Engel 1980 The Clinical Application of the Biopsychosocial Model PDF

Am J Psychiatry 137:5, May 1980 535 THE AMERICAN JOURNAL...

Am J Psychiatry 137:5, May 1980 535 THE AMERICAN JOURNAL OF PSYCHIATRY The Clinical Application of the Biopsychosocial Model BY GEORGE L. ENGEL, M.D. cians. The biopsychosocial model is a scientific model Howphysicians approach patients and the problems constructed to take into account the missing dimen- they present is much influenced by the conceptual sions of the biomedical model. To the extent that it models around which their knowledge is organized. In succeeds it also serves to define the educational tasks this paper the implications ofthe biopsychosocial of medicine and particularly the tasks and roles of psy- modelfor the study and care ofa patient with an acute chiatrists in the education ofphysicians ofthe future. myocardial infarction are presented and contrasted How physicians approach patients and the problems with approaches used by adherents ofthe more they present is very much influenced by the concep- traditional biomedical model. A medical rather than tual models in relationship to which their knowledge psychiatric patient was selected to emphasize the and experience are organized. Commonly, however, unity of medicine and to help define the place of physicians are largely unaware of the power such mod- psychiatrists in the education of physicians of the els exert on their thinking and behavior. This is be- future. cause the dominant models are not necessarily made explicit. Rather, they become that part of the fabric of T he Vestermark award acknowledges contributions education background which against is taken for granted, which they learn to become the cultural physi- to psychiatric education. For the most part cians. Their teachers, their mentors, the texts they awardees have taken the occasion to discuss issues use, the practices they are encouraged to follow, and pertaining to psychiatric education. This paper will do even the medical institutions and administrative organ- so only indirectly. In it I intend to elaborate on the izations in which they work, all reflect the prevailing biopsychosocial model by demonstrating its practical conceptual models of the era. applicability to the understanding and care of a pa- The dominant model in medicine today is called the tient. For this purpose I have deliberately selected a “biomedical” model. The biomedical model repre- medical rather than a psychiatric patient, a man who sents the application to medicine of the classical fac- experienced a myocardial infarction complicated by tor-analytic approach that has characterized Western cardiac arrest. I do so to emphasize the unity of medi- science for many centuries. Elsewhere (1-3), I have cine and the uniqueness of physicianhood, for psychia- considered the limitations of that model and presented try is a medical discipline and psychiatrists are physi- an alternative model, the biopsychosocial model. The new model is based on a systems approach, a develop- ment in biology hardly more than 50 years old, the ori- The Seymour Vestermark Memorial Lecture, presented at the gin and elaboration of which may be credited chiefly to 132nd annual meeting of the American Psychiatric Association, Chi- cago, Ill., May 12-18, 1979. Received July 16, 1979; accepted July the biologists Paul Weiss and Ludwig von Bertalanify. 27, 1979. In this paper I will consider how the biopsychosocial From the Departments of Psychiatry and Medicine, University of model enables the physician to extend application of Rochester School of Medicine and Dentistry. Address reprint requests to Dr. Engel, Strong Memorial Hospital, the scientific method to aspects of everyday practice 300 Crittenden Blvd., Rochester, N.Y. 14642. and patient care heretofore not deemed accessible to a Supported in part by a grant from the Henry Kaiser Family Foun- scientific approach. As a result the goal of the Flexner dation. Dr. Engel is the recipient of a Career Research Award from reform to educate a truly scientific physician will come the U.S. Public Health Service. Copyright © 1980 American Psychiatric Association 0002-953X1 closer to reality (4, 5). 8O/0510535110/$00.50. The most obvious fact of medicine is that it is a hu- IIUIIIIIUIII I IIUII IIIIIIIIIIII 8RE L-JGL-KY57 IU  536 THE BIOPSYCHOSOCIAL MODEL Am J Ps)chi#{224}tr/ 137:5, May 1%O man discipline, one involving role- and task-defined these must first be reduced to physicochemica1 terms activities of two or more people. Such roles and tasks before they can have meaning (2, 3). Hence, the very are defined in a complementary fashion. Roles are essence of medical practice perforce remains “art” based on the linking of the need of one party, the pa- and beyond the reach of science (6). tient, with an expected set of responses (services) from the other party, the physician. Broadly speaking, the need of the patient is to be relieved of “distress” THE BIOPSYCHOSOCIAL MODEL rightly or wrongly attributed to “illness,” however conceptualized. The expectation of