The clinical application of the biopsychosocial model in mental health: a research critique

Self-rated health and health-related quality of life among cancer patients: the serial multiple mediation of anxiety and depression

BACKGROUND

Health-related quality of life (HRQOL) in cancer patients has attracted increasing attention, which may be associated with self-rated health (SRH), anxiety, and depression. However, limited studies have focused on the mediating role of anxiety and depression in the relationship between SRH and HRQOL among cancer patients. Therefore, this study aims to explore the serial multiple mediating effects of anxiety and depression between SRH and HRQOL in cancer patients.

METHODS

This cross-sectional study investigated a total of 565 hospitalized cancer patients in Anhui province in China from November 2020 to October 2021. SRH was assessed using a single-item measure, anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS) and HRQOL was assessed using the EuroQol-5 Dimension (EQ-5D, three-level version). Socio-demographic and clinical characteristics were analyzed using descriptive statistics. The relationships between SRH, anxiety, depression, and HRQOL were evaluated by Pearson correlation analysis. The serial multiple mediation of anxiety and depression was assessed by SPSS PROCESS macro.

RESULTS

SRH, anxiety, depression and HRQOL were significantly correlated(P < 0.001). In comparison to the fair SRH, the good SRH exhibited a significantly positive direct effect (Effect = 0.2366, Bootstrap 95%CI: 0.0642 ~ 0.4090) and total effect on HRQOL (Effect = 0.4761, Bootstrap 95%CI: 0.2975 ~ 0.6546). Conversely, the poor SRH demonstrated a significantly negative total effect on HRQOL (Effect= -0.4321, Bootstrap 95%CI: -0.7544~ -0.1099). When considering the fair SRH as the reference group, the poor SRH displayed a negative indirect effect on HRQOL through the single mediation of anxiety (Effect= -0.1058, Bootstrap 95%CI: -0.2217~ -0.0107) and the serial mediation of anxiety and depression (Effect= -0.0528, Bootstrap 95%CI: -0.1233~ -0.0035). Conversely, the good SRH had a positive indirect impact on HRQOL through the single mediation of anxiety (Effect = 0.1153, Bootstrap 95%CI: 0.0583 ~ 0.1900) and depression (Effect = 0.0667, Bootstrap 95%CI: 0.0206 ~ 0.1234), as well as the serial mediation of anxiety and depression (Effect = 0.0575, Bootstrap 95%CI: 0.0192 ~ 0.1030).

CONCLUSION

SRH can improve HRQOL through the decrease of anxiety and depression in cancer patients. Focusing on SRH would be beneficial for their mental health and HRQOL in cancer patients.

Individualisation, personalisation and person-centredness in mental healthcare: a scoping review of concepts and linguistic network visualisation

BACKGROUND

Targeted mental health interventions are increasingly described as individualised, personalised or person-centred approaches. However, the definitions for these terms vary significantly. Their interchangeable use prevents operationalisations and measures.

OBJECTIVE

This scoping review provides a synthesis of key concepts, definitions and the language used in the context of these terms in an effort to delineate their use for future research.

STUDY SELECTION AND ANALYSIS

Our search on PubMed, EBSCO and Cochrane provided 2835 relevant titles. A total of 176 titles were found eligible for extracting data. A thematic analysis was conducted to synthesise the underlying aspects of individualisation, personalisation and person-centredness. Network visualisations of co-occurring words in 2625 abstracts were performed using VOSViewer.

FINDINGS

Overall, 106 out of 176 (60.2%) articles provided concepts for individualisation, personalisation and person-centredness. Studies using person-centredness provided a conceptualisation more often than the others. A thematic analysis revealed medical, psychological, sociocultural, biological, behavioural, economic and environmental dimensions of the concepts. Practical frameworks were mostly found related to person-centredness, while theoretical frameworks emerged in studies on personalisation. Word co-occurrences showed common psychiatric words in all three network visualisations, but differences in further contexts.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The use of individualisation, personalisation and person-centredness in mental healthcare is multifaceted. While individualisation was the most generic term, personalisation was often used in biomedical or technological studies. Person-centredness emerged as the most well-defined concept, with many frameworks often related to dementia care. We recommend that the use of these terms follows a clear definition within the context of their respective disorders, treatments or medical settings.

