What exactly *is* the biopsychosocial model of ME ? (Poll included)

[Sushi]

It used to be that ME was simply a belief that someone had ME, which could be drummed out of them by exercising them back to health.

Anyone remember when, years ago, we had The Church of False Illness Beliefs" here?

It was part of a rolicking thread that explored such fascinating topics as whether pole dancing helped OI

 

[Wolfiness]

That statement is very vague. Doesn't mean they believe the model is incorrect in my mind.

I have read pretty much all of Peter White's published work on CFS and also keep an eye out for other statements he makes. I haven't seen any major change.

So can you tell me in a few words what the model is?

 

[Hip]

I'm pretty sure there is evidence as part of placebo/nocebo research that people treated surreptitiously with genuine medication don't respond as well as people treated overtly with it.
www.ncbi.nlm.nih.gov/pubmed/15488461

Certainly placebo/nocebo always need to be accounted for, but I don't think that really affects the observation I am making.

My observation would equally apply to infections that clear up by themselves, with no medications involved. The infection could clear up on its own, but you because you keep believing you are ill, according to Wessely, the belief would then maintain your symptoms for years or decades.

But we never see this with infections such as colds for example. If Wessely were right, then you would expect some people never to recover from their colds, with the cold going on forever. But this never occurs.

 

[Dolphin]

So can you tell me in a few words what the model is?

I've already posted links to the rationale in the CBT and GET manuals in the PACE Trial

Here are shorter versions from the Lancet 2011 paper:

Cognitive behaviour therapy (CBT):
CBT was done on the basis of the fear avoidance theory of chronic fatigue syndrome. This theory regards chronic fatigue syndrome as being reversible and that cognitive responses (fear of engaging in activity) and behavioural responses (avoidance of activity) are linked and interact with physiological processes to perpetuate fatigue. The aim of treatment was to change the behavioural and cognitive factors assumed to be responsible for perpetuation of the participant’s symptoms and disability. Therapeutic strategies guided participants to address unhelpful cognitions, including fears about symptoms or activity by testing them in behavioural experiments. These experiments consisted of establishing a baseline of activity and rest and a regular sleep pattern, and then making collaboratively planned gradual increases in both physical and mental activity. Furthermore, participants were helped to address social and emotional obstacles to improvement through problem-solving. Therapy manuals were based on manuals used in previous trials.19–21 CBT was delivered mainly by clinical psychologists and nurse therapists (webappendix p 1).

Graded exercise therapy (GET):
GET was done on the basis of deconditioning and exercise intolerance theories of chronic fatigue syndrome. These theories assume that the syndrome is perpetuated by reversible physiological changes of deconditioning and avoidance of activity. These changes result in the deconditioning being maintained and an increased perception of effort, leading to further inactivity. The aim of treatment was to help the participant gradually return to appropriate physical activities, reverse the deconditioning, and thereby reduce fatigue and disability. Therapeutic strategies consisted of establishment of a baseline of achievable exercise or physical activity, followed by a negotiated, incremental increase in the duration of time spent physically active. Target heart rate ranges were set when necessary to avoid overexertion, which eventually aimed at 30 min of light exercise five times a week. When this rate was achieved, the intensity and aerobic nature of the exercise was gradually increased, with participant feedback and mutual planning. The most commonly chosen exercise was walking. The therapy manual was based on that used in previous trials.22,23 GET was delivered by physiotherapists and one exercise physiologist (webappendix p 1).

.

 

[Wolfiness]

I'm sorry Dolphin, I'm not being intentionally obtuse or obdurate, I'm just trying to write a blog post explaining things to my friends and I need to know I've understood something if I'm going to object to it.

I know what the fear-avoidance-deconditioning theory that underlies PACE is, but is this is the same as the biopsychosocial theory? What about the cytokines changes researched by PDW? Are they among the 'physiological processes' referred to in the CBT paragraph?

 

[Dolphin]

What about the cytokines changes researched by PDW?