the patient is that Focusing on what the physician does in con- the other party, the physician, has the professional tradistinction to what the bench scientist does high- competence and motivation to provide such relief. In lights the appropriateness, indeed the necessity, of a practical terms the doctor’s tasks are, first, to find out systems approach, as exemplified in the proposed how and what the patient is or has been feeling and biopsychosocial model. While the bench scientist can experiencing; then to formulate explanations (hypoth- with relative impunity single out and isolate for se- eses) for the patient’s feelings and experiences (the quential study components of an organized whole, the “why” and the “what for”); to engage the patient’s physician does so at the risk of neglect of, if not injury participation in further clinical and laboratory studies to, the object of study, the patient. Proponents of the to test such hypotheses; and, finally, to elicit the pa- biomedical model often cite this impossibility of deal- tient’s cooperation in activities aimed to alleviate dis- ing with a patient as one would an experimental animal tress and/or correct underlying derangements that may in the laboratory to support their argument that medi- be contributing to distress or disability. The patient’s cine cannot ever be truly scientific. But such a con- tasks and responsibilities complement those of the tention assumes that the factor-analytic approach of physician. reductionism alone qualifies as scientific. Systems the- In a broad sense this characterization of the corn- ory, by providing a conceptual framework within plemeritary roles and tasks ofphysician and patient ap- which both organized wholes and component parts can plies to all healing and health care systems, whether be studied, overcomes this centuries-old limitation. primitive folk medicine or modern scientific medicine. For the clearest and most authoritative exposition of The former is based largely on authority, tradition, and systems theory in biology one must turn to the ic an appeal to magical formulae, while the latter relies writings of Weiss (7-12) and von Bertalanffy (13-45). on scientific knowledge and the scientific method as Weiss pointed out that systems theory is best ap the best means to achieve the goals of health and well- proached through the commonsense observation that being. Both the successes and the deficiencies of the nature is ordered as a hierarchically arranged contin- current scientific approach, predicated as it is on the uum, with its more complex, larger units super- biomedical model, are currently the subject of lively ordinate to the less complex, smaller units. This may controversy. Protagonists of the biomedical model be represented schematically by a vertical stacking to claim that its achievements more than justify the ex- emphasize the hierarchy (see figure 1) and by a nest of pectation that in time all major problems will succumb squares to emphasize the continuum (see figure 2). Ac- to further refinements in biomedical research. Critics tually there are two hierarchies: the single individual argue that such dependence on “science” in effect is (person) is the highest level of the organismic hier- at the expense of the humanity of the patient. This is a archy and at the same time the lowest unit of the social fruitless controversy which cannot be resolved be- hierarchy (16). cause it is predicated, by advocate and critic alike, on Each level in the hierarchy represents an organized a flawed premise, that the biomedical model is an ade- dynamic whole, a system of sufficient persistence and quate scientific model for medical research and prac- identity to justify being named. Its name reflects its tice (2, 3). distinctive properties and characteristics. Cell, organ, The crippling flaw of the model is that it does not person, family each indicate a level of complex in- include the patient and his attributes as a person, a tegrated organization about the existence of which a human being. Yet in the everyday work of the physi- high degree of consensus holds. Each system implies cian the prime object of study is a person, and many of qualities and relationships distinctive for that level of the data necessary for hypothesis development and organization, and each requires criteria for study and testing are gathered within the framework of an ongo- explanation unique for that level. In no way can the ing human relationship and appear in behavioral and methods and rules appropriate for the study and in- psychological forms, namely, how the patient behaves derstanding of the cell as cell be applied to the study of and what he reports about himself and his life. The the person as person or the family as family. Similarly, biomedical model can make provision neither for the the methods needed to identify and characterize the person as a whole nor for data of a psychological or components of the cell have to be different from those social nature, for the reductionism and mind-body required to establish what makes