SCOPING REVIEW REGISTRATION

Open Science Framework: osf.io/uatsc.

Factors Affecting the Life Satisfaction of School-Aged Children with Vietnamese Immigrant Mothers in Korea

Low life satisfaction among multicultural children is an important issue related to children's mental health in Korea. The purpose of this study was to identify factors influencing the life satisfaction of children whose Vietnamese mothers migrated to Korea for marriage. Data from the Multicultural Adolescents Panel Study (MAPS) conducted by the National Youth Policy Institute (NYPI) in 2020 were used. The participants were 586 elementary school students. The mean age was 11.01 years (SD 0.19), and 52.0% were girls. Based on Engel's biopsychosocial (BPS) model, biological factors (gender, physical health, and body mass index), psychological factors (mental health, acculturative stress, self-esteem, and general stress), and sociocultural factors (family economic status, social support, and parenting style) were measured and analyzed by using hierarchical multiple regression. In the final model, self-esteem (β = 0.399, p < 0.001), parental social support (β = 0.184, p < 0.001), and neglectful parenting style (β = 0.085, p = 0.031) were positively related to children's life satisfaction, whereas general stress (β = -0.213, p < 0.001) and acculturative stress (β = -0.104, p = 0.002) were negatively related. The overall explanatory power was 41.7%. In conclusion, it is necessary to develop a specialized program that focuses on strengthening the bonds between parents and their children to enhance family functioning for multicultural families.

Health and Socioeconomic Determinants of Abuse among Women with Disabilities

The double vulnerability of women with disabilities places them at the center of this research paper. Intersectionality is key in research on gender-based violence. This study analyzes the perspective of the victims and non-victims themselves on this issue, through a comparative analysis between women with and without disabilities, at two levels of analysis: quantitative, through the adaptation of various scales (Assessment Screen-Disability/AAS-D, and the Woman Abuse Screening Tool/WAST), and qualitative, with semi-structured interviews (open scripts and different themes), and focus groups with experts from the associative network. The results obtained indicate that the most frequent type of violence is physical, followed by psychological and sexual, mainly perpetrated by partners. The higher their level of education, the more they defend themselves; receiving public aid can be a risk factor for domestic and sexual violence, and belonging to the associative movement and having paid work outside the home act as preventive measures. In conclusion, it is necessary to establish strategic protection measures and effective detection and intervention systems to make victims visible and care for them.

Psychosocial Outcomes Among Veteran and Non-Veteran Survivors of Sexual Assault

Although it is well-established that sexual assault results in variable and long-lasting negative impacts on emotional well-being, perceptions of physical health, and relationship functioning, these "psychosocial" outcomes may vary based on the type(s) of sexual trauma experienced. To identify the differential impact of sexual trauma type(s) on psychosocial outcomes among veterans and non-veterans, we conducted a secondary analysis of data from the Comparative Health Assessment Interview Research Study, a large, national survey study sponsored by the Department of Veterans Affairs. Participants included veterans (n = 3588) and non-veterans (n = 935) who endorsed experiencing childhood sexual assault (CSA), adult sexual assault (ASA, outside of military service for veteran participants), and/or military sexual assault (MSA). Eight measures were used to assess psychosocial outcomes: Well-Being Inventory (WBI) health satisfaction and physical health functioning items, Posttraumatic Stress Disorder Checklist, Patient Health Questionnaire (depression symptoms), Generalized Anxiety Disorder Questionnaire, WBI social satisfaction items, WBI social functioning items, and the Multidimensional Scale of Perceived Social Support (social). A profile analysis was used to determine how sexual trauma type(s) influenced the pattern of responding to the eight psychosocial outcome measures. Veteran sexual assault survivors reported poorer psychological outcomes compared to non-veteran sexual assault survivors. Non-veteran sexual assault survivors reported poorer outcomes on the majority of social variables compared to veteran sexual assault survivors. Survivors of MSA-only reported poorer psychosocial outcomes compared to veteran and non-veteran survivors of CSA-only and ASA-only on most of the variables assessed. Survivors of ASA-only reported similar or modestly worse psychosocial outcomes when compared to survivors of CSA-only on the majority of variables assessed. Survivors of different types of sexual trauma reported distinct psychosocial outcomes, suggesting that assessment and treatment needs may differ by trauma type.

