生物心理社会模式在医疗护理中的实际应用--我们快成功了吗?

IF 5.3 2区 医学 Q1 PSYCHIATRY
Tom Sensky
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Some have argued that it says nothing about the subjective experience of the patient.<span><sup>3</sup></span> Others have gone further in their criticism, claiming that individualising treatment to each patient, as the model implies, gives rise to eclectic freedom which ‘borders on anarchy’ and merely replaces the dogmas which the model was intended to protect against (notably the reductionism of the biomedical model) with other dogmas.<span><sup>4</sup></span> Responding to criticisms that Engel's model lacks a sound theoretical basis, Bolton<span><sup>5</sup></span> noted that the original model needs to be understood as of its time and that despite its limitations, the model anticipated the crucial role in health and illness of ‘concepts such as regulation and dysregulation, information and communication and function and dysfunction’. It has been argued that the main problem with the model as Engel proposed it is that it is too general. One proposed solution to this is to elaborate specific, evidence-based, models for different diagnoses or conditions.<span><sup>6</sup></span> The DCPR represents a different but effective solution to the same problem. Instead of elaborating the details of the biopsychosocial model separately for different conditions (a monumental undertaking), the DCPR aims to describe particular transdiagnostic states (termed ‘syndromes’) which can occur as features of the experience of illness.</p><p>Fava et al.<span><sup>1</sup></span> illustrate the DCPR by characterising some of its syndromes. These are all patterns of responses to life situations involving illness, reflecting dysregulation and/or dysfunction. They are termed syndromes to distinguish them from disorders or diseases which form the basis of standard diagnostic classifications.<span><sup>7</sup></span> The syndromes were intended to be descriptive and without any pathogenic implications, although with progress in research and understanding, this assumption might now be challenged. The original syndromes were not intended to be exhaustive and indeed the original DCPR has been revised to include two additional syndromes.<span><sup>8</sup></span> An important feature of the syndromes is that they each include (or overlay) biological, psychological and social components. Allostatic overload is a prime example, manifestly showing biological, psychological and social factors in its aetiology as well as in its consequences. The key purpose of the DCPR is to provide a richer description of the experience of illness than is possible using standard diagnostic classifications alone. Supporting this, a 2015 review<span><sup>9</sup></span> highlighted that in a variety of clinical samples, the prevalence of DCPR syndromes was substantially higher than that of formal psychiatric diagnoses. The same has been found among patients in primary care.<span><sup>10</sup></span></p><p>One criticism which has been made of Engel's biopsychosocial model, already noted above,<span><sup>3</sup></span> which could also be levelled at the DCPR, is that the model does not explicitly incorporate the patient's perspective but focuses on the patient's illness experience as seen by the clinician or researcher. While both the biopsychosocial model and the DCPR focus on the tasks of the clinician or researcher, both acknowledge the importance of the clinician-patient relationship, which Engel regarded as integral to the biopsychosocial model.<span><sup>2</sup></span> The DCPR affords the clinician and the researcher a more comprehensive understanding of the patient's experience of illness which can contribute to discussion shared in the clinical encounter.<span><sup>11</sup></span></p><p>A more important criticism is that as it stands, the DCPR covers only negative aspects of the illness experience whereas biopsychosocial influences on illness can be positive as well as negative. In his original paper, Engel also made no explicit reference to positive biopsychosocial influences<span><sup>2</sup></span> although there were implicit references to this, for example: ‘the behaviour of the physician and the relationship between patient and physician powerfully influence therapeutic outcome for better or for worse’.<span><sup>2</sup></span> Just as health is not merely the absence of disease, so biopsychosocial factors are more than the presence or absence of (negative) DCPR criteria. A clear example of a positive biopsychosocial factor is the concept of sense of coherence, which Antonovsky intentionally developed as a measure of what he termed ‘salutogenesis’ (as opposed to ‘pathogenesis’).<span><sup>12</sup></span> Someone with a high sense of coherence views life as comprehensible, manageable and meaningful. In epidemiological studies, a high sense of coherence has been associated with reduced all-cause, cardiovascular and cancer mortalities.<span><sup>13</sup></span> There are measures available of other ‘non-negative’ mental states like euthymia.<span><sup>14</sup></span> However, some positive psychosocial effects may be more difficult to characterise than negative ones. One possible example is wellbeing, for which 99 different self-rating scales have been identified.<span><sup>15</sup></span> Perhaps another barrier to extending the DCPR to cover such states lies in their title, specifically the term ‘diagnostic’. Although ‘diagnosis’ strictly means only to ‘distinguish apart’, the term is applied specifically to recognising features of illness. If this is a potential problem to extending the DCPR, perhaps ‘diagnostic’ might be replaced by ‘clinimetric’ or even ‘biopsychosocial’? 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引用次数: 0

