Biomedical or Biopsychosocial or Psychopharmacologist?

Elements of a psychiatric evaluation

Apparently these are desperate times for some professionals.  So desperate that they have nothing better to do than argue about proven psychiatric methods that include the clinical methods that includes data gathering and diagnosis. Some would prefer to move psychiatry away from the rest of medicine based on fallacious arguments that there are no clear connections between biology and clinical phenomenon and no apparent connection between psychiatry and the rest of medicine. These arguments are so extreme that they lack clinical utility and yet there is a small by vocal group of people who try to gain political favor with what is essential reworked antipsychiatry rhetoric. As a reminder I use that term as a philosophical definition that has been used to characterize the work of Szasz and Foucault. It is agnostic in terms of the proponents. In other words, as far as I can tell you don't need to be a cult member to be a proponent of antipsychiatry. You can be a psychiatrist like Szasz.

I posted a good example of this position a few years ago.  In the post I looked at a special interest group using medical model pejoratively and applying it to psychiatry.  I illustrated how the authors account of medical model on 2 1/2 of 3 dimensions that they were using as a basis for their argument.  The eventually develop a trauma based model of psychosis and state that is all that you need to know in terms of etiology and treatment. That is their refutation of the comprehensive psychiatric model for information gathering and analysis.

Another incredible critique of the field came from the journal Health Affairs and it suggested (like most critiques of the field) that the authors really had no knowledge of psychiatry or what psychiatrists do. Specifically they seemed to have no knowledge of the biopsychosocial model of psychiatry, specific psychiatric research in that field, and how all of that information is used in day to day psychiatric practice.

The obvious point that I am making here is that psychiatrists are trained and interested in multiple factors that may be important in both the etiology and treatment of psychiatric disorders.  That includes many biological factors like toxin exposure, endocrine conditions, infectious diseases, and brain injuries as well as more subtle biologically determined factors like temperament and developmental history.  It includes the status of interpersonal relationships and psychological factors. It includes the status of other organ systems in the body and chronic medical conditions.  There are specific posts on this blog about cardiac status, sleep apnea, cirrhosis and liver disease and pancreatitis. All of these illnesses and more are encountered in routine psychiatric practice.  Psychiatrists must in some cases make the diagnosis and in other case modify therapy to account for these illnesses and not provide treatment that is contraindicated.

That leads me to the figure at the top of the page.  All of the elements are contained in the assessment of the patient. It is not unique to psychiatry, and most physicians who directly assess patients have been using one form or another of it since they were first or second year medical students learning how to examine patients.  The main difference for psychiatrists from other physicians is the formulation section. This is not the list of diagnoses, but a synthesis of all of the data gathered during the interview process and at times from collateral sources.  Consider the following hypothetical example:

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Formulation:

The patient is a 48 year old married woman with a history of insomnia and depression dating back to middle school.  She also had nightmares and night terrors during childhood but they resolved by the time she was in her late teens. Her current sleep problem is initial and intermittent insomnia.  She has been on various antidepressant medications about 90% of the time since she was 18 years old and has not found any of them to be very effective, but she does think that she gets some partial relief from fluoxetine.  She has been married for 18 years.  Her husband is supportive and they have a solid relationship.  The couple has 3 sons who are 10, 12, and 17 years old.  she had no episodes of postpartum depression.  She took fluoxetine during the last pregnancy.  There is a family history of depression in her mother and maternal grandmother. Her maternal grandmother was institutionalized and received electroconvulsive therapy.  Father and paternal grandfather had alcohol use problems. She is an electrical engineer and works in the tech industry in chip design.  She was previously active in a group that encouraged girls and young women to focus on STEM subjects in school and as a career choice but she has fallen away from that lately.  Over the past three years her alcohol consumption has increased from 2-3 standard drinks per day to 8-10 drinks per day. When she is drinking on  daily basis her mood is significantly more depressed.  During a recent episode of intoxication she sustained an intracerebral hemorrhage that was noted on an MRI scan of the brain in the left frontal cortex. She reports no cognitive or personality changes with that lesion but has had frequent headaches. She denies any history of abuse or psychological trauma, but said that her parents spent less time with her than her older brothers and that left her with a feeling of being less valued at times and questioning her self worth. She identifies strongly with her father who was also an engineer and encouraged her interest in math and science.

Diagnoses:

1.  Persistent depressive disorder
2.  Primary insomnia
3.  Intracerebral hemorrhage - assessed and treated by Neurosurgery trauma service. Serial scans show resolution with no evident abnormality.
4.  Headaches secondary to 3.

