Specifying the best conception of the biopsychosocial model

‘Specifying the best conception of the biopsychosocial model’ builds on the themes developed in this volume by detailing the relationship between the biopsychosocial model and the aetiology, treatment, nosology, and constitution of mental disorders. It argues that, for the foreseeable future, we should expect all mental disorders to be caused by a conjunction of biological, psychological, and social factors. However, they are not necessarily most effectively treated by a conjunction of biological, psychological, and social interventions. The biopsychosocial model offers minimal guidance regarding how mental disorders are constituted or how they should be classified but it does rule out bioreductive approaches to these issues. Finally, the biopsychosocial model integrates biological, psychological, and social sciences with a concern for subjective experience, meaning, and values-based care, so it doesn’t just count against bioreductive approaches to psychiatry but all forms of scientific reductionism.

The biopsychosocial model, DSM, and neurobiology

This chapter explores the need for a new approach in psychiatry other than the biopsychosocial (BPS) model, the Diagnostic and Statistical Manual of Mental Disorders (DSM), and neurobiology. Pierre Loebel and Julian Savulescu, in their introduction to this book, laid out an honourable purpose, seeking to make sense of psychiatric conditions holistically. They hoped the BPS model could serve this purpose. The model has done so in part, but also, after half a century of effort, it has failed to do so in the end. The goals are worthy and the seekers of those goals have integrity. But perhaps their intentions will be best served by something else, a successor to the past BPS model, built on a rejection of a false DSM diagnostic system as well as a purely neurobiological approach to research. In the end, what Loebel and his colleagues want to do is to preserve a place for humanism in psychiatry, and to link clinical practice to solid scientific research. These laudable principles can be achieved only by a radical departure from the DSM-based neurobiological conventional wisdom of the present and the past.

Psychiatry, folk psychology, and the impact of neuroscience—a response to Steven Hyman’s Loebel Lectures

This chapter reflects on Steven Hyman's Loebel Lectures, which revolve around a contrast between folk psychology and what neuroscience is starting to reveal. Folk psychology is the unscientific picture of what goes on in people’s minds when they perceive, remember, think, feel, decide, and act. It is based on introspection and on intuitive ‘reading’ of other people. In contrast to folk psychology is the fine structure neuroscience is starting to reveal: the brain mechanisms underlying perception, memory, thought, emotion, decision, and action. Hyman says that mapping out this fine structure has the promise of changing the understanding and treatment of psychiatric disorders. Out of this emerges Hyman’s philosophical claim that neuroscience radically challenges the status of folk psychology. Folk psychology, being in conflict with neuroscience, is largely false.

The proper place of subjectivity, meaning, and folk psychology in psychiatry

‘The proper place of subjectivity, meaning, and folk psychology in psychiatry’ argues that Steven Hyman’s vision for psychiatry is excessively bioreductive. Hyman wrongly assumes that conceptual mental content is reducible to brain state descriptions and mistakes the neural vehicle of content for the content itself. Once we see that conceptual content, including the referents of folk psychology, shape brain activity, it becomes clear that content itself (or a lack of it) can be pathological. Therefore, treatment will sometimes be effective, even curative, by addressing that content through discursive interaction with the patient qua person. Diagnosis and effective treatment of mental disorders cannot just focus on neurobiology, as Hyman claims, both processes must also consider conceptual content and the complex interactions between content and the neurobiology instantiating it.

Mental illness: The collision of meaning with mechanism

‘Mental illness: the collision of meaning with mechanism’ is based on the views of psychiatry that Steven Hyman articulated in his Loebel Lectures—mental illness results from the disordered functioning of the human brain and effective treatment repairs or mitigates those malfunctions. This view is not intended as reductionist as causes of mental illness and contributions to their repair may come from any source that affects the structure and function of the brain. These might include social interactions and other sources of lived experience, ideas (such as those learned in cognitive therapy), gene sequences and gene regulation, metabolic factors, drugs, electrodes, and so on. This, however, is not the whole story for psychiatry on Hyman’s view; interpersonal interactions between clinicians and patients, intuitively understood in such folk psychological terms as selfhood, intention, and agency are also critical for successful practice. As human beings who are suffering, patients seek to make sense of their lives and benefit from the empathy, respect, and a sense of being understood not only as the objects of a clinical encounter, but also as subjects. Hyman’s argument, however, is that the mechanisms by which human brains function and malfunction to produce the symptoms and impairments of mental illness are opaque to introspection and that the mechanistic understandings necessary for diagnosis and treatment are incommensurate with intuitive (folk psychological) human self-understanding. Thus, psychiatry does best when skillful clinicians switch between an objectifying medical and neurobiological stance and the interpersonal stance in which the clinician engages the patients as a subject. Attempts to integrate these incommensurate views of patients and their predicaments have historically produced incoherent explanations of psychopathology and have often led treatment astray. For example, privileging of folk psychological testimony, even when filtered through sophisticated theories has historically led psychiatry into intellectually blind and clinically ineffective cul-de-sacs such as psychoanalysis.