摘要

本期由 Fava 及其同事1 撰写的论文重点介绍了《心身医学研究诊断标准》(DCPR)的特点,并强调了 DCPR 是如何受到恩格尔生物心理社会模型的启发的。2 恩格尔写道,他 "提出的生物心理社会模型为研究提供了蓝图,为教学提供了框架,为医疗保健的现实世界提供了行动设计"。然而,它也招致了批评。3 其他人的批评则更进一步,声称该模式所暗示的针对每个病人的个体化治疗,会产生 "近乎无政府状态 "的折衷主义自由,而且只会用其他教条取代该模式旨在抵御的教条(尤其是生物医学模式的还原论)。针对恩格尔模式缺乏坚实理论基础的批评,博尔顿5 指出,需要根据其所处的时代 来理解最初的模式,尽管存在局限性,但该模式预见到了 "调节和失调、信息和交流 以及功能和功能障碍 "等概念在健康和疾病中的关键作用。有人认为,恩格尔提出的模式存在的主要问题是过于笼统。为此提出的一个解决方案是,针对不同的诊断或病症制定具体的、以证据为基础的模 型。6 DCPR 代表了一种不同但有效的解决方法。DCPR 没有针对不同病症分别阐述生物-心理-社会模型的细节(这是一项艰巨的任务),而是旨在描述特定的跨诊断状态(称为 "综合症"),这些状态可能作为疾病体验的特征出现。这些都是对涉及疾病的生活状况的反应模式,反映了调节失调和/或功能障碍。7 综合征的目的是描述性的,没有任何致病影响,尽管随着研究和认识的进步,这一假设现在可能会受到挑战。8 这些综合征的一个重要特点是,它们都包含(或叠加)生物、心理和社会因素。8 综合征的一个重要特点是,它们都包含(或叠加)生物、心理和社会因素。静力过载就是一个典型的例子,在其病因和后果中明显地显示出生物、心理和社会因素。DCPR 的主要目的是提供比仅使用标准诊断分类更丰富的疾病体验描述。为此,2015 年的一篇综述9 强调指出,在各种临床样本中,DCPR 综合征的患病率远远高于正式精神病诊断的患病率。上文已经提到过对恩格尔的生物-心理-社会模型的一个批评,3 而这一批评也同样适用于 DCPR,那就是该模型并未明确纳入患者的视角,而是侧重于临床医生或研究人员所看到的患者的疾病体验。虽然生物心理社会模式和 DCPR 都侧重于临床医生或研究人员的任务,但两者都承认临床医生与患者关系的重要性,恩格尔认为这种关系是生物心理社会模式不可或缺的一部分。DCPR 使临床医生和研究人员对病人的疾病体验有了更全面的了解,这有助于临床会诊中的共同讨论。11 一个更重要的批评是,DCPR 目前只涉及疾病体验的消极方面,而生物心理社会对疾病的影响既可能是积极的,也可能是消极的。恩格尔在其最初的论文中也没有明确提及积极的生物心理社会影响因素,2 尽管他隐晦地提到了这一点,例如:"医生的行为以及病人和医生之间的关系对治疗结果的好坏有着强有力的影响"。安东诺夫斯基有意提出了 "连贯感 "这一概念,作为他所称的 "致救"(与 "致病 "相对)的衡量标准。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Practical application of the biopsychosocial model to medical care—Are we nearly there yet?

The paper in this issue by Fava and colleagues1 highlights features of the Diagnostic Criteria for Psychosomatic Research (DCPR) and stresses how the DCPR was inspired by Engel's biopsychosocial model.2

Engel wrote that his ‘proposed biopsychosocial model provides a blueprint for research, a framework for teaching, and a design for action in the real world of healthcare’.2 Since then, the biopsychosocial model has been widely adopted, particularly by clinicians and clinical teachers. However, it has also attracted criticism. Some have argued that it says nothing about the subjective experience of the patient.3 Others have gone further in their criticism, claiming that individualising treatment to each patient, as the model implies, gives rise to eclectic freedom which ‘borders on anarchy’ and merely replaces the dogmas which the model was intended to protect against (notably the reductionism of the biomedical model) with other dogmas.4 Responding to criticisms that Engel's model lacks a sound theoretical basis, Bolton5 noted that the original model needs to be understood as of its time and that despite its limitations, the model anticipated the crucial role in health and illness of ‘concepts such as regulation and dysregulation, information and communication and function and dysfunction’. It has been argued that the main problem with the model as Engel proposed it is that it is too general. One proposed solution to this is to elaborate specific, evidence-based, models for different diagnoses or conditions.6 The DCPR represents a different but effective solution to the same problem. Instead of elaborating the details of the biopsychosocial model separately for different conditions (a monumental undertaking), the DCPR aims to describe particular transdiagnostic states (termed ‘syndromes’) which can occur as features of the experience of illness.