Factors associated with gender and sex differences in anxiety prevalence and comorbidity: A systematic review

Background: The prevalence and comorbidity of anxiety disorders are significantly different between women and men, with research showing a greater impact on women. The aim of this review was to identify the psychosocial and biological factors that have been considered to explain this gender and sex difference in prevalence and determine whether these factors are related to any anxiety comorbidity differences between men and women. Methods: Following the PRISMA guidelines, we carried out a systematic review of studies published between 2008 and 2021 in PsycINFO and PubMed databases. Empirical and review studies evaluating psychosocial and biological factors that could influence the difference in prevalence and comorbidity between men and women were included. A qualitative narrative synthesis was performed to describe the results. Results: From 1012 studies, 44 studies were included. Retrieved articles were categorized depending on their object of study: psychosocial factors (n = 21), biological factors (n = 16), or comorbidity (n = 7). Results showed that differences in anxiety between women and men have been analyzed by psychosocial and biological factors but rarely together. Among the psychosocial factors analyzed, masculinity may be a protective factor for anxiety development, while femininity can be a risk factor. In the studies that took biological factors into account, the potential influence of brain structures, genetic factors, and fluctuations in sexual hormones are pointed out as causes of greater anxiety in women. Concerning comorbidity, the results noted that women tend to develop other internalizing disorders (e.g. depression), while men tend to develop externalizing disorders (e.g. substance abuse). Conclusions: For an accurate understanding of differences between women and men in anxiety, both biological and psychosocial factors should be considered. This review highlights the need to apply the biopsychosocial model of health and the gender perspective to address differences in anxiety between sexes.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

The Biopsychosocial Model in Paediatric Clinical Practice; - a Multidisciplinary Approach to Somatic Symptom Disorders

AIM

The paper aims to show how the biopsychosocial (BPS) model can be applied as a clinical method and guide the assessment and treatment of children and adolescents with Somatic Symptom Disorders (SSD).

METHODS

Based on relevant literature and our clinical work with children and adolescents with SSD we have developed a method to ensure a structured, interdisciplinary examination of biological, psychological and social factors, operationalising the BPS model into a clinical method.

RESULTS

The BPS model renders assessment and treatment of complex conditions as a basis for evaluating phenomena not confined by diagnostic tools, but still includes all information from these tools. It requires an interdisciplinary approach, giving individual patient and caregivers a central position. A thorough medical examination is required as a starting point for assessments. Good results rest upon a shared understanding between patient, caregivers and professionals.

CONCLUSIONS

"Biopsychosocial" is often claimed as a basis for clinical work with complex cases, medical, functional, and psychiatric, but scarcely with a corresponding BPS method or practice. The BPS method should guide further development of holistic, multidisciplinary health care on all levels, in order to assess and help children and adolescents with SSD.

Choosing a health behaviour theory or model for related research projects: a narrative review

Background

Theories are integral to a research project, providing the logic underlying what, how, and/or why a particular phenomenon happens. Alternatively, models are used to guide a research project by representing theories and visualising the structural framework of causal pathways by showing the different levels of analysis. With the rise in chronic and behaviour-related diseases, health behaviour theories and models have a particular importance in designing appropriate and research led behavioural intervention strategies. However, there is a dearth of papers that explain the role of behavioural theories and models in research projects.

