagnose and categorize symptoms and diseases.
Although the evidence provided for the biopsychosocial model is strong it yet it not widely accepted in everyday medical care. One of the reasons this may be the case is health care costs. There is a limited amount of resources, and the idea of biopsychosocial model is seen to be expensive. The health costs are increasing and there is a limited amount of time for doctors to spend with their patents. “The comprehensive nature of the biopsychosocial approach to clinical care appears to be a luxury that we can’t afford” (Lane, 2014).
The biopsychosocial model provides a good insight into breaking out of the contemporary biomedical approach. However, it is important to identify that diagnosis for such conditions would be problematic as they are based on symptoms and not signs. Diagnoses is based on individual beliefs/judgements. it would be hard to diagnose a patient without a form of measure. This therefore results in the medical world being more apprehensive when looking at mental health problem as it is believed to be subjective than objective. Also, when looking at patients with mental health problems, due to the patients experiences not fundamental method of diagnosis they often have to be revisited and reviewed constantly and analysed compared to traditional biological diagnosis methods (Pilgrim, 2015).
(Smith, Fortin, Dwamena & Frankel, 2013) looked more into the lack of measure and it together three of the main critiques of the biopsychosocial model, it is not testable, it is too general and there is no specific method. The third point as addressed above notes that the information that is needed for the model does not have a specific process of collection. “there is no specified method to operationalize (define) the BPS model for the individual patient” This follows the first point of the study not being testable, many believe it has been defined vaguely and it cannot be tested or evaluated, which brings me to the final point of it being too general. The amount of data required is all of the patient’s history and biopsychosocial information which be time consuming and unproductive on an everyday basis. On the other hand, once the biopsychosocial model is altered slightly and made scientific it can be applied in modern medicine. This is done by using a common patient centred method which will not only provide a basis but will help with professionals understanding the model through research and teaching the model. “Educators can train learners systematically to make and interpret a BPS description of their patients at each encounter, and researchers can systematically define the model for more rigorous study in clinical trials and other research”. (Smith, Fortin, Dwamena & frankel, 2013).
People have differing views when looking at the biopsychosocial model, Engel himself believed the model to be more scientific in comparison to the traditional medical model. Other individuals may look at the biopsychosocial model and believe it to be too humanistic as it is not believed to be an evidence based practice. Furthermore, the model can be seen as too complex as it involves three different aspects. “how do we choose? How do we prioritise one aspect versus another?” the model itself does not provide a means to choose which aspect to prioritise, which therefore results in individuals to choose what they want to prioritise based on their own personal beliefs (Ghaemi, 2009).
When discussing the Biopsychosocial model within its uses in medicine is it important to note although there was an initial good response, it is not widely practiced. There has been a limited amount of application. Some critique the model to be too complex. There has been a main focus on biomedical factors and often psychological and social factors and often completely ignored. (Kusnato, Agustian & Hilmanto, 2018). in the world of medicine there is a limited amount of information and training provided on biopsychosocial. Medics are not taught to deal with biopsychosocial factors that is associated with chronic disease. When looking at figures in the United States non-communicable diseases make up for 88% of total deaths (Jaini & Lee, 2015). Which include chronic diseases such as cancer, cardiovascular disease, obesity etc. This furthermore makes medics unprepared for treating these illnesses that are influence by multiple factors and as the number of deaths increase by chronic diseases it is important to help identify the multiple ways it can be managed (Jaini & Lee, 2015). (Adler, 2009) addresses a point suggesting that although some country such as the US and Germany have clinics specific to pain management via conative methods this is not the vision Engel was going for. Engel and the thoughts of the author believe a physical need to be able to carry a working knowledge of human behaviour.
A medical school survey looked at the use of the biopsychosocial model in undergraduate studies. 41% had expressed that biopsychosocial model was a part of their curriculum which is less than half. Topics included “psychosocial factors 80–93%, cardiovascular 83%, and doctor–patient communication 98%. Some problems that were expressed was the lack of resources to teach the subject, the uncertainty of students and staff members and lastly the lack of continuity (Adler, 2009). If there is a lack of content taught on biopsychosocial models in medical school how do we expect it to process into medicine, the start starts from the content being taught in schools.
In conclusion, there is a number of limitations that need to be addressed in order to see the model process. The authors all have evaluated the biopsychosocial model well. Issues like the lack of method, lack of practice, the idea of it being too general all are valid points, without having a strong basis and a way to attain scientific data that is measureable it would be difficult to incorporate it in medicine. However, there is an ability to take the biopsychosocial model and progress it so it fits into everyday medicine. Looking at the amount of research on the benefits of the biopsychosocial model on chronic pain and the evidence the treatment provides, it is essential to try and merge it into medicine. More research needs to be conducted on creating a method that is testable and efficient this may furthermore open the minds of those who are hesitant on accepting the model. The dramatic and probably unstoppable and ever- increasing fragmentation of medicine with the creation of still new specialties, which are not aware of human suffering and may even negate the necessity of any such contact, makes the implementation of the BPS model all the more important and necessary (Adler, 2009). When progressing this theory, it is important to look at those who will be applying it to the world and the resources. The main priority should be the patient and any method that helps a patient with evidence should be taken into consideration.
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