Everything old is new again, on a history of the ‘biopsychosocial model’

Stumbled on this quite by accident, but it is a rather nice potted history of some thinking about pain. The History of Biopsychosocial Pain – A tale of Gladiators, War, Papal Doctrine and a Wrestler, by Dr Harriet Wordsworth. The essay was a previous winner of The Anaesthesia History Prize awarded by The Association of Anaesthetists of Great Britain and Ireland. Selected excerpts below (all the words in italics)

George Engel and the origin (?) of the biopsychosocial model of illness

George Engel, 1913 – 1999

“The biopsychosocial model of illness was first presented in 1977 by George Engel. His landmark idea described a dynamic interaction between psychological, social and pathophysiological variables, and highlighted the hypothesis that, the workings of the mind, could affect the body, as much as the workings of the body, could affect the mind. Such a model has since been recognised in explaining chronic pain syndromes and has lead to an important shift in the way that pain is researched, diagnosed and treated. Originally the formula was applied to pain by Fordyce and Loeser in the 1970s and 1980s but the construct has blossomed over the last 30 years with a wealth of supporting studies and philosophies…

[However] It could, therefore, be argued that the biopsychosocial model of pain has been evident throughout history and that where the focus lay within the model was dependent on the social, scientific and cultural beliefs of the time.”

The ancient Greeks

Plato 428 BCE – 348 BCE

“As long ago as ancient Greece, pain was philosophised to be an emotional construct, often described as a ‘passion of the soul’ . This focus on the psychological and emotive aspects of pain no doubt arouse because of the dual function of the physician, as philosopher and medic. Aristotle (384- 322BCE) described pain as the opposite to pleasure and as a central sensory function derived from peripheral stimulation. 

Plato, perhaps without realising himself, showed an appreciation of how higher cerebral functioning could affect the perception of pain, through the use of distraction techniques; ‘ I said that the cure itself is a certain leaf, but in addition to the drug there is a certain charm, which if someone chants when he makes use of it, the medicine altogether restores him to health, but without the charm there is no profit from the leaf’.”

Galen and The Romans

Galen of Pergamon 130 AD – 210 AD

“The Romans also had strong ideas about pain medicine. Galen (131- 201AD), perhaps the most famous Roman physician, used his appointment as an ancient day, pitch-side medic, to investigate wounds inflicted on gladiators and wild beasts in the amphitheatre. This along with animal vivisection allowed him to develop an appreciation of neuroanatomy, and to hypothesise an early anatomical pain pathway. However, he was not a biological purist and his background in philosophy meant that he appreciated the complex interactions between mind and body. In his study of psychological disease he describes how mental disturbances arose not only if the brain was directly affected, but also if other organs were afflicted.

He purportedly added a fifth sign to Celsus’ four original signs of inflammation – redness, swelling, heat and pain – in the form of ‘disturbed function’. This highlights an appreciation for the functional component of pain and its importance to the life of the patient, which is often more detrimental than the pain sensation itself.”

The Dark Ages, ‘poena’ and the Pope

Pain, death and punishment in the late Middle Ages. Image from the Holkham Bible

“As with so many forward thinking philosophical and scientific concepts from the ancient era, theories about the origins of pain became enshrined in religious mystery during the Dark Ages. Pain was linked to the theory of original sin. Biblical teachings on pain were taken literally – ‘God told Eve: I will greatly multiply your pain in childbearing; in pain you shall bring forth children.’ (Genesis 3:16). Pain was viewed as a punishment from God which should be endured; indeed the Latin word for pain, ‘poena’, can literally also be translated as ‘punishment’.

This theological belief structure surrounding pain persisted well into the nineteenth century, outlasting the advent of effective analgesic and anaesthetic agents… Well into the nineteenth century, a doctor would use a type of ‘religious and moral calculus’ to determine which patients were of ‘correct sensibility’ to need or benefit from surgical anaesthesia.”

The Enlightenment

René Descartes 1596 – 1650

“The blossoming of science, philosophy and the arts that surrounded the Enlightenment had a huge impact on how pain was interpreted. Descartes developed the Theory of Dualism in the 1600s which described the separation of the body and the spirit as two separate entities. Pain was described as being produced by bodily mechanisms but being perceived by the soul. This theory was at odds with the holistic view of the Greeks and highlighted the shift from a religious or philosophical aetiology to a physiological source.