Aims

The aim of this paper is to synthesise existing evidence on the relevance of health behaviour theories and models in research projects.

Methods

This paper reviews health behaviour theories and models commonly underpinning research projects in public health and clinical practices. The electronic databases, such as MEDLINE, CINAHL, and Scopus, as well as the search engines Google and Google Scholar were searched to identify health behaviour theories and models.

Results

Theories and models are essential in a research project. Theories provide the underlying reason for the occurrence of a phenomenon by explaining what the key drivers and outcomes of the target phenomenon are and why, and what underlying processes are responsible for causing that phenomenon. Models on the other hand provide guidance to a research project and assist in visualising the structural framework of causal pathways by showing the different levels of analysis. Health behaviour theories and models in particular offer valuable insights for designing effective and sustainable research projects for improved public health practice.

Conclusions

By employing appropriate health behaviour theory and/or model as a research framework, researchers will be able to identify relevant variables and translate these into clinical and public health practices.

Barriers to delivering trauma-focused interventions for people with psychosis and post-traumatic stress disorder: A qualitative study of health care professionals' views

OBJECTIVES

Trauma-focused interventions have been shown to be effective treatments for post-traumatic stress disorder (PTSD), and clinical guidelines support their use with people with psychosis. Despite this, they are used relatively infrequently in this population. We sought to explore UK health care professionals' perceptions of what impedes or facilitates the use of trauma-focused interventions among people with psychosis and PTSD.

DESIGN

A qualitative study using constructivist grounded theory methodology.

METHODS

We conducted semi-structured interviews with 18 health care professionals working within the commissioning and delivery of clinical services for people with psychosis.

RESULTS

Three inter-related barriers to the use of trauma-focused interventions were conceptualized: coherent understanding; structural support; and safe space.

CONCLUSIONS

Delivery of trauma-focused interventions within routine clinical practice may be supported by attention to the coherent integration of discussion of trauma into the clinical discourse of services; the processes, pathways, and organizational culture that facilitate access to treatment; and training that targets clinician confidence and skills.

Local understandings of PTSD and complex PTSD among health professionals working with adolescents in violent neighbourhoods of São Paulo city, Brazil

BACKGROUND

Adolescents in low-resource urban settings in Brazil are often exposed to high levels of trauma that can result in post-traumatic stress disorder (PTSD). However, preliminary evidence indicates that PTSD tends to be under-reported in Brazilian health services, despite the high prevalence of trauma. Additionally, little is known about the perceived applicability among clinicians of the new ICD-11 diagnosis of complex PTSD (CPTSD), despite its potential relevance for contexts of chronic trauma. The current study investigated local understandings of PTSD and CPTSD among health professionals working with adolescents in violent neighbourhoods of São Paulo city.

METHODS

Semi-structured interviews were conducted with 58 health professionals working at both the primary care and specialized mental health levels in two areas of São Paulo city with high levels of community violence.

RESULTS

Most participants knew about PTSD, but most did not know about CPTSD. There were mixed views concerning the commonality of PTSD among adolescents exposed to community violence. Many participants reported having no experience working with patients with the PTSD diagnosis. According to some, community violence was normalized by adolescents and health professionals, and did not result in PTSD. Others highlighted how they did not use psychiatric diagnoses in their practice, had critical perspectives towards psychiatric diagnoses and/or PTSD, or simply knew little about PTSD. Furthermore, many highlighted how the chronic nature of multiple traumas experienced by adolescents often resulted in complex clinical presentations characterised by many symptoms beyond PTSD. The diagnosis of CPTSD was considered appropriate to the context by many participants as it captured the complex traumatic histories and symptom presentations of adolescents exposed to community violence in Brazil.

CONCLUSIONS

These findings have important implications for the assessment and treatment of mental health among adolescents exposed to community violence in Brazil.

