BIO-PSYCHO-SOCIAL STRESS-VULNERABILITY MODEL FOR THE DEVELOPMENT OF
(MENTAL) HEALTH AND ILLNESS with implications for treatment
Introduction
The importance of biological, psychological(cognitive),
and social-behavioural factors in the aetiology of health and illness is
generally accepted. Also the influence of stress on vulnerability to
illness has gained wide acceptance. Selye(1956)and
Pelletier(1977), amongst others, were pioneers in bringing these
concepts together and in advocating a “holistic” approach to the
study of the origin of health and disease. “Adaptation” and “self-regulation”
are key concepts within this holistic approach. Another central concept
is that of “response systems”, which
typically refer to the physiological, cognitive and behavioural processes
within an individual organism. Theoretical models based on an holistic
orientation are of necessity “interactionist” in nature, and very complex. Holistic ways of thinking are
challenging established “scientific” concepts of objectivity as the
scientist is inevitably a “participant observer”. This paper
attempts to tentatively grapple with some of these ideas and to propose an
aetiological model which uses the three response systems as the basis for
redefining and integrating hitherto often haphazardly defined health and
illness related concepts.
The regulation of deviant behaviour
Regulation as a social process
Groups of people (societies) have been concerned
with identifying and regulating behaviour which was perceived as harmful and
inimical to the survival of the individual and that society as a whole.
The definition of “deviant behaviour” is obviously central to the
process of regulation. From time to time these definitions are changed to
bring them in line with current knowledge, beliefs
and practices.
Decisions about deviance and what to do about it have needed to deal with the interface of “illness based deviance” and “deliberate anti-social behaviour”. The latter is deemed to be within the individual’s control, whereas in the former this control is believed to be largely lost. Traditionally anti-social behaviour has been the domain of “the law”, illness the domain of “medical science”, with “religion” embracing both domains.
Regulation as an individual process
Organisms live in a kind of symbiosis with their environment and constantly
interact with it in a state of complete interdependence. Taken a step
further, there is a constant alternation between
environment and organism : the organism being its own environment as well
as being part of the environment of other organisms, and the total of
this all strives to grow....etc. maintaining a
status quo in an ultimately cosmic equilibrium. Each organism does this
in its own distinctive way. Human beings are part of this process.
A human being too can be seen as a peculiar conglomeration of many living
organisms, all interacting with each
other. These form an interdependent environment -a physiologically
interdependent environment. All these organisms are “tuned into each
other”. Their sensors are forever firing off responses to which
other organisms react (and an absence of such a response can also act as a
trigger or stimulus). One response system (a sub-set of frequently
interacting sensors, a “team” of
sensors, a sense organ) sets another in motion in a continuous constantly
changing(evolving and revolving) pattern but with usually predictable
outcome [everything flows, nothing lasts(Heraclites, ca. 500
B.C.), and yet there is nothing new under the sun(Parmenides, ca. 500
B.C.)].
Consciousness and self-regulation
Many of the processes of living seem to be automatic,
i.e. they happen independently of our awareness. These processes
do not involve mechanisms which bring them to our awareness -they do not ‘noticeably’
stimulate our sense organs. When the sense organs are sufficiently
stimulated the organism responds -a response may be observed in the form of
behaviour. Human beings become aware of an internal build-up of
stimulation and engage in covert behaviour (thinking)
which seems to give them (i.e. gives
them the perception that they have) some sort of control over the timing
and direction of the overt response, the outcome of which is stored in
memory for future reference. The observed activity seems to stop when the
sense organ’s equilibrium has been restored. ‘Self-regulation’, as is implied here, is not dependent on awareness,
although it may include it. Thus the definition of this concept as it is
used here goes beyond its usual meaning which relies almost exclusively on
conscious volition. It is useful to make this distinction to escape the trap(vortex) of endless self-contemplation.
As suggested before, the human being may be seen as a conglomeration of sense organs(response systems) forming a relatively independent, self-sufficient, more complex sense organ which in turn forms a part (but not a necessarily essential part) of a larger, even more complex organism......etc.
