1037333

960367APY APY Australasian PsychiatryLugg

Australasian PsychiatryVance and Winther

AustrAlAsiAn
Consultation Liaison
Consultation Liaison Psychiatry
Australasian Psychiatry

The
Parent- biopsychosocial model –
and child-reported 2022,
2022,
2021, Vol.
VolVol 30(1)
29(5) 4885
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New Zealand College of Psychiatrists 2021
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history, controversy
anxiety disorders and Engel
differentiating Article reuse guidelines:
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DOI:10.1177/10398562211037333
10.1177/1039856220960367
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major depressive disorder and journals.sagepub.com/home/apy

dysthymic
William Lugg disorder in children
Consultation-Liaison Psychiatry Advanced Trainee, Department of Consultation-Liaison Psychiatry,
Royal Prince Alfred Hospital, Sydney, Australia
and adolescents
Abstract
Objective:
Alasdair VanceThe biopsychosocial
Academic Child (BPS) modelUnit,
Psychiatry remains the predominant
Department of Paediatrics,theoretical
University offramework
Melbourne,underpinning
Australia con-
temporary psychiatric training and practice. Like all models, it has its limitations and its critics. In light of recent
Jo Winther Developmental Neuropsychiatry Program, Royal Children’s Hospital, Australia
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.
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
Keywords: biopsychosocial, biopsychosocial model, George Engel, BPS, psychosomatic
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

B
(N = 126) groups.
iological reductionism in psychiatry can be dehu- Grinker, who had been trained and personally analysed
Results: DD alone
manizing and MDD
and/or alone didInnot
demeaning. differcases
many with respect
it by to comorbid
Freud, anxiety
first coined disorders
the from parent and child
term “psycho-somatic-social”
reports, while parent-reported
exemplifies the faulty and panicsimplistic
disorder (PD)logicwas significantly
that in an addressincreased
to theinChicago
the DD and MDD groupInstitute
Psychoanalytic compared in
to the other
renders three groups
psychiatry liable astowas child-reported
criticism; it can post-traumatic
also be 1952stress wheredisorder (PTSD) compared
he emphasised to the
the biological MDD
aspects of alone
men-
and anxiety
frankly disordersEven
unscientific. alone groups.
those In contrast,
psychiatric specific phobia
syndromes tal health(SpPh)
andwas significantly
illness increased
in a pushback in the
against anxiety
psychoana-
disorders
arising in alone group
context compared to
of identifiable the DD and
biological MDD group.
pathophysi- lytic dogma and stressed the importance of being a doctor
Conclusion:
ology The findings
(e.g. autoimmune suggest that neurodegenera-
encephalitides, specific fear-related anxiety
first and a disorders,
psychiatrist especially parent-reported
or psychoanalyst second.3PD and
A dec-
child-reported
tive PTSD, may
diseases, structural aid pathology)
brain the early recognition of DD and
still ultimately ade MDD.
later, Grinker would expand on his preliminary BPS
exhibit a pathophenotype inextricably sculpted by the concept and again challenge the Freudian church in a
psychological and sociocultural milieu within which the lecture delivered to the Association for the Advancement
Keywords: major depressive disorder, persistent depressive disorder, anxiety disorders
individual exists. The BPS model speaks to this notion of Psychoanalysis (a “breakaway” group of analysts, of
and remains the prevailing aetiological (and manage- which he helped found, who rejected established
ment) framework through which most contemporary Freudian orthodoxy):
psychiatric training and practice is applied. However,