The Cartesian dualistic theory was largely accepted well into the twentieth century. The obvious flaw in the theory was the reliance on an overt stimulus and the causal link between tissue damage and pain. Patients who complained of pain but had no evidence of injury, and conversely, those with large injuries but little sensation of pain, were neatly explained as having ‘illegitimate’ pain; they were declared insane and therefore untreatable by medicine.”

Von Frey and the Victorians

Maximilian Rupert Franz von Frey 1852 – 1932

“Von Frey in 1895 attempted to divide the senses into four broad groups, each with their own free nerve endings and pathways in the nervous system. He termed these the cutaneous senses – touch, cold, warmth and pain and so coined the Specific theory of Pain, in which pain was described as a separate sensation. 

Despite growing physiological evidence, in Victorian times, the view that pain was an inevitable and even beneficial part of life remained… Pain was even inflicted as a treatment for certain diseases.

This superstitious or even spiritual view of pain often hampered physicians, intent on offering analgesia, and seemed to be a hangover from religious teachings linking pain with evilness and sin”

The Great War

Austro-Hungarian soldiers with prosthetic limbs at the First War Hospital, Budapest

“The First World War brought a resurgence of interest into chronic pain. Chronic pain sufferers were regarded as malingerers, addicts or psychologically ill because of the dominance of the specificity theory. However, some recognised the similarity in symptoms of returning soldiers and began to explore ways to treat them beyond the use of opiates.”

World War II and the post war era

Henry Beecher, 1904 – 1976. Image from a field hospital, North Africa, during WWII

“It was not until the Second World War that the importance of the psychosocial component of chronic pain came back into fashion. Henry Beecher observed that soldiers in military hospital reported much lower pain levels in comparison to civilians with similar injuries . He inferred that the pain experience was a complicated mixture of physical injury and emotional and cognitive reaction to the sensation. He noticed that combatants required less opiates and exhibited less suffering behaviours than civilians, and hypothesised that this was due to the positive connotations associated with injury afflicted in war. It could therefore be argued that Beecher, in 1946, was the first to truly observe the complexities of pain and all its biopsychosocial components.

John J. Bonica was a physician at the Madigan Army Hospital in Washington during the Second World War. He was himself a chronic pain sufferer, having accumulated shoulder injuries during his time as a champion wrestler. He became increasingly frustrated at his inability to effectively manage pain conditions in returning soldiers. He noticed that the soldiers who achieved the best functional outcome had received input from many different areas of the medical profession. After the war he investigated the idea of a multidisciplinary team approach and set up a pain clinic at Tacoma General Hospital that involved anaesthetists, neurosurgeons, orthopods, medics, psychologists and radiologists. His concept of multimodal pain management, which he published in 1953, despite showing encouraging results, was not widely accepted.” 

Melzack, Wall and the Gate

Pat Wall and Ron Melzack

“Melzack and Wall’s ground breaking work in 1965 attempted to combine what was understood physiologically with what was observed psychologically and emotionally. The Gate Control Theory describes a system where pain is not an inevitable consequence of stimulation of nociceptors but is dependent on higher cortical functions such as attention and meaning. This model fitted neatly with Bonica’s earlier observations and shows that the world of pain research was heading towards a biopsychological model over ten years before Engel published his work.

The change in thinking coincided with the growth of the Hospice movement and the development of Dame Cicely Saunders’ concept of ‘total pain’. Palliative care in the 1950s was a new specialty and physicians began to recognise the impact of depression, anger, anxiety and social isolation on their patients’ perception of their symptoms. This was particularly obvious with pain, and early trials highlighted how the reaction to pain could be lessened without pharmacological intervention but with talking therapies and careful explanation of symptoms and disease processes.”

The swinging ’60s

Gratuitous image of a 1960s insurance office

“The American Pain Society has since discussed the idea of the ‘swinging pendulum’ in the 1960s, which appears to show financial influence on the world of pain research. Insurance companies in the States were accumulating more and more chronic pain patients and thought that a psychological intervention, where the patient was encouraged to be responsible for the management of their own symptoms, provided a cheap answer to their prayers. This meant that psychological therapies at this time often had financial backing to carry out large trials. However, they had not appreciated the cost of implementing such services and, consequently, the cost passed onto the insurance companies themselves. Gradually the pendulum swung back the other way and financial support was given to drug trials in the hope of finding, somewhat unrealistically, a cheaper golden bullet to treat all pain problems. This is another example of how social pressures affected the course of pain research.”

