Bio-psychosocial model

& stress
Dr. Amrie Morris-Patterson
 Objectives
• Distinguish between the biomedical and bio-psychosocial models, and recognize the
advantages of the latter as a model of the illness process.
• Recognize the biological, psychological, and social components in a case
presentation and possible treatment interventions which reflect those aspects.
• Recognize psychological and behavioral factors which predispose an individual to
certain illnesses.
• Define the term “stress”, and understand how it influences disease and illness.
 Contemporary Definitions of Health – basic
definition:
• Health is multidimensional: it is not merely the presence or absence of disease,
but also has social, psychological and cultural determinants and consequences.

• The WHO defines Health as: “A complete state of physical,

mental and social well-being and not merely the absence of
illness.”

07/12/2011 3
 Health over Time

• 3000 years ago:

• Spirits, Mind, and body seen as one
• Greeks onward (e.g., Descartes):
• Mind and body separate
• Age of Scientific Discovery (17-19th century):
• Rise of the biomedical model of disease
• Inventions drive health care (e.g., 1668 Microscope)

• Beginnings of Health Psychology as we know it

• 1930s Society for Psychosomatic Medicine formed
• 1970s Society for Behavioral Medicine formed
• 1970s Health Psychology formed
• Mind and body are seen as one again
The (Bio) Medical Model

• Health constitutes the freedom from disease, pain, or

defect, thus making the normal human condition
"healthy".
• Focused on the physical processes, such as
the pathology, biochemistry and the physiology of a
disease
• Historically extremely effective
• Focused on removing disease/disability (“germ”)
• No focus on prevention, well-being
• Limited usefulness with current patterns of illness and the
health challenges of the 21st century
 (Bio)Medical Model

• The model is reductionist

• It looks for underlying organic factors.
• Belief that the cause of a disorder, including a psychological disorder, is a physical
disorder.
 Biopsychosocial model
• Theorized by psychiatrist George L. Engel at the University of Rochester
• 1977 article in Science, he posited "the need for a new medical model."
• The biopsychosocial model of illness incorporates physical, psychological and social
factors:
• To provide a basis for understanding the determinants of disease and arriving at rational
treatments and patterns of health care, a medical model must also take into account the
patient, the social context in which he lives and the complementary system devised by
society to deal with the disruptive effects of illness, that is, the physician role and the
health care system. This requires a biopsychosocial model.” Engel, 1977
 Bio-psychosocial model
• Multiple determinants in the development
of disease and the resultant illness process
• Hierarchical organization of biologic and
social systems that contribute to disease
and illness experience

• Each system is a component of a higher

more abstract system
• Changes in one system will affect the other
Biopsychosocial Model
 Clinical vignette -obesity
• At 5 feet 4 inches tall, tipping the scales at 255 pounds and still retaining the 50 pounds she put on during her most recent
pregnancy, Mary MacBride has a BMI of 43.8, well above the level considered healthy for her height and weight. A veteran
of multiple failed diet and exercise regimens, alone and in conjunction with pharmaceutical assistance, Mary eats not only
when she is hungry, but also when she is stressed, bored, excited, happy and, many times, just because food is in front of
her. Today at a check-up, Mary’s primary care provider finds no significant major organ or system abnormality except for
longstanding hypothyroidism.

• Her hypothyroidism is being successfully treated with medication, but despite this, she has not been able to attain a healthy
weight. Worried that Mary may contract diabetes or coronary artery disease and given her previous failed attempts at losing
weight, Mary’s physician mentions bariatric surgery. He and Mary discuss the pros and cons. They decide to schedule an
appointment with a surgeon the next week. At that time, Mary and her husband will learn more about surgical options,
which will probably include a Roux-en-Y gastric bypass, biliopancreatic diversion, a sleeve gastrectomy or a gastric bypass.