C
the BPSomorbid
model isanxiety
not without
disordersits with
faults depressive
and there dis-
are addition,
“Psychoanalysis,
increasingexcept
number for the
andwaning influence
severity of reac-
of anxiety dis-
questions regarding
orders its history
are clinically and contemporary
important in children util-
and orders tionary
andorganizational factions, is
increasing avoidance now an openare
phenomena system by
further
ity. Thisadolescents
piece seeks because
to reviewtheythesehave
issues.
been shown to riskvirtue of the
factors for evolution
comorbidofdepressive
structural theory, ego psychology,
disorders.
adversely affect outcomes. For instance, increased sever- and the concepts of adaptation. As a result, modern psy-
Importantly, to date, the majority of this depressive and
ity of depressive disorders,1 increased suicidal ideation,2 choanalysis is a bio-psycho-social theoretical structure...
anxiety disorders research has focussed on major depres-
History
increased and development
chronicity and recurrence of depressive dis- The frame of reference of a biopsychosocial point of view
sive disorder (MDD) with a systematic examination of
orders,3 and a lesser response to cognitive behaviour has been utilized without sacrificing any of the dynamic
George Engel did not create the BPS model and the con- dysthymic disorder (DD; DSM-V persistent depressive
therapy have all been reported.4 Moreover, rates of concepts which psychoanalysis has contributed to psy-
cept arose well before 1977. Whilst the idea that multiple disorder equivalent) being relatively rare.7 To the
comorbidity with depressive disorders vary between par- chiatry.”4
factors may contribute to any one individual’s particular authors’ knowledge, there has been no investigation of
ticular anxiety disorders. For example, generalised anxi-
form of mental suffering is nothing new, the now widely
ety disorder (GAD) and social anxiety disorder (SOC)
accepted aetiological concept of what psychiatrist
have higher rates of comorbidity than separation anxi-
Kenneth Kendler called “empirically-based pluralism”1 Corresponding author:
ety disorder and indeed demonstrate the highest risk of Corresponding author:
was first formally described some twenty-five years before
subsequently developing depressive disorders.5 In con- Dr. William Lugg, Consultation-Liaison Psychiatry Advanced
Alasdair Vance, Academic Child Psychiatry Unit, Department
Engel’s venerated 1977 Science paper, “The Need for a Trainee, Department of Consultation-Liaison Psychiatry, Royal
trast, panic disorder (PD) is less likely to precede the2 of Paediatrics, University of Melbourne, Royal Children’s
New Medical Model: A Challenge for Biomedicine.” Prince Alfred Hospital, Missenden Road, Sydney, Australia.
onset of depressive disorders, although panic attacks, as Hospital, Flemington Rd, Parkville, VIC 3052, Australia.
Prominent American neurologist-cum-psychiatrist Roy Email: [email protected]
a risk factor, are associated with depressive disorders.6 In Email: [email protected]

488 55
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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)

Going further back, it was existential psychiatrist Victor audience and, ironically, in that paper he used a medical
Frankl who, drawing on his own personal experience in case (ischaemic heart disease) to illustrate his key points.
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 Validity and contemporary utility
book The Doctor and the Soul, Frankl wrote of the
“somatopsychospiritual” essence of humanity.5 A year Some have questioned the validity of the BPS model.9,10
later, in 1947, psychiatrist John Romano wrote about the The first obvious question is, what exactly is a “model”?
need for “a more comprehensive frame of reference... in Respected late British statistician George Box described a
which psychological and social facts exist or coexist with scientific model as a construct which “seeks to represent
more impersonal biological factors, eventually to cause, empirical objects, phenomena, and physical processes in
provoke, or otherwise modify variations in the total a logical and objective way.”11 Box qualified this by say-
human biological behaviour.”6 ing that all scientific models are “in simulacra, that is,
simplified reflections of reality that, despite being
It is important to note that, within the literature, psy- approximations, can be extremely useful.”11 An aetio-
chiatry never “owned” the BPS concept. A PubMed search logical construct for mental disorders that incorporates
for “biopsychosocial” reveals no fewer than fourteen biological, psychological and sociocultural factors in
separate publications prior to 1977, dating as far back as myriad complex, interacting, irreducible, and yet often
1951. More specifically, the first mention of “biopsycho- simplified and hitherto not fully understood ways, is
social model” is still three years earlier, in a 1974 paper arguably both an approximation and extremely useful –
entitled, “An alternative: the biopsychosocial model”7 that is, it is a model. And whilst the “BPS model” cannot,
authored by an occupational therapist (OT). Of the four- by definition, explain everything, on the basis of Box’s
teen papers listed on PubMed prior to 1977, only three definition, it certainly holds validity.
are directly related to psychiatry. Three others are related
to paediatrics, two each to linguistics and nursing, and The recently published RANZCP clinical practice guide-
one each to general medicine, alcoholism, OT and sociol- lines for mood disorders explores four key aetiological
ogy. Indeed, Engel’s 1977 paper was not actually directed realms in some detail: (1) Stress, (2) Genetics and gene-
at a psychiatric audience but a general medical one. It environment interactions, (3) Circadian function, and (4)
was only in his later 1980 paper, “Clinical Application of Cognition.12 The authors provide an informative sum-
the Biopsychosocial Model”,8 published in the American mary of the literature pertaining to the complex ways in
Journal of Psychiatry, that Engel targeted a psychiatric which these biological, psychological and sociocultural

