Etiology & Bio-Psycho-Social Factors
Comprehensive Notes for Nursing Students
Introduction to Etiology
Etiology refers to the study of the causes or origins of diseases, disorders, or conditions. In healthcare, understanding etiology is crucial for effective assessment, diagnosis, treatment planning, and preventive strategies.
In psychiatric and medical nursing, etiological understanding is particularly complex due to several factors:
- Causes are often temporally removed from their effects
- A single cause may lead to various different effects (multi-finality)
- A single effect may arise from several different causes (equi-finality)
- The interaction between genetic predisposition and environmental triggers
- The cumulative and temporal nature of causative factors
Key Concept: Etiological Categories
When studying the causes of health conditions, it’s helpful to categorize etiological factors into three main types:
- Predisposing Factors: Exist before the onset of disease and increase susceptibility
- Precipitating Factors: Occur shortly before disease onset and trigger the condition
- Perpetuating Factors: Maintain or worsen an existing condition
The Biopsychosocial Model
Biopsychosocial Model is a comprehensive approach to understanding health and illness that considers the interplay between biological, psychological, and social factors. First conceptualized by George Engel in 1977, it represents a shift from the traditional biomedical model that focused solely on biological factors.
Biological Factors
Physical and physiological components including genetics, biochemistry, and anatomical structures
Psychological Factors
Mental processes, emotions, behaviors, and cognitive patterns that influence health
Social Factors
Environmental, cultural, economic, and interpersonal elements that affect health outcomes
Clinical Pearl: Holistic Assessment
The biopsychosocial model reminds nurses to consider all dimensions of a patient’s experience. Even conditions with clear biological causes (like infections) can be influenced by psychological factors (stress affecting immunity) and social factors (living conditions that increase exposure).
Mnemonic: “BPS CARE”
To remember the key components of a biopsychosocial assessment:
- Biological factors: Genetics, physiology, and pathophysiology
- Psychological factors: Thoughts, emotions, and behaviors
- Social factors: Relationships, resources, and environment
- Cultural considerations: Beliefs, values, and cultural practices
- Age-related implications: Developmental stages and life transitions
- Resources assessment: Support systems and access to care
- Experiential factors: Past experiences and trauma history
Biological Factors in Etiology
Biological factors are physiological or physical aspects that influence health outcomes. They form the foundation of disease processes and include:
Key Biological Factors
| Factor | Description | Clinical Examples |
|---|---|---|
| Genetic Predisposition | Inherited traits that increase susceptibility to certain conditions | Family history of diabetes, breast cancer genes (BRCA1/BRCA2), cystic fibrosis |
| Biochemical Imbalances | Disruptions in the body’s chemical processes | Neurotransmitter imbalances in depression, hormonal imbalances in endocrine disorders |
| Infectious Agents | Bacteria, viruses, fungi, parasites that cause disease | Streptococcus in pharyngitis, HIV in AIDS, malaria parasites |
| Structural Abnormalities | Alterations in physical structures | Congenital heart defects, spinal malformations, brain lesions |
| Brain Changes | Alterations in brain structure or function | Decreased hippocampal volume in PTSD, prefrontal cortex changes in schizophrenia |
| Immune Dysfunction | Abnormal immune responses | Autoimmune disorders, immunodeficiencies, allergic reactions |
| Endocrine Disorders | Hormone production or regulation issues | Hypothyroidism, diabetes mellitus, Cushing’s syndrome |
| Nutritional Deficiencies | Inadequate intake of essential nutrients | Iron deficiency anemia, vitamin D deficiency, scurvy |
| Aging Processes | Cellular and systemic changes over time | Osteoporosis, macular degeneration, cognitive decline |
| Toxin Exposure | Contact with harmful substances | Lead poisoning, mercury toxicity, pesticide exposure |
Physiological Changes That May Influence Health
Certain normal physiological processes can act as biological factors that influence health:
- Puberty: Hormonal changes affecting mood, behavior, and physical development
- Menstruation: Cyclical hormonal fluctuations affecting physical and emotional well-being
- Pregnancy: Dramatic physiological adaptations that impact multiple body systems
- Menopause: Decreased estrogen production leading to various physical and psychological effects
- Aging: Progressive cellular changes that affect organ function and resilience
Clinical Pearl: Biological Predispositions
Biological factors often represent predisposing factors that create vulnerability to disease. However, they frequently require interaction with psychological or social triggers to manifest as clinical conditions. For example, a genetic predisposition to depression may remain latent until activated by significant stress or trauma.
