A revitalized biopsychosocial model: core theory, research paradigms, and clinical implications.

The biopsychosocial model (BPSM) was proposed by George Engel in 1977 as an improvement to the biomedical model (BMM), to take account of psychological and social as well as biological factors relevant to health and disease. Since then the BPSM has had a mixed reputation, as the overarching framework for psychiatry, perhaps for medicine generally, while also being criticized for being theoretically and empirically vacuous. Over the past few decades, substantial evidence has accumulated supporting the BPSM but its theory remains less clear. The first part of this paper reviews recent well-known, general theories in the relevant sciences that can provide a theoretical framework of the model, constituting a revitalized BPSM capable of theorizing causal interactions within and between biological, psychological, and social domains. Fundamental concepts in this new framework include causation as regulation and dysfunction as dysregulation. Associated research paradigms are outlined in Part 2. Research in psychological therapies and social epidemiology are major examples of programs that have produced results anomalous for the BMM and consistent with the BPSM. Theorized models of causal mechanisms enrich empirical data and two biopsychosocial examples are models of chronic stress and pain perception. Clinical implications are reviewed in Part 3. The BPSM accommodates psychological and social as well as biological treatment effects evident in the clinical trials literature. Personal, interpersonal, and institutional aspects of clinical care are out of the scope of the BMM, assigned to the art of healthcare rather than the science, but can be accommodated and theorized in the BPSM.

Looking forward to a decade of the biopsychosocial model.

The topic of this article is the biopsychosocial model. My main contention is that - notwithstanding doubts as to what exactly it is, or indeed whether it is anything - there is a coherent account of it, in terms of both applications to particular health conditions and mechanisms with wide application. There is accumulating evidence from recent decades that psychosocial as well as biological factors are implicated in the aetiology and treatment of a large range of physical as well as mental health conditions. The original proposer of the biopsychosocial model, George Engel, back in 1977, was substantially correct about what he saw was on its way.

Changes in society and young people's mental health1.

It is well recognized that many psychiatric disorders are strongly influenced by cultural and social factors. Foucault's account of the modern development links together 'madness', psychiatry and the asylum. We pick up the story at the point Foucault left it, the mid-twentieth century, to examine cultural and social processes that are reshaping concepts, discourse and practices - the 'social imaginary' - around mental health, with particular reference to the apparent rise in mental health problems among the young. We conclude that this apparent rise may reflect cultural and social changes in representations of mental health. In addition, over recent decades there have been increasingly evident fractures in social solidarity, interacting with and exacerbating specific socio-political-economic-environmental stressors on younger generations, including increasing intergenerational wealth inequalities and accelerating environmental concerns.

Evaluation of a Community-Led Intervention in South London: How Much Standardization Is Possible?

It is widely recognized that public health interventions benefit from community engagement and leadership, yet there are challenges to evaluating complex, community-led interventions assuming hierarchies of evidence derived from laboratory experimentation and clinical trials. Particular challenges include, first, the inconsistency of the intervention across sites and, second, the absence of researcher control over the sampling frame and methodology. This report highlights these challenges as they played out in the evaluation of a community-organized health project in South London. The project aimed to benefit maternal mental health, health literacy, and social capital, and especially to engage local populations known to have reduced contact with statutory services. We evaluated the project using two studies with different designs, sampling frames, and methodologies. In one, the sampling frame and methodology were under community control, permitting a comparison of change in outcomes before and after participation in the project. In the other, the sampling frame and methodology were under researcher control, permitting a case-control design. The two evaluations led to different results, however: participants in the community-controlled study showed benefits, while participants in the researcher-controlled study did not. The principal conclusions are that while there are severe challenges to evaluating a community-led health intervention using a controlled design, the measurement of pre-/post-participation changes in well-defined health outcomes should typically be a minimum evaluation requirement, and confidence in attributing causation of any positive changes to participation can be increased by use of interventions in the project and in the engagement process itself that have a credible theoretical and empirical basis.

Can a Community-Led Intervention Offering Social Support and Health Education Improve Maternal Health? A Repeated Measures Evaluation of the PACT Project Run in a Socially Deprived London Borough.

