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Influence Of Multidimensional Care Elements On Disorders

Influence Of Multidimensional Care Elements On Disorders

A system is a collection of elements that interact or are interdependent on one another but form a coherent whole that interacts with its surroundings and other systems. A mechanical system is, for example, the car or bus you use for transportation. It has many interconnected parts, such as the fuel system, the electrical system, the engine, the drive train, the wheels, and so on. All of these components work together to generate movement and speed. If any system component fails, such as the engine, electrical system, or wheels, the system becomes dysfunctional and may no longer function properly. The car, in this example, is a system whose purpose is transportation or movement. Cars or buses interact with street systems, highway systems, traffic patterns, and so on, as well as gas stations and other facilities, all representing larger systems of which they are a part. Similarly, our bodies are biological systems comprised of interconnected parts.
Our brains, hearts, circulatory systems, respiration, digestion, and so on are all interconnected and work together. When one part of the system is damaged or disabled, such as by high blood pressure, diabetes, or a broken leg, the entire system suffers. Our bodies/biological systems work together to create life, and we interact with our surroundings and many other social systems, such as the medical system, families, schools, churches, and others.

Multifaceted Approaches to Mental Disorders
An X-ray image of a person’s brain in front of a magnified image of neural activity.
Figure 2: Multidimensional approaches to behavioral explanation contend that mental illness is caused by more than just “chemicals in the brain.”
Influence Of Multidimensional Care Elements On Disorders
Understanding how systems work and how interdependent their parts are helps us understand why simplistic, unidimensional explanations of mental disorders, such as that they are caused by a “chemical imbalance”—a reductionistic or overly simplified biological explanation—or that they are caused by a negative relationship with one’s mother—an overly simplified psychological and social explanation—are insufficient to understand the disorder and its causes fully. Unidimensional explanations limit our understanding of mental disorders’ development and our ability to find effective treatments. To progress in reducing stigma against the mentally ill and improving treatment efficacy, we must first seek to understand more multidimensional models and consider how multiple systems interact to contribute to mental disorders.

A few specific conditions that mimic mental disorders can be traced back to a single, unifying cause. Untreated syphilis, for example, can spread throughout the body, causing damage to multiple organ systems, including the brain, and leading to psychosis and dementia, as well as death. These types of conditions, however, are now uncommon and would not be classified as mental disorders because they are regarded as medical conditions with biological treatments. Mental disorders, on the other hand, do not have a single, simple biological or psychological explanation; they are systemic outcomes influenced by multiple factors, including biological (genetics, hormones, neurotransmitters, and other systems), psychological (learned behaviors, attitudes, emotional responses, cognitive, or social developmental stage), and social and cultural factors.

Some studies, for example, link prenatal exposure to a virus, which has cultural and biological implications, to the development of some forms of schizophrenia. Epigenetics is a newer field of study that sheds light on how social, psychological, and environmental influences can change which genes in a person’s DNA are activated or turned off, potentially leading to the development of disorders. Epigenetic effects characterize human development. Every cell in your body contains the same DNA, or genetic code, as a human being. However, as cells develop in the body, they become specialized, meaning that some genes may be activated in some cells but not others. The genes that allow cells to detect light are a good example; these are turned on or activated in your eye cells but turned off or deactivated in all other cells. [1] As a result, it is not surprising that certain environmental events or experiences may activate or deactivate specific genes, increasing or decreasing (in the case of protective factors such as positive social support) the likelihood of someone developing a mental disorder. Environmental epigenetic effects do not alter DNA but rather influence gene expression. As a result, both nature and nurture are relevant to all types of mental disorders, not just one.

This modern, multidimensional approach to understanding mental disorders can assist us in avoiding labeling individuals with mental disorders (or even medical illnesses) as having only one cause, thereby reducing stigma. To better understand them and their symptoms, we must approach each person individually and seek their biological, psychological, and social history. You will learn later in this module that most approaches to the treatment of mental disorders arose from unidimensional perspectives on mental disorders; clinicians today (and researchers) will better serve their clients by recognizing that they are approaching only one element of a system and being open to new information and thorough in their assessments, even if they may focus on a specific approach or way of treating a mental disorder.

The following sections of this module will describe various “models” that explain how mental disorders occur. We will start with multidimensional models and then move on to unidimensional components or elements of the biopsychosocial system. These fundamental models are significant because they reflect the history of scientific attempts to understand the etiology of mental illnesses. Newer models were either built on top of older ones or were reactions to previous thinking. Although most of them are unidimensional and thus limited, they each explore different aspects of the overall multidimensional picture and can be useful when considering what each of them teaches us. These models also contribute to the evolution of various treatment approaches or “orientations.”


A pie chart represents the Biopsychosocial Model with three equal sections: biological, psychological, and social/cultural.
Diagram 3. The biopsychosocial model emphasizes the interaction of biological, psychological, and social/cultural forces.