The ’70s, the founding of IASP, and Wall’s ‘need state’

Artist’s impression of Patrick Wall, 1925 – 2001

“Engel’s concise description of illness within the biopsychosocial model fitted perfectly the growing functional and psychological impetus in the world of pain research in 1977. The International Association for the Study of Pain was founded in 1973 by Bonica, to bring together the growing areas of science involved in the development of pain medicine. The biopsychosocial model of pain was widely accepted at the IASP which is evident in the publication of a familiar definition of pain in 1979 as an ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage

In an early edition of the IASPs publication, Pain, [Pat] Wall, despite being a physiologist, clearly accepts the importance of the biopsychosocial model as he states that ‘pain is better defined as an awareness of a need state rather than a sensation…it has more in common with the phenomenon of hunger and thirst than with seeing or hearing…in each stage it is shown that pain has only weak connection to injury but a strong connection to body state’”

The ’80s and onwards

Not the BPS model, but all part of my ’80s memories, and if you’ve read this far you deserve a laugh. Click for source

“From the 1980s until today, many pain scientists, psychologists and philosophers have adapted and provided more evidence in support of the importance of the biopsychosocial model of pain.

Today it is hard to find a paper published about pain that does not mention a biopsychosocial aspect of pain, however technical or pharmacological the topic. It is a concept familiar to all those involved in modern healthcare. In the 1970s it was hailed as a modern concept, a product of parallel advancements in physiology, pharmacology, psychology and sociology. However, the appreciation of the importance of psychological and environmental aspects in the aetiology and management of pain are not new.”

Because it’s you and me, we’re history

It’s a great essay from Dr Wordsworth (sorry, couldn’t find a link to a professional page or bio), available in full for anyone to read here. Perhaps the abiding lesson of history is that at any point in time, we are not as clever/novel/forward thinking as we’d like to think we are.

If the biopsychosocial model was a person, it might be a Kardashian – nothing new, better known for its curvy figure and picture than for any substance, in and out of fashion, good to name-drop in the right circles, has had way too much of the same things written about it over and over, is talked about by many, but is understood by few (talk about burying the lede…).

This doesn’t take away from Dr Wordsworth great essay, or Engel’s original idea, but it does suggest that knowing a little history may be humbling and have some benefits – Plato was on to the ‘placebo effect’ thousands of years ago; Galen’s philosophical thinking made him a better physician; strongly held, dogmatic beliefs (religious or otherwise) can harm people; by carefully listening to, and observing soldiers with terrible injuries Beecher was aware of the tenuous link between tissue damage and pain over 70 years ago; Bonica was advocating multidisciplinary approaches to pain in the ’50s but was ignored; Wall and Melzack’s gate control theory was never just a theory of dorsal horn ‘gating’; and very few people to this day understand Wall’s idea of a need state. And there’s so much more – of course.

Back to the future – ‘Understanding Pain in 2025’

My sincere thanks here must go to Mick Thacker for giving his 2015 Louis Gifford Lecture talk the title Understanding Pain in 2025: Top Down before Bottom Up! and allowing a nice way to wrap this post up on an upswing, going back a few years to peer into the future. Discussing perhaps the most truly biopsychosocial (in Engel’s original formulation) model of pain around, Louis Gifford’s Mature Organism Model, Mick explores his own, embodied, formulation of the MOM, introduces the idea of Predictive Processing (PP), and discusses the work he is doing with one of the PP aficionados, Andy Clark, to take a PP approach to pain. Mick highlights along the way Louis’ prescient understanding of where pain science is heading, evident in his top down before bottom up maxim. Click on the image below for a link to the video. It’s long – but put aside the time, you’ll be smarter for having watched it.

