As 30 years ago, the dominant model of disease today is biomedical, with molecular biology being the basic scientific discipline. Indeed, there has been a progressive decline of clinical observation as the primary source of scientific challenges [5] . Yet, the evidence supporting the biopsychosocial model has considerably increased over the years. A large body of research has documented the role of stressful life events and repeated or chronic environmental challenge in modulating individual vulnerability to illness [6] . The tendency to experience and communicate psychological distress in the form of physical symptoms and to seek medical help for them is a widespread clinical phenomenon that may involve up to 30 or 40% of medical patients and increases medical utilization and costs [7, 8] . Medically unexplained symptoms appear to be the rule in primary care [7, 8] and the traditional boundaries among medical specialties, based mostly on organ systems (e.g. cardiology, gastroenterology) appear to be more and more inadequate in dealing with symptoms and problems which cut across organ system subdivisions and require a holistic approach. Moreover, affective disturbances (such as depression, anxiety, hostility) and illness behavior, the ways in which individuals experience, perceive, evaluate and respond to their own health status, may affect the course, therapeutic response and outcome of a given illness episode [7] . Psychological well-being [9] was found to play a protective role in the dynamic balance between health and disease outlined by Engel [1] . The need to include considThirty years ago George L. Engel [1] highlighted the inadequacies and limitations of the traditional biomedical model and advocated the endorsement of a biopsychosocial approach. The article had a considerable impact on the scientific community and attracted nearly 1,900 citations over the years. The biopsychosocial model allows illness to be viewed as a result of interacting mechanisms at the cellular, tissue, organismic, interpersonal and environmental levels. Accordingly, the study of every disease must include the individual, his/her body and his/her surrounding environment as essential components of the total system [1, 2] . Psychosocial factors may operate to facilitate, sustain or modify the course of illness, even though their relative weight may vary from illness to illness, from one individual to another and even between 2 different episodes of the same illness in the same individual. The key characteristic of clinical science is its explicit attention to humanness, where ‘observation (outer viewing), introspection (inner viewing), and dialogue (interviewing) are the basic methodologic triad for clinical study and for rendering patient data scientific’ [3, p. 59]. Engel identified the biopsychosocial model as a more complete conceptual framework to guide clinicians in their everyday work with patients. He thought that the transition from the narrow biomedical model to the biopsychosocial model was the major challenge to medicine in the seventies [1] . Has the challenge been met? Not at all, as examined in a recent monograph on the biopsychosocial approach [4] .
The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient's subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental and physical aspects of health is complex--subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocial model has not been in the discovery of new scientific laws, as the term "new paradigm" would suggest, but rather in guiding parsimonious application of medical knowledge to the needs of each patient.
The biopsychosocial model outlined in Engel's classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel's call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation's International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.
The prevalence and cost of chronic pain is a major physical and mental health care problem in the United States today. As a result, there has been a recent explosion of research on chronic pain, with significant advances in better understanding its etiology, assessment, and treatment. The purpose of the present article is to provide a review of the most noteworthy developments in the field. The biopsychosocial model is now widely accepted as the most heuristic approach to chronic pain. With this model in mind, a review of the basic neuroscience processes of pain (the bio part of biopsychosocial), as well as the psychosocial factors, is presented. This spans research on how psychological and social factors can interact with brain processes to influence health and illness as well as on the development of new technologies, such as brain imaging, that provide new insights into brain-pain mechanisms.
Several studies have reported that musculoskeletal disorders of the stomatognathic system, commonly known as temporomandibular disorders (TMD) resemble musculoskeletal disorders and chronic pain disorders in general. There is also general consensus that combined biomedical and biopsychosocial methods best support the assessment and management of the cardinal features of TMD, i.e., pain and dysfunction or physical (peripheral) and psychosocial (central) factors. This overview of the aetiology of TMD will outline conceptualizations of past models and present the current view that patients with TMD should be assessed according to both the physical disorder and the psychosocial illness impact factors. The conceptual theories outlined in this review include biomedical models related to temporomandibular joints, muscles of mastication and occlusal factors, psychological models and the biopsychosocial models. An integrated and multidimensional approach concerning physical and psychosocial factors in temporomandibular pain and dysfunction is presented as an example of how the biopsychosocial model and information processing theory may apply in the conceptualization and management of TMD for various health care professionals.