The biopsychosocial model is the most important multidimensional model for understanding the causes of mental disorders (BPS). In 1977, George L. Engel and Jon Romano of the University of Rochester proposed the biopsychosocial model (BPS). Unlike the medical model, which emphasizes mental illness as a disease, this model sought a more holistic approach by acknowledging that each patient has their thoughts, feelings, and history. Engel created this model to address both medical illnesses and mental health issues.

Engel, in particular, transformed medical thought by removing the apparent separation of body and mind. The concept of mind-body dualism dates back to the 17th-century French philosopher René Descartes. Still, it was forgotten with the rise of the biomedical approach, which largely ignored individual psychological and social development. Engel emphasized that the biomedical approach is flawed because the body does not cause illness alone. Instead, how an illness is caused and treated is heavily influenced by the individual’s mind (psychological and social factors). Figure 3 depicts a graphical representation of the biopsychosocial model that emphasizes the interaction of all three elements. This model could be used by clinicians, for example, to ensure that they are evaluating a person’s medical or genetic conditions while also exploring the person’s psychological experiences and upbringing, as well as their social and cultural environmental stresses, to understand them better. Researchers could use this model to discuss specific research findings or investigate the interactions between the model’s three major elements.

The natural element in the biopsychosocial model (BPS) can include genetic inheritance related to the risk of developing a disorder, malfunctions or disruptions of the system of neural transmission between neurons in the brain, potential damage to parts of the brain, infections or diseases that may affect the brain or nervous system functioning, and hormonal influences or brain-hormone interactions, among other things. As previously stated, epigenetic research has discovered that environmental stressors or events, particularly those that occur early in life, may interact with a person’s genome (the set of all our genes in our DNA), resulting in a wide range of biological effects.

The psychological component of the BPS encompasses a wide range of thoughts, feelings, and behaviors such as learned behaviors (conditioning or observed behaviors), thought patterns that increase or intensify emotions such as sadness or anxiety, events that occur during key developmental stages in life, strengths and weaknesses in the ability to cope with various life stressors, sense of confidence or self-efficacy, personality or cognitive development, and more.

The social/cultural component of the BPS includes a wide range of external situations that can shape how people respond to events and other people, often by influencing the stress level in a person’s life. These can include abuse, being a victim of a crime, racism and discrimination, poverty, war, the impact of cultural expectations and demands, physical health and nutrition, levels and type of stress in the environment (rural versus city living, for example), the extent of one’s social support network (friends, family, and others to whom one can turn for help and comfort), and more.

Take Erin, for example. Erin was born into a family with strong genetic ties to anxiety. Several members of her family have diagnosable mood and anxiety disorders. Is it possible that Erin will develop a phobia or panic disorder?

Erin inherited at least some genes that make her more likely to react strongly to life events and may shape how her body responds to stress. A lot may also depend on how her parents raise her, as well as the behaviors she observes her family and friends exhibit as she grows up; do they demonstrate effective coping reactions to stress and frightening experiences, or do they strongly react to situations, exacerbating symptoms by avoiding frightening situations? Do her parents teach her that life is dangerous and unpredictable and that she must always be on guard, or do they encourage her to explore, show her how to cope with events as they occur, and provide emotional support?

It may also be influenced by where she lives, whether she has experienced significant negative events in her life, is discriminated against, or is teased and bullied by children at school. This is only a small subset of the possible outcomes in Erin’s life. The interaction of these biological, psychological, and social forces could influence whether or not she develops an anxiety or mood disorder. Don’t forget those epigenetics suggest that her brain and hormonal systems function may change due to her life experiences, increasing or decreasing her likelihood of developing a disorder.

Furthermore, it is critical to recognize that the specific patterns of how the biopsychosocial model functions vary depending on the disorder. Some disorders are influenced more heavily by genetic and other biological factors, whereas others are influenced more heavily by social or psychological factors. Figure 4(a) for depression shows that biological factors significantly influence how a person’s life will turn out more than the other elements. However, both psychological and social/cultural factors still play significant roles. In Figure 4(b), biological factors play a significantly smaller role in developing eating disorders, while social/cultural and psychological factors play a larger role. Even in the case of schizophrenia (see Figure 4(c)), which is frequently misdiagnosed as a “mental disease” by many, biological factors account for less than half of the influence on whether or not a person develops the disorder. Multiple studies have shown that the concordance rate between identical twins is less than half, which measures the likelihood of an identical twin developing schizophrenia if the co-twin already has it. In other words, even with a strongly biologically influenced disorder, an identical twin with identical genes will not develop schizophrenia more than half of the time. Social/cultural and psychological factors play important roles in this case, and epigenetics may play a role as well. These topics will be covered in greater depth in subsequent modules.

