Revisiting the Biopsychosocial Formulation: Neuroscience, Social Science, and the Patient's Subjective Experience.

Psychiatric illnesses force us to confront the vexing problem of the relationship of mind, brain, and culture [1], and therefore, the practice of psychiatry occurs “at the crossroads of biomedicine, the social sciences, and the humanities” [2]. Accordingly, psychiatry has long aspired to the biopsychosocial model first outlined by Engel in his seminal paper, which he intended to preserve a more wellrounded, humanistic approach to medicine from a strictly biomedical model [3]. Engel appreciated that illness must be addressed at each of these explanatory levels. The great challenge for clinicians has been in the actual integration of these orientations in the care of the individual patient, as opposed to an eclectic accumulation of perspectives [4, 5]. In addition, there has sometimes been a tendency to emphasize the “psychosocial” as compared to the “biological” [5]. As a result, when the biopsychosocial formulation was put into practice in clinical case conferences, the three modes were often disconnected, and the biologic was sometimes reduced to a listing of the patient’s medical comorbidities and a cursory reference to inherited genetic vulnerabilities and predispositions. In recent years, however, our understanding of neurobiology has progressed considerably, to a point where it is time to substant ia l ly revise the place of biology in our biopsychosocial model. Indeed, Insel and Quiron argued that we should redefine the “foundation of psychiatry as clinical neuroscience” and that we should best consider ourselves “clinical neuroscientists” [6]. Most recently, Ross and colleagues made a compelling argument that we should substantially enhance the neuroscience education of psychiatry residents and have provided new resources for training directors to use [7]. Anticipated advances in imaging and biomarkers are likely to redefine diagnosis, and future psychiatrists need to be ready to integrate these advances into their practice [8, 9]. In order to meet these goals, psychiatry educators will need to increase the time devoted to teaching neuroscience and also change the culture of some psychiatry departments to include an embrace of neuroscience education by psychiatric clinicians. As exciting as the possibility of personalized medicine rooted in neuroscience may be, the findings of recent neuroscience research should also prompt us to revisit the biopsychosocial model to examine the possibility of a more convergent and integrated use of the model. Indeed, recent neuroscience research repeatedly demonstrates the centrality of the social environment in brain development, and how this environment is subjectively experienced, as a significant cause of serious mental illness. This in turn has implications for the scope of the evidence base that we teach our residents—in particular highlighting those areas of the social sciences that explore the nature of childhood trauma and deprivation, its cultural and social risk factors, the subsequent stigma surrounding its sequelae, and the ways these experiences are internalized. Accordingly, this essay will explore how psychiatry residency educators might integrate selected elements of recent neurobiology and recent social science research with a focus on the patient’s subjective psychology, in the service of demonstrat ing and teaching a substantial ly enriched biopsychosocial model. This goal is consistent with the aspirations expressed in the recently established Psychiatry Milestones of the Accreditation Council for Graduate Medical Education (ACGME) that serve as a guiding framework for the progression of psychiatry residents’ educational * Adam M. Brenner adam.brenner@utsouthwestern.edu