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A typical medical surgical evaluation using the same general outline will not put all of the data together to explain the patients psychiatric diagnoses or symptomatology.  Medical or surgical evaluations typically end with a list of diagnoses that typically focus on an organ system or the brain idendependent of any psychiatric factors.  The diagnostic formulation is a psychiatric innovation that has utility as a way to study diverse etiologies of mental illnesses and in this case to try to understand the unique biological, social, and psychological variables for each person who is being treated.  It is in contrast to the diagnoses which are supposed to be atheoretical (but are not really) in the DSM. The formulation allows us to develop unique theories about what might be contributing to the person's distress.

I have been a longstanding critic of the lack of a psychiatric focus on the conscious state.  Only recently did I have the thought that this biopsychosocial (BPS) formulation is an approach to the study of a unique conscious state. The broadest definition of consciousness is experience.  If you develop a good technique and confirm the observations and theory about how all of the dimensions impact on them - it is basically a study of a unique conscious state.  An elaboration of the elements contained in either outline - would lead to a discussion of the person's experience of any number of life events including growing up in her family of origin, going to school, working, her leisure time experience, and her experiences as a wife and mother.  That is probably a very liberal interpretation of the BPS model.  Interested readers can find original papers written by George Engel in the references below.  The BPS model generally looks at multiple systems relevant to biological organisms and the philosophy of general systems theory.  The reader can get a good overview of Engel's theory by looking at the articles and the accompanying diagrams. Ghaemi has written an excellent book on BPS (6), it shortcomings and what he considers a more appropriate model for psychiatry - method-based psychiatry.  In his book he goes so far to outline how it can be taught to residents. 

The problem with all of the terminology is that I know very few psychiatrists who practice or prefer to practice in a restricted biomedical mode. A few examples that come to mind were some of the psychoanalysts who were my teachers 35 years ago who "prescribed a little amitriptyline for sleep." I suppose there may be some psychiatrists out there prescribing fluoxetine and not attending to their patients medical disorders - but happy to report that I don't know any.

That brings me back to the central point of this post. Do you really need to distinguish yourself as a biomedical or biopsychosocial psychiatrist if every other psychiatrist is doing what you do? Do you need to call yourself a psychopharmacologist?  Do you need to call yourself a medical psychiatrist?

I would say that you do not. Psychiatric training exposes trainees to the same content and clinical contexts where they an observe and treat severe problems. In many of those situations they are responsible for the total medical care of the patient.  They accumulate medical knowledge on a consistent basis as they accumulate knowledge about diagnosis and treating medical conditions. It is an inescapable part of the practice of medicine. Where do all of these titles come from?

I see a couple of origins.  The first is political and that is people who are using the terms in a pejorative way. There are apparently psychiatrists in the UK who use the term biomedical psychiatrist in a pejorative way because they don't believe in any diagnosis or they adhere to the old Szaszian concept of disease and do not want to see psychiatry practiced as a medical specialty. Many would go as far as not using diagnoses at all. They often equate diagnosis with the pejorative term labeling. When I think about that movement and its origins and how psychiatry got to where it currently is today - I ask myself about the development of both paths of thought. Without going into too much detail - there are no geniuses on the antipsychiatry path. Many of the early proponents on that path failed because they really had nothing to offer people with serious mental illnesses. If anyone wants to refer to me as a biomedical psychiatrist - I embrace it because it certainly does not deter me from doing  thorough psychiatric assessment that includes a formulation that contains social, cultural, and biological factors unique to the person I have assessed and trying to appreciate their conscious experience in each one of those domains.

The second application of the various descriptors is to differentiate oneself from the rest of the pack. That also seems to be a dubious distinction. The best example I can think of is psychopharmacologist.  If I have studied the subject, attended the seminars and courses, but spent most of my career discontinuing medications and treating complications in polypharmacy situations - am I psychopharmacologist?  Or do I need to be the person prescribing all of the polypharmacy? As far as I can tell - all psychiatrists are (or should be) psychopharmacologists.  They should also be aware of the limitation and be able to practice specificity in the prescription of psychiatric medications. 

 Psychiatrists are psychiatrists.  They are the same, but different like any other discipline.  Apart from what they know or should know their conscious state is certainly a factor in how they practice and there are always potential differences in skill levels.

I continue to be impressed by the high level of skill of my colleagues and think that we can all be psychiatrists and be confident that we don't have to be defined by anyone else.  Anyone who suggests that they have a better approach or that they can treat patients without a diagnosis should be confident enough to proceed and compete directly.  That said we do need to refine the technical skills in the field.  A primary consideration is realizing that we have come as far as we can go with the DSM approach.  Ghaemi's suggested methods based approach presents some good ideas on a philosophical basis - but the personalized medicine and omics approaches also hold a lot of promise.



George Dawson, MD, DFAPA




References:

1:  Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136.

2:  George L. Engel, MD. JAMA.2000;283(21):2857. doi:10.1001/jama.283.21.2857

3: Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980 May;137(5):535-44. PubMed PMID: 7369396.

