Category: Biopsychosocial

In psychiatry we like to think along bio-psycho-social dimensions. Our current axial diagnosis is a reflection of this.

The reasons for our interest in things beyond the “biological” are straight forward. First, as it’s hard to draw a line in the sand separating where the brain ends and the mind begins and this mind that doesn’t separate clearly from the brain cares about our psychosocial environments. In other words, psychosocial events are, more times than not, an important cause for our thoughts, emotions, and behaviors. This does not mean biology does not matter. But it does mean that any examination of mind/brain continuum needs to include a psychosocial assessment to ensure that the collected data is non-biased and thus valid.

One of the unintended consequences of the DSM descriptive approach has been a shift in the focus of the mental health interview: from the broader themes of nature AND nurture and the implicit goal of attempting to establish cause and effect type of relationships between the different layers of one’s history, to a symptoms-focused, descriptive only approach. The gains in precision came at the price of slashing the context, which, as it turns out, is essential in understanding the deeper levels of pathology. And by “deeper level” I am not referring to the psycho-dynamic foundation of that out-of-consciousness conflict, but only to the fact the there are different levels of description. And chance is that the most superficial layer is, well, the most superficial one. Meaning, subject to much deformation and bias; as such, not nearly as accurate as the deeper levels.

Case and point: A case of chronic exhaustion

Mr. Tiredalot is a middle age gentleman complaining of no longer been able to enjoy things (including sex), feeling exhausted all the time, amotivated, dragging his feet, unable to concentrate, not sleeping for the last few weeks. There are no medical or substance abuse issues. Mr. Tiredalot denies any recent stressors. As he meets DSM criteria for depression he is started on an SSRI.

It turns out that Mr. Tiredalot’s sleep disturbance started after changing his mattress a few weeks back. A softer mattress was bought by his wife as she did not like the prior mattress that she found too hard.  Not only that Mr. Tiredalot does not find the new mattress as comfortable, but going to bed each night brings a lot of resentment about the fact that his wife decided to switch mattress without consulting  him. Going to bed turned into a “nightly” reminder of the fact that she rarely engages him in any decision making. Since the mattress switching conflict began Mr. Tiredalot wakes up in the morning with a slightly sore back and a terrible mood. Each time when he tried to breach the subject of the mattress the wife dismissed it as a “waste of time talking about it as it is a done deal”. Which only further escalated Mr. Tiredalot’s frustration. His troubles/stressors don’t reach the required threshold for an “adjustment disorder” and the patient himself does not identify any of the above as stressors.

This is an example of how an interview focusing exclusively on a description could actually miss the point.

Appearances are misleading and an antidepressant is clearly NOT recommended in this case. To see a couple’s therapist would be the best intervention for this patient at this time.

Understanding the psychosocial context – in this case the primary relationship issues with secondary sleep issues and tertiary mood issues – would not only save this patient from an antidepressant but likely many years of grief in a tense marriage.

“I am co-dependent on my therapist”,  says Mr. Intherapyalot. Is this even a possibility?

Think about it this way: the patient – therapist relationship (and by therapist I am psychiatrists, psychologists, etc.) is characterized by an immense power differential. The therapist is in many respects God-like in the eyes of his patient: omniscient (appearing as if he knows everything about the patient), omnipotent (with the ability of curing deep-seated or maybe even deeper-seeded conflicts), the subject of unfiltered transference (positive for the most part) and yet available.

Who wouldn’t like to have God like figure on the line? So when those always urgent phone calls start coming in the middle of the night, when the patient starts calling repeatedly about trivial matters, when tapering the visits results in increased symptoms, and the discussion of termination is pre-emptied by sudden exacerbations, consider “therapist dependence” in your diagnostic formulation.

Of course, “dependence” on the therapist is not always bad. In fact, during the initial stages of therapy, especially for patients who come from a background of poor object relations, “dependence” might in fact be a good thing. In such instances “dependence” might indicate that the patient is finally able to trust in the context of a safe relationship.

In later stages of therapy however, especially when dependence occurs after relative independence has already been established, chance is that the patient is experiencing a maladaptive regression.

What is the solution? First, as always, prophylaxis is gold. Rather than open-ended therapy decide when the discharge date/the final session will be scheduled from the beginning. There is a lot to be said – and good data as well – supporting the fact that time-limited therapy might be more effective that open-ended therapy.  If the patient manifests dependence do not “up the ante”, in other words, do not offer heroic and out of character solutions (such as special arrangements, rescheduling for more convenient times, changing your process by “doing more as the patient is doing less”). Any such responses can become a positive reinforcement for what in essence is a maladaptive behavior.

Instead, keep doing what you have done all along and do not change the termination date. Chance is that the patient will be able to mobilize enough internal resources to hold it together through termination if you would only give him your vote of confidence that he can do so. For the minority that cannot, a return/continuation of therapy might be recommended. If so, it’s usually better if you let another therapist take over. The rationale for switching therapists follows the idea that one needs to be consistent in preventing positive reinforcements for maladaptive traits or behaviors.

Not to mention that if the patient did not improve within the parameters that you initially discussed you might not be the best therapist (at least for that one patient) and they might really benefit from no longer seeing you.

