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https://doi.org/10.1177/10398562211037333

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B iological reductionism in psychiatry can be dehu- manizing and/or demeaning. In many cases it exemplifies the faulty and simplistic logic that

renders psychiatry liable to criticism; it can also be frankly unscientific. Even those psychiatric syndromes arising in context of identifiable biological pathophysi- ology (e.g. autoimmune encephalitides, neurodegenera- tive diseases, structural brain pathology) still ultimately exhibit a pathophenotype inextricably sculpted by the psychological and sociocultural milieu within which the individual exists. The BPS model speaks to this notion and remains the prevailing aetiological (and manage- ment) framework through which most contemporary psychiatric training and practice is applied. However, the BPS model is not without its faults and there are questions regarding its history and contemporary util- ity. This piece seeks to review these issues.

History and development

George Engel did not create the BPS model and the con- cept arose well before 1977. Whilst the idea that multiple factors may contribute to any one individual’s particular form of mental suffering is nothing new, the now widely accepted aetiological concept of what psychiatrist Kenneth Kendler called “empirically-based pluralism”1 was first formally described some twenty-five years before Engel’s venerated 1977 Science paper, “The Need for a New Medical Model: A Challenge for Biomedicine.”2 Prominent American neurologist-cum-psychiatrist Roy

Grinker, who had been trained and personally analysed by Freud, first coined the term “psycho-somatic-social” in an address to the Chicago Psychoanalytic Institute in 1952 where he emphasised the biological aspects of men- tal health and illness in a pushback against psychoana- lytic dogma and stressed the importance of being a doctor first and a psychiatrist or psychoanalyst second.3 A dec- ade later, Grinker would expand on his preliminary BPS concept and again challenge the Freudian church in a lecture delivered to the Association for the Advancement of Psychoanalysis (a “breakaway” group of analysts, of which he helped found, who rejected established Freudian orthodoxy):

“Psychoanalysis, except for the waning influence of reac- tionary organizational factions, is now an open system by virtue of the evolution of structural theory, ego psychology, and the concepts of adaptation. As a result, modern psy- choanalysis is a bio-psycho-social theoretical structure... The frame of reference of a biopsychosocial point of view has been utilized without sacrificing any of the dynamic concepts which psychoanalysis has contributed to psy- chiatry.”4

The biopsychosocial model – history, controversy and Engel

William Lugg Consultation-Liaison Psychiatry Advanced Trainee, Department of Consultation-Liaison Psychiatry, Royal Prince Alfred Hospital, Sydney, Australia

Abstract Objective: The biopsychosocial (BPS) model remains the predominant theoretical framework underpinning con- temporary psychiatric training and practice. Like all models, it has its limitations and its critics. In light of recent censure, The purpose of this article was to (a) review key aspects of the history, development and contemporary utility of the BPS model and, (b) review key contributions of George Engel. Conclusion: An aetiological model for mental disorders that involves psychological, biological and sociocultural factors has existed since at least the 1940s. The term “biopsychosocial” was arguably first coined by Roy Grinker in 1952. Spurred on by his interest in systems theory, Engel expanded upon the model in 1977 and used it to hypoth- esise about the integration of mind and body. Despite its shortcomings, the BPS model remains relevant and useful.

Keywords: biopsychosocial, biopsychosocial model, George Engel, BPS, psychosomatic

Corresponding author: Dr. William Lugg, Consultation-Liaison Psychiatry Advanced Trainee, Department of Consultation-Liaison Psychiatry, Royal Prince Alfred Hospital, Missenden Road, Sydney, Australia. Email: [email protected]

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C omorbid anxiety disorders with depressive dis- orders are clinically important in children and adolescents because they have been shown to

adversely affect outcomes. For instance, increased sever- ity of depressive disorders,1 increased suicidal ideation,2 increased chronicity and recurrence of depressive dis- orders,3 and a lesser response to cognitive behaviour therapy have all been reported.4 Moreover, rates of comorbidity with depressive disorders vary between par- ticular anxiety disorders. For example, generalised anxi- ety disorder (GAD) and social anxiety disorder (SOC) have higher rates of comorbidity than separation anxi- ety disorder and indeed demonstrate the highest risk of subsequently developing depressive disorders.5 In con- trast, panic disorder (PD) is less likely to precede the onset of depressive disorders, although panic attacks, as a risk factor, are associated with depressive disorders.6 In

addition, increasing number and severity of anxiety dis- orders and increasing avoidance phenomena are further risk factors for comorbid depressive disorders.