for the wholeness of dualism on which the model is predicated requires that the cell. Am J Psychiatry 137:5, May 1980 GEORGE L. ENGEL 537 FIGURE 1 FIGURE 2 Hierarchy of Natural Systems Continuum of Natural Systems SYSTEMS HIERARCHY BIOSPHERE (LEVELS OF ORGANIZATiON) SOCIETY-NATiON CULTURE-SUBCULTURE MMUNfl BIOSPHERE FAMILY TWO PERSON RSON SOCIETY-NATION NERVOUS SYSTEM ORGAN/ORGAN SYSTEMS CULTURE-SUBCULTURE COMMUNITY FAMILY I TWO-PERSON PERSON (experience & behavior) NERVOUS SYSTEM ORGANS/ORGANS I SYSTEMS I TiSSUES boundaries between organized systems across which I material and information flow. CELLS Nothing exists in isolation. Whether a cell or a per- I ORGANELLES son, every system is influenced by the configuration of the systems of which each is a part, that is, by its envi- I MOLECULES ronment. More precisely, neither the cell nor the per- son can be fully characterized as a dynamic system I ATOMS without characterizing the larger system(s) (environ- ment) of which it is a part. This is implicit in the labels SUBATOMIC I PARTiCLES used. rectly The designation and by implication “red blood the larger cell” systems identifies without di- which the red blood cell has no existence. The term “patient” characterizes an individual in terms of a Consideration of the hierarchy as a continuum re- larger social system. Identification of the patient by veals another obvious fact. Each system is at the same name, age, sex, marital status, occupation, and resi- time a component of higher systems (figure 2). System dence identifies other systems of which that patient is cell is a component of systems tissue and organ and a component and which in turn are part of his environ- person. Person and two-person are components of ment. family and community. In the continuity of natural In scientific work the investigator generally is systems every unit is at the very same time both a obliged to select one system level on which to concen- whole and a part. Person (or individual) represents at trate, or at least at which to begin, his efforts. For the the same time the highest level of the organismic hier- physician that system level is always person, i.e., a archy and the lowest level of the social hierarchy. patient. The systems-oriented scientist will be aware Each system as a whole has its own unique character- that the task is always a dual and complementary one. istics and dynamics; as a part it is a component of a On the one hand the constituent components of the higher-level system. The designation “system” be- system must be identified and characterized in detail speaks the existence of a stable configuration in time and with precision. For this end the factor-analytic ap- and space, a configuration that is maintained not only proach has served well. Application of increasingly di- by the coordination of component parts in some kind verse and refined techniques to the study of the cell of internal dynamic network but also by the character- have almost endlessly extended knowledge of the con- istics of the larger system of which it is a component stituent parts (systems) making up a cell. But the sys- part. Stable configuration also implies the existence of tems characteristics of each component part of any 538 THE BIOPSYCHOSOCIAL MODEL Am J Psychiatry 137:5, May 1980 system must also be studied. Different approaches are his employer recognized that the patient was sicker required to gain understanding of the rules and forces than he acknowledged himself to be, reported her ob- responsible for the collective order of a system, servations to the doctor, and persuaded the patient to whether an organelle, a cell, a person, or a commu- let her take him to the hospital. nity. These cannot be understood merely as an assem- How is the clinical approach of the physician influ- blage (or reassemblage) of constituent parts (10). enced by the systems perspective of the biopsychoso- The systems-oriented scientist, including the physi- cial model? With the systems hierarchy as a guide, the cian, always has in mind this distinction and the com- physician from the outset considers all information in plementarity inherent in it. This stands in contrast to terms of systems levels and the possible relevance and the orientation of the reductionist scientist, for whom usefulness of data from each level for the patient’s fur- confidence in the ultimate explanatory power of the ther study and care. factor-analytic approach in effect inhibits attention to Even such minimal screening data as Mr. Glover’s what characterizes the whole. For medicine in particu- age, gender, place of residence, marital and family lar the neglect of the whole inherent in the reduc- status, occupation, and employment already indicate tionism of the biomedical model is largely responsible systems characteristics useful for future judgments for the physician’s preoccupation with the body and and decisions. The information that the patient resist- with disease and the corresponding neglect of the pa- ed acknowledging illness, especially in the face of a tient as a