Bio-Psycho Social-Spiritual Model

Department of Psychiatry and Behavioral Sciences

In all our teaching, we invite students to conceptualize patient problems by using a bio-psycho-social-spiritual formulation. This model is used throughout our curriculum in psychiatry. We ultimately want students to arrive at patient formulations that allow for understanding and drive formation of treatment plan. Formulations help explain "how did this patient get to this psychiatric status?"

What follows is a description of the components of the bio-psycho-social-spiritual formulation. We have added prompts for the students to help them think about and organize clinical material. Students are encouraged to include each component in formulations.

This model generally includes the following:

Biological

Past

Genetics:
  • Consider whether any blood relatives that have had psychiatric problems, substance use problems or suicide attempts/suicides. Is there a history of close relatives who have been hospitalized for psychiatric reasons? What kind of treatments did they get, how did they respond?
History of Pregnancy and Birth:
  • Consider pregnancy variables: Was there in-utero exposure to nicotine, alcohol, medications or substances? Anything unusual about pregnancy?
  • Note birth complications, such as prematurity, birth trauma or extended periods of hospitalization.
Relevant Previous Illnesses
  • Consider any history of head injury, endocrine disorders (e.g. thyroid, adrenal), seizures, malignancies, or neurological illnesses.
  • Consider potential lasting effects of past substance use on brain functions such as cognition, affective regulation, etc.

Present

Current Illnesses:
  • Identify current illnesses and any direct impact they may have on psychiatric presentation.
Medications:
  • Assess current medication regimen. Consider whether these medications have psychoactive effects (e.g. steroids, beta blockers, pain medications, benzodiazepines, SSRI's, antipsychotics). Consider possible side effects of current medications.
Substances:
  • Consider the influence of nicotine, alcohol and street drugs on current psychiatric symptoms.
  • Consider the possible effects of substance withdrawal.

Psychological

Past

  • Comment on any past history of trauma (child abuse, combat, rape, serious illness), as well as resiliency (how the patient coped with trauma, e.g. friends, family, religion).
  • Consider the sources of positive self image and positive role models.
  • Comment on the patient's experience with loss.
  • Comment on the patient's quality of relationships with important figures, such as grand parents, friends, significant teachers, or significant employers.
  • Comment on how past medical problems, substance use or psychiatric problems impacted the patient's development and their relevance to patient today.

Present

  • Describe the recent events and experiences that precipitated the admission or appointment.
  • What are the current stressors? Do they have any symbolic meaning?
  • Assess and comment on coping skills, defense mechanisms, presence or absence of cognitive distortions.
  • Consider current developmental demands on the person, such as marriage, divorce, birth, children leaving home, loss, aging, etc. What stage of development is the patient at now? Is it appropriate?
  • What is the developmental impact of the patient's illness?

Social

  • How adequate is the patient's current support system?
  • What is the current status of relationships with important figures?
  • What are the possible peer influences?
  • Consider the patient's current housing arrangement.
  • Comment on vocational/financial status.
  • Comment on any relevant legal problems.
  • Consider the role of agencies (e.g. Veteran's Administration, Child Protective Services, Criminal Justice System) on the patient.
  • Comment on cultural influences that may impact the current situation and that might impact treatment.

Spiritual

  • Comment on the role of spirituality in the patient's life. Is the patient affiliated with a spiritual community of some sort?
  • How does spirituality contribute to the patient's ability to hope, their position on suicide if relevant, or their contact with a supportive community?

Bio-Psycho-Social-Spiritual Model: Examples of Kinds of Questions to ask During your Interviews

In the small groups and case presentations in this course, we want students to acquire the skills that will help you arrive at a useful bio-psycho-social-spiritual formulation. This model is introduced in the first year and used throughout our curriculum in psychiatry.

When you conduct your diagnostic interviews, you will want to compile information that will allow you to address the components of the bio-psycho-social-spiritual model.

What follows is a description of the components of the bio-psycho-social-spiritual formulation. We have added cues to help you elicit relevant material. It is good to start with open-ended questions in each section, narrowing to closed-ended questions if the open-ended questions do not elicit the relevant material.

Biological

Past

Genetics:
  • Tell me about any family history of psychiatric problems or suicide attempts.
  • Tell me about any relatives that have been hospitalized for psychiatric masons. Tell me about any relatives that might have suffered from emotional problems. How were they treated and how did they respond to these treatments?
History of Pregnancy and Birth:
  • Tell me about the your mother's pregnancy with you. Do you know if she smoked, drank, or used any medications?
  • What have you been told about your actual birth? Were there any birth complications?
Relevant Previous Illnesses:
  • Tell me about any major medical problems you have had in your life. Have you had any history of head injury, endocrine disorders (i.e. thyroid, adrenal), seizures, malignancies or neurological illnesses?