Behaviour occurs as a self-regulatory response to a perceived imbalance in the status quo. In this sense it may be said to be gaol-directed, this goal being ultimately comfort and survival (in that order).
An organism’s behaviour becomes apparent (can be observed, impinges upon an observer) when there occurs a change in the status quo and the change can be commented upon, i.e. measured against certain criteria. Many changes are not directly apparent or obvious and only become so when certain thresholds have been reached. Yet “internal” changes may be inferred. The effect upon the observer’s behaviour can be observed by another organism, etc. There are systems within systems, responding and co-responding constantly. Thus the observer is always a “participant observer”.
The model suggested here goes beyond the conventional bio-psycho-social models in that it views social behaviour as all interactions with the larger environment, not just with human beings. It is deterministic in nature, but does incorporate a ‘relatively free’ will.
An individual (i.e. an identifiable “system”)
can only deal directly with a limited number of systems on either side
(i.e. inside and outside of it), although individuals seem to differ in
the extent to which they can accommodate the “bigger picture”. When
considering the “immediate picture” (i.e. set of current life
circumstances) it is important to keep in mind that these considerations can
only be limited. Basically this means our
sciences and scientific methods present only one of many possible ways of
dealing with survival issues. They are only the current culturally
accepted “best available way”, and are
by no means accepted as such by all.
The (human) organism as a bio-psycho-social response system
Descriptions of the regulatory or adaptive processes that take place within
the human organism seem to fall into three main categories: those that
pertain to bodily(physiological, biological,
somatic) processes, those that pertain to mental(cognitive,
psychological) processes, and those that pertain to behavioural(social)
processes. It seems thus both logical and convenient to distinguish three
(sub)response systems corresponding to these
processes:
Uni-dimensional
versus multi-dimensional theories
Theories of human behaviour have been classified according to the degree to which they emphasize either one(uni-dimensional) or more(multi-dimensional) of these response systems(cf. Molloy,1984). The advantage of uni-dimensional approaches lies mainly in their relative ease of measurement and simplicity of experimental design. However they have led to almost infinite reduction and fragmentation so as to make results almost meaningless.
On the other hand, multi-dimensional approaches are of necessity interactionist and potentially very complex. Here the danger is that they try to explain too much, thereby also running into trouble with measurement and experimental design, with also the risk of near meaningless results.
In practice there are two major problems with the application of
multi-dimensional interactionist approaches in that essentially traditional
measurement and experimental design techniques are
employed to test them.
Measurement
Already ill-defined concepts from uni-dimensional approaches are used to
measure and evaluate multi-dimensional models without clearly specifying which
response system they refer to, and without
specifying how these concepts might relate to each other to create health or
illness. There is a clear need for a framework which provides the means
by which concepts can be defined and related to each other.
Experimental design
The experimental models used in the multi-dimensional approach still try to
predict and ideally control for every possible eventuality. This clearly
is an impossible pursuit, and arguably
unnecessary. There is a need for a model which incorporates randomness
and which is able to recognize and make use of the outcome of chance processes.
In the model proposed here the individual (organism)
is seen as a kind of container, a more or less definable entity of
more or less random ever-changing adaptive processes in which the container
itself also plays an active part.
Incorporating randomness in experimental design
The idea for the model which is proposed here was inspired by the work of Dutch scientist Felix Hess some years ago. Dr. Hess and his associate designed and constructed mobile electro-mechanical devices (little robot creatures) capable of receiving, storing (in a capacitor) and transmitting certain predetermined stimuli (sounds). When the electrical charge in the creature’s capacitor had reached a certain threshold, having “listened to” a certain quantity of sounds transmitted by other creatures, this creature would then be stimulated to perform certain predetermined behaviors: e.g. it would also begin to transmit sounds as well as to move in the direction from where it perceived the sounds to be coming. Thus these creatures would seek each other’s company. This “behaviour” was terminated when the creatures bumped into each other, as this would instantly discharge their capacitors. Dr. Hess judged his creatures to be rather “stupid” in that they could only respond to and transmit one or two stimuli. Even then they behaved never in exactly the same ways (patterns) as conditions were always somewhat different. Nevertheless certain predictable things happened when certain thresholds were reached. It is not hard to imagine how complex these interaction patterns would become if these creatures were even less “stupid”.