Mnemonic: “GENETIC MAP”
To remember key biological factors in disease etiology:
- Genes and inheritance patterns
- Endocrine system disruptions
- Neurological factors and changes
- Environmental toxins and exposures
- Tissue structure and function
- Immune system responses
- Cellular and metabolic processes
- Microorganisms and infections
- Age-related physiological changes
- Physiological stressors
Psychological Factors in Etiology
Psychological factors involve mental processes, emotions, behaviors, and cognitive patterns that influence health outcomes. These factors can act as predisposing, precipitating, or perpetuating elements in disease development.
Key Psychological Factors
| Factor | Description | Clinical Examples |
|---|---|---|
| Cognitive Patterns | Thought processes and mental frameworks | Catastrophizing in chronic pain, negative self-talk in depression, cognitive distortions |
| Emotional States | Sustained feelings that influence behavior and physiology | Chronic anxiety triggering cardiovascular issues, sustained anger contributing to hypertension |
| Stress Response | Physiological and psychological reactions to perceived threats | Cortisol dysregulation, impaired immune function, autonomic nervous system disruptions |
| Developmental History | Early life experiences that shape vulnerability and resilience | Childhood trauma increasing risk for various disorders, secure attachment as protective factor |
| Personality Traits | Enduring patterns of thinking, feeling, and behaving | Type A personality and cardiovascular disease, neuroticism and anxiety disorders |
| Coping Mechanisms | Strategies used to manage stress and difficult situations | Maladaptive coping through substance use, adaptive coping through social support |
| Self-Efficacy | Belief in one’s ability to accomplish tasks and overcome challenges | Low self-efficacy hindering rehabilitation efforts, high self-efficacy enhancing treatment adherence |
| Health Beliefs | Perceptions about health, illness, and treatment | Perceived susceptibility affecting preventive behaviors, treatment expectations influencing outcomes |
| Mental Health Conditions | Psychiatric disorders that affect overall health | Depression worsening diabetes outcomes, anxiety disorders complicating respiratory conditions |
| Childhood Insecurities | Emotional vulnerabilities formed during development | Attachment issues, fear of abandonment, emotional regulation difficulties |
Defense Mechanisms
Defense mechanisms are unconscious psychological processes that protect individuals from anxiety, painful emotions, or threats to self-esteem. While they can provide short-term relief, maladaptive or excessive use can contribute to psychological disorders and physical health problems.
Common Defense Mechanisms:
- Denial: Refusing to accept reality or facts
- Repression: Pushing unacceptable thoughts into the unconscious
- Projection: Attributing one’s unacceptable thoughts to others
- Displacement: Redirecting emotions from original target to a safer substitute
- Rationalization: Creating false but plausible justifications
- Regression: Reverting to behaviors from earlier developmental stages
- Sublimation: Converting unacceptable impulses into socially acceptable activities
- Reaction Formation: Behaving in the opposite way to one’s true feelings
Clinical Pearl: Psychosomatic Connection
Psychological factors can directly influence physiological processes through several pathways:
- Neuroendocrine activation: Stress hormones (cortisol, adrenaline) affecting multiple body systems
- Immune modulation: Emotional states influencing inflammatory responses and immune function
- Autonomic nervous system: Anxiety triggering sympathetic activation (fight-or-flight response)
- Behavioral pathways: Psychological factors influencing health behaviors like medication adherence, lifestyle choices
Understanding these connections helps nurses identify potential psychological factors that may be contributing to physical symptoms or affecting treatment outcomes.
