Journal of Psychosomatic Research 67 (2009) 607 611

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Engel's biopsychosocial model is still relevant today

Rolf H. Adler
Medical School, University of Berne, Berne, Switzerland Received 6 March 2009; received in revised form 18 August 2009; accepted 18 August 2009

Abstract In 1977, Engel published the seminal paper, The Need for a New Medical Model: A Challenge for Biomedicine [Science 196 (1977) 129136]. He featured a biopsychosocial (BPS) model based on systems theory and on the hierarchical organization of organisms. In this essay, the model is extended by the introduction of semiotics and constructivism. Semiotics provides the language which allows to describe the relationships between the individual and his environment. Constructivism explains how an organism perceives his environment. The impact of the BPS model on research, medical education, and application in the practice of medicine is discussed. 2009 Elsevier Inc. All rights reserved.

Keywords: Biopsychosocial; Systems theory; Hierarchy; Semiotics; Constructivism

An illustration of a biopsychosocial vs. a biomedical approach The novel Murder at the Gallop, by Agatha Christie, featuring Miss Marple, presents an opportunity to illustrate the characteristics of the biopsychosocial (BPS) model [1] as opposed to the traditional biomedical (BM) model: Miss Marple and her friend, the librarian, are canvassing for local charity in the streets of a small town. They come to the mansion of a rich man, Mr. Enderby. They enter the main door and call for the old man. He appears on the first floor landing, clutching his chest, collapses, tumbles down the staircase, and ends spread eagled on his back in front of the two visitors. Miss Marple realizes instantly that Mr. Enderby is dead. She climbs the stairs for more evidence, opens a door on the gallery, whereupon an ugly, ferociously looking cat jumps out of the room, over her shoulder and disappears. Miss Marple's hypothesis is murder: Mr. Enderby, who suffers from a longstanding cardiac ailment (bio), and who is known for his pathological horror of cats (psycho), was frightened to death by a cat, which a visitor (soc), perhaps

Leiserenweg 4, 3122 Kehrsatz, Switzerland. Tel.: +41 31 961 54 96. E-mail address: rolf.adler@tele2.ch. 0022-3999/09/$ see front matter 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2009.08.008

one of his four greedy heirs, had smuggled into his house with the intention of frightening the old man to death. Miss Marple goes to the police station and informs the inspector. He ridicules the old lady and remains adamant that the doctor's diagnosis was heart failure (bio) and adds that he has no intention of pursuing the case (he refrains from considering psychological and social data). Miss Marple adheres to a BPS model: Mr. Enderby, due to his pathological horror of cats, was unable to react appropriately to the unexpected appearance of a cat. Immediately his central nervous system activated the fight flight- and the conservationwithdrawal pattern, in turn triggering hyper- and hypocirculatory responses. On the tissue level, myocardial ischemia followed, leading to electric instability and finally to probable ventricular fibrillation. Her thinking follows a hierarchical order, which is illustrated (Fig. 1) by Engel [2]: A man with acute myocardial infarction is brought to the emergency room. His cardiac rhythm is stable and precordial pain has subsided. A resident tries unsuccessfully for several minutes to insert an arterial line. All of a sudden he leaves the patient to get assistance from his superior. The man gets increasingly angry at the unsuccessful attempts of the resident and after the resident has left he feels abandoned and hopeless, upon which ventricular fibrillation sets in. The

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Fig. 1. Unsuccessful attempt at arterial puncture [4].

returning physicians are then able to resuscitate him. Later on, they congratulate the patient for not having gone into fibrillation during his ride to the hospital and for waiting until he was in the emergency department. Both the inspector's and the physicians' train of thought and actions are in keeping with a BM model. The impact of psychosocial influences on the cardiac rhythm in dogs and pigs that have diseased hearts had been demonstrated by Lown et al. [3] in 1977 and had been assumed on clinical grounds by Engel [4] in his paper, Sudden and Rapid Death During Psychological Stress: Folklore or Folkwisdom. The novel, Engel's [4] case report, and the experiments of Lown et al. [3] can best be understood on the basis of a BPS model, depicting a hierarchical organization as its main characteristics. A note of caution: psychosocial factors are neither compulsory nor sufficient for triggering somatic disorders (see Lown et al. [3] and Mr. Enderby's preceding heart condition).