The biopsychosociotechnical model: a systems-based framework for human-centered health improvement

The biopsychosocial model is among the most influential frameworks for human-centered health improvement but has faced significant criticism- both conceptual and pragmatic. This paper extends and fundamentally re-structures the biopsychosocial model by combining it with sociotechnical systems theory. The resulting biopsychosociotechnical model addresses key critiques of the biopsychosocial model, providing a more "practical theory" for human-centered health improvement. It depicts the determinants of health as complex adaptive system of systems; includes the the artificial world (technology); and provides a roadmap for systems improvement by: differentiating between "health status" and "health and needs assessment", [promoting problem framing]; explaining health as an emergent property of the biopsychosociotechnical context [imposing a systems orientation]; focusing on "interventions" vs. "treatments" to modify the biopsychosociotechnical determinants of health, [expanding the solution space]; calling for a participatory design process [supporting systems awareness and goal-orientation]; and including intervention management to support the full lifecycle of health improvement.

Dental Hygienists' BioPsychoSocial Beliefs and Giving Autonomy Support in Treatment of Patients: A Self-Determination Theory Perspective

OBJECTIVES

Self-Determination Theory posits that managers' autonomy-supportive behavior and employees' autonomy causality orientation, are motivation constructs to explain internalization of values, functioning, and wellness at work. Hypothesis 1 tested whether profiles comprising perceived dental clinic managers' autonomy-supportive, as opposed to their controlling interpersonal style, and dental hygienists' autonomy, as opposed to their control and impersonal, causality orientations at baseline, would be positively related to dental hygienists' biopsychosocial (BPS) beliefs and giving autonomy support in treatment of patients after 18 months. Hypothesis 2 tested whether dental hygienists' BPS beliefs in treatment of patients will be positively associated with their autonomy-supportive behavior given to patients after 18 months.

MATERIAL AND METHODS

A prospective cohort design with 299 (M_age = 42.71; SD_age = 12.62) dental hygienists completed an online survey at baseline and after 18 months.

RESULTS

Latent profile and correlational analyses supported the hypotheses. Effect sizes were moderate to large.

CONCLUSIONS

Both perceived managerial styles and dental hygienists' causality orientations are important for dental hygienists' BPS beliefs and autonomy-supportive behaviors when working with dental patients.

Modelling Health in University Students: Are Young Women More Complicated Than Men?

The biopsychosocial model of health in a limited life course perspective was tested among students in higher education using data from a nationwide cross-sectional survey of students on track to become teachers in Hungary. Health determinants were grouped into categories of biological, psychological, and social determinants and arranged in a temporal manner from childhood to the present. The model was tested by canonical correlation analysis followed by multivariate analysis of covariance. One composite outcome of health and six determinant groups were examined out of a total of 24 variables in both genders. Separate sets of health determinants were identified for men and women. The health of men was determined by fewer variables that were more proximal in time, more centred around physical activity, and less influenced by social relations. As opposed to that of men, women’s health was influenced by age; determinants were grouped around the ingestion of various substances and social support. In contrast to men, the health of women seemed to be more obviously multifactorial. The study supports the usefulness of the biopsychosocial model of health in research. The best fit models provided evidence for the importance of gender awareness when designing public health interventions aimed at students.

Fostering 2nd-year medical students' reflective capacity: A biopsychosocial model course

OBJECTIVE

The biopsychosocial (BPS) model has been proposed to take into account the interaction of psychological and social factors in medical practice. Although some studies have explored its application in medical education, little has been evaluated about students' reflection in such courses. This study introduced a BPS model course and aimed to assess changes in students' reflective capacity resulting from this course.

MATERIALS AND METHODS

Eighty-seven written reflections before and after the course were segmented, coded, and rated using the Reflection Evaluation for Learners' Enhanced Competencies Tool rubric, which contains six factors of reflective capacity, namely description of disease experience, presence, attending to emotions, description of conflict or disorienting dilemma, meaning making, and action.

