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8 April 1977, Volume 196, Number 4286

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new discipline based on behavioral sci- The~~~~~~, i..*a. New Medical MO ence. Henceforth would be re- A.ChlegefrBimd sponsible for the treatment and cure of disease, while the new discipline would * t;, 0 - ;:G orge L be concerned with the reeducation of people with ;"problems of living." Im- del: plicit in this argument is the premise that while the medical model constitutes a cjne sound framework within which to under- stand and treat disease, it is not relevant to the behavioral and psychological Engel problems classically deemed the domain of . Disorders directly ascrib- able to brain disorder would be taken care of by neurologists, while psychiatry At asference on psychiatric the is app)ropriate for their as such would disappear as a medical ed_e c sychiatrists seemed to helping functions. Medicine's crisis discipline. be d icine, "Please take us stems from the logi4cal inference that The contrasting posture of strict ad- ba WWill never again deviate since "disease" is defined in terms of so- herence to the medical model is carica- .gg-1* 'medical model.' " For, as one matic parameters, phiysicians need not tured in Ludwig's view of the psychia-

L -C ipsychiatrist put it, "Psychiatry be concerned with psychosocial issues trist as physician (1). According to Lul.i on March 13, 2014 0 m_ne a hodgepodge of unscientific which lie outside mediicine's responsibil- wig, the medical model premises "that i assorted philosophies and ity and authority. At a recent Rockefeller sufficient deviation from normal re:e- 0S00_of thought,' mixed metaphors, Foundation seminar 4on the concept of sents disease, that diseasel is; due to; AIIision, propaganda, and politick- ,. one authority urged that medi- known or unknown natural cause, aind i n ntal health' and other esoteric cine "concentrate on the 'real' diseases that elimination of these causes will e- '',). In contrast, the rest of medi- and not get lost in thejpsychosociological sult in cure or improvement in individual. d, -*ars neat and tidy. It has a firm underbrush. The physiician should not be patients" (Ludwig's italics). While ac-: 8t i the biological sciences, enor- saddled with problemIs that have arisen knowledging that most psychiatric diag ' +_ whnologic resources at its com- from the abdication ofthe theologian and noses have a lower level of confirmation www.sciencemag.org 1niMIM *nd a record of astonishing the philosopher." Ainothet participant than most medical diagnoses, he adds ent in elucidating mechanisms called for "a disentanrglement of the or- that they are not "qualitatively diffrentt and devising new treatments. ganic elements of dis Dase from the psy- provided that mental disease is assumed seem that psychiatry would do chosocial elements oif human malfunc- to arise largely from 'natural' rather tha #imulate its sister medical dis- tion," arguing that me4dicine should deal metapsycholo cal, interpersonal or so- jy finally embracing once and with the former only (2). cietal causes.'Natural" is de¢n4 as

< medical model of disease. "biological brain dysfunctions jthor Downloaded from But I do not accept such a premise. biochemical or neurophysiological inna-W Rather, I contend that all medicine is in The Two Positions ture." On the other hand, 'disQ crisis! and, further, that medicine's crisis such as problems of living, social :a` derives from the same basic fault as psy- Psychiatrists have rresponded to their ment reactions, character disdrder(s- chiatry's, namely, adherence to a model crisis by embracing twro ostensibly oppo- pendency syndromes, existenti l depres- ofdisease no longer adequate for the sci- site positions. One woiuld simply exclude sions, and various social deviancy Condi- entific tasks and social responsibilities of psychiatry from the Ifield of medicine, tions [would] be excluded from the con- either medicine or psychiatry. The im- while the other would adhere strictly to cept of mental illness since these portance of how conceptual- the "medical model" and limit psychia- disorders arise in individuals with pro ize disease derives from how such con- try's field to behavioiral disorders con- sumably intact neurophysiological fuac- cepts determine what are considered the sequent to brain dysfunction. The first is tioning and are produced primarily by proper boundaries of professional re- exemplified in the wriltings of Szasz and psychosocial variables.: Such "non- sponsibility and how they influence atti- others who advance the position that psychiatric disorders" are not properfy tudes toward and behavior with patients. "mental illness is a m,yth" since it does the concern of the physician-psychiatrisW.1 Psychiatry's crisis revolves around the not conform with the accepted concept and are more appropriately handled b question of whether the categories of hu- ofdisease (3). Supporters ofthis position nQnmedical professionals. man with it distress which is concerned advocate the removal1of the functions ._,.______are properly considered "disease" as now perfornved by psychiatry from the X currently conceptualized and w her concepul 4 professional jurisdiction attheathUniversity ofeRochesterM, exercise of the traditional authty o of edice pd their reallocation to a Rochester, New York 14642. 8 APPIL 1977 In sum, psychiatry struggles to clarify ruptive or individually upsetting the phe- of derangement of underlying physical its status within the mainstream of medi- nomenon, the more pressing the need of mechanisms. This permits only two al- cine, if indeed it belongs in medicine at humans to devise explanatory systems. ternatives whereby behavior and disease all. The criterion by which this question Such efforts at explanation constitute de- can be reconciled: the reductionist, is supposed to be resolved rests on the vices for social adaptation. Disease par which says that all behavioral phenome- degree to which the field of activity of excellence exemplifies a category of nat- na of disease must be conceptualized in psychiatry is deemed congruent with the ural phenomena urgently demanding ex- terms ofphysicochemical principles; and existing medical model of disease. But planation (5). As Fabrega has pointed the exclusioni.t, which says that what- crucial to this problem is another, that of out, "disease" in its generic sense is a ever is not cap#ble of being so explained whether the contemporary model is, in linguistic term used to refer to a certain must be excluded from the category of fact, any longer adequate for medicine, class of phenomena that members of all disease. The reductionists concede that much less for psychiatry. For if it is not, social groups, at all times in the history some disturbances in behavior belong in then perhaps the crisis of psychiatry is of man, have been exposed to. "When the spectrum of disease. They categorize part and parcel of a larger crisis that has people of various intellectual and cultur- these as mental diseases and designate its roots in the model itself. Should that al persuasions use terms analogous to psychiatry as the relevant medical dis- be the case, then it would be imprudent 'disease,' they have in mind, among oth- cipline. The exclusionists regard mental for psychiatry prematurely to abandon er things, that the phenomena in ques- illness as a myth and would eliminate its models in favor of one that may also tion involve a person-centered, harmful, psychiatry from medicine. 