The wide usage of antipsychotic medications may indicate social rather than biological etiology
There are many lessons to take away from the New York Times article linked below that describes a rambunctious little boy whose life was nearly ruined by anti-psychotic medications. Increasing numbers of children have been prescribed this class of drugs as of late for conditions ranging from Tourette Syndrome to bipolar disorder, which psychiatrists have begun to diagnose in children at younger and younger ages. There is controversy surrounding the very ability to diagnose these conditions in young children and certainly over the utility and safety of prescribing the most potent of the psychiatric medications for this population. The issues associated with medicating children, especially with this class of medications, as well as the dangers to them, their families and society more broadly are innumerable (even if there are benefits in some cases, which most biological psychiatrists argue there is). But for now, let’s take this as an example of the increasing diagnosis of disorders such as bipolar disorder, which is an intriguing phenomenon that needs exploration at the aggregate level.
In the debate over whether any disorders are purely biological entities, sociologists generally adhere to the argument that bipolar disorder and schizophrenia seem to be heavily rooted in biology, since the rates of these disorders are relatively stable over time and place. As opposed to depression, anxiety, substance abuse, etc., the former disorders do not seem affected by culture (though the course of the illnesses are) or the social environment more broadly. In other words, there is fairly wide agreement that bipolar disorder and schizophrenia are in fact organic conditions, not likely to be born of social or environmental factors alone (or maybe at all). However, as these diagnoses become increasingly common (this does not yet seem to be the trend with schizophrenia but certainly is the case with bipolar disorder), what does this say about the assumption of biological etiology?
A major driving force in increased diagnosis is the use of anti-psychotic drugs, which were once reserved just for adults, with children. The rate of diagnosis, in other words, would expand, at least partly, because children are now lumped into a category with adults who have these disorders (because the stigma around prescribing potent drugs to children has diminished), thereby increasing the number of people who are diagnosed overall. Another trend is the diagnosis of bipolar disorder in people who would once not have met the criteria for a diagnosis, but because of changing diagnostic categories, now do. For instance, the expansion of bipolar disorder to include a bipolar II category, which requires far fewer symptoms to diagnose, means far greater numbers of people are considered to have bipolar disorder. Whereas full-blown mania used to be a necessary precursor to a diagnosis, much more subtle changes in mood can also lead to a diagnosis of hypomania, which may be treated with similar medications.
What does this say about these disorders? For decades, the best evidence that bipolar disorder is a biological condition was it’s stability in terms of how many people are affected. Depression rates have changed dramatically over time. Disorders like substance abuse are clearly influenced by environmental factors. But bipolar disorder, until late, has not seemed to follow this trend. It does now. So, do we have new grounds to look at this disorder and perhaps at schizophrenia as well as potentially influenced by circumstance? If the particular doctor who diagnoses it or the growing trend to use results from medication as a reverse-order diagnosis continues, these things are likely to greatly inflate the rates of these disorders. Is there really more illness? Or is this over-diagnosis or even misdiagnosis, as has been suggested by many scholars who study depression (See, for instance Horwitz and Wakefield)? Can we effectively say that anything is a purely biological condition? Or, maybe we are witnessing a moment where over-diagnosis occurs — where “true” illness and what some have referred to as normal response to situational factors (“normal sadness” according to Horwitz and Wakefield, when discussing depression) are lumped together as one and the same?
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Speaking from experience as someone with bipolar disorder, I think that under-diagnosis would be much more of a problem than over-diagnoses. Of course it’s never good to take chances with a child’s health in either case, but maybe it’s best to err on the side of caution, and treat the illness even if it’s only suspected, before it gets worse.
What a fascinating question you raise in this post “Can we effectively say that anything is a purely biological condition?” What do you think?
Keri
Well, the evidence is mixed but I think the answer is no – nothing is altogether biological, just as nothing is entirely social. I think the issue is the notion of “purely biological.” While this is how the medical fields (particularly in the last several decades) have framed illness, continually pushing for the consideration of biological etiology over all other possible sources of illness, it seems quite evident that we simply don’t know what CAUSES illness. There is clearly a biological element to all of these conditions, given that they often respond to medication and that the body is simply a biological organism, but that doesn’t mean that the root cause is in the body. Biology, after all, responds to social stimuli. And, while there’s uncertainty (no matter what anyone claims to know) about etiology, there’s actually quite obvious evidence of social effects on symptoms. So, I think maybe a more relevant question than the one I posed is actually what these changing notions of illness tell us about the social – so, taking it as a given that nothing is purely bio or social, what’s the message about social influence or environmental influence if there is increasing evidence that biology is not the only important factor? Also, I think this is an interesting moment to look at over-diagnosis because it seems possible that there is another option — which is that there is a biological phenomenon that causes certain illnesses (though I’m not sure which ones) but that then, the diagnostic category is used to identify conditions that seem similar, but which might not actually be identical. So, we wind up with people with possibly biologically-driven symptoms lumped into a category with people whose symptoms may appear similar but are not in fact the same. So I guess the answer is that I’m not sure, but I tend to think that there is a fine line (though a real one) between disease and conditions that may appear similar but are more transient or caused by situations. This is a fairly similar argument that Allan Horwitz and Jerome Wakefield’s argument about depression and “normal sadness” and I think it’s one that usefully assimilates social constructions arguments alongside the biological evidence. In the end, I guess my answer would be that I think sociologists and biologists alike should focus more on the intersection of the bio and social.