Three pie charts depict the balance of biological, psychological, and social/cultural components in depression, eating disorders, and schizophrenia, respectively. Depression is 40% biological, 30% psychological, and 30% social/cultural. There are 45% social/cultural influences, 35% psychological, and 20% biological influences in eating disorders. The breakdown for schizophrenia is roughly 48% biological, 30% social/cultural (stigma, stress), and 22% psychological.
Figure 4. (a) Depression has strong biological components, but psychological and social/cultural forces also play important roles. (b) Social and cultural factors have a greater impact on eating disorders. (c) Schizophrenia is the most biologically/genetically influenced set of disorders in this example; however, there is evidence that psychological and social/cultural forces can impact symptoms and prognosis even in schizophrenia (the future course of the disorder).

The biopsychosocial multidimensional model is very useful in helping us understand the elements that contribute to mental disorders in a more complete and useful way. Still, it does not specifically explain how a person like Erin might develop a disorder. Fortunately, two BPS-related models that provide insight into this situation have emerged: the diathesis-stress and gene-environment correlation models.

This video goes over some of the biological, psychological, and social factors that all interact to influence our mental health.

The “biopsychosocial model” transcript can be found here (opens in a new window).


Diathesis and Stress Model
The biopsychosocial model provides a broad understanding of how the three major elements interact to produce mental disorders. The diathesis-stress model, developed by Paul Meehl in the 1960s and first applied to schizophrenia, is more specific and helps us understand why one person develops a disorder or why two people from similar backgrounds develop different disorders. Diathesis is derived from the Greek word for “predisposition.” Professionals may refer to “vulnerability” as a disorder, but all of these terms are interchangeable. The key assumption of the diathesis-stress model is that both diathesis (usually genetic or biological) and environmental stress are required for disorder development. It is important to note that individuals’ vulnerabilities to the development of a disorder differ greatly. Contrary to popular belief, the brain and how it functions continue to change over the lifespan, even at the genetic level, in response to environmental events (Durand & Barlow, 2013). [2]

The diathesis or vulnerability to developing a mental disorder of a given person represents the person’s pre-existing risk or probability of developing a mental disorder if they are exposed to enough stress. A person raised in a family with a long history of alcoholism and drug use, for example, is much more likely to develop a substance disorder than a person raised in a family without such a history. Diathesis is commonly thought to refer to genetic, biological, and physiological conditions such as gene variations or multiple gene combinations that increase the likelihood of developing a disorder. Still, it can also refer to cognitive, personality-related, and even environmental factors (such as the loss of a parent early in life). However, keep in mind that no simple genetic inheritance leads to a mental disorder; having a vulnerability or diathesis for a disorder does not guarantee that the person will develop the disorder.

Assume, for example, that a person with a strong family history of alcoholism may have biological effects such as a stronger attraction to the taste of alcohol than most and that alcohol has a stronger and more immediate impact on the brain than someone else. However, a lot depends on the interaction with environmental stress. Suppose the person who inherits this diathesis learns alternative ways to cope with stress in life (rather than drinking) and never, or rarely, drinks alcohol. In that case, they may never become an alcoholic. However, if the person follows the example of family members, drinks at a young age, and uses drinking to cope with job loss, relationship problems, and so forth, that person is much more likely to develop alcohol dependence.

Similarly, someone could be exposed to significant life stressors, meaning life events that disrupt a person’s stability or functioning, and not develop a disorder if they do not have a diathesis or vulnerability to a disorder or if that diathesis is weak. For example, someone from a family with no history of alcoholism or addiction may drink at any college party, occasionally drink through life, and may experience divorce, chronic illness, and a motor vehicle accident and not develop alcohol dependence. This is because the diathesis-stress model also presumes that for each person, there is a threshold, a point at which the person’s coping abilities and social, psychological, and biological defenses cannot manage their level of life stress; when the combination of a diathesis/vulnerability and life stress exceeds the person’s threshold, they will develop a disorder that aligns with their vulnerability.

The stick was broken in half.
Figure 5. The diathesis-stress model can be compared to a stick that breaks under strain.

Think of picking up a stick on a walk. If you hold the stick in your hands and bend it, it does not immediately break. It may bend and experience strain until it reaches a threshold point at which it will break. Now consider all the factors that may cause that threshold to vary from stick to stick: is the stick green (not dried out), the thickness of the stick, the type of wood the stick comes from, and so on. Each stick will have its distinctive threshold for how much stress it can take before it breaks.

Water bucket overflowing with water.
Figure 6. Another metaphor to understand the diathesis-stress model is that of a bucket. Buckets may be of varying sizes and come with different amounts of material already inside. Stressors that cause the water to overflow may trigger a mental disorder in someone vulnerable.