RESULTS

After the BPS model course, the overall reflective capacity, as well as the "Presence" and "Meaning making" scores, increased, while scores for "Attending to emotion" decreased significantly. "Description of disease experience," "Description of conflict or disorienting dilemma," and "Action" showed no significant change.

CONCLUSION

Pedagogical suggestions are discussed for a BPS model course with reflective training for young medical students.

The Impact of Social Isolation on Pain Interference: A Longitudinal Study

Background

Evidence suggests social interactions play an important role in pain perception.

Purpose

The aim of this study was to determine whether social isolation (SI) in people with persistent pain determines pain interference (PI) and physical function over time.

Methods

Patients seeking care at a tertiary pain management referral center were administered the Patient Reported Outcome Measurement Information System (PROMIS^®) SI, PI, physical function, depression, and average pain intensity item banks at their initial consultation and subsequent visits as part of their routine clinical care. We used a post hoc simulation of an experiment using propensity score matching (n = 4,950) and carried out a cross-lagged longitudinal analysis (n = 312) of retrospective observational data.

Results

Cross-lagged longitudinal analysis showed that SI predicted PI at the next time point, above and beyond the effects of pain intensity and covariates, but not vice versa.

Conclusions

These data support the importance of SI as a factor in pain-related appraisal and coping and demonstrate that a comprehensive assessment of the individuals’ social context can provide a better understanding of the differential trajectories for a person living with pain. Our study provides evidence that the impact of pain is reduced in individuals who perceive a greater sense of inclusion from and engagement with others. This study enhances the understanding of how social factors affect pain and have implications for how the effectiveness of therapeutic interventions may be improved. Therapeutic interventions aimed at increasing social connection hold merit in reducing the impact of pain on engagement with activities.

Alcohol use disorder relapse factors: A systematic review

A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.

Development of a Self Report Stress Scale Using Item Response Theory-I: Item Selection, Formation of Factor Structure and Examination of Its Psychometric Properties

INTRODUCTION

Due to the absence of Turkish psychometric devices assessing stress, in the present study it was aimed to develop a stress scale, and examine its basic psychometric properties.

METHODS

Current study included two processes, formation of item pool and examination of psychometric properties of the selected items through three studies. In the first study, 611 individuals aged between 18 and 77 responded to 130 selected items. In the second study, 2223 individuals aged between 18 and 68 responded to 80 items. In the third study, 1969 individuals aged between 18 and 79 responded to the final form of 36 items. Further, in study 3 for criterion related validity 163 individuals completed the Coopersmith Self-Esteem Inventory, 113 individuals completed the Beck Anxiety Inventory, 104 individuals completed the Hospital Anxiety and Depression Scale, 107 individuals completed the Beck Depression Inventory, and 265 individuals completed the Perceived Stress Scale. Moreover, in the investigation of test-retest reliability, 119 individuals took the final form of the test after 2 weeks, and 111 individuals took the final form of the test after 3 weeks.

RESULTS

In the first study, out of 130 items, 54 that showed item-total score correlations below 0.30 were excluded from the scale. Fifty-seven items were preserved exactly, and 19 items' sentence structures were changed. Furthermore, by adding 4 new items, 80 were prepared for the second study. In the second study, two factors structure namely "Physiological Reactions/Strain" and "Psychological/Cognitive Appraisals" sub-dimensions were identified, and 36 items were selected via Item Response Theory representing these sub-dimensions. In study 3, exploratory factor analysis provided strong support for our hypothesized two factors structure. Confirmatory factor analysis indicated hypothesized model had a better fit to the data. Internal consistency coefficients were 0.94 for the entire scale, 0.90 for Physiological Reactions/Strain sub-dimension, and 0.91 for Psychological/Cognitive Appraisals sub-dimension. Correlation coefficients between the entire scale and other criterion scales ranged from 0.22 to 0.63. Test-retest correlation coefficients between the first administration of the scale, and the administrations at two and three week intervals were 0.88.