Social adversity can significantly influence the wellbeing of mothers and their children. Maternal health may be improved through strengthened support networks and better health literacy. Health improvement at the population level requires optimizing of the collaboration between statutory health services, civic organizations (e.g., churches, schools), as well as community groups and parents. Two key elements in improving community engagement are co-production and community control. This study evaluated a co-produced and community-led project, PACT (Parents and Communities Together), for mothers in a deprived south London borough. The project offered social support and health education. Intended effects were improvements in mental health, health literacy, and social support, assessed by standardized measures in a pre-post design. Sixty-one mothers consented to take part in the evaluation. Significant improvements were found in mental health measures, in health literacy, for those with low literacy at baseline, and in overall and some specific aspects of social support. Satisfaction with the project was high. We found that the project engaged local populations that access statutory health services relatively less. We conclude that community-organized and community-led interventions in collaboration with statutory health services can increase accessibility and can improve mothers' mental health and other health-related outcomes.

Community organizing and community health: piloting an innovative approach to community engagement applied to an early intervention project in south London.

BACKGROUND: The importance of community engagement in health is widely recognized, and key themes in UK National Institute for Health and Clinical Excellence (NICE) recommendations for enhancing community engagement are co-production and community control. This study reports an innovative approach to community engagement using the community-organizing methodology, applied in an intervention of social support to increase social capital, reduce stress and improve well-being in mothers who were pregnant and/or with infants aged 0-2 years. METHODS: Professional community organizers in Citizens-UK worked with local member civic institutions in south London to facilitate social support to a group of 15 new mothers. Acceptability of the programme, adherence to principles of co-production and community control, and changes in the outcomes of interest were assessed quantitatively in a quasi-experimental design. RESULTS: The programme was found to be feasible and acceptable to participating mothers, and perceived by them to involve co-production and community control. There were no detected changes in subjective well-being, but there were important reductions in distress on a standard self-report measure (GHQ-12). There were increases in social capital of a circumscribed kind associated with the project. CONCLUSIONS: Community organizing provides a promising model and method of facilitating community engagement in health.

Overdiagnosis problems in the DSM-IV and the new DSM-5: can they be resolved by the distress-impairment criterion?

Criticisms of psychiatry for overdiagnosing, for pathologizing normality, are not new, dating at least from the antipsychiatry critiques in the 1960s. Inevitably, revisions of the diagnostic manuals, the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders (DSM), provide an occasion for renewed criticism, and the revision process of the DSM-IV became a focus for further debates on overdiagnosis. The debates are typically not about the presence or absence of a decisive marker of specific illnesses or of illness in general-a complex matter on which there is hardly a consensus-but rather about the relative medical, psychosocial, and financial harms and benefits that may accrue from overdiagnosis on the one side and underdiagnosis on the other. It is proposed in this In Review paper that a useful and valid principle for use in these debates is the tight conceptual linkage between illness and distress and impairment of day-to-day functioning. This linkage is fundamental to the conceptualization of mental disorder in the DSM-IV and can still serve to reduce overdiagnosis by excluding cases where distress and impairment are absent or minimal. The same conceptual linkage provides a way of understanding how conditions may warrant a diagnosis even though they are not associated with current distress or impairment, namely, if they carry risk for such in the future. For these conditions, assessments of costs and benefits of overdiagnosis and underdiagnosis depend crucially on high-quality, replicated data on the sensitivity and specificity of the early diagnostic test.

Les critiques du surdiagnostic ou de la pathologisation de la normalité dans la psychiatrie n'ont rien de nouveau, elles datent au moins des critiques de l'antipsychiatrie des années 1960. Inévitablement, les révisions des manuels diagnostiques, la Classification internationale des maladies et le Manuel diagnostique et statistique des troubles mentaux (DSM), offrent l'occasion d'une critique renouvelée, et le processus de révision du DSM-IV est devenu le centre d'autres débats sur le surdiagnostic. Les débats ne portent habituellement pas sur la présence ou l'absence d'un marqueur décisif de maladies spécifiques ou d'une maladie en général ­ une question complexe qui fait difficilement consensus ­ mais plutôt sur les dommages et avantages médicaux, psychosociaux et financiers relatifs que peuvent entraîner d'une part, le surdiagnostic, et d'autre part, le sousdiagnostic. Il est proposé dans cet article In Review qu'un principe utile et valide à utiliser dans ces débats soit le lien conceptuel étroit entre la maladie et la détresse et l'incapacité du fonctionnement jour après jour. Ce lien est fondamental à la conceptualisation du trouble mental dans le DSM-IV et peut encore servir à réduire le surdiagnostic en excluant les cas où la détresse et l'incapacité sont absentes ou minimales. Le même lien conceptuel offre un moyen de comprendre comment les affections peuvent justifier un diagnostic même si elles ne sont pas associées avec une détresse ou une incapacité actuelle, notamment, si elles portent le risque d'une telle détresse ou incapacité pour l'avenir. Pour ces affections, les évaluations des coûts et avantages du surdiagnostic et du sousdiagnostic reposent essentiellement sur des données répliquées de grande qualité sur la sensibilité et la spécificité d'un test diagnostique précoce.