Importantly, to date, the majority of this depressive and anxiety disorders research has focussed on major depres- sive disorder (MDD) with a systematic examination of dysthymic disorder (DD; DSM-V persistent depressive disorder equivalent) being relatively rare.7 To the authors’ knowledge, there has been no investigation of

Parent- and child-reported anxiety disorders differentiating major depressive disorder and dysthymic disorder in children and adolescents

Alasdair Vance Academic Child Psychiatry Unit, Department of Paediatrics, University of Melbourne, Australia Jo Winther Developmental Neuropsychiatry Program, Royal Children’s Hospital, Australia

Abstract Objective: To date, specific parent- and child-defined anxiety disorders associated with dysthymic disorder (DD; DSM-5 persistent depressive disorder equivalent) with and without major depressive disorder (MDD) have not been investigated in children and adolescents. Method: In a cross-sectional study, we compared point prevalence rates of parent- and child-reported anxiety dis- orders in DD alone (N = 154), MDD alone (N = 29), comorbid DD and MDD (N = 130) and anxiety disorders alone (N = 126) groups. Results: DD alone and MDD alone did not differ with respect to comorbid anxiety disorders from parent and child reports, while parent-reported panic disorder (PD) was significantly increased in the DD and MDD group compared to the other three groups as was child-reported post-traumatic stress disorder (PTSD) compared to the MDD alone and anxiety disorders alone groups. In contrast, specific phobia (SpPh) was significantly increased in the anxiety disorders alone group compared to the DD and MDD group. Conclusion: The findings suggest that specific fear-related anxiety disorders, especially parent-reported PD and child-reported PTSD, may aid the early recognition of DD and MDD.

Keywords: major depressive disorder, persistent depressive disorder, anxiety disorders

Corresponding author: Alasdair Vance, Academic Child Psychiatry Unit, Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 3052, Australia. Email: [email protected]

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Going further back, it was existential psychiatrist Victor Frankl who, drawing on his own personal experience in Auschwitz, and through the lens of “making meaning through suffering,” sought to draw more attention to the spiritual aspects of the human condition. In his 1946 book The Doctor and the Soul, Frankl wrote of the “somatopsychospiritual” essence of humanity.5 A year later, in 1947, psychiatrist John Romano wrote about the need for “a more comprehensive frame of reference... in which psychological and social facts exist or coexist with more impersonal biological factors, eventually to cause, provoke, or otherwise modify variations in the total human biological behaviour.”6

It is important to note that, within the literature, psy- chiatry never “owned” the BPS concept. A PubMed search for “biopsychosocial” reveals no fewer than fourteen separate publications prior to 1977, dating as far back as 1951. More specifically, the first mention of “biopsycho- social model” is still three years earlier, in a 1974 paper entitled, “An alternative: the biopsychosocial model”7 authored by an occupational therapist (OT). Of the four- teen papers listed on PubMed prior to 1977, only three are directly related to psychiatry. Three others are related to paediatrics, two each to linguistics and nursing, and one each to general medicine, alcoholism, OT and sociol- ogy. Indeed, Engel’s 1977 paper was not actually directed at a psychiatric audience but a general medical one. It was only in his later 1980 paper, “Clinical Application of the Biopsychosocial Model”,8 published in the American Journal of Psychiatry, that Engel targeted a psychiatric

audience and, ironically, in that paper he used a medical case (ischaemic heart disease) to illustrate his key points.