It is postulated here that organic creatures (e.g. humans) behave rather like Dr. Hess’ creatures, but that they are infinitely more “intelligent”, resulting in infinitely more complex behaviour patterns. Add to this, as mentioned before, that each individual “unit” consists of and is part of an infinite number of other units, and “old-fashioned” notions of predictability become rather meaningless. This is not to say that they are not useful in certain situations. Moreover these ideas are of course not new (cf. gaia theory, chaos theory).
Especially in the study of physical and so-called mental illness multi-modal interactionist models seem to offer more promise in answering questions about which people develop illnesses and what kind of illnesses they develop, and who and what gets “healed” when. For instance traditional scientific methods of prediction have failed in predicting adequately who will get cancer or schizophrenia and when, and who will get cured, or whose disease will go into remission and when, without the use of highly intrusive methods.
Stress and vulnerability
Stress-vulnerability models, which are typically interactive and holistic in nature, postulate that stress, however defined, plays the central role in activating and influencing vulnerability thresholds for a wide variety of diseases. In medical science the concept of an “immune system” has been proposed to explain the self-healing nature of living organisms. The immune system may be seen as an example of complex, but reasonably identifiable self-contained and self-regulating “internal interactive processes” which behave rather like a capacitor in Dr. Hess’ creatures. Although it is possible to predict that illness or healing will occur when certain pre-conditions are met, it is much less possible to predict exactly what will happen and when it will happen. It is however believed that “stress”(i.e. the regulatory demands placed on the system) influences the vulnerability of the immune system, i.e. stress seems to control the threshold levels, it controls the thermostat as it were. It is also known that there is a point where the system begins to behave in an out of synch fashion. This is the point where the organism seems to be attacking itself. It is believed that this is for instance how cancers develop.
It is proposed here, perhaps somewhat
symplistically, that the auto-immune system may be seen as forming
part of the larger physiological response system, and that the
intellectual and assertive sub-systems may be helpful concepts for explaining
the functioning of the cognitive and behavioural response systems
respectively. Thus just as the immune system “looks after” physical functioning, so does the intellectual
response system (intelligence, i.e. reasoning)
take care of mental processes. Physiological and cognitive functioning is
“covert” and not so easily
observable. However, the way the entire
organism acts to modify its environment (i.e. asserts
itself - the assertive response system -) is overt and more
easily observable. In this model the physiological element plays a
pivotal role (cf. Molloy’s assertion about what he calls the
“physiological imperative”, Molloy,
1984 ).
Health/illness and the management of stress
If behaviour is instigated as a neutralizing response to stress, then health and illness (i.e. the level of comfort of the organism ) are dependent on the manner in which the organism “manages” this behaviour and thus manages stress to produce either positive or negative outcomes. Languages have many words and concepts that describe and define the various stages of this process: e.g. we may say that the organism is stressed, anxious, stimulated, angry, depressed, in panic, obsessed, happy, neurotic, psychotic, etc.). Most of these words are so common that their meanings are hardly questioned. Even if they are defined in psychological research their meanings often vary from study to study. This has led to inconsistencies and difficulties in comparing results.
The model proposed here attempts not only to find a way of arriving at
consistent definitions (figure 1),
but also to describe a logical progression from healthy to disordered
responses, thereby making it possible to imply appropriate intervention
strategies(figure 2). In that sense it follows
the “positivist” tradition. However, where the model may
perhaps be seen to depart from this tradition is that it acknowledges
interactive processes that are too complex to unravel, and
which have “ideographic” outcomes, i.e. they are beyond accurate prediction. Yet, once such an outcome has been observed it can then be
treated as a pre-condition for other events in the traditional positivist
manner.
Description of the model (figure 1)
The model attempts to describe how a (human) organism might respond when it is stimulated by a “stressor”, i.e. how it might manage the “stress” caused by the stressor. Theoretically the organism can be any organism.
The three Response Systems described earlier are at the core
of the model. The organism (O) progresses or
regresses through a number of Response States depending on how
the O “manages” the stress.