Mnemonic: “PSYCHE MATTERS”
To remember key psychological factors in disease etiology:
- Personality traits and temperament
- Stress response and coping styles
- Yearning and motivation levels
- Cognitive patterns and beliefs
- Health behaviors and habits
- Emotional regulation abilities
- Mental health conditions
- Attachment patterns and relationships
- Trauma history and adverse experiences
- Thinking styles and cognitive processes
- Expectations about illness and treatment
- Resilience factors and strengths
- Self-efficacy and perceived control
Social Factors in Etiology
Social factors include environmental, cultural, economic, and interpersonal elements that influence health outcomes. These factors can significantly impact disease development, progression, and management.
Key Social Determinants of Health
| Factor | Description | Clinical Examples |
|---|---|---|
| Socioeconomic Status | Income, education, and occupation | Limited access to healthy food in low-income areas, financial barriers to medication adherence |
| Housing Conditions | Quality, stability, and safety of living environment | Asthma exacerbations due to mold exposure, injuries from unsafe housing |
| Social Support | Available assistance from family, friends, and community | Isolation increasing risk for depression, strong support network improving recovery outcomes |
| Education Access | Quality and level of educational opportunities | Health literacy affecting treatment adherence, educational level influencing health behaviors |
| Employment Status | Work conditions, job security, and benefits | Occupational hazards, stress from job insecurity, lack of health insurance |
| Community Resources | Availability of services and support in local area | Food deserts limiting nutritional options, lack of safe spaces for physical activity |
| Cultural Factors | Beliefs, practices, and traditions affecting health | Cultural dietary patterns, traditional healing practices, health beliefs influencing care-seeking |
| Discrimination | Systemic biases based on race, gender, age, etc. | Healthcare disparities, chronic stress from experienced discrimination, delayed care-seeking |
| Healthcare Access | Availability, affordability, and quality of health services | Transportation barriers to appointments, inability to afford medications, limited specialist availability |
| Environmental Exposures | Physical surroundings and environmental hazards | Air pollution exacerbating respiratory conditions, lead exposure in older housing |
Social Pathways to Disease
Social factors can influence health through several pathways:
- Material pathway: Direct effects of material deprivation (e.g., malnutrition, exposure to hazards)
- Psychosocial pathway: Stress from social conditions affecting physiological systems
- Behavioral pathway: Social influences on health behaviors (e.g., smoking, diet, exercise)
- Access pathway: Barriers to healthcare services and preventive care
- Structural pathway: Systemic inequities embedding health disparities in society
Clinical Pearl: Upstream Factors
Social determinants are often considered “upstream factors” because they occur before and influence the more immediate “downstream” biological and psychological factors. Addressing these root causes can have more substantial and sustainable impacts on population health than focusing solely on individual medical interventions.
For example, improving housing conditions for a community may do more to reduce asthma hospitalizations than simply providing more inhalers, though both approaches are necessary for comprehensive care.
Mnemonic: “SOCIAL HEALTH”
To remember key social factors in disease etiology:
- Socioeconomic status and resources
- Occupational factors and working conditions
- Community environment and infrastructure
- Interpersonal relationships and support
- Access to healthcare services
- Living conditions and housing quality
- Health literacy and education
- Equality and justice in society
- Adverse childhood experiences
- Lifestyle norms and cultural factors
- Transportation and mobility resources
- Historical context and structural factors
Biopsychosocial Interactions and Clinical Applications
The biopsychosocial model emphasizes that biological, psychological, and social factors don’t operate in isolation but interact in complex ways. Understanding these interactions is crucial for comprehensive nursing assessment and care planning.
Factor Interactions
Examples of Biopsychosocial Interactions
Diabetes Management:
- Biological: Insulin resistance, pancreatic β-cell dysfunction
- Psychological: Depression affecting self-care motivation, stress increasing blood glucose
- Social: Food insecurity limiting dietary options, lack of safe spaces for exercise
- Interaction: Stress (psychological) can increase cortisol levels (biological), which raises blood glucose. Poor social support (social) can worsen depression (psychological), reducing medication adherence and affecting biological control.
Chronic Pain:
- Biological: Tissue damage, inflammation, central sensitization
- Psychological: Catastrophizing, fear-avoidance beliefs, depression
- Social: Job-related factors, disability benefits, family responses to pain
- Interaction: Fear of movement (psychological) leads to disuse, resulting in muscle deconditioning (biological). Workplace stressors (social) can increase muscle tension (biological) and anxiety (psychological), worsening pain perception.