Various authors have noted that interethnic group and intraethnic group racism are significant stressors for many African Americans. As such, intergroup and intragroup racism may play a role in the high rates of morbidity and mortality in this population. Yet, although scientific examinations of the effects of stress have proliferated, few researchers have explored the psychological, social, and physiological effects of perceived racism among African Americans. The purpose of this article was to outline a biopsychosocial model for perceived racism as a guide for future research. The first section of this article provides a brief overview of how racism has been conceptualized in the scientific literature. The second section reviews research exploring the existence of intergroup and intragroup racism. A contextual model for systematic studies of the biopsychosocial effects of perceived racism is then presented, along with recommendations for future research.
OBJECTIVE: To review the evidence supporting the biopsychosocial model in understanding patients with gastrointestinal disorders (GI). METHOD: Essay of personal experience and review of related literature through a MEDLINE search. RESULTS: Through clinical examples of three common gastrointestinal disorders, a case is made to refocus our understanding from a biomedical or disease-based model of illness to a biopsychosocial model. With the latter model, the psychosocial and biological predeterminants are seen to interact in the clinical expression of illness and disease. With gastroesophageal reflux disease, the evidence shows that stress can lead to amplification of heartburn symptoms that is independent of the degree of reflux. Functional gastrointestinal pain is "an illness without disease," where structural or physiological disturbance of the GI system does not exist. Rather, the symptoms are understood in terms of visceral hypersensitivity as modulated by central nervous system activity. With the Crohn's disease example, the clinical expression of the disorder is not explained by the degree of disease activity. Rather, the symptoms and impaired quality of life relate to preexisting psychosocial determinants. The observed association of stress with disease activation in Crohn's disease is explained by stress-related alterations in psychoimmunological function via the hypothalamic-pituitary-adrenal axis. CONCLUSIONS: Gastrointestinal disorders, as a model for other medical conditions, exemplify the important role of an integrated, biopsychosocial model of illness.
Although advances have been made in specifying connections between biological, psychological, and social processes, the full potential of the biopsychosocial model for health psychology remains untapped. In this article, 4 areas that need to be addressed to ensure the continued evolution of the biopsychosocial model are identified and a series of recommendations concerning initiatives directed at research, training, practice and intervention, and policy are delineated. These recommendations emphasize the need to better understand and utilize linkages among biological, psychological, social, and macrocultural variables. Activities that facilitate the adoption of a multisystem, multilevel, and multivariate orientation among scientists, practitioners, and policymakers will most effectively lead to the kinds of transdisciplinary contributions envisioned by the biopsychosocial perspective.
Abstract The biopsychosocial model has dominated research and theory in health psychology. This article expands the biopsychosocial model by applying systems theories proposed by developmental scholars, including Bronfenbrenner's ecological models and Sameroff's transactional model, as well as contemporary philosophical work on dynamic systems. The proposed dynamic biopsychosocial model construes human health as a product of the reciprocal influences of biological, psychological, interpersonal, and macrosystem contextual dynamics that unfold over personal and historical time. The importance, or centrality, of these influences varies within a person over time. The model is explicated using two hypothetical case studies derived from existing interdisciplinary health research. Implications for health, theory, research, and policy are discussed.
OBJECTIVE: To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. DESIGN: Systematic review and random effects meta-analysis of randomised controlled trials. DATA SOURCES: Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials. STUDY SELECTION CRITERIA: Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention. RESULTS: Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, -0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery. CONCLUSIONS: Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care.
The biopsychosocial model has been demonstrated to be the most heuristic approach to chronic pain assessment, prevention, and treatment. Currently, this model also provides the best foundation for tailoring the most comprehensive pain management program for each specific patient. Chronic pain patients have an increased risk for developing deficits in physical functioning, emotional reactivity, and cognition. Interdisciplinary treatment, based on the biopsychosocial model, is vital to address these multifaceted issues facing chronic pain sufferers. These interdisciplinary pain management strategies have progressed with advancements in science and technology in an attempt to provide the best possible outcomes for pain patients. However, while research has made enormous advances, there are still some clinical research gaps to be addressed. This article will begin with a historical overview of pain management in order to demonstrate the evolution in theory from ancient practices to the modern biopsychosocial model. Additionally, functional restoration and other early interdisciplinary intervention programs will be highlighted for their importance and effectiveness in chronic pain management, assessment, and prevention.
OBJECTIVE: The aim of this review is to provide an analysis of the epistemic status of the biopsychosocial model. METHOD: A critical comparison of the biopsychosocial model with the general concept of models. RESULTS: In its present form, the biopsychosocial model is so seriously flawed that its continued use in psychiatry is not justified. CONCLUSION: Further development of theory-based models in psychiatry is urgently needed.