Present

Current Illnesses:
  • Can you describe your health right now? Do you have any illnesses right now? Do you worry that you have something that has not been diagnosed?
Medications:
  • Tell me about the prescribed and non-prescribed medications that you are taking? (Probe for medications that have psychoactive effects, such as steroids, beta blockers, pain medications, benzodiazepines, SSRI's, Herbal remedies).
Substances:
  • Can you tell me about your use of alcohol or take street drugs? (Probe for whether current substance use could account for patient's psychiatric symptoms).

Psychological

Past

  • How were you treated as a child? (Probe for trauma as well as evidence for family strengths).
  • Can you tell me about any trauma's you might have experienced in life? (Probe for military/combat, rape, violence, and serious illness).
  • Can you describe to me any losses you have experienced? How did you cope with this?
  • Tell me about your relationships like with important figures, such as parents, grandparents, friends, significant teachers, or significant employers.
  • How have medical problems or psychiatric problems in your past influenced your life today?

Present

  • Tell me about the recent events and experiences that bring you here today?
  • How have you already tried to solve your problems? (Probe for coping skills).
  • How do you usually cope with difficult life-situations? (Probe for and observe defense mechanisms).
  • Tell me about how you are coping with marriage, divorce, birth, children leaving home, loss aging, etc. (The point here is to get a sense of what is being demanded of the person at this time, developmentally).
  • How do current medical problems or psychiatric problems influence your life today?

Social

  • Tell me about who you tum to if you need help. Do you have friends or family you can turn to if you need help?
  • Tell me about who you rely on for company, support, and fun. Do you have friends or family that you can rely on for company, support, and fun?
  • Currently, describe the kind of social life that you have? How often do you get together with people you can relate to, and do you enjoy it?
  • When you were feeling better, describe the kind of social life you had. How often did you get together with people you could relate to?
  • Tell me about your present housing arrangement? Are you satisfied with it?
  • Tell me about your work life. Are you working? Is your work satisfying or do you need help in this area?
  • Tell me about your financial circumstances?
  • To help me understand you, can you tell me about cultural/family beliefs that might help me get a more clear sense of your life-circumstance/symptoms right now?

Spiritual

  • Can you describe your spiritual belief system?
  • Can you tell me about how you get spiritual needs met?
  • Can you tell me about your religious community?
  • Can you describe your childhood experience of religion?

Bio Psycho Social Spiritual Treatment Plan

The Bio Psycho Social Spiritual formulation can guide the treatment planning process. We want all of your treatment plans, in this course and in our clerkship, to include comment in all of the areas specified below. As with the formulation, the treatment plan is individualized and this guide may provide a starting point. There is some overlap as noted below.

Biological

Diagnostic:

To "work up" current medical and psychiatric symptoms labs (i.e. thyroid, metabolic panel, Urine Drug Screen, blood alcohol level, current blood level of medication if relevant) Imaging (i.e. MRI, chest X-ray) Other: EEG, Biopsies, etc.

Therapeutic:

Treatment of current illness and associated symptoms Medications for underlying psychiatric disorder: antidepressant, mood stabilizer, antipsychotic, etc. Medications related to substance use disorder: methadone, alcohol withdrawal protocol, nicotine replacement therapy, etc. Medications for symptom relief: sleeping medication Medications for other medical problems: antibiotics, etc. life style prescriptions such as exercise and diet changes. Give your rationale as to why you are or are not choosing a biological treatment for particular problems with particular patients.

Psychological

Diagnostic:

Psychological testing: personality, IQ, other relevant tests. Behaviors and personality styles noted in the interview or reported by staff. Obtain more information: (old records, speak with outside providers, family) with written consent

Treatment:

Individual Psychotherapy: (tailored to patient — may include behavioral treatments such as DBT, relaxation therapy, behavioral activation, social skills training, coping skills development or cognitive behavioral therapy or psychodynamic therapy — be prepared to justify your choice for this patient). Couple's Therapy/Group Therapy: (tailored to patient, many choices, may include 12 step). Give you rationale as to why you are or are not suggesting a type of psychotherapy. Are there any interventions that could decrease psychological barriers to treatment?

Social

Diagnostic:

Assessment of patient's social and financial resources, qualifications for various aid programs (housing, Vocational Rehabilitation, Medicaid, GA, etc.)

Therapeutic:

Assistance with housing, job training, benefits groups (may include 12 Step, "Self-Help," Reminiscence, Clubs, etc.) Encouraging hobbies, encouraging social activities, family meetings.

Give a statement about why these kinds of supports are or are not indicated. Are there any interventions that could decrease social barriers to treatment?

Spiritual

Diagnostic:

Assessment of patient's past religious and spiritual affiliations.

Therapeutic:

Identifying resources: Organized religious activities, Meditation/Mindfulness training, Groups (may include 12 step).

Give a statement about why these kinds of supports are or are not indicated.

Other:

Inpatient vs. Outpatient Treatment (would you admit, discharge or continue current level of care?) Legal 2000 (Does patient meet criteria?) Removal of firearms from home Mandated Reporting (child, elder abuse? Tarasoff considerations?)