Person-centered psychopathology of schizophrenia: building on Karl Jaspers' understanding of patient's attitude toward his illness.

In this article, building on and extending Jaspers' concept of the "patient's attitude toward his illness" we draw attention to the active role that the person, as a self-interpreting agent engaged in a world shared with other persons, has in interacting with his/her basic disorder and in the shaping of psychopathological syndromes. This person-centered approach helps us to see patients as meaning-making entities rather than passive individuals and their attempt at self-understanding as not necessarily pathological and potentially adaptive. We describe 3 contemporary resources for a person-centered psychopathology: dialectical psychopathology, contemporary approaches to the meanings-causes debate, and value-based practice. Each of these provides a theoretical framework and practical resources for understanding the diversity of schizophrenic phenotypes, including symptom presentation, course, and outcome as a consequence of the different ways people with schizophrenia seek to make sense of the basic changes in self and world experiences. A person-centered approach, in building on patients' individual values and experiences as key aspects of their self-understanding of their psychosis, supports recovery and development of self-management skills.

Applicability of a cognitive model of worry to children and adolescents.

BACKGROUND: Intolerance of uncertainly (IU), cognitive avoidance (CA) and positive beliefs about worry (PB) independently predict worry frequency in older adolescents and adults, and when targeted together in treatment produce significant reductions in both worry and anxiety in this age range. The present study addresses a gap in the literature by testing whether a cognitive model of excessive worry and anxiety incorporating these process variables is applicable to children and adolescents. METHOD: Primary and secondary school students (n = 515; aged 7-19 years) completed modified self-report measures of worry frequency, anxiety, IU, CA and PB and a path analysis undertaken to test whether IU was a higher order variable for CA and PB and whether the relationship between IU/CA/PB and anxiety was mediated by worry frequency. RESULTS: Significant (bivariate) correlations were observed between the measures of IU, PB, CA, worry and anxiety across the age range. However separate path models had to be fitted for children (aged 7-12 years) and adolescents (aged 13-19) with PB being dropped from the child model. CA was related to anxiety only through worry in children while IU showed direct paths to worry and anxiety in both children and adolescents. CONCLUSIONS: Cognitive models of persistent worry in adults and older adolescents may, with some modification, have applicability to children. Further testing and refinement of these cognitive models of worry may lead to improvements in existing treatments for anxious youth.

Randomized controlled trial of full and brief cognitive-behaviour therapy and wait-list for paediatric obsessive-compulsive disorder.

BACKGROUND: Reviews and practice guidelines for paediatric obsessive-compulsive disorder (OCD) recommend cognitive-behaviour therapy (CBT) as the psychological treatment of choice, but note that it has not been sufficiently evaluated for children and adolescents and that more randomized controlled trials are needed. The aim of this trial was to evaluate effectiveness and optimal delivery of CBT, emphasizing cognitive interventions. METHODS: A total of 96 children and adolescents with OCD were randomly allocated to the three conditions each of approximately 12 weeks duration: full CBT (average therapist contact: 12 sessions) and brief CBT (average contact: 5 sessions, with use of therapist-guided workbooks), and wait-list/delayed treatment. The primary outcome measure was the child version of the semi-structured interviewer-based Yale-Brown Obsessive Compulsive Scale. CLINICAL TRIAL REGISTRATION: http://www.controlled-trials.com/ISRCTN/; unique identifier: ISRCTN29092580. RESULTS: There was statistically significant symptomatic improvement in both treatment groups compared with the wait-list group, with no significant differences in outcomes between the two treatment groups. Controlled treatment effect sizes in intention-to-treat analyses were 2.2 for full CBT and 1.6 for brief CBT. Improvements were maintained at follow-up an average of 14 weeks later. CONCLUSIONS: The findings demonstrate the benefits of CBT emphasizing cognitive interventions for children and adolescents with OCD and suggest that relatively lower therapist intensity delivery with use of therapist-guided workbooks is an efficient mode of delivery.

Conceptualisation of mental disorder and its personal meanings.

BACKGROUND: Mental disorder has been conceptualised as a matter of objective scientific fact, in versions of so-called 'naturalism'. AIMS: To elucidate the personal meanings involved in attribution of mental disorder. METHOD: Critical review of literature on the definition of mental disorder, with reference to the context of personalised medicine and healthcare. CONCLUSIONS: Personal meanings are not brought into focus by naturalism, but the current genetics paradigm creates space for three kinds of process: natural, social and individual, with corresponding conceptions of dysfunction. The individual conception is broadly a matter of experience and behaviour not going as the person intends, manifesting as unmanageable distress and self-identified disability. On the other hand in the problems that give rise to diagnosis of mental disorder, more than one person and their personal meanings are involved, creating need for empathy and negotiation.