Validity and contemporary utility

Some have questioned the validity of the BPS model.9,10 The first obvious question is, what exactly is a “model”? Respected late British statistician George Box described a scientific model as a construct which “seeks to represent empirical objects, phenomena, and physical processes in a logical and objective way.”11 Box qualified this by say- ing that all scientific models are “in simulacra, that is, simplified reflections of reality that, despite being approximations, can be extremely useful.”11 An aetio- logical construct for mental disorders that incorporates biological, psychological and sociocultural factors in myriad complex, interacting, irreducible, and yet often simplified and hitherto not fully understood ways, is arguably both an approximation and extremely useful – that is, it is a model. And whilst the “BPS model” cannot, by definition, explain everything, on the basis of Box’s definition, it certainly holds validity.

The recently published RANZCP clinical practice guide- lines for mood disorders explores four key aetiological realms in some detail: (1) Stress, (2) Genetics and gene- environment interactions, (3) Circadian function, and (4) Cognition.12 The authors provide an informative sum- mary of the literature pertaining to the complex ways in which these biological, psychological and sociocultural

Figure 1. Genetic and environmental influences in the development of mood disorders (Source: Malhi et al., 2021). The variety of factors listed in this diagram could be considered under the broader domains of “biological” (e.g. polygenetic heritability), “psychological” (e.g. consequences of loss, neglect and/or domestic violence) and “social” (e.g. consequences of broken relationships, financial difficulties and/or loss of employment)

Lugg

substrates may interact and, collectively, play a causal role in ultimately producing the pathophenotypes we call “mood disorders” (see Figure 1). The mechanisms dis- cussed are arguably consistent, observable, (often) pre- dictable, quantifiable and testable – that is, they are scientific. When considered together, and in context, they provide a useful aetiological approximation of what is believed to occur in reality – that is, they form a model, a so-called “BPS model.” Indeed, distinguished American professor of psychiatry, Ronald Pies, endorsed this view when he said, “[mood disorders] are best understood using a bio-psycho-sociocultural model, which has been the mainstay of academic psychiatry for over 30 years.”13

More recently, Jim van Os and colleagues have advocated for the addition of an “existential” (E) component to the BPS model (i.e. a BPSE model) that would be considered central to its clinical application.14 They contend that whilst the BPS model provides a useful avenue to concep- tualise mental health, illness and treatment, it says little

about the ultimate purpose of doing so. The addition of an existential component would arguably therefore inject a sense of meaning and purpose into the model: “restoration of health is not the goal, but rather the means to enable the patient to find and pursue meaning- ful goals.”14 The authors nonetheless acknowledge that there are challenges in reconciling prevailing symptom- reduction (psychobiological) approaches with more meaningful-life (existential) perspectives within contem- porary mental health services.

George Engel

Despite the common misconception that Engel “origi- nally proposed” the BPS model,13 no discussion would be complete without an exploration of his significant contribution to it. Engel trained as a gastroenterologist and did not undergo any formal psychiatric training, but neither did Sigmund Freud and, on the matter of mental experience, Freud’s credentials are seldom questioned. Spurred on by his interest in the psychological aspects of gastroenterological conditions, Engel did complete five years of formal psychoanalytic training at the same place Roy Grinker had worked as an analyst, the Institute for Psychoanalysis in Chicago (which at the time was run by the esteemed Franz Alexander and was considered the epicentre of “psychosomatic medicine” – what we now broadly refer to as Consultation-Liaison psychiatry).

Engel’s interest in psychiatry and mental disorders is pal- pable through his writings. In 1962 he authored a medi- cal textbook entitled Psychological development in health and disease, and in 1969 he co-authored The Clinical Approach to the Patient which included psychological considerations. In his famous 1977 Science paper, Engel mentioned “mental” or “behavioural disorder” no fewer than seven times, and he mentioned “psychiatry” twenty-two times.2 According to Nassir Ghaemi, Engel’s key areas of interest included psychogenic pain and the psychological states of infants with gastric fistulas.15 And, whilst in approximately 175 authored articles and reviews Engel apparently never wrote anything specific about mania or schizophrenia15 (he was not, after all, a psychiatrist), he certainly spoke at length about a range of mental disorders and concepts central to psychiatric theory and practice.