Click on image above for link to video

-Tim Cocks

 


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10 Responses to “Everything old is new again, on a history of the ‘biopsychosocial model’”

  1. Keith Roper

    Brilliant, Tim. Thanks for the great read, the added pictures, the laugh 2/3 through, and the link to Micks brilliant work as well! Cheers

    Reply
  2. jqu33431quintner

    Tim, is it possible that the ancient theological beliefs of mediaeval Christianity in relation to women (about the Fall and Original Sin) have persisted to this very day and are playing a part in our societal stigmatisation (and punishment) of women experiencing pain that cannot be medically explained? As yet, I have not located any substantial evidence to support this rather radical opinion but wonder what others who have read your blogs are thinking.

    Reply
    • NOI Group

      Thanks John, it would seem a logical and defensible argument to me. In more recent times the Victorian (and earlier) notion of ‘hysteria’ may be a link in a causal chain? I believe that the American Psychiatric Association only ceased using the term in 1952.
      Tim

      Reply
  3. jqu33431quintner

    Tim, I cannot defend it with any solid evidence, which is why I raised it in this forum.

    The two great neuroses of the late 19th and early 20th century were “hysteria” and “neurasthenia”.

    The former lives on buried under the label “somatoform disorders” and the latter under that of “fibromyalgia”.

    Extricating fibromyalgia from this connotation of being a psychological disorder is proving to be exceedingly difficult.

    Reply
  4. jqu33431quintner

    The swinging ’60’s: “Insurance companies in the States were accumulating more and more chronic pain patients and thought that a psychological intervention, where the patient was encouraged to be responsible for the management of their own symptoms, provided a cheap answer to their prayers. This meant that psychological therapies at this time often had financial backing to carry out large trials. However, they had not appreciated the cost of implementing such services and, consequently, the cost passed onto the insurance companies themselves.”

    What is happening to these patients in the more enlightened 2010’s? How are compensable insurers managing these long-term claims and containing the costs thereof?

    Are there any contributors to this discussion?

    Reply
  5. jqu33431quintner

    Tim, let me be even more provocative.

    As I see the current situation, health care professionals are inextricably enmeshed in systems of personal injury compensation that can only result in these patients being treated as expendable commodities.

    Certain medical professionals willingly provide insurers with medico-legal reports that deny the reality of persistent (chronic) pain conditions, and many physiotherapists in private practice are providing these patients with copious amounts of useless and outdated treatment.

    The evidence provided to the Royal Commission related to the insurance sector has lifted the lid on the bad behaviour of insurance companies.

    Does such behaviour extend to their pivotal roles in workers’ compensation insurance?

    In my opinion, it would be worth having some feedback from health professionals who follow this blog, as it remains to be seen whether the vaunted “Pain Revolution” is going to improve this situation.

    Reply
    • Jason Kiely

      It becomes an issue of “causation”, and whether the issues identified are due to conscious actions of “bad actors”, or something more unconscious and more about the inevitable consequences of how our institutions developed and hence the “systematic processes” we have thus inherited. From a Marxist perspective it boils down to greed and exploitation on the part of bad actors…perhaps which accounts for some of the variation within health care but I think it goes deeper. From Weberist perspective (Max Weber, the other great sociologist of the 19th C), it boils down to a deep and potentially fatlisitic existence angst that underlies the human condition itself. I think the deeper issues relate to bigger questions that can only be addressed through rexamination of foundational ideas like the basis of a viable “social contract” and many of the issues raised in game theory like the “tradegy of the commons”

      Reply
      • jqu33431quintner

        Jason, as I see the situation in retrospect, the financial liability of systems of personal injury compensation in Australia was being increasingly threatened in the 1980s and 1990s by the relatively large percentage of patients with long-term claims due to persistent pain and the resultant disability.

        In response, state Governments enacted legislation to change the systems from their previous emphasis on disability in relation to employability to that of apparently medically-measurable impairment.

        Persistent pain was then deemed not to be an impairment and therefore not compensable.

        By contrast, psychological and psychiatric conditions became impairments and thereby attracted compensation.

        This change left many of our patients “in limbo” and at the mercy of increasingly unsympathetic claims officers and their medical advisors who had become dependent upon them for their daily bread.

        The industry of “independent medical examiners” has sprung up and is now increasingly under the control of multinational corporations.

        Incidentally, I looked up the “tragedy of the commons” as I was unfamiliar with it.

        I found it (on Wikipedia) to be a “term used in social science to describe a situation in a shared-resource system where individual users acting independently according to their own self-interest behave contrary to the common good of all users by depleting or spoiling that resource through their collective action.”

        Reply

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