4mpngphy- be flawed. and undesirable deviation or discontinu- cians and psychia ath uc- ity . . . associated with impairment or tionists are the trug.bheerspthe exclu- discomfort" (5). Since the condition is sionists are the apostates, while both The Biomedical Model not desired it gives rise to a need for cor- condemn as heretics those who dare to rective actions. The latter involve beliefs question the ultimate truth of the bio- The dominant model of disease today and explanations about disease as well as medical model and advocate a Fore use- is biomedical, with molecular its rules of conduct to rationalize treatment ful model. basic scientific discipline. It assumes dis- actions. These constitute socially adapt- ease to be fully accounted for by devia- ive devices to resolve, for the individual tions from the norm of measurable bio- as well as for the society in which the Historical Origins of the Reductionistic logical (somatic) variables. It leaves no sick person lives, the crises and uncer- Biomedical Model room within its framework for the social, tainties surrounding disease (6). psychological, and behavioral dimen- Such culturally derived belief systems In considering the requirements fdr a sions of illness. The biomedical model about disease also constitute models, but more inclusive scientific medical mode1 not only requires that disease be dealt they are not scientific models. These for the study of disease, an ethnomedica,l with as an entity independent of social may be referred to as popular or folk perspective is helpful (6). In all societies; behavior, it also demands that behavior- models. As efforts at social adaptation, ancient and modern,pEr ite r. al aberrations be explained on the basis they contrast with scientific models, ate, the major criteria for identification of disordered somatic (biochemical or which are primarily designed to promote of disease have always been behavioral, neurophysiological) processes. Thus the scientific investigation. rthe historical psychological, and social in nature. Clas- biomedical model embraces both reduc- fact we have to face is that in modem sically, the onset ofdisease is marked by tionism, the philosophic view that com- Western society biomedicine not only changes in physical appearance that plex phenomena are ultimately derived has provided a basis for the scientific frighten, puzzle, or awe, and by alter4- from a single primary principle, and study of disease, it has also become our tions in functioning, in feelings, in per.! T1nd:b94_dua1is m the doctrine that own culturally specific perspective about formance, in behavior, or in relation- separates the mental from the somatic. disease, that is, our folk modeflIndeed ships that are experienced or perceived Here the reductionistic primary principle the biomedical model is now the domi- as threatening, harmful, unpleasant, is physicalistic; that is, it assumes that nant folk model ofdisease in the Western deviant, undesirable, or unwanted. Re- the language of chemistry and physics world (5, 6). ported verbally or demonstrated by the will ultimately suffice to explain bio- In our culture the attitudes and belief sufferer or by a witness, these constitute logical phenomena. From the reduction- systems of physicians are molded by this the primary data upon which are based ist viewpoint, the only conceptual tools model long before they embark on their first-orfrr judgments as to whether or available to characterize and experimen- professional education, which in turn re- not a person is sick (7). To such disturb- tal tools to study biological systems are inforces it without necessarily clarifying ing behavior and reports all societies typ-, physical in nature (4). how its use for social adaptation con- ically respond by-designating individuals The biomedical model was devised by trasts with its use for scientific research. and evolving social institutions whose medical scientists for the study of dis- The biomedical model has thus become a primary function is to evaluate, inter- ease. As such it was a scientific model; cultural imperative, its limitations easily pret, and provide corrective measures that is, it involved a shared set of as- overlooked. In brief, it has now acquired (5, 6). Medicine as an institution and as a sumptions and rules of conduct based on the status ofdosma. In science, a model discipline, and physicians as profession- the scientific method and constituted a is revised or abandoned when it fails to als, evolved as one form of response to blueprint for research. Not all models account adequately for all the data. A such social needs. In the course of his- are scientific. Indeed, broadly defined, a dogma, on the other hand, requires that tory, medicine became scientific as phy- model is nothing more than a belief sys- discrepant data be forced to fit the model sicians and other scientists developed a tem utilized to explain natural phenome- or be excluded. Biomedical dogma re- taxonomy and applied scientific methods na, to make sense out of what is puzzling quires that all disease, including "men- to the understanding, treatment, and pre- or disturbing. The more socially dis- tal" disease, be conceptualized in terms vention of disturbances which the public 130 SCIENCE, VOL. 196 first had designated as "disease" or Limitations ofthe Biomedical Model clear that he does not regard the genetic "sickness." factors and biological processes in schiz- Why did the reductionistic, dualistic We are now faced with the necessity ophrenia as are now known to exist (or biomedical model evolve in the West? and the challenge to broaden the ap- may be discovered in the future) as the Rasmussen identifies one source in the proach to disease to include the psycho- only important influences in its etiology. concession of established Christian or- social without sacrificing the enormous He insists that equally important is eluci- thodoxy to permit dissection of the hu- advantages of the biomedical approach. dation of "how experiential factors7and man body some five centuries ago (8). On the importance of the latter all agree, their interactions with biological vulner- Such a concession was in keeping with the reductionist, the exclusionist, and ability make possible or prevent the the Christian view of the body as a weak the heretic. In a recent critique of the ex- development of schizophrenia." But and imperfect vessel for the transfer of clusionist position, Kety put the contrast whether such a caveat will suffice to the soul from this world to the next.No between the two in such a way as to help counteract basic reductionism is far from surprisingly, the Church's permission to define the issues (9). "According to the certain. study the human body included a tacit in- medical model, a human illness does not terdiction against corresponding scientif- become a specific disease all at once