Further development of the BPS model Examining Mr. Enderby isolated from his social context leads to the inspector's impression: sudden cardiac

death, superimposed on chronic cardiac ailing. Sudden changes in the level of the central nervous system are, as we shall see later, not the only reasons for his sudden death. On the one-person system level, inclusion of his horror of cats, his wealth, and, on a several-persons level, his greedy heirsintegrating him as a person with social relationshipsleads to the emergence of a new interpretation: Miss Marple's. New characteristics of a suprasystem emerging after the integration of lower systems were not mentioned expressively by Engel [1,2]. Von Uexkll and Wesiack [5] have assumed that emergence is mainly the result of inhibitions on lower system levels. Engel [1] has not explicitly mentioned either the question of how lower and higher systems are coupled and how coupled systems are separated. He was, however, aware of the crucial importance of this problem. Von Uexkll and Wesiack [5] introduced the term coupling and decoupling of systems. Coupling and decoupling are, in my opinion, the main issue of psychosomatic medicine. Von Uexkll and Wesiack [5] suggested classical Pavlovian conditioning as one possible mechanism of coupling: Ader [6] demonstrated such a coupling by injecting mice intraperitoneally with the immunosuppressant cyclophosphamide and administering at the same time an oral saccharine solution. When the mice were immunized some

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days later with sheep erythrocytes and simultaneously given saccharine per mouth, they developed lower antibody titers to the erythrocytes compared to the mice immunized, but not given, the conditioned stimulus saccharine [6]. The experiences, the history of the organism, are pivotal for coupling. Constructivism and semiotics The organism does not react uniformly and thus mechanically and predictably to a defined stimulus. A psychobiological system, developing during the ontogenesis of an organism, which the mathematician Peirce (1834 1914) [7] designated the interpretant, imprints meanings on the receptor, which is activated by stimuli. (He constructs his environment. The interpretant as used in our context is akin to Freud's ego.) The interpretant encompasses the organism's unconscious, preconscious, and conscious memories in the implicit-, the working-, and the autobiographic memory. After the admission to the system (the interpretant), the imprinted stimuli are processed and only at this point will the organism exploit the processed stimuli. A stimulus, whether physical or chemical, which is imprinted with a meaning by the organism, is semiotically designated as a sign. The imprinting with meaning depends on the organism's motives, relationship needs, metabolic conditions, thoughts, and fantasies. The sign does not represent anything physical. The physical appearance of a cat represents a horror for Mr. Enderby, whereas for a cat lover it represents a highly cherished companion. Individual reality The experience of Mr. Enderby stresses a further characteristic of the interpretant: individual reality. It is Mr. Enderby's individual reality which creates, i.e., constructs, a situation that another person without horror of cats would never have constructed. In summary, Engel's [1] model can be extended by semiotics and constructivism. By the immaterial nature of the sign, the separation into somatic and psychological stimuli has become obsolete. This is well illustrated by Tom, the laboratory assistant of Wolf and Wolff [8], who as a 9-year-old had scalded his esophagus so severely with hot soup that it led to stenotic scars necessitating an epigastric fistula. During the operation, the large curvature of the stomach was attached to the abdominal wall. The gastric mucosa grew into the opening, which had a diameter of 3 cm. As a result, the mucosa was visible to the naked eye. Tom's stomach was instilled with prostigmin via the fistula. He responded with cramps and diarrhea. Later, a placebo resulted in the same symptoms. Even the administration of atropine, which is known to produce atony of the stomach, resulted in cramps and diarrhea. The interpretant within Tom had transferred the experience with prostigmin to the placebo and then to