person. This has contributed importantly to documented heart attack six months earlier, and had the widespread public feeling that scientific medicine to be persuaded to seek medical attention, tells some- is impersonal, an attitude consistent with how the bio- thing of this man’s psychological style and conflicts. medically trained physician views the place of science From this alone the systems-oriented physician is in his everyday work. For him “science” and the sci- alerted to the possibility, if not the probability, that the entific method have to do with the understanding and course of the illness and the care of the patient may be treatment of disease, not with the patient and patient importantly influenced by processes at the psychologi- care. The reductionist scientific culture of the day is cal and interpersonal levels of organization. Of course, largely responsible for the public view of science and the similarity of Mr. Glover’s current symptoms to humanism as antithetical. those of his recent myocardial infarction prepares the physician to consider systems derangements at the cardiovascular level as well as at the symbolic level of APPLICATION OF THE BIOPSYCHOSOCIAL “another heart attack.” MODEL Such an inclusive approach, with consideration of all the levels of organization that might possibly be im- Let us examine how this antithesis between science portant for immediate and long-term care, may be con- and humanity might be attenuated, if not eliminated trasted with the parsimonious approach of the biomed- altogether, were the physician to approach clinical ical model. In that mode the ideal is to find as quickly problems from the more inclusive perspective of the as possible the simplest explanation, preferably the di- systems-oriented biopsychosocial model, free of the agnosis of a single disease, and to regard all else as constraints imposed by the exclusively reductionistic complications, “overlay,” or just plain irrelevant to approach of the biomedical model. The hierarchy and the doctor’s task. For the reductionist physician a di- continuum of natural systems, as depicted in figures 1 agnosis of “acute myocardial infarction” suffices to and 2, provide a guide to the systems that the physi- characterize Mr. Glover’s problem and to define the cian keeps in mind when undertaking the care of a pa- doctor’s job. Indeed, once so categorized Mr. Glover tient. How this works out in practice may be illus- is likely to be referred to by the staff as “an MI.” trated by a particular clinical example, the case of Mr. The Sequence of Events Glover (a pseudonym); a 55-year-old married real es- tate salesman with two adult sons, who was brought to Let us now reconstruct in systems terms the se- the emergency department with symptoms similar to quence of events comprising the acute phase of Mr. what he had experienced six months earlier, when he Glover’s illness. To simplify presentation we arbi- had had a myocardial infarction. trarily take as the starting point for this analysis the 90- We begin consideration of the model by reminding minute period during which the patient experienced ourselves that in practice the physician’s first source evolving myocardial ischemia in the form of symp- of information is the patient himself (or some other in- toms. This and subsequent critical events and their formed person). Thus, clinical study begins at the per- consequences for intra- and intersystemic harmony son level and takes place within a two-person system, are schematized in figures 3-9. Each diagram indi- the doctor-patient relationship. The data consist of re- cates the system level that the event in ques- ported inner experience (e.g., feelings, sensations, tion affected as well as its reverberations up and thoughts, opinions, and memories) and reported and down the systems hierarchy. Appreciating the unity of observable behavior. In the instance of Mr. Glover, the hierarchy, that each system is at the same time Am J Psychiatry 137:5, May 1980 GEORGE L. ENGEL 539 FIGURE 3 physiological adjustments occurring in response to the Event 1: Coronary Artery Occlusion processes originating in the oxygen-deprived myo- EVENT #1 SYSTEMS HIERARCHY INTRASYSTEM CHANGES cardium. Such CNS-mediated processes are not nec- (10-11:30 A.M.) essarily in harmony with one another. Physiological adjustments to myocardial ischemia may be countered Coronary artery COMMUNITY by cardiovascular responses to pain and discomfort as occlusion well as by the demand for increased work by the heart resulting from inappropriate behavior. FAMILY Mr. Glover well exemplified this incompatibility be- tween psychological and physiological reactions. TWO-PERSON disengages Whereas the infarcting of the myocardium called for reducing the demand for myocardial work and mini- IPTERSON symptoms. #{149} uncertainty, alarm mizing such arrhythmogenic factors as excessive cate- #{149} denies, rationalizes (experience & behavior) #{149} more active cholamine secretion, the patient’s psychological re- sponse was to oscillate between alarm and increased