• Discuss the biopsychosocial factors that may impact on Mary’s condition and her long-term outcome
“…Engaging with social drivers requires methods and approaches beyond
traditional conceptualizations that seek to identify and intervene on single,
causal determinants or universal mechanisms of influence.”
Source: (Auerbach, Parkhurst, Cáceres et al., aids2031 Working Paper 24)
 Bio-psychosocial model
To apply the bio-psychosocial approach to clinical practice, the clinician should:
• Recognize that relationships are central to providing health care
• Elicit the patient’s history in the context of life circumstances
• Decide which aspects of biological, psychological, and social domains are
most important to understanding and promoting the patient’s health
• Provide multidimensional treatment
How Do Psychological and Social Factors
Influence Medical Illness?
 Stress

• “Stress may be defined as a real or interpreted threat to the physiological or

psychological integrity of an individual that results in physiological and/or
behavioural responses” (McEwen 2000)
 Stress response
• Described by Walter Cannon as the
fight or flight response
• Selye (1976)
• Eustress (healthy stress) optimal
degree of arousal to motivate and
enhance performance
• Distress
• Stress response influenced by degree
and duration of stress (Yerkes Dodson
Law)
 STRESS RESPONSE
• Incoming sensory information is collected by the thalamus
• Forwarded to amygdala, hippocampus and cortical areas ( first response team)
• The ANS and HPA axis coordinate the stress response to an acute stressor.
• Within seconds, the cathecholamines (NE and E) and CRH, followed quickly by ACTH, are
released into the circulation. The glucocorticoids enter the circulation later.
• The stress response includes two phases, the faster sympathetic response mediated by
cathecholamines, and the slower hormonal response mediated by the HPA axis.
• Hippocampus modulates the amygdala
• Generalized sympathetic arousal cannot be sustained at such a high level in the face prolonged
stress
 Stress and the HPA axis
• Chronic stress and/or a high level of glucocorticoids alters certain serotonergic receptors (increases
the 5-HT2A receptors in the cerebral cortex and reduces the 5-HT1A receptors in the hippocampus).
• These same changes have been observed in humans who have committed suicide or suffered from
diseases that cause hypersecretion of glucocorticoids.
• Prolonged chronic stress also seems to alter the response of the steroid receptors and to have very
harmful effects on people's mental equilibrium, especially when social or family supports are absent.
• Thus, all indications are that the end products of the HPA axis—glucocorticoids— play a role in
depression by influencing several neurotransmitter systems, including those for serotonin,
norepinephrine, and dopamine, all three of which are involved in depression
 Role of glucocorticoids
• Chronic stress can be maladaptive . Effects of excess glucocorticoids in the
circulation include:
• Impairs ability of hippocampus to suppress the amygdala and terminate
stress response
• Impair cells ability to respond to insulin leading to increased glucose and fat
in blood stream; can predispose to or worsen NIDDM
 Stress and Immune system

• Excess glucocorticoids depress immune system functioning

• Stress can increase the release of adrenocorticotropic hormone (ACTH)

• This leads to release of cortisol
• Decreased lymphocyte response to mitogens and antigens
• Impaired function of natural killer cells
• Leads to damaged T cells and premature migration of T cells from thymus
 Stress
• Cardiovascular system
• Sustained elevations of BP leading to atherosclerosis
• Growth process
• Chronic stress can inhibit growth hormone release, reducing target cell sensitivity and the synthesis of new
proteins
• Reproductive processes
• Glucocorticoid inhibition of the hypothalamic release of LH and FSH.
• Inhibition of testosterone release and sperm production in men and estrogen release and egg production in
females
• Stress induced fat cell consumption in females can impede estrogen production resulting in relative build up
of male hormone that contributes to amenhorrhea
 Common disorders resulting from chronic stress-induced
system failures

• Gastrointestinal: peptic ulcer, GERD, irritable bowel syndrome

• Cardiovascular: essential hypertension,
• Respiratory: Asthma , hyperventilation
• Dermatologic: eczema, acne, psoriasis
• Musculoskeletal: muscle strain, tension headache
• Emotional: affective disorders, PTSD, reactive psychosis
 The Life stress Test or Holmes and Rahe Test

• Question 1 of 8
Your Finances
Foreclosure of mortgage or loan (30)
Mortgage or loan less than $10,000 (18)
Mortgage more than $10,000 (31)
Change in financial state (38)
 The Life stress Test or Holmes and Rahe Test