Response States are categorized into three Response Modes:
Response Modes
|
Automatic |
The
stressor does not present any unusual problem to the O. |
|
Rational/Constructive |
The
stressor has an element of novelty and provides a challenge to the O. |
|
Irrational/destructive/Self-defeating |
The
O fails to cope with the stressor (fails to neutralize it). |
In order to define Stress and Relaxation Levels it seemed
useful to associate these levels with the Response Modes as follows (these are
suggestions only and more appropriate words could be substituted at a later
stage):
|
Stress
and Relaxation Level |
Response
Mode |
|
Not
stressed---Relaxed |
The
response state of the O when no stressor is perceived and it functions in
automatic mode. |
|
Stressed--------Stimulated |
A
(non- threatening) stressor has been perceived, the
mode is still automatic. |
|
Stressed--------Alert |
A
novel stressor has been perceived, the mode is now
rational/constructive. |
|
Distressed-----Alarmed |
The
O is having difficulty in dealing with the stressor in a
rational-constructive way, but is still coping overall. |
|
Distressed-----in
Panic |
The
O has been unable to cope rationally and constructively and begins to “grasp
at straws”, i.e. to behave in an irrational ad hoc fashion. |
|
Stressed
out--Chronic Hyper-Vigilance |
The
O has failed to adequately neutralize one or more stressors. Thus it
can’t relax in the presence of these stressors,
and continues to attempt to find any kind of solutions. These
solutions are likely to be irrational and ad hoc, but provide at least
temporary relief, although in the longer term they become stressors in
themselves, creating more stress etc. In this sense they are like
cancers. |
The Response States associated with Response Modes and Stress-Relaxation
Levels for the three Response Systems may be described as follows:
|
Response
Mode:
Automatic |
|
|
Response
System |
Stress/Relaxation
Level:
Not stressed/Relaxed |
|
Physiological |
Relaxation
Response, Limp, Resting |
|
Cognitive |
Meditative,
Dreamlike, Placid |
|
Behavioural |
No
observable activity, Inactive |
When a STRESSOR is
introduced it is hypothesized the following occurs:
|
Response
Mode:
Automatic |
|
|
Response
System |
Stress/Relaxation
Level:
Stressed/Stimulated |
|
Physiological |
The
O becomes aroused. |
|
Cognitive |
This
makes the O attentive. |
|
Behavioural |
If
the situation is familiar the O will engage in routine habitual behaviour
to neutralize the stressor. |
If the outcome is positive, then in terms of mood/affect the O is euphoric (content).
If the situation is novel and routine behaviour is ineffective, the outcome is negative and the O may be said to be dysphoric (discontent).
In terms of the three response systems the following happens:
|
Response
Mode:
Rational/Constructive |
|
|
Response
System |
Stress/Relaxation
Level:
Stressed/Alert |
|
Cognitive |
The
O becomes concerned |
|
Physiological |
This
mental concern instigates physical excitement. |
|
Cognitive |
This
in turn may add to concern(thinking takes place). |
|
Behavioural |
As
a result the O will engage in experimental and innovative behaviour. |
If effective(outcome perceived as positive) these novel behaviours are likely to be learned and become part of the automatic cycle. The outcome in terms of mood/affect is satisfaction.
If the novel behaviours are ineffective(outcome
perceived as negative), mood/affect is characterized by dissatisfaction.
In terms of the three response systems the following happens:
|
|
Response
Mode: Rational/Constructive |
|
Response
System |
Stress/Relaxation
Level:
Distressed/Alarmed |
|
Cognitive |
The
O experiences fear which is directed towards the specific stimulus
situation. |
|
Physiological |
The
physiological concomitant of fear is an increase in level of arousal akin to irritation
(inflammation) |
|
Cognitive |
This
in turn may add to fear. |
|
Behavioural |
Behaviourally
this is likely to manifest itself in an increase in frequency and
intensity of attempts to overcome; the behaviour is hyperactive, but
goal-directed. |
If the outcome of this activity is successful(positive), then eventually it will be learned and become routine and habitual. In terms of mood/affect the O may be said to be happy.
Mood/affect is characterized by anger if the outcome is
unsuccessful(negative).
