Anyone who works in healthcare should be familiar with the concept of a bio-psycho-social approach to health conditions. However, most healthcare providers are still mainly trained using a biomedical approach, and therefore give less consideration for the psychological and sociological aspects of patient care. Furthermore, most of our patients don’t know what a biopsychosocial approach even means. Yet, there is increasing evidence to show that psycho-social factors matter a lot when it comes to healthcare, especially when treating complex conditions. So, what is a biopsychosocial approach and why does it matter?
The biopsychosocial approach considers not only the biological aspects of a health condition (what is going on physically) but also the psychological and sociological aspects. Before I lose you on this, let’s take a step back and think about the example of pain. Let’s start with the definition of pain, which was recently updated by the International Association for the Study of Pain (IASP).
The IASP defines pain as,
“an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
What does all of this mean?
Firstly, no one needs convincing that pain is often the result of actual tissue damage. If we cut our finger, the danger message is sent to our brain, and pain is produced to get our attention, so we tend to the cut and stop it bleeding. But what about potential tissue damage? To understand this, it helps to know that pain is produced by our brain as a warning signal. Sometimes the brain produces this warning not only when we cause actual damage, but when we might cause damage. If we bend a finger back, pain warns us not to go any further before we actually cause damage - the finger is fine if we listen to that warning and stop. I heard another great example of this recently. A carpenter accidentally punched a nail into his foot using a nail gun. He presented to emergency in agonising pain. However, when they X-rayed his foot, it turned out the nail had missed his foot entirely and was only in his boot! His brain had good reason to assume he had caused damage, and until proven otherwise, the pain was warning him to seek help.
What about the first part of the pain definition? We would all agree that pain is an unpleasant sensation – its purpose is to get our attention and alert us to something wrong. But have you ever thought of pain as an unpleasant emotion? There is always some kind of unpleasant emotion associated with pain – for example, sadness (crying) when it hurts, anger if it stops us doing what we want, or fear that it won’t go away. When we realise that pain encompasses both a sensory and emotional experience, we can already see there are both biological and psychological aspects to pain. Let’s look further at the biopsychosocial model.
The biological side of any health condition, including pain, is usually fairly self-explanatory. We have already seen how pain is produced as a warning of tissue damage or potential tissue damage. Of course, pain is not the only symptom of a problem. For example, nausea and vomiting may be produced with stomach cancer, or bladder urgency with interstitial cystitis. But not everyone with nausea and vomiting has stomach cancer, and not everyone with bladder urgency has interstitial cystitis.
What about the psychological side? The most common question I get asked about this part is “do you think it’s all in my head?” The short answer is no – at least not in the way people think. Biologically, everything we do, think, and feel is created in our brains. But this does not mean anyone is making up their symptoms. As we saw with the pain, many, if not all, physical symptoms also include a psychological (or emotional) component. The reverse also applies too. All emotions also include a physical aspect. An obvious example is when we feel scared or anxious – the heart races, the pupils dilate and the palms get sweaty. However, although nearly everyone has experienced these physical symptoms with fear or worry, many still do not realise the importance of psychological factors in health. As far as our brain is concerned, any type of stress (physical or emotional) is a threat and can trigger the sympathetic nervous system – our “fight and flight” response. I wrote another blog on this last year, which you can read here. However, it’s not even that simple. Context also matters.
The sociological side of the biopsychosocial model includes things like cultural beliefs, and social support from friends or family. The role this plays in health has been recognised in some ways. For example, it has long been known that people from a lower socio-economic background have poorer health outcomes. This is not just due to access to good healthcare, but also because more people from these backgrounds tend to engage in “riskier” health behaviours, such as smoking or having a poor diet. However, there are also less obvious ways that social context can influence health symptoms. An interesting study published this year showed women given the same painful stimulus reported less pain when their partner was holding their hand, compared with when their partner was present but not holding their hand, or wasn’t there at all. Some other examples might help.
Imagine you just got married. You are on the dance floor with your new spouse, in front of all your family and friends, and you feel immense joy. Then, partway through the dance, your partner accidentally steps the wrong way and you stub your toe hard up against their foot. Now imagine it is a month later. You are having the first big argument in your married life. As you storm from the room in anger, you stub your toe hard against the sofa. The same tissue injury has occurred in both cases. But do you think you’d feel the same pain? It’s very likely that in the first example you would notice it somewhat, but be able to keep dancing, swept up in the joy of the occasion. In the second, I bet it would hurt like crazy! This is a good example of how emotional and social context are important.
You may be thinking, that’s all very well, but how does that apply to a disease process? Let’s think about a pelvic health example. Overactive bladder (OAB) gives symptoms of needing to rush to the toilet often and very suddenly, and you may leak on the way there. This is a problem experienced by many of the patients I see, and I wrote about OAB in more detail previously. OAB can be associated with biological factors such as low oestrogen, or a prolapse. OAB can also be influenced by psychological factors - people with OAB often report anxiety or stress makes their symptoms worse. Finally, OAB is also influenced by social context. It is common for people with OAB to report their symptoms are worse when home, but not when out (or vice versa). Now imagine you have OAB related to low oestrogen levels after menopause. You are feeling stressed because you have a lot of deadlines at work, and you have forgotten to use your oestrogen cream. In a mad hurry, you arrive home from work, put your key in the door, and BAM, the urgency hits you out of the blue. “Oh no, not again!” you think, “last time this happened I peed myself.” What do you think will happen to the urgency? There’s a good chance it will get worse and you will wet yourself again. Now imagine you are on holiday, feeling relaxed and carefree. You arrive back to your holiday rental after a long walk, put the key in the door, and … what happens? Chances are your urgency will be much easier to control.
Examples like this occur through all aspects of healthcare, if we take care to look for them. The influence of psycho-social factors on our health outcomes are proving to be more important than we ever realised. If we only ever look at the biological aspects, we may miss key elements of the whole picture. This is not to say the biological aspects don’t matter – they still do! But they are not the only thing that influences health conditions.
That’s why I think a biopsychosocial approach is so important. It considers all the potential things influencing a health condition for each individual. That’s why I give many of my patients questionnaires asking about their sleep and mood, and ask them about what’s going on in their lives. I do this to understand the bigger picture behind their problem. For some people the biological side will be the biggest factor, for others the psychological side will matter more, and for others the social context will be the most important factor. For many, all three will play some role in the whole condition. But if we never look at all factors, we may miss something important for the individual’s problem.
If you have any questions about this blog, or would like to know more, please contact me at Life Cycle Physiotherapy.
Yours in good health. Jenny.