I suggest you read Peter White's papers yourself and make up your own mind. You don't seem to be that impressed in what people are saying here or have written in other threads such as Orla's ones.

I looked over this paper and don't see a discussion of any treatment implications.

Brain Behav Immun. 2015 Nov;50:186-95. doi: 10.1016/j.bbi.2015.07.004. Epub 2015 Jul 3.
Chronic fatigue syndrome and circulating cytokines: A systematic review.
Blundell S1, Ray KK2, Buckland M3, White PD4.

 

[Wolfiness]

I suggest you read Peter White's papers yourself and make up your own mind. You don't seem to be that impressed in what people are saying here or have written in other threads such as Orla's ones.

No, it's not a question of being impressed or unimpressed, more that I simply don't have the mental stamina to read pages and pages of text, especially in technical language. If I could read Peter White's book for myself I would have started it by now.

And as I said, Orla's thread is on the psychiatric view of CFS and a lot of the papers it cites are from Wessely in the 90s rather than White et al now, and I don't know whether the psychiatric view described then is identical to the biopsychosocial view now. I keep hearing some patients saying that doctors say it's all in our heads and doctors saying No, we're not saying that, and there's always the possibility that their views have evolved or are subtler than I think but I can't even track down the reading required to assess this myself, let alone read it all.

But I'm happy to take the explanations that people have given so far if, as many of you have said, there's no definitite explanation because the BPS model just doesn't offer one.

 

[Sea]

I'm sorry Dolphin, I'm not being intentionally obtuse or obdurate, I'm just trying to write a blog post explaining things to my friends and I need to know I've understood something if I'm going to object to it.

I know what the fear-avoidance-deconditioning theory that underlies PACE is, but is this is the same as the biopsychosocial theory? What about the cytokines changes researched by PDW? Are they among the 'physiological processes' referred to in the CBT paragraph?

They accept physiological processes as triggers and as downstream effects of deconditioning and stress. They will agree you are physically ill but believe that is maintained by unhelpful beliefs and inactivity.

 

[Wolfiness]

They accept physiological processes as triggers and as downstream effects of deconditioning and stress. They will agree you are physically ill but believe that is maintained by unhelpful beliefs and inactivity.

Ah, OK, that clears things up, thank you.
I'm not trying to wind anyone up or suggest BPS is right, I just want to make sure I'm not attacking a straw man. Or as sure as I can without actually reading it all myself.

 

[wastwater]

They used to say something like enjoys the sickness role and the attention and financial gain it brings.

 

[Skippa]

Look, it's how the body, mind and environment/behaviours combine to create perpetuating symptomatic conditions.

You can draw it as a triangle, a bit like the fire triangle (fuel, oxygen, heat) where each component is required/implied to create the condition in the centre (fire).

It is open to interpretation as to how much two of the corners (mind and behavioural) are really needed in order to understand the common cold (body) for example.

Consider two people catching "the common cold".

One person sniffles for a couple of days, but attends work and is right as rain in a jiffy.

The other spends a week in bed feeling "awful".

The latter might claim that they experienced the symptoms much worse than the former.

But the bio psycho social model seeks to undermine this and somehow demonstrate that poor illness management and prior lifestyle choices (deconditioning, trauma et al) - the mind - combines with social/environmental/behavioural phenomena (work bosses being lenient, family members saying poor baby ENABLING) to perpetuate the symptoms and make one condition SEEM WORSE than the other when it may or may not be.

 

[alex3619]

A good article on BPS ideas is this one: The rise and fall of the biopsychosocial model.

My three part blog on the author's book of the same name starts here: http://forums.phoenixrising.me/inde...e-and-fall-of-the-biopsychosocial-model.1075/

 

[Valentijn]

Are there any diseases which aren't biopsychosociable?

Diseases themselves are not biopsychosocial. Diseases are biological processes. Psychological and social forces would not impact on them anymore than they impact on any other aspect of life.

But they do say, "Oh no no, we never said it was purely psychiatric."

