08/12/2015 Biopsychosocial Dimensions of Illness

08:30 – 09:30 Principles and Perspectives

YL6: 01.06.01 Aileen B. Pascual, M.D., FPAFP

OUTLINE
I. Biopsychosocial A. Case Revisited –
Dimension “Tulo”
II. Case 1: Biomedical B. Human
Dimension Immunodeficiency
A. Basic Information Virus
B. Pathophysiology C. Summary
C. Management Review Questions
III. Case 2: Biopsychosocial Freedom Space
Dimension References

I. BIOPSYCHOSOCIAL DIMENSION

Biomedical vs. Biopsychosocial Models in Medicine

Figure 2. Biomedical Data vs. Biopsychosocial Data (Dr. Pascual’s
In the biomedical model, the assumption is that disease is Presentation)
only accounted for by deviations from measurable, biological
factors. However in the biopsychosocial model, interactions
II. CASE 1: BIOMEDICAL DIMENSION
of the biological factors with psychological and social factors
(personal, emotional, family, community) is taken into
account in understanding the disease and its management. A. BASIC INFORMATION
1,2

• Identifying Information
→ Joseph E.
§ 35 year old male
§ Call center supervisor (Team Leader)
§ Currently married to Alice, 33
§ Has two daughters
− May, 5
− Beth, 2
• Genogram

Figure 1. Biopsychosocial Approach to Illness (Dr. Pascual’s

Presentation)

Table 1. Components of Biomedical, Psychological, Social Aspects

of Illness
Biomedical Psychological Social
• Pathophysiology • Perceptions • Social
• Causative • Feelings systems:
Agents • Beliefs Family,
• Pharmacologic • Expectations School, Work, Figure 3. Genogram of Joseph E. (Dr. Pascual’s Presentation)
Management • Personality Church,
• Genetics • Coping style Government • Chief Complaint
• Environmental • Emotional • Social values → Dysuria
Factors Reactions and Customs → Urethral Discharge.
• Access to • Pertinent Information
Health Care → During history taking, Joseph mentioned that he had
• Quality of multiple sexual partners and was advised to have
Patient’s HIV screening
Health

YL6: 01.06.01 Group 6: Dacalanio, Dela Cruz G., Du, Fajardo, Martin, Marzo, Reyes, Santos, Tuason, Uy, Vasquez, Zabala 1 of 5
• Differential Diagnosis

Gonococcal Neisseria
Urethritis gonorrhea

Dysuria + Chlamydia
Urethral trachomatis
Discharge
Mycoplasma
Non- hominis Figure 5. Discharge from the Penis (www.the-clap.com)
Gonococcal
Urethritis Ureaplasma • Chlamydia trachomatis
urealyticum → Urethral discharge is clear and watery (in contrast to
Neisseria urethral discharge)
Trichomonas → Gram negative
vaginalis → Obligate intracellular organism

Chlamydia trachomatis is a bacterium that is passed on via

Figure. Differential Diagnosis for the case of Joseph E. (Dr.
Pascual’s Presentation)
unprotected sex or through vertical transmission (mother to
baby). Pathology occurs once the bacterium latches on to a
healthy cell and depends on its nutrients for survival. This
• Diagnosis
dependence causes the bacterium to divide and grow which
→ Through differential diagnosis, it was discovered that he
causes numerous serious problems like the inflammation of
has Neisseria gonorrhea and Chlamydia
the genitourinary tract. Penile discharge and dysuria can be
trachomatis
observed among infected male patients.
5
B. PATHOPHYSIOLOGY

• Neisseria gonorrhea
→ Gram negative diplococcus
→ Can be isolated by Thayer-Martin agar

Neisseria gonorrhea, transmitted often in people with

multiple partners, is a bacterium that easily multiplies and
grow in warm mucus areas in the body including the male (a) (b)
urethra. Figure 6. Chlamydia trachomatis (a) and Trichomonas vaginalis (b)
(www.wishart.biology.ualberta.ca)
The pathophysiology of this bacterium and its subtypes
depend on the antigenic characteristics of the respective
surface proteins. Some subtypes may evade the serum
immune response and may cause systemic infections such
as Urethritis.

