Biopsychosocial model

The biopsychosocial model (BPS model) or cognitive behavioral model (CBM) looks at biological, psychological and social factors to explain why disorders occur and is a tool used by psychologists to examine how psychological disorders develop.

BPS model in chronic fatigue syndrome
ChronicFatigueSyndrome-BPS-model-CBT-GET.jpg by Vercoulen et al (1998).''' Fatigue: the subjective feeling of fatigue; fatigue subscale of the Checklist Individual Strength. Focusing on (Bodily) Symptoms: somatisation subscale of the Symptom Checklist. (Level of) Physical Activity: Sickness Impact Profile (SIP) subscale mobility (SIP-MOB) and the Physical Activities Rating Scale. (Functional) Impairment: impairment in daily life; subscale of activities at home of the SIP. Sense of Control (over Symptoms): selected items of the modified Pain Cognition List on a specific five-point scale. Causal Attributions: Causal Attributions List (high scores: physical attributions, low scores: psychosocial attributions).

''Source: Maes, M., & Twisk, F. N. (2010). Chronic fatigue syndrome: Harvey and Wessely's (bio) psychosocial model versus a bio (psychosocial) model based on inflammatory and oxidative and nitrosative stress pathways. BMC medicine, 8(1), 35. License: CC-BY-2.0'']]

Vercoulen et al (1998) created a highly influential biopsychosocial (BPS)model for "chronic (subjective) fatigue" which was used for myalgic encephalomyelitis/chronic fatigue syndrome, and justified the use of both cognitive behavioral therapy and graded exercise therapy as treatments. However, Vercoulen et al's BPS was developed using patients that did not meet any recognized diagnostic criteria for CFS, instead they selected a mix of patients with idiopathic chronic fatigue and chronic fatigue syndrome; only 68% of these patients experienced post-exertional malaise, which later became regarded as the hallmark symptom of ME/CFS.



Wessely and Harvey (2009) proposed a development of Vercoulen's biopsychosocial model for not only chronic fatigue syndrome, but for all causes of fatigue, including psychiatric disorders, biological illnesses including AIDS, and fatigue without a known cause. Wessely and Harvey's model has been referred to as a psychosocial model. This theoretical model proposed that the all chronic fatigue syndrome and all fatigue was caused by the 3Ps: predisposing factors (e.g. personality traits or other pre-existing risk factors), precipitating factors (e.g. a virus, stress or other trigger) and perpetuating factors (psychological or behavorial factors, e.g., too much rest, being excessively focused on symptoms, beliefs about the illness being caused by a virus, or the patients' other thoughts and behaviors). It did not recognize a genetic predisposition for CFS.

History
In a 1977 article in Science, psychiatrist George L. Engel called for "the need for a new medical model." The BPS model is the dominant model used to understand mental illness and combines biological, psychological and social factors.

Evidence
Song and Jason (2005) concluded that their "current investigation found that the Vercoulen et al. model adequately represented chronic fatigue secondary to psychiatric conditions but not CFS."

Criticism
Song and Jason (2005) attempted to replicate Vercoulen's model, but found it did not fit patient data.

The BPS model has been criticized for being inappropriately applied to organic biological diseases, and medically unexplained physical symptoms (diseases that cannot yet be fully explained by medical science). Psychologization is the assumption that a disease or illness that cannot yet be explained by medical science must be wholly or partly psychological in nature, and is used to justify psychological treatments such as cognitive behavioral therapy.

BPS models have frequently been applied to ME/CFS, fibromyalgia (FM/FMS), peptic ulcers and other illnesses that are now understood to be physiological diseases. Davey Smith states that peptic ulcer was "the classic BPS disease" but that "Cognitive behavioural therapy rather disturbingly had no effect"; only the discovery of helicobacter pylori in 1983 allowed the patients to be cured.

The application of the BPS model for ME/CFS has led to graded exercise therapy (GET or GES) and cognitive behavioral therapy (CBT) as treatment for ME/CFS in a number of countries including the UK.

Controversy
The use of the BPS model, and its CBT and GET treatments, in ME/CFS has been heavily criticized by many researchers, charities and patient groups. The BPS model provides the justification for the use of exercise therapy in ME/CFS.

These controversial treatments were used in the PACE trial, which David Tuller, Keith Geraghty, Robert Courtney, Angela Kennedy, Tom Kindlon, Alem Matthees, Mark Vink and many others have exposed the PACE trial as deeply flawed, and potentially fraudulent, and many others have analyzed and reported on the significant harms and ethical issues resulting from the use of CBT or GET in patients with ME/CFS.

The UK Parliament House of Lords PACE Trial debate 6th February 2013 and the UK Parliament Grand Committee Room debate 21st June 2018 debated the PACE trial. Carol Monaghan MP for the Scottish National Party stated at a February 20th debate in the House of Commons Hansard, “I think that when the full details of the trial become known, it will be considered one of the biggest medical scandals of the 21st century.”

Notable studies

 * 1997, The Need for a New Medical Model: A Challenge for Biomedicine (Abstract)


 * 1998, The Persistence of Fatigue in Chronic Fatigue Syndrome and Multiple Sclerosis: The Development of a Model (Abstract)


 * 2005, A population-based study of chronic fatigue syndrome (CFS) experienced in differing patient groups: An effort to replicate Vercoulen et al.'s model of CFS (Full text)


 * 2009, Chronic fatigue syndrome: identifying zebras amongst the horses. (Full text)


 * 2009, A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS (Abstract)


 * 2010, Chronic fatigue syndrome: Harvey and Wessely's (bio) psychosocial model versus a bio (psychosocial) model based on inflammatory and oxidative and nitrosative stress (Full text)


 * 2011, Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up (Full text)


 * 2016, 'Blaming the victim, all over again: Waddell and Aylward’s biopsychosocial (BPS) model of disability' (Full text)


 * 2016, 'Chronic fatigue syndrome: is the biopsychosocial model responsible for patient dissatisfaction and harm? (Abstract)


 * 2017, Contesting the psychiatric framing of ME/CFS (Full text)


 * 2018, 'Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter' (Abstract)


 * 2019, The ‘cognitive behavioural model’ of chronic fatigue syndrome: Critique of a flawed model (Full text)

Learn more

 * Notes on the Ineffectiveness of the Biopsychosocial Model for Treating Myalgic Encephalomyelitis - Invest in ME Research