They also lie a lot, and abuse and redefine terminology. The interesting phenomenon with BPS treatments is that they focus almost entirely on psychological (not psychiatric) components. Biological investigation and treatment is very strongly discouraged, and the only social aspect is to attempt to cut off physical support from family members.

I have this feeling that they tried to oversimplify by presenting us with the purely psychiatric model in case we were too stupid to understand BPS, and that backfired…

It's actually the opposite. They use terms like "biopsychosocial" to make it sound like they're addressing all aspects, but they are not. Deconditioning is given lip service, even though they've explicitly stated that GET is not capable of having a physiological impact. The new fad is to attribute psychosomatism to "central sensitivity", which is never adequately defined and never put to the test.

"Our finding that studied treatments were only moderately effective also suggests research into more effective treatments is needed.

Any time a more specific suggestion is made, it's for more CBT/GET, or a marginally different form of CBT/GET.

The effectiveness of behavioural treatments does not imply that the condition is psychological in nature.

First of all, they are lying to say that the behavioral treatments are effective. When it comes to objective measurements, they are completely ineffective. It is only questionnaire answers which improve after months of being told the answers the patients should give if they're to cure themselves. And regardless of what their treatments imply, their beliefs about ME/CFS have been pretty clearly described by themselves as being psychological.

The PACE findings can be generalised to patients who also meet alternative diagnostic criteria for chronic fatigue syndrome and myalgic encephalomyelitis but only if fatigue is their main symptom.

An ME patient with fatigue as their main symptom is probably not an ME patient. If patients are struggling with PEM, OI, pain, etc ... are they really going to list "fatigue" as their biggest problem? Not a chance in hell.

I know what the fear-avoidance-deconditioning theory that underlies PACE is, but is this is the same as the biopsychosocial theory?

The only consistent BPS belief (it doesn't qualify as a theory or hypothesis, since it has been disproven) is that CBT is the cure for ME/CFS. The philosophical (not medical or scientific) musings regarding how this works evolves as biomedical and other research evidence disproves each prior explanation.

First it was atypical depression in patients who refuse to acknowledge depression. Except we have the opposite pattern regarding cortisol.

Then it was probably more classical psychosomatic beliefs, with a baseless fear of exercise. This is when GET (as a psychological treatment) came into play.

They also ran into trouble in the face of research showing Orthostatic Intolerance in nearly all patients. This got into deconditioning theories, and somehow GET with CBT was still the solution, even though GET at the levels used was known to be incapable of having an impact.

Now we have the two-day CPET, and they're pretty well screwed. It's objective evidence of major dysfunction when patients exert verified maximal effort. This is probably why Wessely jumped ship.

Other BPS practitioners are sticking to their guns, with a mishmash of the various components listed above. But they are pretty clearly at the point where there explanations make no sense in light of the biological research results. This is why the psychosomatic model (sometimes disguised under the BPS label) got pretty well trashed when a bunch of independent scientists reviewed the research.

What about the cytokines changes researched by PDW?

Psychosomatic proponents sometimes research biological aspects. Often this is done in an attempt to disprove a biological claim, and such trials are usually too small to obtain a statistically significant result. But if you want to discuss a specific paper, it's best to provide a link to it on a new thread so it can be examined in detail.

No, it's not a question of being impressed or unimpressed, more that I simply don't have the mental stamina to read pages and pages of text, especially in technical language.

The bits of text you're referring to are not that long. If you want the thorough understanding which you are demanding, it's going to require some reading. If you're not up to it, I suggest providing a link to other sources for your friends and family instead of attempting to blog on it without being able to even read about it.

And as I said, Orla's thread is on the psychiatric view of CFS and a lot of the papers it cites are from Wessely in the 90s rather than White et al now, and I don't know whether the psychiatric view described then is identical to the biopsychosocial view now.

Their explanations have evolved a bit, though not fundamentally. The biggest change is that the internet has forced them to be more cautious about what they publish. Paywalls helped them hide some of their most noxious statements for a while, but those are falling too.