Characterized plasmid may carry antibiotic-resistant genes

(ie. Penicillinase). Because of these genes, plasmids and
non plasmids are interchanged across subtypes. Ensuing
exchange of this structure causes high susceptibility to
reinfection.
4 Figure 7. Non-Gonoccocal Urethritis: Mucoidal Discharge
(www2a.cdc.gov)

C. MANAGEMENT

“Empiric treatment of symptoms without documentation of

urethritis is recommended only for patients at high risk for
infection who are unlikely to return for a follow-up evaluation.
Such patients should be treated for gonorrhea and
chlamydia.”
6

• Recommended Drug Regimen

→ Cefixime 400 mg orally in a single dose
Figure 4. Gram stain of Neisseria gonorrhoeae § Broad spectrum cephalosporin
(www.textbookofbacteriology.net) § Mechanism of Action: Inhibits cell wall synthesis
→ Azithromycin 1 g orally in a single dose
§ Macrolide
§ Mechanism of Action: Inhibits protein synthesis
→ You have to consider the etiologic organisms in
prescribing medications; do not just give antibiotics for
the patient

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 III. CASE 2: BIOPSYCHOSOCIAL DIMENSION
A. CASE REVISITED - “TULO”
Some patients may use “Nililinis ang tubo” to refer to
masturbation
• Joseph disclosed that he had sexual relations with
someone other than his wife
→ Family Life Cycle stage: Family with Young Children
§ Decreasing intimacy between husband and wife
§ More time and focus on children - going to school,
providing food and shelter
§ Begins with the birth of first child
§ Can have significant effect on the couple’s level of
physical and emotional intimacy
§ Emotional Process of Transition
− Accepting new members into the system
• Joseph underwent HIV screening and was found to be
HIV positive
→ He felt anxious and scared
→ He became more irritable
→ He could not sleep well and concentrate on his work
→ Confirmatory test: Western blot
injuries
• Maternal HIV infection (for newborns, infants, and
children):
→ Steps taken to reduce the risk of transmission at birth
include cesarean delivery and prenatal antiretroviral
therapy in the mother and antiretroviral therapy in the
newborn immediately after birth.
Anti-retrovirals are the principal method for improving
longevity and preventing opportunistic infections in PLHIV.
8
Epidemiology
• Latest HIV & AIDS registry from June 2015
• From 154 cases of HIV in April 2010, there are now 772
cases in June 2015
→ This tells us that either more people are being
diagnosed of HIV in the Philippines or the numbers
before were underreported because fewer people were
taking HIV screening

B. HUMAN IMMUNODEFICIENCY VIRUS

Basic Information
• Lentivirus
• Mode of transmission
→ Sexual contact with infected person
→ Mother to child transmission
→ Receiving infected blood and blood products
§ Notably needle - sharing among injecting drug users Figure 8. Number of New HIV Cases per month. 772 new cases of
HIV have been reported last June 2015. This is the highest reported
Human Immunodeficiency Virus is a blood-borne monthly new HIV cases since 1984 (Dr. Pascual’s Presentation)
retrovirus. It produces cellular immune deficiency
characterized by a decrease in helper T lymphocytes (CD4+ Table 2. Quick Facts on HIV in the Philippines
cells). This weakens the immune system and allows
opportunistic infections to develop in an HIV-positive patient
(called a person living with HIV or PLHIV). A PLHIV will
present with whatever opportunistic infection that developed.
They typically manifest the following: flulike illness including
fever, malaise, and generalized rash; and generalized
lymphadenopathy. At times they may develop AIDS-
associated dementia/encephalopathy or HIV wasting
syndrome (chronic diarrhea and weight loss with no
identifiable cause). Its asymptomatic phase is generally
benign.
7

Diagnosis of HIV
A person can know her/his HIV status only through HIV
antibody testing. If you suspect that you have been infected
with HIV, you should have yourself tested at least three
months after you have been exposed to the virus. This is
because it is only at this point when antibodies against HIV
are detectable in the blood. If one tested positive after HIV
antibody testing, a Western blot is typically done as a
confirmatory test.

Risk factors for HIV infection include the following:

• Unprotected sexual intercourse, especially receptive anal
intercourse
• Prior or current sexually transmitted diseases (STDs):
Gonorrhea and chlamydia infections increase the HIV
transmission risk 3-fold, syphilis raises the transmission
risk 7-fold, and herpes genitalis raises the transmission
risk up to 25-fold during an outbreak
• Sharing of intravenous drug paraphernalia
• Mucosal contact with infected blood or needle-stick
In June 2015, 97% of people living with HIV (PLHIV) were
male. Median age is 27 years old (age range: 13-64 years).
More than half (54%) belong to the 25-34 year age group
while 29% were youth aged 15-24 years old. Reported
modes of transmission (MOT) were sexual contact (764) and
needle sharing among injecting drug users (IDU). 87%
percent of the sexually transmitted cases were among males
who have sex with males (MSM).