and ic investigation of man's mind and be- is not equivalent to it. The medical mod- The Requirements of a New Medical havior. For in the eyes of the Church el of an illness is a process that moves Model these had more to do with religion and from the recognition and palliation of the soul and hence properly remained its symptoms to the characterization of a To explore the requirements of a medi- domain. This compact may be consid- specific disease in which the etiology and cal model that would account for the ered largely responsible for the anatomi- pathogenesis are known and treatment is reality of diabetes and schizophrenia as cal and structural base upon which scien- rational and specific." Thqs taxonomy human experiences as well as disease ab- tific Western medicine eventually was to progresses from symptoms, to clusters stractions, let us expand Kety's analogy be builQtFor at the same time, the basic of symptoms, to syndromes, and finally by making the assumption that a speci- principle of the science of the day, as to diseases with specific pathogenesis fic biochemical abnormality capable of enunciated by Galileo, Newton, and an4yatholqgy. This sequence accurately being influenced pharmacologically ex- Descartes, was analytical, meaning that describes the successful application of ists in schizophrenia as well as in diabe- entities to be investigated be resolved in- the scientific method to the elucidation tes, certainly a plausible possibility. By to isolable causal chains or units, from and the classification into discrete en- obliging ourselves to think of pa-tients which it was assumed that the whole tities of disease in its generic sense (5, 6). with diabetes, a "somatic disease," and could be understood, both materially and The merit of such an approach needs no with schizophrenia, a "mental disease," conceptually, by reconstituting the argument. What do require scrutiny are in exactly the same terms, we will see parts. With mind-body dualism firmly es- the distortions introduced by the reduc- more clearly how inclusion of somatic tablished under the imprimatur of the tionistic tendency to re&ard t'hespecific and psychosocial factors is indispensable Church, classical science readily fos- disease as adequately, if not best, char- for both; or more pointedly, how con- tered the notion of the body as a ma- acterized in terms of the smallest isolable centration on the biomedical and exclu- chine, of disease as the conseqeiie of component having causal implications, sion of the psychosocial distorts per- breakdown of the machine, and of'the for example, the biochemical; or even spectives and even interferes with doctor's task as repair of the machine. more critical, is the contention that the patient care. Thus, the scientific approach to disease designation "disease'' does not apply in 1) In the biomedical model, demon- began by focusing in a fractional-analytic the absence of perturbations at the bio- stration of the specific biochemical de- way on biological (somatic) processes chemical level. viation is generally regarded as a specific and ignoring the behavioral and psycho- Kety approacnes this problem by com- diagnostic criterion for the disease. Yet social. Jis was so,even though in prac- paring diabetes mellitus and schizophre- in terms of the human experience of ill- tice many physicians, at least until the nia as paradigms of somatic and mental ness, laboratory documentation may on- beginning of the 20th century, regarded diseases, pointing out the appropriate- ly indicate disease potential, not the ac- emotions as important for the devel- ness of the medical model for both. tuality of the disease at the time. The ab- opment and course of disease] Actually, "Both are symptom clusters or syn- normality may be present, yet the patient such arbitrary exclusion is an acceptable dromes, one described by somatic and not be ill. h D°a e- strategy in scientific research, especially biochemical abnormalities, the other by chemical defect of diabetes or schizQ- when concepts and methods appropriate psychological. Each may have many eti- phrenia at best defines a necessayj2ut for the excluded areas are not yet avail- ologies and shows a range of intensity not a sufficient conditiQDn for eocbr-ccur- able. But it becomes counterproductive from severe and debilitating to latent or rence ofthe human experience ofthe 4js- when such strategy becomes policy and borderline. There is also evidence that ease,-,the illness. More accurately, the the area originally put aside for practical genetic and environmental influences op- biochemical defect constitutes but one reasons is permanently excluded, if not erate in the development of both." In faictor among many, the complex inter- ,rgotten altogether. The greater the suc- this description, at least in reductionistic action of which ultimately may culmi- cess of the narrow approach the more terms, the scientific characterization of nate in active disease or manifestillnctss likely is this to happen. The biomedical .diabetes is the more advanced in that it (10). Nor can the biochemical defect be approach to disease has been successful has progressed from the behavioral made to account for all of the illness, for beyond all expectations, but at a cost. framework of symptoms to that of bio- full understanding requires additi9nal For in serving as guideline and justifica- chemical abnormalities. Ultimately, the concepts and frames of reference. Thus, tion for medical care policy, biomedicine reductionists assume schizophrenia will while the diagnosis of diabetes i first has also contributed to a host of prob- achieve a similar degree of resolution. In sutggested by certain core clinicalimani lems, which I shall consider later. developing his positidn, Kety makes festations, for example, polyurim.,polye 8 APRIL 1977 'I33l dipsia, polyphagia, and weight loss, and perience. The biomedical model ignores apeutic outcome for better or for worg5J is then confirmed by laboratory docu- both the rigor required to achieve reliabi- These constitute psychological effects mentation of relative insulin deficiency, lity in the interview process and the ne- which may directly modify the illness ex- how these are experienced and how they cessity to analyze the meaning of the perience or indirectly affect underlying are reported by any one individual, and patient's report in psychological, social, biochemical processes, the latter by vir- how they affect him, all require cop- and cultural as well as in anatomical, tue of interactions between psycho- sideration of psy cqlQgical, social, and physiological, or biochemical terms (7). physiological reactions and biochemical cultural factors, not tQ mention other 3)Niabetes and schizophrenia have in processes implicated in the disease (11). concurrent or complicating biological common the fact that conditions of life Thus, insulin requirements of a diabetic factors. Variability in the clinical expres- and living constitute significant variables patient may fluctuate significantly de- sion of diabetes as well as of schizo- influencing the time of reported onset of pending on how the patient perceives his phrenia, and in the individual experi- the manifest