BIOPSYCHOSOCIAL

APPROACH
Ma. Victoria Pilares-Cruz, MD, FPAFP
Associate professor
UST Faculty of Medicine and Surgery
Department of Preventive, Family and Community Medicine
 LEARNING OUTCOMES
DIFFERENTIATE THE MODELS OF
HEALTH CARE

ANALYZE DIFFERENT CASES (ACUTE,

CHRONIC, TERMINAL) USING THE
BIOPSYCHOSOCIAL APPROACH

APPLY THE DIFFERENT ROLES OF THE

PHYSICIAN USING CASES & EXAMPLES
NO TWO PATIENTS ARE ALIKE
PATIENT-CENTEREDNESS
HOW PHYSICIANS APPROACH
PATIENTS AND THE
PROBLEMS THEY PRESENT IS
MUCH INFLUENCED BY THE
CONCEPTUAL MODELS
AROUND WHICH THEIR
KNOWLEDGE IS ORGANIZED

GEORGE L. ENGEL
THE BODY THE MIND
BRAIN & BEHAVIOR - linked by the plasticity of the
Nervous system
Brain=organ of mental function
Psychological phenomena- have their origin in that
complex organ
- represented in the brain thru memories &
learning which involve structural changes in
the neurons and neuronal circuit
 BIOMEDICAL

SYMPTOMS TREATMENT CURE

?
 BIOPSYCHOSOCIAL
SYMPTOMS TREATMENT CURE
Genes
B
I
Health & illness
Exercise
H
PHARMACOLOGIC
O Diet
Medication/drugs O
P
Sleep
Beliefs
L
S
Y
Emotions
Habits
BEHAVIORAL INTERVENTIONS I
C
H
Knowledge
Memories S
Stress
T
O
Perspective
S Family/
O
C
Relationships
Culture/media FAMILY SUPPORT
I
I
A
Society and politics
Education
Environmental CONTROL C
L Environment
 COMPARISON OF 2 MODELS
PATIENT COMPLAIN: HEADACHE
BIOMEDICAL BIOPSYCHOSOCIAL

PRESENTATION MD asks questions on MD asks history of

pain history, family
history, diet, activities recent life stressors
and behavior
DIAGNOSIS MD orders lab tests MD diagnosed based
and monitor vital
signs
on a combination of
psychological factors
THERAPY MD prescribes anddiscusses
MD lab tests lifestyle
medicine interventions
 FOUNDATION OF THE
BIOPSYCHOSOCIAL MODEL

SYSTEMS THEORY
APPLICATION IN MEDICINE
 APPLICATION OF THE
BIOPSYCHOSOCIAL MODEL

ACUTE ILLNESS

CHRONIC ILLNESS

TERMINAL ILLNESS
BURDEN OF CHRONIC PAIN
BIOPSYCHOSOCIAL PERSPECTIVE
Anatomy of Pain
The dorsal (rear) root is
the sensory root.
A-delta fibers are
myelinated (insulated with
a myelin sheath). The pain
is fast and well localized
C fibers are nonmyelinated
and smaller than A-delta
fibers. They transmit pain
much slower. The pain is
more lasting, generalized
and described as a dull
ache.
PAIN CYCLE
CHALLENGE OF PAIN
PATIENT-CENTERED PAIN
MANAGEMENT
 Neuropathic Nociceptive
Pain Mixed Pain
Pain
Pain caused by
Pain initiated or
injury to body tissue
caused by a
(musculoskeletal or
primary lesion
or dysfunction viceral)
Pain with
in the nervous
neuropathic and
system
nociceptive
component
 PHASES
OF
CHRONIC
PAIN
 Case 1
SP, 26 y/o office clerk
Cc: headache
HPI:
3 months PTC right-sided headache of
moderate intensity, pulsating occurring once
a month relieved by OTC medications;
occasional nausea; attacks last for 4 hrs.
PE: essentially normal
 Clinical features of migraine
Normal Headache Normal

n g Vom
Vomiti itin
a nausea g
ex i Deep
Anor sleep Lim
ite
Crav ing ng
Appetite
ep y yawni d food tolerance Appetite
Sle bia
Photopho
ng
Awake/sleep Tired yawni phobi
a Tired Awake/sleep
Phono bia
Photopho
a
Light tolerance phobi
Phono hobia Feeling Light tolerance
Heighten
ed Osmop
a high or
Noise perceptio
n phobi Noise
Osmo
low
Smell Smell

ion
Fluid balance Fluid retent Diuresis Fluid balance

I II III IV V
Normal Prodromes Aura Headache Resolution Postdromes Normal

Blau (1992)
 Application of the Biopsychosocial
Model: ACUTE ILLNESS
S.P. a 26 year old male was diagnosed to have MIGRAINE
SYSTEM INTRASYSTEM CHANGES
HIERARCHY

Community No support group in the community

Family Role shifts among members; Reassignment of tasks- breadwinner, taking turns in
care-giving.
Two-person Total dependency on wife; conflicts may arise due to inability to relate with family
members

Person Difficulty ambulating due to pain, stiffness and fatigue

Frustrated, low mood
Concern about work, role in the family & loss of leisure activities

Nervous system activation of trigeminal/cervical nociceptive neurons and dysfunction of brain-stem

pathways that normally modulate sensory input
Organ system Fight flightofreaction
Dilatation blood vessels
Tissue aberrant firing of neurons and related cellular elements
 Case 2
LP, 67 year old male, married, retired engineer

Chief complaint: knee pain, bilateral

6 months persistent knee pain, VAS 7/10, worse

with cold weather and prolonged walking, (-)
morning stiffness noted, (+) swelling of both
knees; self-medicate with Mefenamic acid 500
mg as needed but cannot tolerate side effect
 CASE 2: PSYCHOSOCIAL HISTORY

