Biopsychosocial Models

Question 1

Biomedical Model

Answer 1

Only biological, physical aspects of an illness are considered.

Psychological or social factors are largely ignored

Question 2

Psychosomatic medicine

Answer 2

Developed by Franz Alexander a student of Freud in the early 20th century.

Suggested illness can have psychological causes as well as consequences.

Claimed emotions could be expressed physically

Question 3

George Engel (1913-1999)

Answer 3

American psychiatrist

Trained in psychoanalysis

Focused on medical, not psychiatric, illness

Formulated the biopsychosocial model

Question 4

Biopsychosocial models

Answer 4

Biopsychosocial models are the mainstream ideology in contemporary psychiatry

The medical model (that disorders are the result of purely biological factors) has little support

Biopsychosocial models suggest that disorders (psychological and physical disorders) are cause by a combination of biological, psychological, and social factors

Provides a more holistic, humanistic and pragmatic framework than one of these factors alone

Question 5

What causes illness- Biopsychosocial Model

Answer 5

Illness can have biological, psychological and social causes.

The individual may have some responsibility.

The whole person should be treated, not just the physical changes.

What causes illness: The medical profession and the individual.

Relationship between health and illness: They exist on a continuum.

What is the relationship between the mind and body: They are separate but interact.

What is the role of psychology in health and illness: Psychological factors contribute at all stages along the continuum from healthy through to being ill.

Question 6

Phenotype (symptoms of a disorder):

Answer 6

Social
E.g. Poverty, Isolation (not having someone to talk to about problems), Discrimination, Migration

Psychological
E.g. Childhood trauma, Stress, Frustration, Grief, Shock

Biological
E.g. Genetic (inherited) causes, Chemical Imbalance, Brain damage/abnormalities

Question 7

Factors

Answer 7

In research, we would generally increase the social component to include all environmental factors

This would include some factors which would likely have a direct effect on biological factors (e.g. cause brain damage/ chemical changes)

Psychological factors are now likely to refer to cognitive factors (ways of thinking about things/situations/self) and behavioural (learned behaviours) in addition to childhood trauma etc.

Relationships between factors are multidirectional

Question 8

Schizophrenia

Answer 8

Dopamine Hypothesis:

Symptoms of Schizophrenia are caused by an excess of dopamine.

Post mortems of Schizophrenics show higher than normal levels of dopamine in the limbic system of the brain.

Anti-schizophrenic drugs inhibit the ability of dopamine receptors to respond to dopamine. Produce side effects similar to Parkinson’s disease which is caused by low levels of dopamine.

Sustained amphetamine abuse produces symptoms similar to psychosis. Effects are caused by increasing brain dopamine activity.

Question 9

Dopamine Hypothesis:

Answer 9

However, the evidence is, inconclusive.

No consistent difference in dopamine and levels between normals and schizophrenics.

Time taken for antipsychotic drugs to reduce symptoms.

Direction of relationship unclear

Even if dopamine were found to be a causative factor, this might only be indirect.

There are a number of forms of schizophrenia - unlikely dopamine plays a role in them all.

Question 10

Genetic Theory of Schizophrenia:

Answer 10

Schizophrenia has heritability levels comparable to other medical conditions known to have strong genetic components.

Concordance studies have found that if an individual is diagnosed as schizophrenic, the probability with which the family member or relative will develop schizophrenia is dependent on how closely they are related ranging from 1% for spouses to 44% for monozygotic twins.

Question 11

Social Approaches to Schizophrenia

Answer 11

The role of family dynamics

Expressed Emotion (EE)

Three aspects of family interaction important in determining relapse following discharge from hospital.

Number of critical remarks made by family members
Number of expressions of hostility towards the individual
Number of comments indicating emotional over-involvement with individual

High levels of EE related to increased relapse rates.

Question 12

Psychological Approaches to Schizophrenia

Answer 12

Cognitive Approach – Schizophrenia as psychological processes that go wrong.

Breakdown in source monitoring:

Dysfunctional metacognitive beliefs about their own mental processes may:
Lead hallucinating schizophrenics to make self-defeating efforts to control their thoughts
Lead to poor perception in cause and effect

Question 13

Psychological Approaches to Schizophrenia pt2

Answer 13

Breakdown in ability to monitor intentional states.
Voice hearing schizophrenics are able to tickle themselves
Unable to dampen auditory perception areas of the brain during talking and inner speech.

Patients with delusions perform normally on measures of reasoning, however, they show a tendency to jump to conclusions and ask for less information before reach a decision.

Theory of mind deficits have been specifically implicated in persecutory delusions.

Question 14

Childhood Trauma

Answer 14

Trauma can be defined as:
Exposure to actual or threatened death,
serious injury, or sexual violence.

In children this may be as a result of motor vehicle accidents, bullying, terrorism, exposure to war, child maltreatment (physical, sexual, and emotional abuse; neglect) and exposure to domestic and community violence (De Bellis & Zisk, 2014).

Therefore trauma has almost entirely social and environmental causes.

Question 15

Childhood Trauma Outcomes:

Answer 15

Post Traumatic Stress Disorder

Depression

Anxiety

Development of psychosis in later life

Development of bipolar disorder in later life

Physical health problems

Antisocial behaviour

Increased risk of alcohol and substance abuse

Question 16

Evidence for link between childhood trauma and psychosis.