NERVOUS SYSTEM. activation at sympathetic nervous system activity and denial and in- emergency systems #{149} mob.hzation of appropriate physical activity (figure 3). learned patterns As he was later to report, almost from the start the ORGAN/ORGAN SYSTEM -. cardiovascular reactions possibility of a second heart attack came to mind, but and adjustments he dismissed this in favor of “fatigue,” “gas,” ‘ ‘muscle strain,’ ‘ and, finally, ‘emotional ‘ tension.” rnyocardsal ischem#{232}a.. #{149} myocartat infarction But the negation itself, “not another heart attack,” #{149} electrical instabEldy leaves no doubt that the idea “heart attack” was very much in his mind despite his apparent denial. Behav- CELL myocardial #{149} cell damage iorally he alternated between sitting quietly to “let it pass,” pacing about the office to “work it off,” and I _______________ MOLECULE products #{149} of calf taking Alka Seltzer. Another employee came into the office, but Mr. Glover avoided him. When he could no longer deny the probability , if not a component of systems higher in the hierarchy, under- the certainty, of another heart attack, a different set of scores the significance of the disruption of the whole- concerns emerged as Mr. Glover’s personal values of ness of any one system for the intactness of other sys- responsibility and independence and his fear of losing tems, especially those most proximate. These inter- control over his own destiny gained ascendancy. The relationships are indicated in the diagrams by using new formula became, “If this really is a heart attack double arrows to connect system levels. (but maybe it will still prove not to be), I must first get Figure 3 depicts the critical event of progressive ob- my affairs in order so that no one will be left in the struction of coronary artery blood flow interrupting lurch.” In this way he tried to sustain his self-image of the oxygen supply and disrupting the organization of a competence, responsibility, and mastery, but at the segment of myocardium. Note that while changes are cost of imposing an even greater burden on the already taking place at the levels of tissue, cell, molecule, or- overburdened heart and cardiovascular system. In gan, organ system, and nervous system, illness and systems terms, feedback was becoming increasingly patienthood do not become issues until the person lev- positive and a dangerous vicious cycle was in the mak- el is implicated, that is, not until the person experi- ing. Disruptive processes were gaining ascendancy ences something untoward or exhibits some behavior over regulatory processes, increasing the risk of a le- or appearance that is interpreted as indicating illness. thal arrhythmia (17-20). The patient persisted in this For Mr. Glover such changes began around 10 in the determined, almost frenetic behavior for more than an morning. While alone at his desk he began to experi- hour until the intervention of his employer brought it ence general unease and discomfort and then during to an end and enabled him to accept hospitalization the next minutes growing “pressure” over his mid-an- and patient status. terior chest and an aching sensation down the left arm Figure 4 diagrams the psychological stabilization to the elbow. The similarity of these symptoms to that took place as a result of his employer’s inter- those of his heart attack six months earlier immediate- vention and the stabilizing consequences for other sys- ly came to mind. Thus began the threat of disruption at tems. The intervention took place within the two-per- the person level and with it still another wave of rever- son system, immediately affectingperson, and for the berations up and down the systems hierarchy. moment at least terminated the vicious cycle, thereby Central here is the role played by the central ner- lessening the impact on the damaged heart of poten- vous system in the integration and regulation of the tially deleterious extracardiac influences. By the time individual’s inner experiences and behavior and the the patient reached the hospital he was no longer hay- 540 THE BIOPSYCHOSOCIAL MODEL Am J Psychiatry 137:5, May 1980 FIGURE 4 doubts that the onset of ventricular fibrillation could Event 2: Intervention of Employer be ascribed solely to processes originating in the in- EVENT #2 SYSTEMS HIERARCHY INTRASYSTEM CHANGES jured myocardium alone. Rather, it suggested a major (11:30 A.M.