4:  Campbell WH, Rohrbaugh RM. The Biopsychosocial Formulation Manual. New York, Routledge Taylor & Francis Group, 2006, 164 pages.

5:  Chisholm MS, Lyketsos CG. Systemic Psychiatric Evaluation. Baltimore, The John Hopkins University Press, 2012, 243 pages.

6:  Ghaemi SN. The Rise and Fall of the Biopsychosocial Model.  The John Hopkins University  Press, 2010, 253 pages.  

Supplementary:

Some useful books for those interested in this topic (all referenced above):

A Grand DSM critique from Health Affairs

There is a large Health Affairs article that just became available online.  It criticizes (what else) the DSM 5.  The article and its initiatives all seem to flow from the conclusion:

"Inadequate interdisciplinary review and collaboration translate into missed opportunities to increase the accuracy of explanations for mental disorders.  They also lead to suboptimal care and outcome disparities for millions of patients at a time when dramatic differences in psychiatric diagnosis and treatment rates by sociodemographic status, ethnicity, and geography have undermined public confidence in psychiatry.” (p 7)

I hope that anyone reading this blog knows what the factors are in the mismatch between psychiatric diagnoses and care.  I hope that anyone reading this blog knows the biases against psychiatry and how that influences the allegations of overdiagnosis, diagnostic reliability, overprescriptions and conflict of interest that are typically leveled at psychiatrists and their professional organization.  The most obvious example and a point that seems to be completely lost on these authors is the rationing of psychiatric services and the resulting fact that most of the diagnostic disparities that they are complaining about are not due to psychiatrists or the DSM.   I hope that any reader here has also noted my running commentary about the real causes of “suboptimal care and outcome disparities”.  It is directly related to managed care, pharmacy benefit managers, and the adoption of these same rationing practices by local, state, and federal governments charged with the provision of mental health and substance abuse services.

The authors seem to lack an understanding of some of the basic social processes that they believe to be impacted by the DSM.  They cite the New York Times as a source for the issue of whether the DSM committee backed down on diagnostic revisions that would have disqualified “half of those who currently receive benefits for autism spectrum disorders” and various other changes.  As a psychiatrist who is intimately familiar with the disability process, the determination of disability is a political process at the level of the Social Security Administration.  A diagnosis is an entry point but it does not assure a disability award or even ongoing disability payments.  I have seen patients who were hospitalized for severe problems who did not get a disability determination in their favor.  I have seen people who clearly misrepresented themselves, did not believe they have a mental disability, and who received disability determinations that they requested.  As far as I can tell, the system is currently set up to favor people with mental illnesses who have been hospitalized at least three times in two years.  There are companies who facilitate applications.  It generally takes a series of two or three appeals that can drag out over a year or two.  If it comes to a hearing, those hearings are uncontested and they are not adversarial in that the government does not have an attorney present to oppose the application and the decision is made by a judge and not a jury.  The most  significant political event in this process occurred about 15 years ago when the government decided it would not consider alcoholism and drug addiction a disability.  Prior to that alcoholism was a leading cause of disability in many states.  With all of those political variables how can a DSM diagnosis be seen as the rate limiting step in that process?

The authors also conclude “Psychiatric conditions result from a combination of biological and environmental factors”.  The arguments that follow suggest that psychiatrists are basically clueless about these phenomenon.  I did not see George Engel or the biopsychosocial model of illness referenced.  In Engel's seminal 1977 paper in Science, he directly addressed the limitations of the biomedical model and changed the paradigm for the future by proposing a biopsychosocial model.  This paper is dramatic in its intellectual scope and it addresses practically all of the issues brought up in the Health Affairs article including several areas that are not addressed such as the experience of the patient.  Engel also addressed the issue of “When is grief a disease?”, a popular current DSM critique:

“…Hence the physician’s basic professional knowledge and skills must span the social, psychological, and biological for his decisions and the actions on the patient’s behalf involve all three.  Is the patient suffering normal grief or melancholia?  Are the fatigue and weakness of the woman who recently lost her husband conversion symptoms, psychophysiological reactions, manifestations of a somatic disorder, or a combination of these.  The patient soliciting the aid of a physician must have confidence that the MD degree has indeed rendered that physician competent to make such differentiations.”  

A reference to Engel would seem appropriate but it detracts from the authors’ contentions that physicians seem to need to have their biopsychosocial horizons broadened and acknowledging that a physician discussed this definitively 35 years ago would detract from their argument.