• Question 2 of 8
Your Living Conditions
Change in living conditions (25)
Change in residence (20)
Change in recreation (19)
Change in church activities (19)
Change in sleeping habits (16)
Change in eating habits (15)
 The Life stress Test or Holmes and Rahe Test
• Question 3 of 8
Your Family and Personal Life
Death of a Spouse (100)
Death of a Close Family Member (63)
Divorce (73)
Marital Separation (65)
Marriage (50)
Marital Reconciliation (45)
Retirement (45)
Pregnancy (40)
Gain of new family member (39)
The Life stress Test or Holmes and Rahe Test

Death of close friend (37)

Son or daughter leaving home (29)
Trouble with in-laws (29)
Outstanding personal achievement (28)
Change in number of arguments with spouse (35)
Wife begins or stops work (26)
Revision of personal habits (24)
Change in number of family members (15)
 The Life stress Test or Holmes and Rahe Test
• Question 4 of 8
You and the Law
Jail term (63)
Minor violations of the law (11)

• Question 5 of 8
Your Work
Fired from work (47)
Business readjustment (39)
Change to different line of work (36)
Change in responsibilities at work (29)
Change in work hours or conditions (20)
Trouble with boss (23)
 The Life stress Test or Holmes and Rahe Test
• Question 6 of 8
Holidays
Vacation (13)
Christmas (12)

• Question 7 of 8
Your Education
Begin or end school (26)
Change in schools (20)

• Question 8 of 8
Your Health
Personal injury or illness (44)
Change in health of family member (39)
Sex difficulties (63)
 Scores- Holmes –Rahe test
• The more change you have, the more likely you will suffer a decline in health.
• Of those who scored over 300 "life change units", 80 percent have a chance
of a serious health change.
• 150-299 life change units, you have a 50 percent chance of getting sick in the
near future.
• Less than 150 life change units – 30 % chance
 Holmes and Rahe scale
• Used to quantify stressful life events
• Death of spouse is rated a most stressful event
• Not only negative events are rated
• Correlation between stressful life events and developing ill health is small but
significant positive correlation
Magnitude of stress associated with selected life events according to
the Holmes and Rahe social readjustment rating scale (directly
correlated with increased risk of medical and psychiatric illness)

Relative Stressfulness Life event ( Point Value)

Very High Death of a spouse (100)
( events with the highest scores require people to Divorce (73)
make the most social readjustment in their lives) Marital separation (65)
Death of a close family member (63)
High Major personal loss of health as a result of illness (53)
Marriage (50)
Job loss(47)
Retirement (45)
Major loss of health of close family member (44)
Birth or adoption of a child (39)
Moderate Assuming major debt ( eg taking out a mortgage)
Promotion or demotion at work (29)
Child leaving home (29)
Low Changing residence (20)
Vacation (15)
 Cognitive factors
• Cognitive appraisal
• Individuals’ interpretation of events in their lives as harmful, threatening or
challenging and their determination of whether they have the resources to
effectively cope with the situation ( Lazarus, 1998)
 Personality factors
• Hardy personality type
• Clear sense of values, goals and capabilities
• Unshakeable sense of the meaningfulness of life
• Tendency to see life as a series of challenges, rather than a series of threats
or problems
 Personality factors
• Type A behaviour pattern
• Cluster of characteristics –being excessively competitive, hard driven,
impatient and hostile
• Associated with increased prevalence and incidence of coronary heart
disease
• Key component in Type A behaviour pattern is time urgency, and chronic
anger or hostility
 Medical conditions associated with
psychological symptoms
• Certain patient populations are more likely to be psychologically stressed
than others
• Surgical patients
• Patients undergoing renal dialysis
• Patients in Intensive Care Units
• Patients with HIV/AIDS
• Patients with chronic pain
 Social determinants of Health

• The social determinants of health (SDH) are the conditions in which people
are born, grow, work, live, and age, and the wider set of forces and systems
shaping the conditions of daily life. These forces and systems include
economic policies and systems, development agendas, social norms, social
policies and political systems.
 Social determinants of health