Reacting to abuse

This chapter assesses the effects of childhood abuse and neglect. It begins by discussing the ‘overgeneral memory effect’. This is the finding that abused children tend to forget many of the specific happenings in their childhoods. Reflection on it can perhaps help to shed some light on how memory, and its suppression, works. The chapter then draws some parallels with the findings on delayed gratification. It is striking that in both cases one finds a need to shut down certain sorts of thought; the therapeutic interest is in how and when one might get it going again. The chapter also poses a question about how much the effects of childhood abuse are mediated by the expectations of the subjects. Many have claimed, with some plausibility, that one finds such mediation in various psychological illnesses: that the way that subjects understand their own condition affects the symptoms that they display.

Biopsychosocial pathways to mental health and disease across the lifespan: The emerging role of epigenetics

The biopsychosocial (BPS) model of psychiatry has had a major impact on our modern conceptualization of mental illness as a complex, multi-determined phenomenon. Yet, interdisciplinary BPS work remains the exception, rather than the rule in psychiatry. It has been suggested that this may stem in part from a failure of the BPS model to clearly delineate the mechanisms through which biological, psychological, and social factors co-act in the development of mental illness. This chapter discusses how epigenetic processes that regulate gene expression, such as DNA methylation, are fast emerging as a candidate mechanism for BPS interactions, with potentially widespread implications for the way that psychiatric disorders are understood, assessed, and, perhaps in future, even treated.

Which biopsychosocial view of mental illness?

Biopsychosocial theories of mental illness claim that biological, psychological, and social factors are all central to every mental illness. This general approach cannot be assessed or employed properly without specifying the precise relation between mental illnesses and these three levels of understanding. This chapter distinguishes disjunctive, causal, explanatory, therapeutic (or treatment), and constitutive (or definitional) versions of biopsychosocial theories. However, all of these claims are uncontroversial and not distinctive of the biopsychosocial approach, except the constitutive claim. That constitutive claim is inaccurate, because almost all mental illnesses are and should be defined by their psychological symptoms instead of their biological or social causes. These lessons are applied to case studies of post-traumatic stress disorder, disinhibited social engagement disorder, obsessive–compulsive disorder, and scrupulosity.

The biopsychosocial model in psychiatry: Engel and beyond

This chapter examines the biopsychosocial model in psychiatry. The term ‘biopsychosocial’ is most strongly associated with George L. Engel, whose most famous article on the biopsychosocial model was published in 1977. In advancing the model, Engel aimed to make explicit how the biological, the psychological, and the social all had a place in conceptualizing mental disorder, and to systematize and enshrine this recognition in the way in which psychiatry is practised. In making decisions about how to treat mental illness, or a given patient, adopting a biopsychosocial approach should involve keeping in mind that the most effective treatment may involve a solely biological intervention, a solely psychological one, a solely social one, or a combination of these. Indeed, a useful and effective biopsychosocial approach reminds one to consider all of these possibilities, and select the most promising one, based on the available empirical evidence.

Introduction

This introductory chapter discusses the lack of a unifying theory in psychiatry. No generally accepted theory of mental illness exists, in part because there is little agreement on what the concepts ‘mental’ and ‘illness’ entail. Lacking such a theory, the profession has experienced internal divisiveness, uncertainty among applicants for training, and attacks from outside. Since the decline of nineteenth- and twentieth-century paradigms such as psychoanalysis and behaviourism, psychiatrists have been in search of one that acknowledges what is universally recognized, that is, that human beings function in a nexus comprising the psyche, the soma, and the social surround, and that each domain requires consideration when drawing up a psychiatric formulation and treatment plan. Thus, the biopsychosocial (BPS) paradigm proposed by George L. Engel in 1977 was adopted without much enquiry into details. This book presents a nascent, stronger version of the concept based on a growing body of genetic, epigenetic, and other evidence that encompasses a central, overlapping component to the Venn diagram description of the BPS conceptualization.