The British Journal of
Psychiatry (2006) 189: 194. doi: 10.1192/bjp.189.2.194
© 2006 The Royal College of
Psychiatrists
Biopsychosocial Medicine: An Integrated Approach to Understanding Illness
D. B. Double, Consultant Psychiatrist
Norfolk and Waveney Mental Health Partnership NHS Trust,
Norwich NR6 5BE, UK
By Peter White. Oxford: Oxford University Press.
2005. 242pp. £ 29.95 (pb). ISBN 019853034X
I did not find too much new in this book. It is composed of twelve
presentations on biopsychosocial medicine given at a conference in
London in 2002 to which international experts were invited. The
edited transcripts of the discussions after each talk are included,
together with a final discussion chapter. The editor of the book,
Peter White, Professor of Psychological Medicine at Queen Mary,
University of London, provides a concluding chapter. I wish he had
attempted to incorporate the discussions with the rest of the book,
but he preferred to try to keep them as `spontaneous as they were on
the day'.
I also think there were lost opportunities to contribute to
progress in the field. For example, Francis Creed, Professor of
Psychological Medicine at Manchester University, discusses whether
the patientcentred and biopsychosocial approaches are compatible. In
his chapter, he juxtaposes them, whereas, as pointed out in the
discussion after his paper, Moira Stewart, Ian McWhinney and others,
who have developed the patient-centred method at the University of
Western Ontario, would look for integration rather than distance
between the approaches.
The contributions of George Davey Smith, Professor of Clinical
Epidemiology at Bristol University, redeemed the book for me.
As he points out in discussion, George Engel's work in the
1970s, which of course is seminal for the understanding of the
biopsychosocial approach, became influential in the context of the
acknowledgement of the limits of biomedicine by, for example, Thomas
McKeown and Ivan Illich. I found this a useful insight. Davey Smith's
own chapter argues that there is, in fact, little evidence that
psychosocial factors have a direct aetiological effect on physical
illness and biological processes. Correlation of stress, for example,
with outcome may be explained by confounding, rather than reflecting
a causal explanation. Bias is also introduced into observational
studies through an increased reporting tendency of stressed
individuals. The number of experimental studies of psychosocial
interventions for physical disease has been relatively few, and any
significant effects, if found, are small and may not be
specific.
Davey Smith's critique should not be taken to imply that physical
symptoms cannot be psychogenic in origin. Doctors fail to recognise
the emotional and psychological nature of too many patients'
complaints. So-called medically unexplained symptoms are common.
For this reason alone, more emphasis should be placed on
comprehending the biopsychosocial approach. This book is a useful
contribution to that aim.