In terms of the three response systems the following happens:
|
Response
Mode:
Irrational/Destructive/Self-defeating |
|
|
Response
System |
Stress/Relaxation
Level: Distressed/Panic |
|
Cognitive |
The
O experiences worry i.e. mental activity over a situation over which
there is perceived loss of control. |
|
Physiological |
Somatically
this is akin to “infection”. The O experiences pain. |
|
Cognitive |
This
adds to worry. |
|
Behavioural |
The
concomitant behaviour is likely to be random and tantrum-like. |
Random behaviour may still lead to a satisfactory outcome, where the mood/affect may be described as elated.
However it is more likely that the outcome is unsatisfactory, where the mood/affect is characterized by anxiety.
In terms of the three response systems the following happens:
|
Response
Mode:
Irrational/destructive/self-defeating |
|
|
Response
System |
Stress/Relaxation
Level:
Stressed out/Chronic hypervigilance |
|
Cognitive |
Here
the O (at least the human O) is increasingly experiencing chronic
ruminations, self doubts, paranoia, depressive thoughts etc. |
|
Physiological |
Somatically
the O becomes increasingly “concerned” with healing physiological
subsystems at the expense of the larger system; it begins to attack itself
rather like a cancer. This causes more pain, chronic distress,
physiological breakdowns.... |
|
Cognitive |
At
the cognitive level the O now also needs to deal with what is happening physiologically,
thus adding to the severity of the symptoms at this level. |
|
Behavioural |
Behaviourally
the O will tend to increasingly avoid or neutralize the stressful
situation(s) in any way it can. Chronic avoidance, hostile-dependent
behaviour and obsessive compulsive behaviour are examples at this level.. |
Relatively pseudo-satisfactory outcomes may be arrived at, although there is
likely to be permanent damage in the longer term. Depending on outcome mood/affect
is either manic (positive outcome) or depressed
(negative outcome).
DIAGNOSTIC CATEGORIES and THERAPEUTIC INTERVENTION STRATEGIES
The point at which the various physiological, cognitive and behavioural adjustment responses transgress the threshold between “healthy” and “unhealthy” is dependent on social convention (as indicated earlier). It is clear though that very complex interactive processes are at work. The “flow-chart”(figure 1) only portrays the process at its “simplest” level. Moreover these interactions are influenced in mostly unpredictable ways by both nature and nurture. Thus outcomes of these processes are highly idiosyncratic. This is where an adaptation of Dr. Hess’ model would seem appropriate: when certain response state thresholds are reached, preconditions are established for further processes to be triggered; these processes may either lead to further “deterioration”, but they may also initiate “healing processes”.
Within this context it is possible to make some assumptions about health
(order) and illness (disorder), as well as about types of intervention
strategies. Figure 2 describes a model for the
diagnosis, treatment and prognosis of (psychological and psychiatric)
health/illness states.
The Healthy Organism
The Health/Illness Status of an organism is defined as healthy when the Stressor Status of the three response systems is intact and as a whole they function in a way which leads to stress reduction through effective coping with stressors within the context of the “normal” life expectancy and operating functions of the organism as a whole. The healthy organism has within itself regulatory systems which guide this process. The “immune sub-system” looks after the physiological (sub)system. The “intellectual sub-system” could be said to look after the cognitive (sub)system. Both together look after the behavioural (sub)system and the organism as a whole. Interactions with the social/environmental system within which the individual lives are mutually reinforcing in a balanced way.
In terms of Therapeutic Intervention Strategies the organism may be
said to be self-healing through work and play activities.
The Prognosis if the Interventions are Successful is for continued
good health.
The Prognosis if the Interventions are Not Successful is for
increasing stress levels, leading to probable impairment of one or more
response systems when thresholds have been reached.
The Ill or Disordered Organism
An important feature of the Bio-Psycho-Social model as described above is that it allows for and encourages the taking into account of the degree to which all three response systems are involved in the development of an illness. This in turn allows it to suggest which kind of mix of physiological, cognitive and behavioural interventions is most likely to be effective in halting, stabilizing or reversing the disease process. These interventions may be seen as adaptive responses by the “social system” to which the organism belongs -thus a social system too may be diagnosed as sick if there appears to be too much emphasis on the application of only one intervention strategy to the exclusion of the other two (cf. medical interventions in our present day culture).