-12:20 P.M.) role for extracardiac (neurogenic) influences originat- COMMUNITY C motskzation of ing the disturbances at the two-person and person 1ev- of employer els. According to Mr. Glover, everything had been I medical resources proceeding smoothly until the house officers ran into FAMILY w e strain, concern 4 altered #{149} roles. difficulty doing an arterial puncture. They persisted in tasks and reahgnments their fruitless efforts for some 10 minutes and then left, TWO-PERSON communication #{149} explaining only that they were going for help. For Mr. 4 e engagement #{149} accepts help Glover the procedure was not only painful and dis- agreeable, but, more importantly, he felt his con- PERSON l-e’. #{149} a new goals fidence in the competence of the medical staff being #{149} confidence in doctors e acknowledges illness undermined and with that his sense of personal mas- a symptoms decrease tery and control over his situation. Rather than being NERVOUS SYSTEM ‘ C deactivation Of helped by powerful but concerned and competent pro- emergency systems a infegration of fessionals he began to feel that he was being victimized regulatory systems and goal-directed behavior by beginners who themselves needed help. Yet he ORGAN/ORGAN SYSTEM -. circulatory adjustments couldn’t bring himself to protest. His comment, tape- recorded, was, TISSUE myocardial #{149} schemia 4 e myocardial infarction I didn’t wanna tell ‘em that I didn’t think, ah, that I I CELL #{149} electrical myocardial #{149} instab#{243}lty cell damage knew, he wasn’t doing it right they tried here and they... tried there the poor fellow was having such a tough... time, he just couldn’t get it. I ______________ MOLECULE ie #{149} products of cell damage Within a short time the patient found himself getting hot and flushed. Chest pain recurred and quickly be- came as severe as it had been earlier that morning. ing chest discomfort; he was feeling relatively calm When the staffleft to get help he first felt relieved. But and confident and was coming to terms with once anticipating more of the same, he began to feel outrage again being a hospital patient. and then to blame himselffor having permitted himself How had the employer brought about such a felici- to be trapped in such a predicament. A growing sense tous result? We later learned from Mr. Glover that the of impotence to do anything about his situation culmi- employer’s approach was to commend his diligence nated in his passing out as ventricular fibrillation su- and sense of responsibility, even in the face of being so pervened. obviously ill, and to reassure him that he had left his This sequence of events is diagramed in figure 5. It work in suitable condition for others to take over. But provides an opportunity to draw a contrast between she also challenged him to consider whether a higher different models and how the model adhered to influ- responsibility to his family and his job did not require ences the physician’s approach. In the case of Mr. him to take care of himself and go to the hospital. In- Glover the judgment to institute without delay an acute tuitively she had appreciated this man’s need to see coronary regimen is beyond dispute. Differences himself as responsible and in control, and she had emerge in the priorities set and the behavior dis- sensed his deep fear of being weak and helpless. played by adherents of each model as they went By the time Mr. Glover was admitted to the emer- about their study and care of the patient. The emergen- gency department shortly before noon he was no long- cy room approach was conventionally and narrowly er having any discomfort. But the staff agreed that biomedical. It was predicated on the reductionist prompt institution of a coronary care routine was premise that the cause of Mr. Glover’s problem, and nonetheless justified. This was in fact reassuring to the therefore the requirements for his care, could be local- patient, who had by now accepted the reality of a sec- ized to the myocardial injury. Because of this, plus the ond heart attack. Thirty minutes later, however, in the high risk attendant on such injury, they felt justified mids( of the continuing workup, he abruptly lost con- proceeding with the technical diagnostic and treatment sciousness. The monitor documented ventricular fib- procedures, giving only passing attention to how Mr. rillation. Defibrillation was successfully carried out, Glover was feeling and reacting. When the arrest oc- and the patient made an uneventful recovery. curred the staff congratulated each other and the pa- Interviewed a few days later, Mr. Glover was able to tient on his good fortune, claiming that had his arrival reconstruct the events in the emergency department in the hospital been delayed another 30 minutes, he leading up to the cardiac arrest. His account raised might well have not survived. It was assumed that the Am J Psychiatry 137:5, May 1980 GEORGE L. ENGEL 541 FIGURE 5 FIGURE 6 Event 3: Unsuccessful Attempt at Arterial Puncture Event 4: Cardiac Arrest EVENT #3 SYSTEMS HIERARCHY INTRASYSTEM CHANGES EVENT #4 SYSTEMS HIERARCHY INTRASYSTEM CHANGES (12:20 P.M.-12:30 P.M.) (12:30 P.M.) Unsuccessful attempt COMMUNITY a- mobilization #{149} of Cardiac Arrest COMMUNITY a’ Blue 100 at arterial puncture medical resources 4 organized #{149} responses #{149} disorganized responses FAMILY -a- e strain, concern FAMILY a reactions to threat #{149} altered roles of loss by death and tasks TWO-PERSON a-. disengages TWO-PERSON a disrupted PERSON ]-,.