Most notably, none of them have disavowed their most shocking and abusive statements from the past, such as recommending that therapists not allow patients to see specialists, that financial and physical support be withheld until a patient complies with CBT/GET, that investigation of symptoms will make patients sicker, strict avoidance of medication other than antidepressants, that abnormal lab results should be ignored, etc etc.

I keep hearing some patients saying that doctors say it's all in our heads and doctors saying No, we're not saying that, and there's always the possibility that their views have evolved or are subtler than I think but I can't even track down the reading required to assess this myself, let alone read it all.

Deceiving patients is considered by many such therapists and doctors to be an acceptable approach. The "biopsychosocial" label is part of that. Show me any such doctors using real biological treatments (other than antidepressants and maybe sleep meds), and I'll be quite shocked.

 

[alex3619]

Let me ask the question a different way.

Are there any diseases which aren't biopsychosociable?

Does biopsychosocial simply mean that no disease is purely physical?

Do all chronic or disabling diseases become biopsychosocial?

Are some diseases are more obviously biopsychosocial than others? Where would ME sit on the continuum?

These questions have no simple answers. This is complex and often waffly stuff.


Here are strict but misleading answers:

1. There are no diseases that are not biopsychosociable in the broadest sense, though I wonder how environmental disease would fit, depending on the disease factor.

2. Biopsychosocial does indeed imply that no disease is purely physical.

3. All diseases are biopsychosocial.

4. No disease is more biopsychosocial than any other but some can be more biological or more psychological or more social.

This is very VERY misleading though.

I will try to disambiguate some of the answers:

1. Biopsychosocial is a broad definition and categorization of disease. By definition any disease is biopsychosocial. Or we can simply call them diseases, or diseases and disorders, and so on. Biopsychosocial is a philosophy of medicine, not a natural order of thing.

2. The issue on physical disease versus social and psychological aspects is again misleading.

Let me cite a broken bone. The break is physical. The proximate consequences are biological. The recovery is mostly biological and physical. The patient's attitude can involve depression or various attitudes and motivation toward rehabilitation. Social factors can determine if home help is available (for a bad break), including family and friend's help. Psychology might lead to someone drinking, or not taking their meds, or ignoring doctor's advice etc. In other words, even a broken bone has a biopsychosocial profile.

Its not the basics of biopsychosocial that are the issue. Its what happens to the story next, not the science but the story, that leads it down the yellow brick road.

With a sneak peak at a blog I am slowly working on, lets take depression. Clearly a psychiatric disorder? Not so. Its a psychiatric disorder by definition, by an imposed category. Depression is a symptom not a disease, and I doubt calling it a disorder helps clarify things. Its clearly a result of a huge number of potential causes. Here it helps to distinguish between what triggers it and what causes it. Triggers can be environmental, psychological, physical, and even social. So this affirms the importance of these factors, and hence the lure of the biopsychosocial claims.

Physical diseases can induce psychological symptoms. Psychological and other sensory stimuli can trigger physiological changes in the brain. Symptoms can derive from those changes. All of this is implied by "biopsychosocial". The biology of depression is still being worked out, and its not as simple as a serotonin deficiency .. that has been known to be wrong since the 80s.

Now in one case only do I concede thought disorders, since I am a monist and take "mind" to be just a description of brain function. That is false belief systems. Its very dangerous to medicalize that though. Who have the false beliefs, athiests, agnostics or the devout? What about those who barrack for their local football team? Finally, how about those who believe, without unequivocal evidence, that ME is a mental disorder??? Hmmmm .... They cannot even prove that mind exists.

3. All diseases are biopsychosocial. This is by definition. It says nothing about the reality of the diseases, or their natural causation. Its an invented philosophy.