Disorders can range from an isolated single-subsystem disorder to complex multi-subsystem disorders, where the subsystems and eventually the whole organism become increasingly concerned with ad hoc “inverted” self-healing (i.e. self-attacking) activities at the expense of neighbouring systems and sub-systems. The more sub-systems become involved. the more vulnerable the organism becomes.
The distinction between physical, mental and behavioural disorders thus
becomes somewhat blurred and perhaps even irrelevant. However, it may
still be useful to make such distinctions depending on which of the three
response systems is primarily involved.
This model also implies that there is not necessarily a dichotomous distinction
between health and illness. An organism can be both healthy and ill in varying
degrees.
The model suggests three stages of illness development:
Stage 1: Only one of the three response systems has become impaired and has thus acquired stressor status. The other two systems are still relatively intact and functioning “normally. The illness may be said to be “specific”.
Stage 2: Two of the response systems have become significantly impaired and have acquired stressor status, with the third remaining relatively unaffected. The illness may be said to be “generalizing”.
Stage 3: All three response systems have become significantly
impaired. The illness may be said to have “generalized”.
A fuller description of the three stages follows:
STAGE 1
|
STRESSOR
STATUS OF THE RESPONSE SYSTEMS |
|
||||||
|
HEALTH/ILLNESS
STATUS |
The
diagnosis here is one of physical illness. |
||||||
|
SYMPTOMATOLOGY |
This
diagnosis is based on symptoms of physical discomfort and pain. |
||||||
|
INTERVENTION
STRATEGIES |
Physiological
interventions,
medical as well as non-medical interventions, based on advice or
recommendations aimed at maintaining and or strengthening the intact
cognitive and behavioural response systems. This includes advice to the
relevant social support systems. |
||||||
|
PROGNOSIS
IF INTERVENTIONS SUCCESSFUL |
Full
and relatively speedy adaptation. |
||||||
|
PROGNOSIS
IF INTERVENTIONS NOT SUCCESSFUL |
Increased
“strain”(defined as: condition of a body
subjected to stress), resulting in increased likelihood of impairment of the
intact response systems. |
||||||
|
STRESSOR
STATUS OF THE RESPONSE SYSTEMS |
|
||||||
|
HEALTH/ILLNESS
STATUS |
Cognitive
illness. |
||||||
|
SYMPTOMATOLOGY |
This
diagnosis is made on the basis of symptoms of cognitive(i.e.
mental) discomfort likely to be reported as fear, anxiety, worry and
depression. |
||||||
|
INTERVENTION
STRATEGIES |
Cognitive
therapeutic counselling methods based on advice or recommendations aimed at maintaining
and /or strengthening the intact physiological and behavioural response
systems. This includes advice to the relevant social support systems. |
||||||
|
PROGNOSIS
IF INTERVENTIONS SUCCESSFUL |
Full
and relatively speedy adaptation |
||||||
|
PROGNOSIS
IF INTERVENTIONS NOT SUCCESSFUL |
Increased
“strain”, resulting in increased likelihood of impairment of the
intact response systems. |
||||||
|
STRESSOR
STATUS OF THE RESPONSE SYSTEMS |
|
||||||
|
HEALTH/ILLNESS
STATUS |
Behavioural
illness |
||||||
|
SYMPTOMATOLOGY |
This
diagnosis is bases on ineffective(faulty) coping behaviour |
||||||
|
INTERVENTION
STRATEGIES |
Behavioural
counselling methods
based on advice or recommendations aimed at maintaining and/or strengthening
the intact physiological and cognitive response systems. This includes
advice to the relevant social support systems. |
||||||
|
PROGNOSIS
IF INTERVENTIONS SUCCESSFUL |
Full
and relatively speedy adaptation. |
||||||
|
PROGNOSIS
IF INTERVENTIONS NOT SUCCESSFUL |
Increased
“strain”, resulting in increased likelihood of impairment of the