- a Obliteration of awareness #{149} local pain, anger and organized behavior #{149} frustration experience & Dehavior) #{149} angina, flushing #{149} loss of confidence #{149} self-blame giving up #{149} NERVOUS SYSTEM a mobilization of a NERVOUS SYSTEM a cerebral #{149} ischemia flight-fight and 4 regulatory #{149} responses #{149} conservation-withdrawal I toanoxia 4 a anoxic damage ORGAN/ORGAN SYSTEM-a- hyper- #{149} & hypocirculatory a ORGANORGAN SYSTEM-a- anoxic #{149} damage responses ___________________ I ___________________ TISSUE a- increased ischemia, infarction a TISSUE a a anosic damage 4 #{149} increased electrical instability I a ventricular fibrillation ____________________ I _____________________ CELL a- #{149} increased cell damage a- CELL. a- e anoxic damage I _______________ MOLECULE w a products of cell MOLECULE a increased products of cell damage damage onset of ventricular fibrillation at 12:30 p.m. was part ented physician alert to information aboutperson -level of the natural progression of the myocardial injury. factors that might contribute to instability of the car- The model used by the emergency staff in their han- diovascular system. dling of Mr. Glover was based on the factor-analytic Valuable as a guide for the physician’s personal ap- design of the controlled laboratory experiment in proach to Mr. Glover’s care would have been to learn which all factors are to be held constant except for the how the employer had helped him accept the reality of one under study. For the biomedically trained clinician his heart attack and the need for prompt medical atten- this constitutes the standard against which the ‘scien- ‘ tion. As the coronary care regimen was being imple- tific” quality ofclinical work is to be measured. Trans- mented, the physician would also be closely mon- lated into clinical practice it is typically reflected in the itoring the patient’s reactions to the procedures, espe- predilection to focus down on one issue at a time and cially in the light of Mr. Glover’s documented pursue a sequential “ruling out” technique for both reluctance to acknowledge a need for help. The diffi- diagnosis and treatment. - culty with the arterial puncture would have been rec- ognized early as a risk for the patient, notjust a problem A Different Approach for the doctors. Mr. Glover’s failure to complain A systems approach to Mr. Glover would have dif- would have been anticipated as consistent with his fered in notable respects. From the outset the decision personality style and not interpreted as acquiescence for and implementation of coronary care would have to what was happening to him. Whether such an ap- included consideration of factors other than cardiac proach would in fact have averted the cardiac arrest is status, notably those manifest at the person level. The impossible to know. But certainly, sufficient experi- interview of Mr. Glover would have been conducted in mental and clinical evidence exists linking psychologi- such a manner as to elicit simultaneously information cal impasse, as displayed by Mr. Glover, and in- needed to characterize him as a person and to evaluate creased risk of lethal arrhythmias, especially with pre- the status of his cardiovascular system. This could existing myocardial electrical instability (17, 19). have been readily and efficiently accomplished by hav- Further elaboration of the biopsychosocial model as ing the patient report the symptoms in a life context, applied to the care of Mr. Glover may be found in fig- noting activities, reactions, feelings, and behavior as ures 6-9, which diagram in sequence the cardiac ar- symptoms were evolving, as well as his life circum- rest, defibrillation, and eventual stabilization of the in- stances at the time of onset. Particularly when consid- jured myocardium, as well as what might have hap- ering possible myocardial infarction is the systems-on- pened if defibrillation had been unsuccessful. With the 542 THE BIOPSYCHOSOCIAL MODEL Am J Psychiatry 137:5, May 1980 FIGURE 7 FIGURE 9 Event 5A: Successful Defibrillation Event 6: Stabilization of Myocardial Damage EVENT #SA SYSTEMS HIERARCHY INTRASYSTEM CHANGES EVENT #6 SYSTEMS HIERARCHY INTRASYSTEM CHANGES (1.1:15 P.M.) Successful COMMUNITY a. satisfaction of Stabilization of SOCIETY-NATION social #{149} policies re deon medical team myocardial damage 4 toll of heart disease and rehabilitation FAMILY a a relief CULTURE-SUBCULTURE -a-. attitudes toward 4 e heightened awareness of 4 SurvivOr of heart threat to family structure attack TWO-PERSON -a e recovery of capacity COMMUNITY a #{149} reactions to a to act and relate 4 changing member I realignments. #{149} altered t roles and tasks I PERSON “J-a- return of awareness FAMILY a a reactions to a [jXPenence&b.havj : #{149} 4 e changing member realignments. altered 4 roles and tasks TWO-PERSON -a changing #{149} relationships NtRVOUS SYSTEM a- #{149} recovery of functions ORGAN/ORGAN SYSTEM -a- e restoration of r I PERSON -a-. self image, expectations, orculatory support goals. needs, concerns (experience & behaviorl all in flux a TISSUE a #{149} restoration of myocardtal + electrical stability and pumping action NERVOUS SYSTEM -a- a compensation a- CELL a- improved #{149} environment for t MOLECULE