disease as well as of varia- relationship with his doctor. Further- ence and expression of these illnesses, tions in its course3. In both conditions more, the successful application of ratio- reflects as much these other elements this results from the fact that psycho- nal is limited by the physician's as it does quantitative variations in the physiologic responses to life change may ability to influence and modify the specific biochemical defect. interact with existing somatic factors to patient's behavior in directions con- 2) Establishing a relationship between alter susceptibility and thereby influence cordant with health needs. Contrary to particular biochemical processes and the the time of onset, the severity, and the what the exclusionists would have us be- clinical data of illness requires a scientif- course of a disease.jxperimental stud- lieve, the physician's role is, and always ically rational approach to behavioral ies in animals amply document the role has been, very much that of educator and psychosocial data, for these are the of early, previous, and current life expe- and psychotherapist. To know how to in- terms in which most clinical phenomena rience in altering susceptibility to a wide duce peace of mind in the patient and en- are reported by patients. Without such, variety of diseases even in the esence hance his faith in the healing powers of the reliability ofobservations and the va- of a genetic predisposition3j(1).assel's his physician requires psychological lidity of correlations will be flawed. It demonstration ofhigher rates of ill health knowledge and skills, not merely charis- serves little to be able to specify a bio- among populations exposed to in- ma. These too are outside the biomedical chemical defect in schizophrenia if one congruity between the demands of the framework. does not know how to relate this to par- social system in which they are living ticular psychological and behavioral ex- and working and the culture they bring pressions of the disorder. The biomedi- with them provides another illustration The Advantages ofa Biopsychosocial cal model gives insufficient heed to this among humans of the role of psych- Model requirement. Instead it encourages by- socil variables in disease causation (12 passing the patient's verbal account by 4)cPsychological and social factors a e This list surely is not complete but it placing greater reliance on technical pro- also crucial in determining whether and should suffice to document that diabetes cedures and laboratory measurements. when patients with the biochemical ab- mellitus and schizophrenia as paradigms In actuality the task is appreciably more normality ofdiabetes or of schizophrenia of "somatic" and "mental" disorders complex than the biomedical model en- come to view themselves or be viewed are entirely analogous and, as Kety ar- courages one to believe. An examination by others as sic7k Still other factors of a gues, are appropriately conceptualized of the correlations between- cicaland similar nature influence whether or not within the framework of a medical model laboratory data requires not only reliable and when any individual enters a health of disease. But the existing biomedical methods of clinical data collection, spe- care system and becomes a patient. model does not suffice. To provide a cifically high-level interviewing- skills, Thus, the biochemical defect may deter- basis for understanding the determinants but also basic understanding of the psy- mine certain characteristics of the dis- of disease and arriving at rational treat- chological, social,.and cultural determi- ease, but not necessarily the point in ments and patterns of , a med- nants of how patients communicate time when the person falls ill or accepts ical model must also take into account symptoms of disease. For example, the sick role or the status of a patient. the patient, the social context in which many verbal expressions derive from 5) "Rational treatment" (Kety's he lives, and the complementary system bodily experiences early in life, resulting term)girected only at the biochemical devised by society to deal with the dis- in a significant degree of ambiguity in the abnormality does not necessarily restore ruptive effects of illness, that is, the phy- language patients use to report symp- the patient to healtieven in the face of sician role and the health care system. toms. Hence the same words may serve documented correction or major allevia- This requires a biopsychosocial model. to express primary psychological as well tion of the abnormality. This is no less Its scope is determined by the historic. as bodily disturbances, both of which true for diabetes than it will be for schiz- function of the physician to establish may coexist and overlap in complex ophrenia when a biochemical defect is whether the person soliciting help is ways. Thus, virtually each of the symp- established.'i5ther factors may combine "sick" or "well"; and if sick, why sick toms classically associated with diabetes to sustain patienthood even in the face of and in which ways sick; and then to de, may also be expressions of or reactions biochemical recoveryj Conspicuously velop a rational program to treat the jlI 4 to psychological distress, just as keto- responsible for such discrepancies be- ness and restore and maintain health. acidosis and hypoglycemia may induce tween correction of biological abnormal- the boundaries between health and psychiatric manifestations, including ities and treatment outcome are pscho- disease, between well and sick, are far some considered characteristic of schiz- logical and social variables. from clear and never will be clear, for ophrenia. The most essential skills of the 6)[ven with the application of ratio- they are diffused by cultural, social, and physician involve the ability to elicit ac- nal therapies, the behavior of the physi- psychological considerations) The tradi- curately and then analyze correctly the cian and the relationship between patient tional biomedical view, that biological .- patient's verbal account of his illness ex- and physician powerfully influence ther- indices are the ultimate criteria defining 132 SCIENCE, VOL. 196 disease, leads to the present paradox dressed this question in a paper entitled had acquired certain technical skills in thatCsome people with positive laborato-. "Is griefa disease? A challenge for medi- such matters. developed out of ry findings are told that they are in need cal research" (13). Its aim too was to the need for treatment of wounds and in- oftreatment when in fact they are feeling raise questions about the adequacy of juries and has different historical roots quite well, while others feeling sick are the biomedical model. A better title than medicine, which was always closer assured that they are well, that is, they mighst have been, "When is grief a dis- in origin to magic and religion. Only later have no "disease'5, 6). A biopsycho- ,ease?2 wst as one might ask when in Western history did surgery and medi- social model which includes the patient schizophrenia or when diabetes is adis- cine merge as healing arts. But even as well as the illness would encompass ease. For while there are some