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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
Figure 2. The “continuum of natural systems” as broadly refer to as Consultation-Liaison psychiatry).
proposed by Engel (1980). Note that the individual person Engel’s interest in psychiatry and mental disorders is pal-
exists in the middle of the continuum and that at each pable through his writings. In 1962 he authored a medi-
level above and below the individual is an interconnected cal textbook entitled Psychological development in health
“system.” Each system may be subsumed under and disease, and in 1969 he co-authored The Clinical
“biological,” “psychological” and/or “sociocultural” Approach to the Patient which included psychological
domains – any perturbation at one of these domains has considerations. In his famous 1977 Science paper, Engel
the potential to cause a variety of “intrasystem changes” mentioned “mental” or “behavioural disorder” no fewer
than seven times, and he mentioned “psychiatry”
anywhere within the hierarchy
twenty-two times.2 According to Nassir Ghaemi, Engel’s
key areas of interest included psychogenic pain and the
substrates may interact and, collectively, play a causal role psychological states of infants with gastric fistulas.15
in ultimately producing the pathophenotypes we call And, whilst in approximately 175 authored articles and
“mood disorders” (see Figure 1). The mechanisms dis- reviews Engel apparently never wrote anything specific
cussed are arguably consistent, observable, (often) pre- about mania or schizophrenia15 (he was not, after all, a
dictable, quantifiable and testable – that is, they are psychiatrist), he certainly spoke at length about a range
scientific. When considered together, and in context, of mental disorders and concepts central to psychiatric
they provide a useful aetiological approximation of what is theory and practice.
believed to occur in reality – that is, they form a model, a
Like Grinker, Engel was interested in “Systems Theory”
so-called “BPS model.” Indeed, distinguished American
and drew heavily on the work of Weiss and von
professor of psychiatry, Ronald Pies, endorsed this view
Bertalanffy.8 In his 1980 paper, Engel detailed how the
when he said, “[mood disorders] are best understood
various components of the BPS model may interact in
using a bio-psycho-sociocultural model, which has been
complex, yet irreducible, ways and how the application of
the mainstay of academic psychiatry for over 30 years.”13
its principles served to benefit patients – in his view, not
More recently, Jim van Os and colleagues have advocated in a fluffy humanistic way, but in a scientific way.8
for the addition of an “existential” (E) component to the Pertinent to his theory was the idea of a “continuum of
BPS model (i.e. a BPSE model) that would be considered natural systems” that are organised within a hierarchy –
central to its clinical application.14 They contend that from subatomic particles, through to cells and organs, the
whilst the BPS model provides a useful avenue to concep- individual person, the doctor-patient dyad, all the way up
tualise mental health, illness and treatment, it says little to society, nation and the biosphere at large (see Figure 2).

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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.”

Conceptually, Engel argued these different systems may artery occlusion, Engel provided seven diagrams to illus-
be subsumed under broader biological, psychological trate his theory (see Figure 3. for one example).
and sociocultural domains. Any perturbation of one
domain may lead to various “intrasystem changes” that
The integration of mind and body
occur at different levels within the hierarchy. Using the
example of a 55-year-old man who presented with chest Engel was recently criticised for writing “nothing of any
pain and is subsequently diagnosed with a coronary intellectual significance” about the infinitely complex

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notion of the integration of mind and body.9 However, Disclosure

in his 1980 paper, Engel explicitly addressed this age-old The author reports no conflict of interest. The author alone is responsible for the content and
conundrum by using the same clinical example (coro- writing of the paper.
nary artery occlusion):
Funding
“Central here is the role played by the central nervous sys- Nothing to declare
tem (CNS) in the integration and regulation of the indi-
vidual’s inner experiences (i.e. mind) and behaviour and ORCID iD
the physiological adjustments occurring in response to the William Lugg https://orcid.org/0000-0002-7377-1338
processes originating in the oxygen-deprived myocardium
(i.e. body). Such CNS-mediated processes are not neces- References
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inappropriate behaviour.”8 196: 129–136.

3. Grinker RR. Training of a Psychiatrist-Psychoanalyst. J Am Acad Psychoan 1994; 22:

Engel argued that in recognising the connections 343–350.
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5. Frankl VE. The Doctor and the Soul: from psychotherapy to Logotherapy. Knopf (1946);
physician may potentially prevent another heart attack Random House Group (1988), 1946.
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cho-bio” physiological mediators, whereas the purely future. Rochester, NY: University of Rochester Press, 2003.
biomedical physician will not - take what you will from
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