CONCLUSION

Results showed that the scale has basic psychometric requirements provided that the scale will be supported by validity studies.

Research Domain Criteria as Psychiatric Nosology

Diagnostic classification systems in psychiatry have continued to rely on clinical phenomenology, despite limitations inherent in that approach. In view of these limitations and recent progress in neuroscience, the National Institute of Mental Health (NIMH) has initiated the Research Domain Criteria (RDoC) project to develop a more neuroscientifically based system of characterizing and classifying psychiatric disorders. The RDoC initiative aims to transform psychiatry into an integrative science of psychopathology in which mental illnesses will be defined as involving putative dysfunctions in neural nodes and networks. However, conceptual, methodological, neuroethical, and social issues inherent in and/or derived from the use of RDoC need to be addressed before any attempt is made to implement their use in clinical psychiatry. This article describes current progress in RDoC; defines key technical, neuroethical, and social issues generated by RDoC adoption and use; and posits key questions that must be addressed and resolved if RDoC are to be employed for psychiatric diagnoses and therapeutics. Specifically, we posit that objectivization of complex mental phenomena may raise ethical questions about autonomy, the value of subjective experience, what constitutes normality, what constitutes a disorder, and what represents a treatment, enablement, and/or enhancement. Ethical issues may also arise from the (mis)use of biomarkers and phenotypes in predicting and treating mental disorders, and what such definitions, predictions, and interventions portend for concepts and views of sickness, criminality, professional competency, and social functioning. Given these issues, we offer that a preparatory neuroethical framework is required to define and guide the ways in which RDoC-oriented research can—and arguably should—be utilized in clinical psychiatry, and perhaps more broadly, in the social sphere.

The biopsychosocial model of illness: a model whose time has come

The biopsychosocial model outlined in Engel’s classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel’s call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation’s International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.

The (re)-introduction of semiotics into medical education: on the works of Thure von Uexküll

Thure von Uexküll's reputation as a pioneer in biosemiotics and also in psychosomatic medicine is well documented. It is easy to see these disciplines reflected in his notable publications, both in English and in German. However, if one spares the time to filter through all of his articles, monographs, conference papers and editorials in English and in German, a notable gap arises in his English language publications: that of clinical education. This gap in the English language literature may seem unimportant in and of itself, but it speaks volumes when we consider the total absence of medical semiotics in the curriculum of medical schools in the English speaking world. This runs in stark contrast to the strong traditions of psychosomatic medicine in Germany, which Thure von Uexküll largely helped to instil. Do the works of Thure von Uexküll offer a possible step towards a resurrection of medical semiotics in clinical education? This chapter attempts to explore the lesser known German literature on clinical education that Thure von Uexküll produced, and explore the role semiotics can play in Medical Education in the English speaking world. While also seeking to contrast this literature with other existing approaches in British and American medical schools who have attempted to reintroduce medical humanities and reflexive thinking into clinical education.

Are Mental Disorders Brain Diseases, and What Does This Mean? A Clinical-Neuropsychological Perspective