atropine. Tom had attributed to the atropine a meaning which overruled the chemical effect of that substance. Semiotically spoken, the instilled liquid with atropine acted as a carrier for a meaning. This meaning had been imprinted on the carrier by the interpretant. The two links of the causeeffect chain of the mechanistic model now become three. The carrier, as the first link, has the task of stimulating the receptors. The interpretant, the second link, imprints the perturbation of the receptor by the stimulus with a meaning. This imprinted mark prompts the organism to process the sign. Only after the organism has evaluated the sign does he impregnate his environment with an effect mark, thus concluding the circular chain of events as a third link.

Resistance against the introduction of the BPS model Fear of the emergence of one's own feelings (designated as countertransference feelings by psychoanalysis), e.g., sadness, shame, anger, disgust, annoyance, impatience, confusion, helplessness and hopelessness, fear of death, fear of loss of control, and fear of loosing control over too many things have been discussed by several authors. These threats have led to the sacrifice of the recognition of the individual element (the interpretant) in favor of a more or less strictly mathematically expressible generalization [9]. The reason for this is obvious. The tendency to devalue the individual aspects is directly proportional to the emotional distance of the observer. Medicine has to decide whether the randomized patient represents its benchmark, or whether every patient contact requires that the patient be also defined as an organism with an individual reality based on his own personal history. The decision to introduce a mechanistic evidence and an evidence of meaning is a consequence of the understanding that man is at the same time an open and a closed system. An open system means that man is approachable like a defective machine, which can be examined and repaired without the necessity to establish a relationship. In Agatha Christie's novel, the attempt at resuscitation of Mr. Enderby would best have followed an algorithm established by emergency room physicians. Immediately after the stabilization of the cardiopulmonary systems, Mr. Enderby would have to be approached as a so-called closed system, because his psychological problems, his fear of cats, and his relationship with his greedy heirs can only be understood if he is accepted as a person with an individual reality. This can only be assessed after a working alliance is established between him and his physicians. Empathy and the BPS interview then open the closed system. The BM (open) model and the BPS (open and closed combined) model are not mutually exclusive. The former is a subsystem of the latter. Why is discussion of the theoretical aspects of medicine necessary? Because without theory practical medicine is blind, and theory of medicine without practical medicine is lame.

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The relevance of the BPS model in today's research A great amount of scientific evidence in this area has been accrued. I have selected a small segment thereof to illustrate it. It is the relationship between the effects of helplessness and hopelessness and somatic disorders. This is self-evident, because it has been one of Engel's main topics of interest. Von Kaenel et al. [10] have illustrated the connection of feelings of helplessness and of depressed mood with the procoagulant load in Alzheimer caregivers. Schwarz et al. [11] have observed a significant reduction in high-frequency heart rate variability in master chess players during episodes of hopelessness in championship games. Anda [12] has found an increased risk for ischemic heart disease in a hopeless cohort of US adults. In a study by Appels and Mulder [13], recent feelings of hopelessness have predicted myocardial infarction with a relative risk of 1.68. Stern et al. [14] have shown that hopelessness predicts mortality in older Mexican- and European Americans. A review on the relationship between negative affect states and cardiovascular disorders has been published by Buerki and Adler [15]. What each medical student should be taught in the field of psychosomatic medicine was recently summarized by Novack et al. [16]. The core research encompasses basic psychophysiological mechanismscentral nervous system/ autonomic nervous system, psychoneuroimmunology, and psychoendocrinologyin three major disease states cardiovascular, gastrointestinal, and HIV infections. The current relevance of the BPS model in undergraduate medical education The dramatic and probably unstoppable and everincreasing fragmentation of medicine with the creation of still new specialties, which are not aware of human suffering and may even negate the necessity of any such contact, makes the implementation of the BPS model all the more important and necessary. The BPS model has become one of the main theoretical foundations for a number of reform curricula in undergraduate medical education (Berne, Maastricht, Harvard, Glasgow, Witten-Herdecke, etc.). In a survey of the 118 US medical schools (19971999), Waldstein et al. [17] inquired about the impact of the BPS model on undergraduate medical education. Of the 118 medical schools, 46% replied. Of those, 41% indicated that they provide teaching on topics related to the BPS model, i.e., psychosocial factors 8093%, cardiovascular 83%, doctorpatient communication 98%. On average, BPS topics amounted to 10% of all the curricula. Obstacles were limited resources, resistance by students and faculty, lack of continuity of courses. In Western Europe, no such survey has ever been published. That is why I am presenting three examples of BPS curricula. At Maastricht Medical School [18] in the 1980s, a model for teaching doctorpatient