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22,032 cases (83%) out of all the diagnosed cases of HIV in At the end of YL6, we are expected to explain cases in the
the Philippines were reported in the last five years, from integrative oral exam using the biopsychosocial lens – aside
January 2010 to June 2015. from the pathophysiology, management, mechanism of
9
action of drugs prescribed, we should also ask about
psychosocial factors that affect the patient.
Cost of Treatment
• Free anti-retrovirals (ARVs) from HIV & AIDS treatment REVIEW QUESTIONS
hubs under the outpatient HIV & AIDS Treatment Package
of Philhealth as long as her/his member is active or Determine which biopsychosocial aspect is involved in
updated the following situations:
• Philhealth Outpatient HIV/AIDS Treatment (OHAT) a. Biomedical
Package Program b. Psychological
→ P 30,000/year (P 7,500/quarter) c. Social
→ Includes medications, laboratory examinations, CD4 d. None of the above
count
1. Joseph is suffering from dysuria and urethral discharge.
His doctor, Alfonso, requested for several laboratory tests
Referrals
to know whether the causative agent of his condition is
• HIV & AIDS Treatment Hubs in Metro Manila are found in Neisseria gonorrhea.
the following institutions: 2. Marvin tested positive for HIV. When he knew about this,
→ Makati Medical Center he started to worry about his relationship with his wife and
→ Philippine General Hospital family.
→ The Medical City 3. Katherine, an ASMPH intern, was doing history taking at
→ Research Institute for Tropical Medicine Ospital ng Makati on her first day of internship. She didn’t
→ San Lazaro Hospital include family and social history because she thinks that
• Social Support groups can provide assistance for HIV those aren’t vital in making the diagnosis for her patient.
testing, treatment hub referrals, as well as medical and 4. Before doing an appendectomy on one of his patients,
shelter assistance. Examples are: John asked the patient’s mother about who will take care
→ The Project Red Ribbon of the hospital finances and if the patient is enrolled in
→ The Positive Action Foundation Philippines PhilHealth.
Incorporated 5. After check-up, Anna knew that her mom is suffering from
→ Pinoy Plus Association, Inc. Alzheimer’s disease. When she started thinking about
→ It is important for a patient to have a support group how she would take care her mom, she realized that she
because the implications of being diagnosed with HIV would have to quit her job that she enjoyed for 15 years;
has a big change in the life of the patient and his family because of this, she felt miserable and depressed.

Legislation: RA 8504 Answers: a, c, a, c, b

• “Philippine AIDS Prevention and Control Act of 1998”
• Articles on: FREEDOM SPACE
→ HIV/AIDS Education
→ Safe practices and procedures Table 4. Biomedical vs. Biopsychosocial (From 2018 Trans)
→ Testing, Screening and Counseling Biomedical Biopsychosocial
§ Pre- and post-testing counseling for a patient are Mind-Body Separate/Indepen Part of a dynamic
required during HIV screening Relationship dent Dualism system; influence
→ Support services each other
→ Monitoring Cause of Pathogens Multiple factors at
→ Confidentiality Disease different levels
→ Discriminatory Act and Policies Psychosocial Irrelevant Essential
§ If Joseph is being discriminated upon at his Factors
workplace due to his HIV status, he can cite this law Approach to Reductionist Holistic
• HIV testing is non compulsory Illness and
Treatment
C. SUMMARY Responsibilit Medical MD/Individual/Society
y for Health Professionals
Table 3. Summary of Biopsychosocial Dimensions of Joseph’s case Focus of Eradication or Physical,
Biomedical Psychological Social Treatment containment of psychological, and
• HIV • Fear • Relational pathology social factors
• Neisseria • Anxiety problems with wife contributing to illness
gonorrhea • Irritability • Health financing Focus of Avoidance of Reduction of physical,
Health pathogens psychological, and
• Chlamydia • Depression • Access to health
Promotion social risk factors
trachomatis services
• Pharmacologic • Education
Treatment • Screening
• Treatment
• Disease
monitoring

Physicians should consider the different dimensions of the

patient and not just a collage of pathological information.

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