intact response systems. |
STAGE 2
|
STRESSOR
STATUS OF THE RESPONSE SYSTEMS |
|
||||||
|
HEALTH/ILLNESS
STATUS and SYMPTOMATOLOGY |
Somato-Cognitive
Illness:
Physiological symptoms significantly affecting cognitive processes. |
||||||
|
INTERVENTION
STRATEGIES |
Advanced
physiological and cognitive intervention strategies, while maintaining and/or
strengthening intact behaviour patterns, with advice and instructions to the
relevant social support systems. |
||||||
|
PROGNOSIS
IF INTERVENTIONS SUCCESSFUL |
Prevention
of further deterioration, while increasing the likelihood of appropriate
adaptation. |
||||||
|
PROGNOSIS
IF INTERVENTIONS NOT SUCCESSFUL |
Increased
“strain”, resulting in increased likelihood of impairment of the
intact response system and the establishment of a negative feedback loop. |
||||||
|
STRESSOR
STATUS OF THE RESPONSE SYSTEMS |
|
||||||
|
HEALTH/ILLNESS
STATUS and SYMPTOMATOLOGY |
Somato-Behavioural
Illness:
Physiological impairment compounded by inappropriate behavioural responses to
it. |
||||||
|
INTERVENTION
STRATEGIES |
Advanced
physiological and behavioural intervention strategies, while maintaining and/or
strengthening intact cognitions, with advice and instructions to the relevant
social support systems. |
||||||
|
PROGNOSIS
IF INTERVENTIONS SUCCESSFUL |
Prevention
of further deterioration, while increasing the likelihood of appropriate
adaptation. |
||||||
|
PROGNOSIS
IF INTERVENTIONS NOT SUCCESSFUL |
Increased
“strain”, resulting in increased likelihood of impairment of the
intact response system and the establishment of a negative feedback loop. |
||||||
|
STRESSOR
STATUS OF THE RESPONSE SYSTEMS |
|
||||||
|
HEALTH/ILLNESS
STATUS and SYMPTOMATOLOGY |
Cognitive-Behavioural
Illness:
Faulty cognitions which have led to and are compounded by inappropriate
behaviours. |
||||||
|
INTERVENTION
STRATEGIES |
Advanced
cognitive and behavioural intervention strategies, while maintaining and/or
strengthening the intact physiological response system, with advice and
instructions to the relevant social support systems. |
||||||
|
PROGNOSIS
IF INTERVENTIONS SUCCESSFUL |
Prevention
of further deterioration, while increasing the likelihood of appropriate
adaptation. |
||||||
|
PROGNOSIS
IF INTERVENTIONS NOT SUCCESSFUL |
Increased
“strain”, resulting in increased likelihood of impairment of the
intact response system and the establishment of a negative feedback loop. |
STAGE 3
|
STRESSOR
STATUS OF THE RESPONSE SYSTEMS |
|
||||||
|
HEALTH/ILLNESS
STATUS and SYMPTOMATOLOGY |
Somato-Cognitive-Behavioural
Illness:
Reciprocal involvement of all three response systems to a significant extent. |
||||||
|
INTERVENTION
STRATEGIES |
Complex
and largely experimental combinations of physiological, cognitive and
behavioural interventions, where full involvement of the social support
system is essential. |
||||||
|
PROGNOSIS
IF INTERVENTIONS SUCCESSFUL |
Reversal
of the negative feedback loop and increasing possibility of appropriate
adaptation. |
||||||
|
PROGNOSIS
IF INTERVENTIONS NOT SUCCESSFUL |
The
entrenching of the negative feedback loop with eventual full dependence on social support systems. |
Diagnosis of Multiple-System Disorders
In psychiatric an psychological literature, definitions of concepts referring to combinations of physical, mental and behavioural functioning are notoriously vague and confusing. Such concepts as “psychosomatic”, “psychogenic”, “organic”, “functional”, “somatogenic”, etc., seem often to refer to single system impairments as well as to combined system impairments. By recognizing and giving virtually equal status to the three response systems, the model presented in figure 2 seems to provide some interesting and possibly useful implications and guidelines for the diagnosis of multiple-system disorders.