obvious from earliest times there were people both circumstances. The doctor's task is analogies between grief and disease, who behaved as though grief-stricken, to account for the dysphoria and the dys- there are also some important dif- yet seemed not to have suffered any loss; function which lead individuals to seek ferences. But these very contradictions and others who developed what for all medical help, adopt the sick role, and ac- help to clarify the psychosocial dimen- the world looked like wounds or frac- cept the status of patienthood. He must sions of the biopsychosocial model. tures, yet had not been subjected to any weight the relative contributions of so- Grief clearly exemplifies a situation in known trauma. And there were people cial and psychological as well as of bio- which psychological factors are primary; who suffered losses whose grief deviated logical fictors implicated in the patient's no preexisting chemical or physiological in one way or another from what the cul- dysphoria and dysfunction as well as in defects or agents need be invoked. Yet ture had come to accept as the normal his decision to accept or not accept pa- as with classic diseases, ordinary grief course; and others whose wounds failed tienthood and with it the responsibility to constitutes a discrete syndrome with a to heal or festered or who became ill cooperate in his own health care. relatively predictable symptomatology even though the wound had apparently .y evaluating all the factors contrib- which includes, incidentally, both bodily healed. Then, as now, two elements uting to both illness and patienthood, and psychological disturbances. It dis- were crucial in defining the role of rather than giving primacy to biological plays the autonomy typical of disease; patient and physician and hence in deter- factors alone, a biopsychosocial model that is, it runs its course despite the suf- what should be regarded as dis- would make it possible to explain why ferer's efforts or wish to bring it to a ease. For the patient it has been his not some individuals experience as "illness" close. A consistent etiologic factor can knowing why he felt or functioned badly conditions which others regard merely as be identified, namely, a significant loss. or what to do about it, coupled with the "problems of living," be they emotional On the other hand, neither the sufferer belief or knowledge that the healer or reactions to life circumstances or somat- nor society has ever dealt with ordinary physician did know and could provide ic symptomsPFor from the individual's grief as an illness even though such ex- relief. For the physician in turn it has point of view his decision between pressions as "sick with grief" would in- been his commitment to his professional whether he has a "problem of living" or dicate some connection in people's role as healer, From these have evolved is "sick" has basically to do with wheth- minds. And while every culture makes sets ofexpectations which are reinforced er or not, he accepts the sick role and provisions for the mourner, these have by the culture, though these are not nec- seeks entry into the health care system, generally been regarded more as the re- essarily the same for patient as for physi- not with what, in fact, is responsible for sponsibility ofreligion than ofmedicine. cian. his distress. Indeed, some people deny On the face of it, the arguments A biopsychosocial model would take the unwelcome reality of illness by dis- against including griefin a medical model all of these factors into account. It woul missing as "a problem of living" symp- would seem to be the more persuasive. acknowledge the fundamental fact that toms which may in actuality be in- In the 1961 paper I countered these by the patient comes to the physician be- dicative of a serious organic process.)t comparing grief to a wound. Both are cause either he does not know- vwhat is is the doctor's, not the patient's, respon- natural responses to environmental wrong or, if he does, he feels incapable sibility to establish the nature of the trauma, one psychological, the other of helping himself. The psychobiological problem and to decide whether or not't physical. But even at the time I felt a unity of man requires that the phydician is best handled in a medical frameworkJ vague uneasiness that this analogy did accept the responsibility to evluate Clearly the dichotomy between "dis- not quite make the case. Now 15 years whatever problems the patient presents ease" and "problems of living" is by no later a better grasp of the cultural origins and recommend a course of action, in- means a sharp one, either for patient or of disease concepts and medical care cluding referral to other helping profes- for doctor. systems clarifies the apparent inconsis- sions. Hence the physician's basic pro- tency. The critical factor underlying fessional knowledge and skills miust span man's need to develop folk models of the social, psychological, and biological, When Is Griefa Disease? disease, and to develop social adapta- for his decisions and actions on the tions to deal with the individual and patient's behalf involve all three. Is the To enhance our understanding of how group disruptions brought about by dis- patient suffering normal grief or melan- it is that "problems ofliving" are experi- ease, has always been the victim's igno- cholia? Are the fatigue and weakness of enced as illness by some and not by oth- rance of what is responsible for his dys- the woman who recently lost her hus- ers, it might be helpful to consider grief phoric or disturbing experiencJ(5, 6). band conversion symptoms, psycho- as a paradigm of such a borderline condi- Neither grief nor a wound fits fully into physiological reactions, manifestations tion. For while grief has never been con- th'at category. In both, the reasons for of a somatic disorder, or a combintios. sidered in a medical framework, a signifi- the pain, suffering, and disability are on- of these? The patient soliciting th*ai 't" cant number of grieving people do con- ly too clear. Wounds or fractures in- a physician must have co sult doctors because of disturbing symp- curred in battle or by accident by and the M.D. degree has IinI" toms, which they do nottnecessarily large were self-treated or ministered to that physician com tio l relate to grief. Fifteen years ago I ad- with folk remedies or by individuals who differentiations. I APRIL 1977 A Challenge for Both Medicine and How ironic it would be were psychiatry organic medicine [has been] exaggerat- Psychiatry to insist on subscribing to a medical ed" and "psychosomatic medicine is on model which some leaders in medicine the way out" can only be ascribed to the The development of a biopsychosocial already are beginning to question. blinding effects of dogmatism. medical model is posed as a challenge for Psychiatrists, unconsciously commit- The fact is that medical schools have both medicine and psychiatry. For de- ted to the biomedical model and split constituted unreceptive if not hostile en- spite the enormous gains which have ac- into the warring camps of reductionists vironments for those interested in psy- crued from biomedical research, there is and