Tag Archive: 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.

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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