communication was developed. A longitudinal training program was installed covering 4 years. Students meet in small groups once every 2 weeks and practice doctorpatient communication. At the Medical School of Cologne (Germany), 20 h of basic BPS medicine with reference to clinical medicine are taught in the first semester; in the fifth semester, 12 h on doctorpatient communication featuring BPS aspects; in the eighth semester, 24 h on psychosomatic medicine and psychotherapy; from the fifth to the eighth semester, 12 h on doctorpatient communication and on medical didactics. In the same period, the students are introduced to scientific BSP work, and 19 h cover topics like abdominal pain, anxiety, depression, cancer pain, eating disorders, diabetes, myocardial infarction, etc. The barriers to more BPS topics are akin to those mentioned by Waldstein et al. [17]. At the Medical School, University of Berne, 200 h of teaching BPS topics are distributed over the 6-year curriculum. The topics are doctorpatient communication; interviewing real patients; medical ethics; working in surgeries of practicing doctors; lectures on stress, coping, CNSs and emotions, CNS and social system, psychocardiology, neuroses, psychoses, introduction to Balint-group medicine. The BPS teaching amounts to about 5% of the entire curriculum. The current relevance of the BPS model in postgraduate medical education The integration of the BPS model into clinical medicine has been less successful than it has been into research and into undergraduate clinical education. However, the development of integrated care models such as in pain clinics and medical-psychiatric units in the US and in psychosomatic units in Germany , as well as in departments of internal medicine using BPS assessment instruments in standard cases (e.g., the Intermed method) [19,20], is worth mentioning. At the Medical School, University of Berne, a residency program in integrated BPS internal medicine has been successfully established [21]. Residents are trained in the clinical approach to the patient on the wards and in the outpatient department based on Engel's Psychological Development in Health and Disease [22] and on his Clinical Approach to the Patient [23]. A follow-up of these residents after 5 to 28 years has shown that these residents now working as general practitioners and general internists still practice the integrated approach and demonstrate higher skills in diagnosing psychophysiological disorders and at lower costs than the physicians lacking this kind of training [24]. A curriculum in integrated BPS medicine cutout for practicing physicians was established in 2002. It is affiliated with all of the five Swiss medical schools. The curriculum encompasses 360 h spaced over 3 years covering knowledge in psychosocial aspects, communication skills, and selfexperience. At the end of this curriculum, the participants receive a diploma called Fhigkeitsausweis.

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The author would like to stress a point: a whole bunch of physicians in different specialties, e.g., in pains clinics, medical-psychiatric units, etc., do not adhere to Engel's and the author's comprehension of the BPS model. According to Engel and to this author, the integration has to be established within the somatic physician himself (see Refs. [22,23]). Each physician must carry within himself a working knowledge of human behavior. Engel's [1] dictum from 32 years ago is a continuous stimulus to our endeavors (cited in Ref. [25]): Nothing will change unless or until those who control resources have the wisdom to venture off the beaten path of exclusive reliance on biomedicine as the only approach to health care. References
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