exclusionists, are today so pre- chosomatic research and teaching, and a growing uneasiness among the public occupied with their own professional medical journals have all too often fol- as well as among physicians, and espe- identity and status in relation to medi- lowed a double standard in accepting pa- cially among the younger generation, cine that many are failing to appreciate pers dealing with psychosomatic rela- that health needs are not being met and that psychiatry now is the only clinical tionships (17). Further, much of the that biomedical research is not having a discipline within medicine concerned work documenting experimentally in ani- sufficient impact in human terms. This is primarily with the study of man and the mals the significance of life circum- usually ascribed to the all too obvious in- human condition. While the behavioral stances or change in altering susceptibili- adequacies of existing health care deliv- sciences have made some limited in- ty to disease has been done by experi- ery systems. But this certainly is not a cursions into teaching mental psychologists and appears in complete explanation, for many who do programs, it is mainly upon psychia- psychology journals rarely read by have adequate access to health care also trists, and to a lesser extent clinical psy- physicians or basic biomedical scientists complain that physicians are lacking in chologists, that the responsibility falls to (11). interest and understanding, are pre- develop approaches to the understanding occupied with procedures, and are in- ofhealth and disease and patient care not sensitive to the personal problems of readily accomplished within the more General Systems Theory Pe'ypective patients and their families. Medical insti- narrow framework and with the special- tutions are seen as cold and impersonal; ized techniques of traditional biomedi- The struggle to reconcile the psycho- the more prestigious they are as centers cine. Indeed, the fact is that the major social and the biological in medicine has for biomedical research, the more com- formulations of more integrated and ho- had its parallel in biology, also domi- mon such complaints (14). Medicine's listic concepts of health and disease pro- nated by the reductionistic approach of unrest derives from a growing awareness posed in the past 30 years have come not . Among biologists too among many physicians of the con- from within the biomedical establish- have emerged advocates of the need to tradiction between the excellence of ment but from physicians who have develop holistic as well as reductionistic their biomedical background on the one drawn upon concepts and methods explanations of life processes, to answer hand and the weakness of their qualifica- which originated within psychiatry, no- the "why?" and the "what for?" as well tions in certain attributes essential for tably the psychodynamic approach of as the "how?" (18, 19)ion Bertalanffy, good patient care on the other (7). Many Sigmund Freud and psychoanalysis and arguing the need for a more fundamental recognize that these cannot be improved the reaction-to-life-stress approach of reorientation in scientific perspectives in by working within the biomedical model Adolf Meyer and psychobiology (16). order to open the way to holistic ap- alone. Actually, one of the more lasting contri- proaches more amenable to scientific in- The present upsurge of interest in pri- butions of both Freud and Meyer has quiry and conceptualization, developed mary care and clearly been to provide frames of reference general systems theory (20 his ap- reflects disenchantment among some whereby psychological processes could proach, by treating sets of related events physicians with an approach to disease be included in a concept of disease. Psy- collectively as systems manifesting func- that neglects the patient. They are now chosomatic medicine-the term itself a tions and properties on the specific level more ready for a medical model which vestige of dualism-became the medium of the whole, has made possible recogni- would take psychosocial issues into ac- whereby the gap between the two paral- tion of isomorphies across different lev- count. Even from within academic cir- lel but independent ideologies of medi- els of organization, as molecules, cells, cles are coming some sharp challenges to cine, the biological and the psychosocial, organs, the organism, the person, the biomedical dogmatism (8, 15). Thus Hol- was to be bridged. Its progress has been family, the society, or the biosphefr7 * man ascribes directly to biomedical re- slow and halting, not only because of the trom such isomorphies can be devel- ductionism and to the professional domi- extreme complexities intrinsic, to the oped fundamental laws and principles nance of its adherents over the health field itself, but also because of unremit- that operate commonly at all levels ofor- care system such undesirable practices ting pressures, from within as well as ganization, as compared to those which as unnecessary hospitalization, overuse from without, to conform to scientific are unique for eac7 Since systems theo- of drugs, excessive surgery, and in- methodologies basically mechanistic and ry holds that all levels oforganization are appropriate utilization of diagnostic reductionistic in conception and in- linked to each other in a hierarchical tests. He writes, "While reductionism is appropriate for many ofthe problems un- relationship so that change in one affects a powerful tool for understanding, it also der study. Nonetheless, by now a sizable change in the others, its adoption as a creates profound misunderstanding body of knowledge, based on clinical and scientific approach should do much to when unwisely applied. Reductionism is experimental studies of man and animals mitigate the holist-reductionist dichoto- particularly harmful when it neglects the has accumulated. Most, however, re- my and improve communication across impact of nonbiological circumstances mains unknown to the general medical scientific disciplines. For medicine, sys- -,upon biologic processes." And, "Some public and to the biomedical community tenis theory provides a conceptual ap- +Oiedic omes are inadequate not be- and is largely ignored in the education of proach suitable not only for the proposed s- appropriate technical inter- physicians. The recent solemn pro- biopsychosocial concept of disease but ons are lacking but because our nouncement by an eminent biomedical also for studying disease and medical Weptual thinking is inadequate" (15). leader (2) that ''the emotional content of care as interrelated processes(00, 21). If 1434 SCIEN%1C, VOL...196 and when a general-systems approach being recognized as reflecting a genuine sources. It would appear that given the becomes part of the basic scientific and discrepancy between illness as actually opportunity, the younger generation is philosophic education of future physi- experienced by the patient and as it is very ready to accept the importance of cians and medical scientists, a greater conceptualized in the biomedical mode learning more about the psychosocial di- readiness to encompass a biopsychoso- (26). The professionalization of