Fava et al.1 illustrate the DCPR by characterising some of its syndromes. These are all patterns of responses to life situations involving illness, reflecting dysregulation and/or dysfunction. They are termed syndromes to distinguish them from disorders or diseases which form the basis of standard diagnostic classifications.7 The syndromes were intended to be descriptive and without any pathogenic implications, although with progress in research and understanding, this assumption might now be challenged. The original syndromes were not intended to be exhaustive and indeed the original DCPR has been revised to include two additional syndromes.8 An important feature of the syndromes is that they each include (or overlay) biological, psychological and social components. Allostatic overload is a prime example, manifestly showing biological, psychological and social factors in its aetiology as well as in its consequences. The key purpose of the DCPR is to provide a richer description of the experience of illness than is possible using standard diagnostic classifications alone. Supporting this, a 2015 review9 highlighted that in a variety of clinical samples, the prevalence of DCPR syndromes was substantially higher than that of formal psychiatric diagnoses. The same has been found among patients in primary care.10

One criticism which has been made of Engel's biopsychosocial model, already noted above,3 which could also be levelled at the DCPR, is that the model does not explicitly incorporate the patient's perspective but focuses on the patient's illness experience as seen by the clinician or researcher. While both the biopsychosocial model and the DCPR focus on the tasks of the clinician or researcher, both acknowledge the importance of the clinician-patient relationship, which Engel regarded as integral to the biopsychosocial model.2 The DCPR affords the clinician and the researcher a more comprehensive understanding of the patient's experience of illness which can contribute to discussion shared in the clinical encounter.11

A more important criticism is that as it stands, the DCPR covers only negative aspects of the illness experience whereas biopsychosocial influences on illness can be positive as well as negative. In his original paper, Engel also made no explicit reference to positive biopsychosocial influences2 although there were implicit references to this, for example: ‘the behaviour of the physician and the relationship between patient and physician powerfully influence therapeutic outcome for better or for worse’.2 Just as health is not merely the absence of disease, so biopsychosocial factors are more than the presence or absence of (negative) DCPR criteria. A clear example of a positive biopsychosocial factor is the concept of sense of coherence, which Antonovsky intentionally developed as a measure of what he termed ‘salutogenesis’ (as opposed to ‘pathogenesis’).12 Someone with a high sense of coherence views life as comprehensible, manageable and meaningful. In epidemiological studies, a high sense of coherence has been associated with reduced all-cause, cardiovascular and cancer mortalities.13 There are measures available of other ‘non-negative’ mental states like euthymia.14 However, some positive psychosocial effects may be more difficult to characterise than negative ones. One possible example is wellbeing, for which 99 different self-rating scales have been identified.15 Perhaps another barrier to extending the DCPR to cover such states lies in their title, specifically the term ‘diagnostic’. Although ‘diagnosis’ strictly means only to ‘distinguish apart’, the term is applied specifically to recognising features of illness. If this is a potential problem to extending the DCPR, perhaps ‘diagnostic’ might be replaced by ‘clinimetric’ or even ‘biopsychosocial’? However, adding further syndromes, whether positive or negative, risks making unwieldy the current use of the DCPR as a unitary instrument, that is, screening all patients for all syndromes. This would be a particular problem for researchers. For clinicians and their patients, particular biopsychosocial syndromes could be selected from an extended ‘toolkit’ to contribute to or enhance (biopsychosocial) formulations of the person's illness experience.

Richer descriptions of the illness experience have an important purpose. As Fava et al.1 indicate, the DCPR may help ‘to demarcate major prognostic and therapeutic differences among patients who are otherwise deceptively similar’. There is already evidence, some cited in their paper, that when present, the syndromes of the DCPR have an adverse effect on illness outcomes. In addition, in most instances, the presence of a DCPR syndrome is expected to increase the patient's psychosocial burden. Alleviating such burdens should be one focus for intervention. Once characterised and recognised, the psychological aspects of these syndromes should be amenable to effective intervention.16 Given that the DCPR syndromes turn out to be prevalent in people with physical illnesses, developing and testing interventions tailored to individual DCPR syndromes is the logical next step.

The author declares no conflict of interest.

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来源期刊
Acta Psychiatrica Scandinavica
Acta Psychiatrica Scandinavica 医学-精神病学
CiteScore
11.20
自引率
3.00%
发文量
135
审稿时长
6-12 weeks
期刊介绍: Acta Psychiatrica Scandinavica acts as an international forum for the dissemination of information advancing the science and practice of psychiatry. In particular we focus on communicating frontline research to clinical psychiatrists and psychiatric researchers. Acta Psychiatrica Scandinavica has traditionally been and remains a journal focusing predominantly on clinical psychiatry, but translational psychiatry is a topic of growing importance to our readers. Therefore, the journal welcomes submission of manuscripts based on both clinical- and more translational (e.g. preclinical and epidemiological) research. When preparing manuscripts based on translational studies for submission to Acta Psychiatrica Scandinavica, the authors should place emphasis on the clinical significance of the research question and the findings. Manuscripts based solely on preclinical research (e.g. animal models) are normally not considered for publication in the Journal.
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