Another common metaphor for understanding the diathesis-stress model is the visual image of a bucket filling with water. Genetics influence the size of the bucket we have or the amount of material already inside the bucket. Life stressors and other events can add water to the bucket, while coping mechanisms and positive experiences can open taps to remove some of that stress. We can think of genetic/biological diathesis as the sand inside the bucket. The larger that vulnerability, the less life stress (the water on top) is necessary to exceed the threshold and trigger the disorder. The reverse is also true; if a person has a very low vulnerability to a particular disorder, the same amount of stress will not exceed the threshold, and no disorder will be triggered. Alternatively, the person would have to experience a significant and large amount of stress to exceed the threshold, which is possible, but not as likely. This model reinforces the importance of understanding how nature and nurture interact in the etiology of mental disorders.

A few other aspects of the diathesis-stress model are worth considering. Protective factors, such as positive parent-child relationships, positive social networks, effective coping strategies, or high self-esteem, can counteract the effects of stressors and prevent or curb the effects of the disorder. Many psychological disorders have a window of vulnerability, during which an individual is more likely to develop the disorder than others. For these reasons, diathesis-stress models are often conceptualized as multi-causal developmental models, which propose that multiple risk factors throughout development interact with stressors and protective factors contributing to normal development or psychopathology.

The development of the diathesis-stress model was a significant advance from the biopsychosocial model in helping to understand how people would vary in their symptoms and diagnoses even if they had similar genetics or came from similar environments. However, the model was still based mostly on a simple additive idea: the biological diathesis (vulnerability) plus the amount of environmental stress experienced would cause a disorder if it were enough to cross the threshold. A newer model, called the gene-environment correlations model or rGE[3], emphasizes the interactions that can occur between a person’s biological elements (genetics, neurotransmitter systems, brain development) and the psychosocial and cultural environment.

Gene-Environment Correlation Models
The rGE (the little r is the statistical symbol for correlation) model and related studies have greatly expanded since the decoding of the human genome was finished in 2003, creating the possibilities of new research into genes and genetic variants (alternative copies of the same gene such as genes that code for brown eyes versus blue eyes) and how they interact with the environment. However, because this field is rapidly evolving, there are still areas of controversy, and new information is emerging regularly.

A review of 315 studies conducted through 2015 found that a large number of them (67–83%) showed significant interactions between genes and the environment. The gene-environment correlation model (rGE) is defined as the tendency of individuals to select and generate their environment based on genetic features that influence behavior, thoughts, and feelings[4].

In other words, instead of the simple diathesis-stress additive model of a diathesis plus sufficient stress to cross the threshold producing a disorder, the rGE model has demonstrated evidence that a person’s genetically influenced personality traits and behaviors may either select for or create the stressful life events or experiences that exceed the threshold and trigger the diathesis. The GE model differs from epigenetics which emphasizes the influence of environmental forces on genetic expression, although that field has also greatly benefited from the mapping of the human genome. Some evidence suggests that cultural forces may also be involved, although this needs to be fully understood. Leighton and colleagues (2017) noted that some gene-environment interactions are robust in western nations like the United States but have not been replicated in eastern nations. They further concluded that there is an increasing consensus among experts that “most common psychiatric disorders, such as depression and anxiety, are best explained as complex disorders involving dysfunctions in several biological systems in interaction with environmental factors” (p.2) (p.2). [5]. [/footnote]

As an example of how the rGE model works, Jaffee and Price (2007)[6] described a study conducted in 2006 that found that persons with a variant gene that conveyed high risk (diathesis) for alcoholism also showed personality traits, such as less desire to please other people, that increased their risk for a diagnosis of antisocial personality disorder. These personality traits are more likely to lead to disrupted relationships and increased social isolation, as well as life events that could generate stress, including divorce, never marrying, and potentially criminal behavior that could increase a desire to drink, exceeding the threshold and triggering the underlying vulnerability to alcohol dependence.

In the diathesis-stress and gene-environment correlation models, we see the evolution and increased complexity of the biopsychosocial model over time; at the same time, this complete understanding of the mechanisms involved in how biological forces interact with and are shaped by environmental influences (including psychological and social/cultural elements) holds out the promise of greater understanding and new treatments to come. These models also reinforce the inadequacy of simplistic unidimensional explanations of mental disorders, like the “chemical imbalance” explanation. That said, we will now explore different elements of the biopsychosocial model and the treatment approaches they have generated over time.
Disorders of the endocrine system affect many individuals. Providing multidimensional patient care can be challenging for patients experiencing these disorders. Ensuring the plan of care meets the patient and family needs is important in order to increase adherence to proper medical treatment following discharge.

What does it mean to provide a multidimensional approach? Provide at least three examples of how the care team can meet the patient and the family’s needs? List at least three care team members and how are they involved in providing multidimensional care?

Please make your initial post by midweek, and respond to at least one other student’s post by the end of the week. Please check the Course Calendar for specific due dates.

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