No longer plays golf with friends and brother

because of pain

Sad over limitation of physical activities

Feels old

Feels useless that he cant drive his grandson

to school
 Case 2: Physical examination

Ambulatory, with difficulty

Weight = 95 kg height = 1.64 m BMI = 35
BP = 130/70 CR = 84 RR = 20 VAS = 8/10
Extremities: (-) deformities/ cyanosis/ edema,
(-) swelling, (+) tenderness on knee joints, (-) stiffness
(-) atrophy, (+) crepitus on motion
Range of motion: with limitation on the lower extremities
Neuro exam & others: normal
OSTEOARTHRITIS: RADIOLOGIC FINDINGS
 Application of the Biopsychosocial
Model: CHRONIC ILLNESS
L.P. a 67 year old male was diagnosed to have RHEUMATOID
ARTHRITIS
SYSTEM INTRASYSTEM CHANGES
HIERARCHY

Community No support group in the community

Family Role shifts among members; Reassignment of tasks- breadwinner, taking turns
in care-giving.

Two-person Total dependency on wife; conflicts may arise due to inability to relate with
family members

Person Difficulty ambulating due to pain, stiffness and fatigue

Frustrated, low mood
Concern about work, role in the family & loss of leisure activities
Nervous system Descending messages from the brain to the pain gate. Peripheral and central
sensitization
Organ system Fight flight reaction
Osteoclasts differentiate under the influence of cytokines
Tissue Inflammation, integrity, resilience and water content are all impaired
 Case 3
MJ 56 year old female diagnosed with Breast Cancer Stage IV
for 6 months experiencing chronic low back pain, persistent,
mild to moderate at rest, described as heavy, localized at
the lumbar area more pronounced during prolong walking
with radiculopathy.
! Underwent 6 cycles of chemotherapy and 33 cycles of
radiation therapy.
! VAS present: 3-4
least 1-2
usual 3-4
worst 5-6
! complains of nausea and vomiting
 Case 3

Impression:

Somatic Pain with Neuropathic component

probably secondary to bone metastasis vs.
radiotherapy induced pain secondary to breast
carcinoma Stage IV
 Application of the Biopsychosocial
Model: TERMINAL ILLNESS
M.J. a 56 year old female was diagnosed to have Breast cancer

SYSTEM INTRASYSTEM CHANGES

HIERARCHY
Community Breast cancer support group in the community
Family Role shifts among members; Reassignment of tasks- breadwinner, taking
turns in care-giving.
Two-person conflicts may arise due to inability to relate with family members; caregiver
strain
Person Back pain, radiculopathy, nausea, vomiting; Depression; realization of ability to
regain functions in ADL

Nervous system Fight flight reaction

Organ system Presence of tumor and lymph nodes

Cells and Tissue estrogen enters the cell, it binds the ER and the complex migrates into the
nucleus and leads to the production of transcription proteins that induces
5 Star Physician
HEALTH CARE PROVIDER

EDUCATOR/COUNSELOR

SOCIAL MOBILIZER

RESEARCHER

MANAGER
 Health Care Provider
History taking and physical
examination
Clinical and diagnostic reasoning
Screening
Prescription writing
Family assessment
Family health care plan
 SOAP
S subjective
O objective
A assessment
P plan
 SCOAP
S subjective
C context (psychosocial)
O objective
A assessment
P plan
 Educator/ Counselor

Provide information and motivation through

health education

Uses techniques and skills in counseling to

help people manage their own problems

Address patient and familys emotionally

critical misperceptions by doing CEA
CEA
 Researcher
Recognizes the importance of research in the
improving the delivery of health care services
Apply epidemiologic principles
Identifies and applies the best available clinical
evidences in patient care
Applies the steps of critical appraisal in evaluating
scientific literature
Practice quality assurance
Updates knowledge & skills
 Social Mobilizer
Lead and actively participate in health
policy-making
Advocate for patients rights and safety
Acts as a catalyst in generating active and
coordinated participation across all sectors/
levels
Family empowerment
Community empowerment
 Manager
Coordinates with other specialist through
the referral system

Establishes linkages and networking with

agencies and institutions to help in the
provision of holistic care

Organize and manage community projects

 ROLES OF PHYSICIAN IN CANCER
MANAGEMENT
ROLES TASKS

HEALTH PAIN MANAGEMENT

CARE
PROVIDER
EDUCATOR/ DISCLOSE ILLNESS
EDUCATE ON PROGNOSIS
COUNSELOR COUNSEL PATIENT FOR ANXIETY

SOCIAL EMPOWER FAMILY

MOBILIZER ADVOCATE FOR RIGHTS OF CANCER PATIENTS
MANAGER ORGANIZE SUPPORT GROUPS

RESEARCHE SEARCH FOR PREVALENCE OF CANCER, NEWER TREATMENT

OPTIONS
R UTILIZE QUALITY ASSURANCE FOR PATIENT SAFETY
 PRACTICE QUESTION
What role is portrayed when a physician
joined in the lobbying for Sin Tax bill
approval?

A. Health care provider

B. Social mobilizer
C. Manager
D. Researcher
 PRACTICE QUESTION
What systems level is involved when the patient
becomes depressed and withdrawn because of
a acute stroke with right sided hemiplegia ?

A. Cells
B. Organ
C. Person
D. Family
 REFERENCES
Maglonzo, EI. The Filipino Physician Today
2nd ed. Manila: UST Publishing house,
2010. PP 17-35
Care for the patient is
more personal than
care of a patient.
THANK
YOU