An interesting question. We live in a day and age when emphasis shifted from psychological to biological theories and interventions. However, it seems like a psychiatrist persona in the public eye, continues to be defined not by one’s pill-pushing abilities but first and foremost by his ability to understand the twists and swirls of another’s mind. If a prescription for a medication follows, that is fine as long as the psychiatrist bases his recommendation on a in-depth understanding of the patient’s mental and emotional workings. Despite all biological advances it remains anathema to pill push based on a straightforward symptom count. Counting is not a core competence of a psychiatrist, understanding is.

Symptoms checklists are barely acceptable in non-psych medical specialties; at least, non-psych doctors can realistically justify the long duration of training as necessary due to the high number of symptoms, syndromes, diagnoses, and treatments that one needs to master. The higher the quantity of data, the longer the training.

That is not the case in psychiatry.

An Aristotelian take on modern psychiatry finds that Axis I genu has only 10 “species”: affective and psychotic disorders, substance use, anxiety, eating, somatoform and factitious disorders, dissociative and impulse control disorders, and adjustment disorders. Of course, there are subspecies variations; nevertheless, this is a rather small number of definitions and categories.

Axis II genu with its 3 “species” (Clusters A, B, C) and N=12 subspecies is not much more complicated. Count this: Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorder; Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorder; Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorder, and Personality Disorder Not Otherwise Specified. Not that hard, is it?

Does one really need 4 years of training (after 4 years of medical school, and 4 other pre-med years) to learn how to identify 23 categories?

The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) define physician general competences in terms of 6 organizing principles: 1. Patient care; 2. Medical Knowledge; 3. Interpersonal and communication skills; 4. Practice based learning and improvement; 4. Professionalism; 6. Systems based practice.

I am of the opinion that for Psychiatry this order needs to be changed.

#1 should be the interpersonal and communication skills domain. While important for any physician this area of competence is the foundation of a good psychiatrist. A psychiatrist who is not a master communicator faces the risk of gathering invalid and unreliable data – as psych data is mostly self reported and subjective. Thus, the quality of the data directly correlates with the quality of the relationship/rapport.

Poor rapport à poor data à poor assessment à poor intervention.

What are the requirements of a good communicator?

  1. Awareness: Be present. Notice everything. Verbal communication can (and will be) censored, i.e. only partly informative. Always notice the lesser controlled, i.e. more informative, non-verbal behavior. In therapy this is “going after the affect”.
  2. Focus: Give undivided attention. The most frequent reason for distraction is your own agenda.
  3. Curiosity: Let the patient (and not yourself) paint on the canvas.
  4. Empathy: Put oneself in the other’s shoes.
  5. Unconditional acceptance: withhold judgment (N.B. does not equal condoning or withholding action).
  6. Competence: Lead and support.

Everything else can be learnt in a couple of years (incidentally, an Internal Medicine residency takes 3 years).

But developing a “good communicator” skills-set is an entirely different story. This is a life time project and thus, an additional two years might not even be enough for anything else but scratching the surface.

The important point here is that 4 years is way too long for a training limited to descriptive approaches to diagnosis/symptomatic approaches to treatment, but not nearly enough if the goal is to master and use the complexities of social interaction to enhance mental health growth, and mental illness prevention and recovery.

A social brain perspective, emphasizing communication (see the Group for Advancement in Psychiatry 2009 report), is a useful model to bridge apparent opposites (bio versus psycho) and promote a training “climate” change.



There is a lot of discussion about the BPS model. Trouble is that in today’s climate this is more a point of discussion of academical interest than a reality informing our day-to-day assessments and treatment plans. Excuses of why this is are plenty: from the severely limited time allowed in most treatment settings for the regular intake and follow-up,  to the dis-interest of managed care in anything that is not clearly linked to medical/biological outcomes and interventions, viz medications.

It turns out that when one compares a patient-centered with a system-centered approach, the former is both more efficient (i.e. allows for more complete data collection) and more effective (i.e. captures more data per unit of time). Counterintuitive, yes – nevertheless, true.

One way to self-monitor one’s exam focus is to jot down the info in a 3 column format: 1st: biological data; 2nd: psychological data; 3rd: social data. Each piece of data would be placed on a line; the more data, the higher their column. An ideal interview/history should produce 3 columns of fairly comparable sizes, while a biologically/system-centered interview will necessarily result in a pretty sizable biological column and rather small psycho-social columns.

Of course this way of organizing the information is cross sectional in terms of the classical categories of anamnesis, i.e. history of present illness (HPI), past psychiatric, substance and medical history, family history etc.

Instead, each of the above categories will be constructed across the 3 BPS axes. For example, an HPI of recent neuro-vegetative symptoms (B), poor self-esteem (P), and recent break-up with the significant other (S), in context of work stress due to a difficult boss (S), which brings up memories of parental emotional abuse (P), will be divided along the 3 axes. By organizing the information accordingly, one can have a visual cue about the overall balance of the BPS contributors. An obvious unbalance can thus be easily noted and corrected.

Last but not least, by organizing the info visually along the 3 axes, dominant themes become more easily noticeable. Finally, a comprehensive BPS case formulation naturally emerges after this simple act of BPS organizing.

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