Hypertension:
- Biological: Genetic predisposition, renal mechanisms, vascular changes
- Psychological: Chronic stress, hostility, anxiety
- Social: Food environment, socioeconomic status, healthcare access
- Interaction: Food deserts (social) limit access to fresh produce, leading to high-sodium diets (biological). Job stress (social) increases sympathetic activation (biological) and contributes to sustained hypertension.
Clinical Applications for Nursing Practice
Case Study: Applying the Biopsychosocial Model
Patient Profile: Mrs. Chen, 68-year-old with poorly controlled type 2 diabetes
Biomedical Approach (Limited):
- Adjusts insulin dosage
- Orders additional lab tests
- Recommends standard diabetic diet
- Explores factors beyond medication adherence
- Addresses emotional and social context
Biopsychosocial Approach (Comprehensive):
- Biological: Assesses medication regimen, comorbidities, and physiological factors affecting glucose control
- Psychological: Explores depression screening (PHQ-9 reveals moderate depression), diabetes distress, and beliefs about illness
- Social: Discovers patient is primary caregiver for husband with dementia, has limited time for self-care, and faces financial strain affecting food choices
- Integrated Assessment: Recognizes that depression and caregiver burden are significant barriers to diabetes management
- Holistic Intervention Plan: Includes medication adjustment, referral for depression treatment, connection to caregiver support services, and meal planning assistance that fits her time and budget constraints
This biopsychosocial approach addresses the interrelated factors affecting Mrs. Chen’s health, leading to more effective and sustainable diabetes management than focusing solely on medication adjustment.
Clinical Pearl: PSCEBSM Assessment Framework
The PSCEBSM framework provides a practical guide for biopsychosocial assessment in clinical settings:
- P – Pain/Presenting Problem: Detailed assessment of the primary concern
- S – Somatic and Medical Factors: Physical examination, medical history, biological factors
- C – Cognitive Factors: Beliefs, perceptions, understanding of condition
- E – Emotional Factors: Psychological state, emotional responses
- B – Behavioral Factors: Health behaviors, coping strategies, lifestyle
- S – Social Factors: Support systems, relationships, resources, environment
- M – Motivation: Readiness for change, treatment goals
This structured approach ensures comprehensive assessment across all domains of the biopsychosocial model.
Nursing Assessment and Documentation
Applying the biopsychosocial model in nursing practice requires systematic assessment and documentation. Below are examples of how to structure nursing documentation using this approach.
| Sample Nursing Assessment Using Biopsychosocial Framework | ||
|---|---|---|
| Domain | Assessment Focus | Sample Documentation |
| Biological | Physical Examination | “BP 158/94, HR 88, RR 20. BMI 32.5. Bilateral peripheral edema +2. Fasting blood glucose 210 mg/dL.” |
| Symptoms | “Reports fatigue, polyuria, blurred vision, and numbness in feet. Pain rated 6/10 in lower extremities.” | |
| Medical History | “Type 2 diabetes diagnosed 8 years ago. Family history of cardiovascular disease. Current medications: metformin, lisinopril, atorvastatin.” | |
| Psychological | Mental Status | “Alert and oriented x3. Affect flat. PHQ-9 score 14 indicating moderate depression. Expresses feelings of hopelessness about managing diabetes.” |
| Health Beliefs | “States ‘Nothing I do seems to make a difference with my blood sugar.’ Low self-efficacy for diabetes management. Believes condition is ‘punishment for past lifestyle.'” | |
| Coping Strategies | “Reports using food for comfort when stressed. Avoids checking blood glucose when anticipates high readings. Has stopped exercising due to fear of hypoglycemia.” | |
| Social | Support Systems | “Lives with spouse who works long hours. Adult children live out of state. Reports feeling isolated and lacking support for diabetes management.” |
| Economic Factors | “Recently retired with fixed income. Reports difficulty affording healthy foods and occasional rationing of medications to save money.” | |
| Environmental Factors | “Lives in apartment complex without exercise facilities. Reports neighborhood safety concerns limiting outdoor activities. No grocery stores within walking distance.” | |
Important: Etiology in Nursing Diagnosis Format
When formulating nursing diagnoses, the etiology component (the “related to” section) should incorporate relevant biopsychosocial factors identified in your assessment. This helps target interventions at the underlying causes rather than just the symptoms.