Neuroscientific research has substantially increased our knowledge about mental disorders in recent years. Along with these benefits, radical postulates have been articulated according to which understanding and treatment of mental disorders should generally be based on biological terms, such as neurons/brain areas, transmitters, genes etc. Proponents of such a 'biological psychiatry' claim that mental disorders are analogous to neurological disorders and refer to neurology and neuropsychology to corroborate their claims. The present article argues that, from a clinical-neuropsychological perspective, 'biological psychiatry' is based on a mechanistic, 'cerebrocentric' framework of brain (dys-)function which has its roots in experimental neuroscience but runs up against narrow limits in clinical neurology and neuropsychology. In fact, understanding and treating neurological disorders generally demands a systems perspective including brain, organism and environment as intrinsically entangled. In this way, 'biological' characterizes a 'holistic', nonreductionist level of explanation, according to which the significance of particular mechanisms can only be estimated in the context of the organism (or person). This is evident in the common observation that local brain damage does not just lead to an isolated loss of function, but to multiple attempts of reorganization and readaptation; it initiates new developments. Furthermore, treating brain disorders necessarily includes aspects of individuality and subjectivity, a conclusion that contradicts the purely 'objectivist', third-person stance put forward by some proponents of biological psychiatry. In sum, understanding and treating brain damage sequelae in the clinical neurosciences demands a biopsychosocial perspective, for both conceptual and historical reasons. The same may hold for psychiatry when adopting a brain-based view on mental disorders. In such a perspective, biological psychiatry seems an interesting project but falls short of its original claims.

Getting personal: can systems medicine integrate scientific and humanistic conceptions of the patient?

RATIONALE, AIMS AND OBJECTIVES

The practicing doctor, and most obviously the primary care clinician who encounters the full complexity of patients, faces several fundamental but intrinsically related theoretical and practical challenges - strongly actualized by so-called medically unexplained symptoms (MUS) and multi-morbidity. Systems medicine, which is the emerging application of systems biology to medicine and a merger of molecular biomedicine, systems theory and mathematical modelling, has recently been proposed as a primary care-centered strategy for medicine that promises to meet these challenges. Significantly, it has been proposed to do so in a way that at first glance may seem compatible with humanistic medicine. More specifically, it is promoted as an integrative, holistic, personalized and patient-centered approach. In this article, we ask whether and to what extent systems medicine can provide a comprehensive conceptual account of and approach to the patient and the root causes of health problems that can be reconciled with the concept of the patient as a person, which is an essential theoretical element in humanistic medicine.

METHODS

We answer this question through a comparative analysis of the theories of primary care doctor Eric Cassell and systems biologist Denis Noble.

RESULTS AND CONCLUSIONS

We argue that, although systems biological concepts, notably Noble's theory of biological relativity and downward causation, are highly relevant for understanding human beings and health problems, they are nevertheless insufficient in fully bridging the gap to humanistic medicine. Systems biologists are currently unable to conceptualize living wholes, and seem unable to account for meaning, value and symbolic interaction, which are central concepts in humanistic medicine, as constraints on human health. Accordingly, systems medicine as currently envisioned cannot be said to be integrative, holistic, personalized or patient-centered in a humanistic medical sense.

Technique in medicine and its implications for the biopsychosocial model

One of the challenges of integrating the biopsychosocial model into medical teaching and practice is the effect of technique on medicine. Relying heavily on the thought of Jacques Ellul, this article defines technique as the systematic application of machine principles to all domains of life, and the evaluation and adjustment of all human activity according to the criterion of efficiency. The article then considers the tension between technique and the biopsychosocial model of medicine, and explores ways to offset the problems technique causes while preserving the good that technique achieves, with particular reference to the teaching of family medicine residents.

At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.

Harmonizing WHO's International Classification of Diseases (ICD) and International Classification of Functioning, Disability and Health (ICF): importance and methods to link disease and functioning

Background

To understand the full burden of a health condition, we need the information on the disease and the information on how that disease impacts the functioning of an individual. The ongoing revision of the International Classification of Diseases (ICD) provides an opportunity to integrate functioning information through the International Classification of Functioning, Disability and Health (ICF).

Discussion

Part of the ICD revision process includes adding information from the ICF by way of “functioning properties” to capture the impact of the disease on functioning. The ICD content model was developed to provide the structure of information required for each ICD-11 disease entity and one component of this content model is functioning properties. The activities and participation domains from ICF are to be included as the value set for functioning properties in the ICD revision process.

Summary

The joint use of ICD and ICF could create an integrated health information system that would benefit the implementation of a standard language-based electronic health record to better capture and understand disease and functioning in healthcare.