How physicians approach patients and the problems they present is much influenced by the conceptual models around which their knowledge is organized. In this paper the implications of the biopsychosocial model for the study and care of a patient with an acute myocardial infarction are presented and contrasted with approaches used by adherents of the more traditional biomedical model. A medical rather than psychiatric patient was selected to emphasize the unity of medicine and to help define the place of psychiatrists in the education of physicians of the future.
There is now a growing movement that views a number of behaviours as potentially addictive including many that do not involve the ingestion of a drug (such as gambling, sex, exercise, videogame playing and Internet use). This paper argues that all addictions consist of a number of distinct common components (salience, mood modification, tolerance, withdrawal, conflict and relapse). The paper argues that addictions are a part of a biopsychosocial process and evidence is growing that excessive behaviours of all types do seem to have many commonalities. It is argued that an eclectic approach to the studying of addictive behaviour appears to be the most pragmatic way forward in the field. Such commonalities may have implications not only for treatment of such behaviours but also for how the general public perceive such behaviours.
Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non-threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence-based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation.
The etiology of alcoholism is best understood within the context of a longitudinal-developmental framework that includes physiological behavioral and sociocultural variables. The recently reported Vaillant fol- low-up study, although ostensibly set within such a frame- work, in fact understates the role of personality influences and dismisses childhood effects out of hand. We review these data and offer a different set of conclusions about the roles of childhood influences, personality, and cultural factors in the etiologic process. An alternative integrative review of the existing longitudinal literature is presented that sets these findings in the context of a biopsychosocial process. Alcoholism is a profoundly damaging disorder whose im- pact spreads far beyond the one who suffers from it. The problem of understanding its causes is also an especially interesting one. Recent evidence suggests that the char- acteristics that lead an individual to begin drinking may only be tied loosely to influences on later stage drinking and problem drinking phenomena. The factors connected with beginning a pattern of problem use are not neces- sarily the same as those pharmacological and behavioral characteristics that contribute to the maintenance of the alcohol use pattern or to the later build-up of a habitual problem involving alcohol abuse or dependency. Given this state of affairs, it is also likely that different orderings of the importance of etiologic factors will be needed to adequately describe cause and effect at different stages in the process. Thus, Korsakoff's syndrome, one end-state phenomenon of chronic alcohol abuse, is a pathology best described in neuropathological terms; the direction of ef- fect is best understood as going from brain dysfunction to behavior (Wilkinson & Carlen, 1981). In contrast, the onset of alcohol use is best understood as a phenomenon predicted by individual difference variables and social in- fluences (Jessor & Jessor, 1975; Margulies, Kessler, & Kandel, 1977). The theoretical models and data language used to describe these multiple phenomena of onset, maintenance, and dependency involve radically different levels of explanation and different orderings of physio- logical, behavioral, and socioenvironmental variables at different points in the life cycle. It is not surprising, there- fore, that such a complex multidisciplinary problem has in earlier times generated simplistic and reductionistic explanations in an effort to describe its process. In the past decade, several etiologically focused lon- gitudinal studies have been carried out with a broad enough data set and a multivariate analytic strategy that begins to allow for the partitioning of variance contri- butions. However, all of those that have moved far enough along to warrant publication have been concerned with the early stages of drinking and problem drinking ac- quisition (Huba & Bentler, 1984; Jessor & Jessor, 1977; Kandel & Logan, 1984), or have dealt with a group of subjects who have had largely normal or at worst episod- ically disturbed drinking patterns (Fillmore, 1975; Fill- more, Bacon, & Hyman, 1979). None have dealt with frankly alcoholic respondents, and none have been suf- ficiently comprehensive to allow for the evaluation of the extent of effect contributed by biological (including ge- netic), psychological, social, and cultural factors. It is, therefore, a significant event for the field when a data set is presented that promises to address the etiological ques- tion of how alcoholism evolves, with a prospective method and a sufficiently broad array of variables such that the potential biopsychosocial nature of the disorder can be examined. This is the importance of a recent report by Vaillant and Milofsky (1982). Since its publication, this study has received sub- stantial attention in the literature. Given the significant disagreement we have with the authors' interpretation of their own data as well as their interpretation of earlier longitudinal work in the area, we felt that an alternative interpretation of their findings and of the earlier studies was in order. In the present article, we examine very closely the details of Vaillant and Milofsky's study with particular attention to the role of personality and of childhood influences on alcoholic behavior, reach a dif- ferent set of conclusions, and find significant support for an alternative position based on our own integrative re- view of the prospective literature on alcoholic etiology that substantially differs from Vaillant and Milofsky's ac- count. Vaillant's Follow-up Study
A biopsychosocial model of the development of adolescent chronic conduct problems is presented and supported through a review of empirical findings. This model posits that biological dispositions and sociocultural contexts place certain children at risk in early life but that life experiences with parents, peers. and social institutions increment and mediate this risk. A transactional developmental model is best equipped to describe the emergence of chronic antisocial behavior across time. Reciprocal influences among dispositions, contexts, and life experiences lead to recursive iterations across time that exacerbate or diminish antisocial development. Cognitive and emotional processes within the child, including the acquisition of knowledge and social-information-processing patterns, mediate the relation between life experiences and conduct problem outcomes. Implications for prevention research and public policy are noted.