Like Grinker, Engel was interested in “Systems Theory” and drew heavily on the work of Weiss and von Bertalanffy.8 In his 1980 paper, Engel detailed how the various components of the BPS model may interact in complex, yet irreducible, ways and how the application of its principles served to benefit patients – in his view, not in a fluffy humanistic way, but in a scientific way.8 Pertinent to his theory was the idea of a “continuum of natural systems” that are organised within a hierarchy – from subatomic particles, through to cells and organs, the individual person, the doctor-patient dyad, all the way up to society, nation and the biosphere at large (see Figure 2).

Figure 2. The “continuum of natural systems” as proposed by Engel (1980). Note that the individual person exists in the middle of the continuum and that at each level above and below the individual is an interconnected “system.” Each system may be subsumed under “biological,” “psychological” and/or “sociocultural” domains – any perturbation at one of these domains has the potential to cause a variety of “intrasystem changes” anywhere within the hierarchy

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George Engel

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Conceptually, Engel argued these different systems may be subsumed under broader biological, psychological and sociocultural domains. Any perturbation of one domain may lead to various “intrasystem changes” that occur at different levels within the hierarchy. Using the example of a 55-year-old man who presented with chest pain and is subsequently diagnosed with a coronary

artery occlusion, Engel provided seven diagrams to illus- trate his theory (see Figure 3. for one example).

The integration of mind and body

Engel was recently criticised for writing “nothing of any intellectual significance” about the infinitely complex

Figure 3. “Event 6: Stabilisation of myocardial damage.” From Engel’s 1980 paper where he describes the case of Mr. Glover, a 55-year-old married real estate salesman with two adult sons, taken to the Emergency Department with symptoms suggestive of myocardial ischaemia. “Event 1” is the coronary artery occlusion itself. “Event 6” is after he has been medically assessed, initially managed and attained a state of relative myocardial stabilisation. At this point, Engel illustrates how such an event induces a wide variety of “intrasystem changes” within all levels of the “systems hierarchy” and how each system is inextricably linked to each other – i.e. a “system of systems.”

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notion of the integration of mind and body.9 However, in his 1980 paper, Engel explicitly addressed this age-old conundrum by using the same clinical example (coro- nary artery occlusion):

“Central here is the role played by the central nervous sys- tem (CNS) in the integration and regulation of the indi- vidual’s inner experiences (i.e. mind) and behaviour and the physiological adjustments occurring in response to the processes originating in the oxygen-deprived myocardium (i.e. body). Such CNS-mediated processes are not neces- sarily in harmony with one another. Physiological adjust- ments to myocardial ischaemia may be countered by car- diovascular responses to pain and discomfort as well as by the demand for increased work by the heart resulting from inappropriate behaviour.”8

Engel argued that in recognising the connections between mind-body systems, and therefore the “intrasys- tem changes” that occur within them, the BPS-minded physician may potentially prevent another heart attack because they will identify and address these crucial “psy- cho-bio” physiological mediators, whereas the purely biomedical physician will not - take what you will from this. Whilst Engel’s expansion on the BPS concept may have a touch of the “Theory of Everything” about it, it is not without its merits – and one need not agree in entirety to give credit where credit is due. For example, the association between psychiatric morbidity and car- diovascular disease is now well established, complex mechanisms are increasingly understood and, overall, the emerging literature seems to vindicate much of what Engel postulated forty years ago.

Conclusion

The BPS model is an old concept with many past cham- pions – George Engel being one such exemplar. Whilst it is both important and necessary to maintain a healthy skepticism of the ultimate coherence (and, at times, unfettered eclecticism) of the prevailing BPS model, it nonetheless remains a relevant and useful component of contemporary psychiatric theory and practice.

Disclosure The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.

Funding Nothing to declare

ORCID iD William Lugg https://orcid.org/0000-0002-7377-1338

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