The authors more direct arguments about the role of “social and institutional influences on diagnosis” can be similarly addressed.  Although they don’t acknowledge the DSM, they discuss post traumatic stress disorder as an example of environmental exposure.  They cite evidence gathered in the psychiatric literature as their proof.  In fact, any psychiatric evaluation should contain a formulation section that considers social, biological, and consciousness based factors in the overall evaluation of the person seeking help.  This is nothing new and every competent psychiatrist is trained to do this.  The now abandoned oral Board exam, used to test these skills.  The idea that these factors are relevant to psychiatric diagnosis have been taught to psychiatrists for decades.  Do we really need to learn that from a panel of social experts who don't talk with people about that information every day like we do?

The idea that social context,  is a relevant factor has also been obvious to psychiatrists for a long time.  Psychiatrists are routinely asked to evaluate and treat patients from various socioeconomic and cultural groups and frequently work with interpreters in the process.  There is no basis in fact for their speculative comment that “Identifying and understanding the causes of diagnostic disparities can lead to improved diagnostic criteria and their more accurate application.”

On the issue of institutional and policy factors the authors also miss the mark.  They make the previous mistake about diagnosis and Social Security disability by suggesting that a specific diagnosis results in a disability check.  They do not point out how the Social Security process rather than a DSM diagnosis may be more important in the issue of disabilities for mental health. Interestingly they are concerned about the “major consequences for payers and patients" and reference a study looking at the prescription of atypical antipsychotic medications for children.  They ignore the fact that the actual treatment of mental illnesses are outside of the purview of the DSM and that overprescription (if this is actually overprescription) is a widespread problem that extends well beyond the field of psychiatry.  As is the case with all critics of psychiatry and the DSM, they give a pass to the real causes of systemic poor treatment and a focus on medications rather than psychosocial therapies and that is the managed care industry and its supporters at all levels in the government.

Their final focus on publicity and marketing is certainly not a problem specific to psychiatry.  It is also a process that is not DSM dependent.  Restless leg syndrome or insomnia do not need to be in the DSM to end up being treated on a large scale by primary care physicians.  All it takes is a pharmaceutical company web site with a checklist.  They provide no insight into why the political process of direct-to-consumer advertising as determined by lobbyists, politicians, and the associated exchange of money should be part of a DSM oversight process.

The authors proposed Psychiatric Diagnosis Review Body and its potential benefits are equally speculative.  Their idea that there would be “greater sophistication” in the explanations of mental illness is doubtful, especially considering the impact that Engel’s biopsychosocial model has had on both the field and DSM development.  Their idea that the work of a review body would “heighten mental health practitioners’ awareness of population level differences in diagnoses, in some instances improving their ability to tailor diagnoses to patient’s demographic characteristics and cultural backgrounds…” is also problematic.  First off, the DSM is written for psychiatrists and a psychiatric diagnosis and formulation is much more than looking at a list of symptoms that possibly identifies a person as being a statistical outlier in a group.  Any person can pick up a copy of the DSM and presume to make a "diagnosis" based on these criteria, but that is not a psychiatric diagnosis.  Secondly, cultural, demographic characteristics, and demographic factors have already been incorporated into psychiatric evaluations for decades.  An even greater question is what broad scale social data would add to the evaluation of the individual patient given the biases that are usually present in those studies.

The authors suggest that the incorporation of feedback from the review body would “increase public confidence in the manual and psychiatry as a medical profession”.  The single most important factor that would enhance psychiatry’s image would be the recognition that rhetorical negative arguments against the profession abound and need to be corrected.  That could start by recognizing what psychiatrists actually do and what a DSM is actually used for.  It would also take a critical look at why 20 years of rationing of psychiatric services by the managed care industry and the government is the single largest factor in why these services have deteriorated and now operate on the premise that getting people on one medication or another is the best way to treat mental illness.  The authors in this case banter about million and billion dollar amounts that are typically used to suggest the impact of the DSM or significant conflicts of interest in psychiatry.  Nobody is focused on the fact that the managed care industry makes far more money than that by denying medical care.  Psychiatric services make up a disproportionately large amount of denied care.

If you are really interested in improving the care of people with mental illness in this country it would seem logical to attack those who routinely deny them care and interfere at all levels with the provision of care rather than those providing the care and trying to improve it.   That is the most important social problem affecting the provision of mental health services and access to psychiatry.  Social scientists seem to be as disinterested in that fact as the average journalist.

George Dawson, MD, DFAPA

Hansen HB, Donaldson Z, Link BG, Bearman PS, Hopper K, Bates LM, Cheslack-Postava K, Harper K, Holmes SM, Lovasi G, Springer KW, Teitler JO.  Independent Review Of Social And Population Variation In Mental Health Could Improve Diagnosis In DSM Revisions. Health Aff (Millwood). 2013 Apr 24. [Epub ahead of print] PubMed PMID: 23614899.

Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136.

George L. Engel, MD. JAMA.2000;283(21):2857. doi:10.1001/jama.283.21.2857