Part I. An Introduction: Basic Issues and Processes. Chapter 1. An Overview of Psychology and Health. Chapter 2. The Body's Physical Systems. Part II. Stress, Illness, and Coping. Chapter 3. Stress -- Its Meaning, Impact, and Sources. Chapter 4. Stress, Biopsychosocial Factors, and Illness. Chapter 5. Coping with and Reducing Stress. Part III. Lifestyles to Enhance Health and Prevent Illness. Chapter 6. Health-Related Behavior and Health Promotion. Chapter 7. Substance Use and Abuse. Chapter 8. Nutrition, Weight Control and Diet, Exercise, and Safety. Part IV. Becoming Ill and Getting Medical Treatment. Chapter 9. Using Health Services. Chapter 10. In the Hospital: The Setting, Procedures, and Effects on Patients. Part V. Physical Symptoms: Pain and Discomfort. Chapter 11. The Nature and Symptoms of Pain. Chapter 12. Managing and Controlling Clinical Pain. Part VI. Chronic and Life-Threatening Health Problems. Chapter 13. Serious and Disabling Chronic Illnesses: Causes, Management, and Coping. Chapter 14. Heart Disease, Stroke, Cancer, and AIDS: Causes, Management, and Coping. Part VII. Looking to the Future. Chapter 15. What's Ahead for Health Psychology.
PURPOSE: This article presents a model for research and practice that expands on the biopsychosocial model to include the spiritual concerns of patients. DESIGNS AND METHODS: Literature review and philosophical inquiry were used. RESULTS: The healing professions should serve the needs of patients as whole persons. Persons can be considered beings-in-relationship, and illness can be considered a disruption in biological relationships that in turn affects all the other relational aspects of a person. Spirituality concerns a person's relationship with transcendence. Therefore, genuinely holistic health care must address the totality of the patient's relational existence-physical, psychological, social, and spiritual. The literature suggests that many patients would like health professionals to attend to their spiritual needs, but health professionals must be morally cautious and eschew proselytizing in any form. Four general domains for measuring various aspects of spirituality are distinguished: religiosity, religious coping and support, spiritual well-being, and spiritual need. A framework for understanding the interactions between these domains is presented. Available instruments are reviewed and critiqued. An agenda for research in the spiritual aspects of illness and care at the end of life is proposed. IMPLICATIONS: Spiritual concerns are important to many patients, particularly at the end of life. Much work remains to be done in understanding the spiritual aspects of patient care and how to address spirituality in research and practice.
INTRODUCTION: The term neurodiversity is defined and discussed from the perspectives of neuroscience, psychology and campaigners with lived experience, illustrating the development of aetiological theories for included neurodevelopmental disorders. The emerging discourse is discussed with relevance to adults, social inclusion, occupational performance and the legislative obligations of organizations. SOURCES OF DATA: Literature is reviewed from medicine, psychiatry, psychology, sociology and popular press. No new data are presented in this article. AREAS OF AGREEMENT: There is consensus regarding some neurodevelopmental conditions being classed as neurominorities, with a 'spiky profile' of executive functions difficulties juxtaposed against neurocognitive strengths as a defining characteristic. AREAS OF CONTROVERSY: The developing nomenclature is debated and the application of disability status versus naturally occurring difference. Diagnosis and legal protections vary geographically, resulting in heretofore unclear guidance for practitioners and employers. GROWING POINTS: The evolutionary critique of the medical model, recognizing and updating clinical approaches considering the emerging consensus and paradigmatic shift. AREAS TIMELY FOR DEVELOPING RESEARCH: It is recommended that research addresses more functional, occupational concerns and includes the experiences of stakeholders in research development, moving away from diagnosis and deficit towards multi-disciplinary collaboration within a biopsychosocial model.