It would be tempting to translate these traditional concepts into the
proposed model. However this would probably not be very useful, as was
the case when it was attempted to translate psychoanalytic terminology into
behavioural terminology, and vice versa. For instance the concept of “Behavioural
Disorder” could replace “Personality Disorder”. However, “Psychosomatic”
could equally be replaced with “Cognitive-Somatic” as with “Cognitive-Behavioural”.
Thus the proposed system offers more specificity and precision.
Treatment of Multiple-System Disorders
With the decline of metaphysical explanations of illness and the rapid advances in the medical sciences, there has been a tendency for medically based interventions to take precedence over other types of treatment. A feature of the “medical model” is that it focuses almost exclusively on the “sick” or “disordered” response system, while generally only paying lip-service to the status of the “intact” systems. In practice cognitive and behavioural models have also tended to follow this path, although perhaps to a lesser extent. The model presented in figure 2 highlights the importance of combined physiological(both medical -i.e. pharmaceutical- and non-medical), cognitive and behavioural intervention strategies especially in the treatment of multiple-system disorders. Moreover, this model implies that interventions which exclusively target impaired response systems are less likely to be effective than interventions which equally aim to maintain or strengthen relatively intact response systems.
The model also acknowledges the role of the systems(in particular the social system) within which the individual “organism” lives, and with which it has an interdependent relationship. It views social and medical “scientist-practitioners” not only as the social system’s experts at treating physiological, cognitive and behavioural illnesses within the individual, but also as having a knowledge and understanding of the reciprocal ways in which social structures and individuals can impact on each other in producing or alleviating stress. Thus their task will often include relevant advice and recommendations to the social support system, based on this knowledge and understanding.
While the eatiology of multiple system disorders is complex (it may be difficult to tease out the order in which the response systems become impaired and to what extent) the basic conceptual framework presented above is relatively straightforward, comprising just three elements: (1) an individual (organism).represented by three response systems, (2) a stressor, and (3) a (social) environment.
Equally straightforwardly intervention strategies basically aim to achieve modifications in one of more of these three elements. More specifically in this model agents of the social environment are seen as assisting an individual with bringing about modifications in his/her three response systems in order to more effectively deal with a stressor, ultimately for the benefit of the larger system of which they form a part. Again the philosophy underlying the principles by which change in each of the response systems is effected is relatively uncomplicated: ie.changes in the pgysiological response system are brought about by behavioural and medical techniques such as physical exercise, diet, relaxation, medication; changes in the cognitive response system are achieved by appeal to “rationality”; and changes in the behavioural response system are brought about by manipulation of consequences. However, since these response systems are highly interrelated, any interventions strategy must be expected to affect the system as a whole, and this is where application and monitoring of interventions can become very complex.
An integrated intervention approach based on the model summarized in figures
1 and 2 has been developed and is in need of further evaluation. The
approach is ecclectic in the sense that it uses combinations of established and
proven physiological, cognitive and behavioural methods. A similar
approach has been used successfully by Barlow et al.(1988)
for the treatment of panic. However it is here suggested that this
approach can also have beneficial applications outside the field of mental
illness, as an adjunct to other forms of intervention(eg. medical) or even as a
primary intervention strategy. It would be particularly applicable to so-called
“life-style diseases”.
Taxonomy of bio-psycho-social interventions
The interventions referred to above may be classified as follows:
|
Physiological |
Bio-feedback
training, include. relaxation training |
|
Cognitive |
Evaluation
of faulty logic(eg.Beck et al.1985) |
|
Behavioural |
Shaping,
modeling, systematic reinforcement of desired responses etc. |
|
Cognitive/Physiological |
Rational
“emotive” methods, positive self-talk combined with applied
relaxation |
|
Cognitive/Behavioural |
Behaviour
rehearsal in imagination |
|
Physiological/Behavioural |
Desensitization |
|
Physiological/Cognitive/Behavioural |
In
vivo exposure therapy combined with applied relaxation methods and rational
self-talk |
Strictly speaking of course physiological, cognitive and behavioural methods
all contain elements of each other. This would also apply to various models of
Hypnotherapy.
Dan Plooij
1996/1998