Example Format:
Problem “related to” Etiology “as evidenced by” Signs/Symptoms
Examples Using Biopsychosocial Framework:
- Ineffective Breathing Pattern related to anxiety and pain (psychological factors) as evidenced by shallow respirations, tachypnea, and verbalized difficulty breathing.
- Impaired Physical Mobility related to inflammatory process (biological factor) and lack of assistive devices (social factor) as evidenced by limited range of motion and difficulty ambulating.
- Non-adherence related to health beliefs (psychological factor), medication side effects (biological factor), and financial constraints (social factor) as evidenced by missed doses and verbalized concerns about medication.
Summary and Key Takeaways
Etiology is the study of causation in disease, involving complex interactions between biological, psychological, and social factors.
Biopsychosocial Model provides a comprehensive framework for understanding health and illness as products of the interplay between these three domains of factors.
Key Principles for Nursing Practice
- Health and illness result from complex interactions between biological, psychological, and social factors.
- Comprehensive assessment across all three domains is essential for effective care planning.
- Etiological factors can be categorized as predisposing, precipitating, or perpetuating.
- Interventions should target modifiable factors across biological, psychological, and social domains.
- A multidisciplinary approach is often necessary to address complex biopsychosocial factors.
- Understanding etiological factors is crucial for both treatment and prevention strategies.
- The same disease may have different combinations of etiological factors in different individuals.
Applying the Biopsychosocial Model in Nursing
Assessment
- Collect data across all domains
- Use validated screening tools
- Consider cultural context
- Identify patterns and interactions
- Recognize strength and resilience factors
Diagnosis
- Formulate nursing diagnoses with multifactorial etiology
- Prioritize based on patient needs and input
- Consider how factors interact and reinforce each other
- Incorporate risk and protective factors
- Document clear “related to” statements
Intervention
- Design holistic care plans
- Target modifiable factors
- Collaborate across disciplines
- Engage patient’s support system
- Address upstream social determinants
Mnemonic: “BIOPSOCIAL FACTORS”
A comprehensive mnemonic for remembering key components of etiological assessment:
- Biological predispositions and physical factors
- Interactions between different domains
- Ongoing assessment across all factors
- Psychological processes and emotional states
- Social determinants and environmental context
- Outcomes influenced by multiple pathways
- Cultural considerations in all assessments
- Individual variations in factor combinations
- Adaptation and coping mechanisms
- Lifestyle components affecting health
- Family history and genetic influences
- Access to resources and healthcare
- Cognitive processes and health beliefs
- Treatment approaches targeting multiple factors
- Optimize care through holistic assessment
- Relationships and support systems
- Strengths-based perspective in care planning
References
- Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136.
- Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. Annals of Family Medicine, 2(6), 576-582.
- Wade, D. T., & Halligan, P. W. (2017). The biopsychosocial model of illness: A model whose time has come. Clinical Rehabilitation, 31(8), 995-1004.
- World Health Organization. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization.
- Lehman, B. J., David, D. M., & Gruber, J. A. (2017). Rethinking the biopsychosocial model of health: Understanding health as a dynamic system. Social and Personality Psychology Compass, 11(8), e12328.
- Herdman, T.H., & Kamitsuru, S. (Eds.) (2018). NANDA International Nursing Diagnoses: Definitions and Classification, 2018-2020. Thieme.
- Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129(Suppl 2), 19-31.
- Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), 1378-1382.
- Hatala, A. R. (2012). The status of the “biopsychosocial” model in health psychology: Towards an integrated approach and a critique of cultural conceptions. Open Journal of Medical Psychology, 1(4), 51-62.
- American Nurses Association. (2021). Nursing: Scope and Standards of Practice, 4th Edition. American Nurses Association.