Normative childhood repetitive routines and obsessive compulsive symptomatology in 6-year-old twins.

BACKGROUND: To investigate the association between normative repetitive routines of childhood and paediatric obsessive compulsive symptom syndrome (OCSS) and the extent to which it is genetically mediated. METHODS: In a two-phase design a community sample of 4,662 6-year-old twin-pairs were sampled and 854 pairs were assessed in the second phase for normative repetitive routines using the Childhood Routines Inventory (CRI) and for OCSS by maternal-informant diagnostic interview. The OCSS phenotype was defined using standard diagnostic criteria for obsessive compulsive disorder, though regardless of impairment. RESULTS: In the bivariate model, correlation between the CRI defined phenotype and the OCSS phenotype was estimated to be .40 (95% CI .27-.50), and this correlation was attributable wholly to additive genetic effects. The bivariate model also provided estimates of heritability of the two phenotypes separately: 55% (95% CI 80-89%) for the OCSS phenotype, with the remaining variance attributable mainly to non-shared environment, and 50% (95% CI 39-62%) for CRI assessed normative repetitive routines of childhood, with 36% of the remaining variance attributable to shared environment and 14% to non-shared. CONCLUSIONS: The moderate correlation between normative childhood repetitive routines and obsessive compulsive symptomatology, attributable to genetic factors, is consistent with the hypothesis that high levels of this trait in young children constitute a risk factor for the development of obsessive compulsive symptoms.

A multivariate genetic analysis of specific phobia, separation anxiety and social phobia in early childhood.

BACKGROUND: Comorbidity amongst anxiety disorders is very common in children as in adults and leads to considerable distress and impairment, yet is poorly understood. Multivariate genetic analyses can shed light on the origins of this comorbidity by revealing whether genetic or environmental risks for one disorder also influence another. We examined the genetic and environmental influences on the comorbidity between three common childhood anxiety disorders: Specific Phobia, Separation Anxiety and Social Phobia. METHODS: Using a two-phase design 4,662 twin-pairs were screened in the first phase and 854 pairs were assessed in the second phase by maternal-informant diagnostic interview using DSM-IV criteria. RESULTS: Multivariate genetic analysis revealed significant shared environmental over-lap between Specific Phobia and Separation Anxiety and significant familial and non-shared environmental over-lap between Specific Phobia and Social Phobia. CONCLUSIONS: Familial influences, especially shared environment, are central to the comorbidity between Specific Phobia and both Separation Anxiety and Social Phobia.

Evaluation of exposure with response-prevention for obsessive compulsive disorder in childhood and adolescence.

The present study was undertaken to estimate the effect of exposure plus response-prevention (E/RP), delivered alone intensively over 5-weeks and without concomitant pharmacotherapy, for children and adolescents with OCD. Twenty children and adolescents with OCD, not receiving medication for this condition, were randomized to E/RP or a wait-list condition. Statistically and clinically significant symptomatic improvement was found in the E/RP group compared with controls, with improvement maintained at follow-up an average of 14 weeks later. Effect size in the main intention-to-treat analysis was 1.23 and in the secondary per protocol analysis was 1.64. This study lends further support to the view that E/RP is an effective treatment for childhood OCD.

Obsessive-compulsive disorder, tics and anxiety in 6-year-old twins.

BACKGROUND: Previous reports of genetic influences on obsessive-compulsive disorder (OCD) symptoms have suggested moderate heritability. Family history studies of co-morbidity have found familial aggregation with tics, especially for early-onset OCD, and familial aggregation with anxiety disorders. METHOD: Heritability of OCD and familial aggregation of OCD, tics and anxiety disorders were investigated in a community sample of 6-year-old twins using a two-phase design in which 4662 twin pairs were sampled and 854 pairs were assessed in the second phase by maternal-informant diagnostic interview using DSM-IV criteria. RESULTS: In the multivariate model combined additive genetic and common environmental effects were estimated as 47% for sub-threshold OCD, and the model was unable to distinguish these sources of familial aggregation. There were strong familial aggregations between sub-threshold OCD and tics and between sub-threshold OCD and other anxiety disorders (80% and 97% respectively), although again specific sources could not be distinguished. CONCLUSIONS: The findings are consistent with the hypothesis of a tic-related early-onset OCD phenotype, but also with the hypothesis of an anxiety-related early-onset OCD phenotype.