Answer 16

Children who experience physical maltreatment by a parent have higher risk of developing psychotic symptoms by age 12. This effect is greater if the child is also bullied by peers (Arseneault et al., 2011).

Other studies have found associations with child maltreatment and psychosis in adults.
Patients approaching treatment for the first time with psychotic disorders have a higher level of childhood maltreatment (Fisher et al., 2010).

Meta-analysis by Varese et al. (2012) found childhood adversity and trauma substantially increases the risk of psychosis.

Question 17

Psychological Explanations

Answer 17

Development of depression and anxiety immediately following trauma related to increased risk of psychosis in later life.

Exposure to threatening environment may lead to hostile attributions towards others intentions or hypervigilance.

Adaptive in short term, may have long term affect on ability to form secure attachments.

Being overly suspicious of others intentions and behaviour may predispose towards psychotic symptoms such as paranoid delusional beliefs.

Question 18

Social/Environmental Explanations

Answer 18

Childhood maltreatment is related to increased likelihood of victimisation in adulthood which is in turn associated with psychosis.

Social isolation resulting from mistrust of others removes normalising alternative explanations from peers in relation to anomalous psychotic experiences and full blown hallucinations may develop.

Having a parent with psychosis increases the likelihood of being maltreated and increases susceptibility to developing the condition.

Childhood trauma has been linked to alcohol and substance abuse both known risk factors for psychosis.

Question 19

Biological Explanations pt2

Answer 19

Direct consequences of maltreatment e.g. head injuries.

Brain development: Childhood trauma has been associated with reduction in grey matter in areas related to the limbic system abnormalities of which have been linked to schizophrenia.

Question 20

Biological Explanations

Answer 20

Increased stress response following trauma, amplified by repeated trauma events may eventually lead to psychotic symptoms.

Evidence of dysregulation of hypothalamic-pituitary-adrenal (HPA) axis (central to hormonal responses to stress) has been found in girls expose to sexual abuse. Similar abnormalities can be found in those experiencing psychosis.

Genetic predisposition. May make individuals exposed to trauma more susceptible to developing psychosis.
Individuals with the A allele of the FKBP5 gene more likely to have symptoms following childhood trauma than those without this gene variant (Diathesis Stress Model).

Childhood trauma has been linked to gene expression impacting on dopamine regulation.

Question 21

Summary

Answer 21

Biopsychosocial models suggest that the interaction of biological, psychological and social factors cause both psychological and physical disorders

The interaction of these factors is multi-direction – all factors can interact with each other

Biopsychosocial models may not be particularly helpful in psychiatry as it often allows the physician to pick and choose based on personal opinion

The diathesis-stress model suggests that people have a predisposition towards mental illness, which then manifests as a result of a stressor

Question 22

Eclecticism

Answer 22

the ability to individualise treatment to the patient

Can be advantageous – tailoring treatment to the patient

Can be disadvantageous – the freedom to do whatever one wants to

Question 23

The more is better fallacy

Answer 23

Truth is achieved by adding more and more perspectives – getting closer and closer to a highly complex reality

But sometimes reductionism is not wrong

Peptic Ulcer Disease was long considered a psychosomatic illness, but is now known to be caused by Helicobacter Pylori

Also fallacious in terms of treatment

Common sense suggests that a combination of cognitive therapy and pharmacological treatment would be more efficient than either alone

Empirical evidence is mixed, so does not support this outright

Depends on the condition and the patient

Question 24

The problems with the biopsychosocial model are partially historical and partially practical:

Answer 24

Historically, the ‘psycho’ in biopsychosocial models referred to psychoanalysis, and so psychoanalytic theory has been over represented

Practically, therapists/psychiatrists could pick and choose therapies based on personal opinion rather than empirical evidence

In terms of research, however, it is a good framework

While it is possible that some psychological disorders are not always caused by a combination of all three factors, they should be considered

Question 25

Practical Difficulties

Answer 25

The biopsychosocial framework suggests the complex interaction of biological, psychological and social factors

Designing and carrying out experiments which look at all of these factors is extremely problematic – maybe even impossible

Practical difficulties include:
Sample size
Difficulty in recruiting – both practically and ethically – samples with particular environmental influence, e.g. trauma
Cost

Question 26

Diathesis-Stress

Answer 26

Diathesis is defined as a predisposition towards an illness

The Diathesis-Stress model of psychopathology is somewhat similar to the biopsychosocial model

Biopsychosocial models emphasise the interdependence of biological, psychological, and social factors

The Diathesis-Stress model suggests that some people have a predisposition to a mental illness, and that the occurrence of a stressor (i.e traumatic or stressful life event) will cause the disorder to manifest

Question 27

Predispositions

Answer 27

A predisposition can be present in varying amounts

Someone with a strong predisposition will only require a small stressor to cause the disorder to manifest

Someone with a weaker predisposition will require a far greater stressor to cause the disorder to manifest

Question 28

What causes illness- Biomedical Model

Answer 28

External or internal agents that cause physical changes.

Individuals are not responsible.

By using interventions that seek to change the physical state of the body.

What causes illness: The medical profession.

Relationship between health and illness: They are distinct from one another.

What is the relationship between the mind and body: They function independently from one another.

What is the role of psychology in health and illness: Illness can have psychological consequences but not causes.