biomedi- mensions of illness and health care and cial perspective ofdisease may be antici- cine constitutes still another formidable the need for such education to be pated. barrier (8, 15). Professionalization has soundly based on scientific principles. engendered a caste system among health Once exposed to such an approach, most care personnel and a peck order con- recognize how ephemeral and in- Biomedicine as Science and as Dogma cerning what constitute appropriate substantial are appeals to humanism and areas for medical concern and care, with compassion when not based on rational In the meantime, what is being and can the most esoteric disorders at the top of principles. They reject as simplistic the be done to neutralize the dogmatism of &Ihe list. Erofessional dominance "has notion that in past generations doctors biomedicine and all the undesirable so- tperpetuated prevailing practices, deflect- understood their patients better, a myth cial and scientific consequences that ,ed criticisms, and insulated the profes- that has persisted for centuries (30). flow therefrom? How can a proper bal- &sion from alternate views and social rela- Clearly, the gap to be closed is between ance be established between the frac- tions that would illuminate and improve teachers ready to teach and students ea- tional-analytic and the natural history health care'jlS, p. 21). Holman argues, ger to learn. But nothing will change un- approaches, both so integral for the work not unconvincingly, that "the Medical less or until those who control resources of the physician and the medical scientist establishment is not primarily engaged in have the wisdom to venture offthe beat- (22)? How can the clinician be helped to the disinterested pursuit of knowledge en path of exclusive reliance on biomedi- understand the extent to which his scien- and the translation of that knowledge in- cine as the only approach to health care. tific approach to patients represents a to medical practice; rather in significant The proposed biopsychosocial model distinctly "human science," one in part it is engaged in special interest advo- provides a blueprint for research, a which "reliance is on the integrative cacy, pursuing and preserving social framework for teaching, and a design for powers of the observer of a complex power" (15, p. 11). action in the real world of health care. nonreplicable event and on the experi- Under such conditions it is difficult to Whether it is useful or not remains to be ments that are provided by history and see how reforms can be brought about. seen. But the answer will not be forth- by animals living in particular ecological Certainly contributing another critical coming if conditions are not provided to settings," as Margaret Mead puts it (23)? essay is hardly likely to bring about any do so. In a free society, outcome will de- The history of the rise and fall of scientif- major changes in attitude. The problem pend upon those who have the courage ic dogmas throughout history may give is hardly new, for the first efforts to in- to try new paths and the wisdom to pro- some clues. Certainly mere emergence troduce a more holistic approach into the vide the necessary support. of new findings and theories rarely suf- undergraduate medical curriculum ac- fices to overthrow well-entrenched dog- tually date back to Adolph Meyer's pro- mas. The power of vested interests, so- gram at Johns Hopkins which was ini- Summary cial, political, and economic, are formi- tiated before 1920 (27). At Rochester, a dable deterrents to any effective assault program directed to medical students The dominant model of disease today on biomedical dogmatism. The delivery and to physicians during and after their is biomedical, and it leaves no room of health care is a major industry, con- residency training, and designed to in- within its framework for the social, psy- sidering that more than 8 percent of our culcate psychosocial knowledge and chological, and behavioral dimensions of national economic product is devoted to skills appropriate for their future work as illness. A biopsychosocial model is pro- health (2). The enormous existing and clinicians or teachers, has been in exis- posed that provides a blueprint for re- planned investment in diagnostic and tence for 30 years (28). While difficult to search, a framework for teaching, and a therapeutic technology alone strongly fa- measure outcome objectively, its im- design for action in the real world of vors approaches to clinical study and pact, as indicated by a questionnaire on health care. care of patients that emphasize the im- hoW. students and graduates view the is- personal and the mechanical (24). For sues involved in illness and patient care, References and Notes example,-from 1967 to 1972 there was an appears to have been appreciable (29). In 1. A. M. Ludwig, J. Am. Med. Assoc. 234, 603 (1975). increase of 33 percent in the number of other schools, especially in the immedi- 2. RFIllustrated, 3, 5 (1976). 3. T. S. Szasz, The Myth ofMental Illness (Harper laboratory tests conducted per hospital ate post-World War II period, similar ef- & Row, New York, 1961); E. F. Torrey, The adnmission (25). Planning for systems of forts were launched, and while some Death of Psychiatry (Chilton, Radnor, Pa., 1974). medical care and their financing is exces- flourished briefly, most soon faded away 4. R. Rosen, in The Relevance ofGeneral Systems sively influenced by the availability and under the competition of more glam- Theory, E. Laszlo, Ed. (Braziller, New York, 1972), p. 45. promise of technology, the application orous and acceptable biomedical ca- 5. H. Fabrega, Arch. Gen Psychiatry 32, 1501 and effectiveness of which are often used reers. Today, within many medical (1972). 6. , Science, 189, 969 (1975). as the criteria by which decisions are schools there is again a revival of interest 7. G. L. Engel, Ann. Intern. Med. 78, 587 (1973). 8. H. Rasmussen, Pharos 38, 53 (1975). made as to what constitutes illness and among some faculty, but they are few in 9. S. Kety, Am. J. Psychiatry 131, 957 (1974). who qualifies for medical care. The frus- number and lack the influence, prestige, 10. G. L. Engel, Perspect. Biol. Med. 3,459 (1960). 11. R. Ader, in Ethology and Development, S. A. tration of those who find what they be- power, and access to funding from peer Barnett, Ed. (Heinemann, London, 1973), p. 37; lieve to be their legitimate health needs review groups that goes with conformity G. L. Engel, 67, 1085 (1974). 12. J. Cassel, Am. J. 54, 1482 (1964). inadequately met by too technologically to the prevailing biomedical structure. . G. L. Engel, Psychosom. Med. 23, 18 (1961). is misinter- Yet today, interest among students 14. R. S. Duffand A. B. Holiingshead, Sickness and oriented physicians generally Society (Harper & Row, New York, 1968). preted by the biomedical establishment and young physicians is high, and where 15. H. R. Holman, Hosp. Pract. 11, 11 (1976). 16. K. Menninger,Ann. Intern. Med. 29,318(1948); as indicating "unrealistic expectations" learning opportunities exist they quickly J. Romano, J. Am. Med. Assoc. 