• The United States is among the wealthiest nations in the world, but it is far from the
healthiest. Although life expectancy and survival rates in the United States have
improved dramatically over the past century, Americans live shorter lives and
experience more injuries and illnesses than people in other high-income countries.
The U.S. health disadvantage cannot be attributed solely to the adverse health status
of racial or ethnic minorities or poor people: even highly advantaged Americans are
in worse health than their counterparts in other, "peer" countries.
• National Research Council. U.S. Health in International Perspective: Shorter Lives, Poorer
Health. Washington, DC: The National Academies Press, 2013.
 Social determinants of Health
• Health systems
• Unlike its peer countries, the United States has a relatively large uninsured population and
more limited access to primary care. Americans are more likely to find their health care
inaccessible or unaffordable and to report lapses in the quality and safety of care outside of
hospitals.
• Health behaviours
• Although Americans are currently less likely to smoke and may drink alcohol less heavily
than people in peer countries, they consume the most calories per person, have higher rates
of drug abuse, are less likely to use seat belts, are involved in more traffic accidents that
involve alcohol, and are more likely to use firearms in acts of violence
 Social determinants of Health
Social and economic conditions.
• Although the income of Americans is higher on average than in other countries, the United
States also has higher levels of poverty (especially child poverty) and income inequality and
lower rates of social mobility. Other countries are outpacing the United States in the
education of young people, which also affects health. And Americans benefit less from
safety net programs that can buffer the negative health effects of poverty and other social
disadvantages.
Physical environments.
• U.S. communities and the built environment are more likely than those in peer countries to
be designed around automobiles, and this may discourage physical activity and contribute to
obesity.
 Demographics of health
Socioeconomic status (SES)
• Construct determined primarily by occupation, education and income
• People with lower SES typically have poorer mental and physical health and
decreased life expectancies
• Low SES pts more likely to delay seeking treatment
• In USA, 85% of people with low SES are African- American or Latino
 Physician stress and burnout
• Stress and burnout are extremely prevalent, with 88.0% of all 2015 survey
respondents identifying themselves as moderately to severely stressed and/or
burned out on an average day, and 45.6% specifying severe stress and/or
burnout. This is compared to 86.9% and 37.7% in the 2011 sample,
respectively.
Nationwide, multispecialty survey of more than 2,000 physicians conducted by
VITAL WorkLife & Cejka Search Physician Stress and Burnout Survey , 2015
 Physician burnout
• Burnout is more common among physicians than among other US workers.
• Burnout rates were highest among physicians on the front line of care access,
including family medicine, general internal medicine, and emergency
medicine. It was lowest among pathologists, dermatologists, general
pediatricians, and those practicing preventive medicine.

• Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population .Arch Intern Med.
2012;172(18):1377-1385. doi:10.1001/archinternmed.2012.3199
 Symptoms of physician burn out
• Constellation of emotional exhaustion, detachment and a low sense of
accomplishment
• Chronic lateness
• Increased irritability
• Abuse of drugs and alcohol
• Feeling trapped
 Physician stress and burnout
Many doctors find it difficult to admit that their work is stressful, that they
have a drink or drug problem or that they need help.
• The high personal standards of the people who choose careers in medicine
• A culture of always coping
• Fears about damaging job prospects
• Uncertainty about who to tell.
 Ten Tips For Better Health
• 1. Don't smoke. If you can, stop. If you can't, cut down. • 1. Don't be poor. If you can, stop. If you can't, try not to
be poor for long.
• 2. Follow a balanced diet with plenty of fruit and vegetables.
• 2. Don't live in a deprived area, if you do move.
• 3. Keep physically active.
• 3. Be able to afford to own a car.
• 4. Manage stress by, for example, talking things through and
making time to relax.
• 4. Don't work in a stressful, low paid manual job.
• 5. Don't live in damp, low quality housing or be homeless.
• 5. If you drink alcohol, do so in moderation.
• 6. Be able to afford to go on an annual holiday.
• 6. Cover up in the sun, and protect children from sunburn.
• 7. Don’t be a lone parent.
• 7. Practice safer sex.
• 8. Claim all benefits to which you are entitled.
• 8. Take up cancer screening opportunities.
• 9. Don't live next to a busy major road or near a polluting
• 9. Be safe on the roads: follow the Highway Code. factory.
• 10. Learn the First Aid ABC : airways, breathing, circulation. • 10. Use education to improve your socio-eco
Dr. Liam Donaldson, UK CMO 1999 David Gordon, Centre for Poverty Research