4. The claims made about more or less bio- or -psycho- or -social- are a big part of where the psychobabble arises.

Let me take psychogenic disease, which is more or less psychosomatic disease, and similar to modern functional disorders. In the history of medicine, every single disease entity claimed as psychogenic, where we finally have a proven explanation, has been proved to be physical. With one exception I think every single mental disorder, the entirety of the DSM, will most likely be proved physical. Mental disorders are most likely nearly all physical disorders that are awaiting discovery of the pathophysiology. Physical problems in the brain can lead to all sorts of symptoms.


Let there be no mistake. This is a very hard area to do science in. Which is in part why so much of it is unscientific and qualifies as psychobabble.

 

[Valentijn]

I voted "D" as well. The BPS researchers and practitioners involved in ME/CFS do not believe "A". That is merely one of their BS explanations to bridge the gap between ME/CFS and CBT/GET. Their actual explanation changes frequently, as they get backed into corners when their old explanations fail.

I would say that the BPS model is simply that CBT cures ME/CFS. They are happy to revise everything else about their model in the context of ME/CFS.

 

[A.B.]

This is why the psychosomatic model (sometimes disguised under the BPS label) got pretty well trashed when a bunch of independent scientists reviewed the research.

Are you referring to the IOM report? It didn't even bother with the psychosomatic hypothesis because there's nothing to support it and plenty of evidence to the contrary.

 

[alex3619]

I know what the fear-avoidance-deconditioning theory that underlies PACE is, but is this is the same as the biopsychosocial theory?

No, they are not the same.

The biopsychosocial theory is a vague general theory, so vague that it can encompass everything from sound science to total psychobabble. The fear-avoidance-deconditioning claims, of which the deconditioning angle has been repeatedly debunked, is simply one model within the vague umbrella that is BPS. The may cite it as BPS because they hope this gives it some credibility, or in other words in the hope it makes their claims more persuasive. Pity they are lacking in sound science.

EVERY theory of ME can be said to be a biopsychosocial theory, either directly or when you consider the broader situation that patients and doctors find themselves in. For example, let us suppose that ME is directly a mitochondrial disorder. Social factors determine funding and how others treat patients. Psychological factors include reaction to societal attitudes, and coping styles.

BPS is best thought of as a smokescreen. Its so broad it has almost no meaning.

 

[A.B.]

The biopsychosocial banner was raised in the USA around 1980, coincidentally with the rise of DSM–III and psychopharmacology, and the decline of psychoanalysis. Perhaps the biopsychosocial model was, as one historian suggests, a method to preserve psychoanalysis ‘through the back door’.5 This interpretation is supported by recent biopsychosocial manuals, which overwhelmingly describe psychoanalytic concepts (like defence mechanisms) as part of the model’s formulation, with scant attention given to biological or social features.6

http://bjp.rcpsych.org/content/195/1/3#ref-6

The model was proposed at a time when psychiatry was under attack for ignoring biological aspects and being unscientific.

 

[Cheesus]

Diseases themselves are not biopsychosocial. Diseases are biological processes. Psychological and social forces would not impact on them anymore than they impact on any other aspect of life.

Psychological and social forces impact other aspects of life in differing ways and to varying extents depending on which forces are being examined and which aspect of life you're talking about. So, to follow your logic, psychological and social forces would impact disease in differing ways and to varying extents depending on the particular psychological and social force we're talking about and what the disease process is they're influencing.

Is that correct or have I misinterpreted your argument? Do psychological and social forces have a fixed degree of influence regardless of the psychological or social force in question and the aspect of life they're influencing?

 

[Cheesus]

EVERY theory of ME can be said to be a biopsychosocial theory, either directly or when you consider the broader situation that patients and doctors find themselves in. For example, let us suppose that ME is directly a mitochondrial disorder. Social factors determine funding and how others treat patients. Psychological factors include reaction to societal attitudes, and coping styles.

And depending on the cause of mitochondrial dysfunction, you might be able to say that the events leading up to that cause were psychological or social. For example LPS-induced mitochondrial dysfunction from intestinal dysbacteriosis could be caused by a medical culture of handing out antibiotics like sweets or perhaps due to a standard western diet driven by the fast food industry.

It's freakonomics.