143, 409 (1950); on the part of the public rather than overwhelm the available meager re- G. L. Engel, Midcentury Psychiatry, R. Grin- 8 APRIL 1977 135 ker, Ed. (Thomas, Springfield, Ill., 1953), p. 33; ziller, New York, 1972); The Systems View of 77 (1967); L. Young, Ann. Intern. Med. 83, 728 H. G. Wolff, Ed., An Outline ofMan's Knowl- the World (Brazilier, New York, 1972); Dubos (1975). edge (Doubleday, New York, 1960), p. 41; G. L. (19). 29. G. L. Engel,J. Nerv. Ment. Dis. 154, 159 (1972); Engel, Psychological Development in Health 21. K. Menninger, The Vital Balance (Viking, New Univ. Rochester Med. Rev. (winter 1971-1972), and Disease (Saunders, Philadelphia, 1962). York, 1963); A. Sheldon, in Systems and Medi- p. 10. 17. G. L. Engel and L. Salzman, N. Engl. J. Med. cal Care, A. Sheldon, F. Baker, C. P. McLaugh- 30. , Pharos 39, 127 (1976). 288, 44 (1973). lin, Eds. (MIT Press, Cambridge, Mass., 1970), 31. This article was adapted from material present- 18. R. Dubos, Mirage of Health (Harper & Row, p. 84; H. Brody, Perspect. Biol. Med. 16, 71 ed as the Loren Stephens Memorial Lecture, New York, 1959); Reason Awake (Columbia (1973). University of Southern California Medical Cen- Univ. Press, New York, 1970); E. Mayr, in Be- 22. G. L. Engel, in , Emotion, and Psy- ter, 1976; the Griffith McKerracher Memorial havior and Evolution, A. Roe and G. G. Simp- chosomatic Illness, R. Porter and J. Knight, Lecture at the University of Saskatchewan, son, Eds. (Yale Univ. Press, New Haven, Eds. (Elsevier-Excerpta Medica, Amsterdam, 1976; the Annual Hutchings Society Lecture, Conn., 1958), p. 341; Science 134, 1501 (1961); 1972), p. 384. State University of New York-Upstate Medical Am. Sci. 62, 650 (1974); J. T. Bonner, On Devel- 23. M. Mead, Science 191, 903 (1976). Center, Syracuse, 1976. Also presented during opment. The Biology of Form (Harvard Univ. 24. G. L. Engel, J. Am. Med. Assoc. 236, 861 1975 to 1976 at the University of Maryland Press, Cambridge, Mass., 1974); G. G. Simpson, (1976). School of Medicine, University of California- Science 139, 81(1963). 25. J. M. McGinnis, J. Med. Educ. 51, 602 (1976). San Diego School of Medicine, University of 19. R. Dubos, Man Adapting (Yale Univ. Press, 26. H. Fabrega and P. R. Manning, Psychosom. California-Los Angeles School of Medicine, New Haven, Conn., 1965). Med. 3S, 223 (1973). Massachusetts Mental Health Center, and the 20. L. von Bertalanffy, Problems of Life (Wiley, 27. A. Meyer, J. Am. Med. Assoc. 69, 861 (1917). 21st annual meeting of Midwest Professors of New York, 1952); General Systems Theory 28. A. H. Schmale, W. A. Greene, F. Reichsman, Psychiatry, Philadelphia. The author is a career (Braziller, New York, 1968). See also E. Laszlo, M. Kehoe, G. L. Engel, Adv. Psychosom. Med. research awardee in the U.S. Public Health The Relevance ofGeneral Systems Theory (Bra- 4, 4 (1964); G. L. Engel,J. Psychosom. Res. 11, Service.

tate is located in the iron matrix is ofgreat importance in terms of what effect it can have on the properties of the steel. Even very small quantities of a precipitate lo- cated at a grain boundary can induce Second Phases in Steel cracking or corrosion, whereas a larger amount of the same material located ran- domly throughout the steel will not have New analytical methods can identify the types and the same effect. Small particles ofcarbide amounts ofcomplex precipitates in steel. or nitride arranged in rows will form a barrier to slip and dislocation movement in the crystals of the iron matrix and are W.R.Bandi therefore much more effective in confer- ring strength than randomly arranged par- ticles. The particle size of the precipitated For many years better analytical meth- Ni3Ti, but most often the second phases phase is also important. As an example, ods for the determination of second are oxides, nitrides, carbides, sulfides, the strength ofa steel is changed more by phases in steel have been needed, be- carbonitrides, carbosulfides, and similar particles ofcarbide and nitride that are 30 cause these phases are often more closely compounds. These compounds may be to 400 angstroms in size than by larger related to the heat treatment and mechan- formed in the molten bath, during solidi- particles because these smaller particles ical properties of the steel than the ele- fication, during rolling or forming, during are much more effective in preventing mental composition. I discuss here some heat treatment, and sometimes even dur- grain growth, and fine-grained steels are of the recent approaches to solving this ing storage at ambient temperature. stronger. Frequently very large particles problem. Table 1 shows how precipitates can af- ofcarbide or nitride are detrimental to the Ever since steel was first manufac- fect some of the mechanical and physical steel, whereas small particles ofthe same tured, metallurgists have been searching properties of steel. Only a portion of the compound can be beneficial. for methods of changing its mechanical approximately 200 precipitates found in The magnitude of the analytical chem- properties so that specific grades can be low-alloy, high-alloy, and specialty steels ical problem can be appreciated when one made for particular applications. Often and some of the important mechanical realizes that more than 50 nitrogen com- such changes are brought about by the properties are listed. Often metallurgists pounds can be present in simple and com- addition ofone or more alloying elements can associate precipitates with additional plex steels. These include simple nitrides to the steel, and at least 35 elements have changes in the mechanical, physical, and such as titanium nitride (TiN) or more been added for this purpose. Most of chemical properties of steel. No attempt complex nitrides such as niobium carbo- these elements can be present in solid so- has been made in Table 1 to note whether nitride (NbCrNV), manganese silicon ni- lution in iron, but they often change the a particular precipitate has a detrimental tride [(MnSi)N2], and aluminum oxyni- mechanical properties of the steel by or beneficial effect on the mechanical tride (AlO.N.). A like number ofcarbides combining with oxygen, nitrogen, car- properties of steel because in many in- and oxides and a smaller number of sul- bon, or sulfur to form precipitates in the stances the effect can be either positive or fides and carbosulfides may also be found steel that are referred to as second-phase negative depending on the amount, size, in steels. There are thus several hundred compounds. Sometimes the second and distribution of the precipitate. Pre- compounds that can exist in the carbon, phase will contain two metals such as cipitate concentration can vary from as alloy, and specialty steels presently being nickel and titanium combining to form much as 10 percent (by weight) (cement- produced in the United States. As a re- ite, Fe3C) to as little as 0.002 percent [bo- sult, the identification and determination ron nitride (BN) and ferrous sulfide ofsecond-phase compounds in steel have The author is an associate research consultant at the United States Steel Corporation Research Labo- (FeS)]. been a real challenge in the development ratory, Monroeville, Pennsylvania 15146. The determination of where a precipi- of improved steels. 136 SCIENCE, VOL. 196