Adam Blatner

Words and Images from the Mind of Adam Blatner


Originally posted on November 25, 2012

This is the tendency to treat things as if they were a disease when instead they should be better imagined as something else, such as a common problem in ordinary life. A friend suggested that a number of conditions are “medicalized”—implying that they should not be. This is really interesting from multiple viewpoints.

When is irritability a problem, or pre-menstrual dysphoria? Are there types of attention-deficit that should rightly be called temperamental variations rather than a disorder? Such questions have a number of implications:
   1. Should “severe” cases be treated only by physicians? What about mild cases? How does one tell the difference? There is a bias here by people who have a vested interest in either having such people “treated” by medical professionals or non-medical practitioners—or through a self-help book that advises self-acceptance and channeling natural inclinations into the right kinds of jobs or family life.

  2. Just because a tendency can be helped by a pill or drug, that doesn’t necessarily medical. The border between the medical specialty of opthalmology and the non-medical specialty of optometry may be a model—some conditions such as nearsightedness or the far-sightedness of eldering (“presbyopia”) seem not to require medicalization in order to adjust and use prostheses (i.e., spectacles).

  3. Some medicines also are used nowadays to regulate mood and attention. They seem to make a great difference. These medicines are used for years on end, and the person using them is otherwise healthy. These drugs are prostheses, not something use to treat an acute illness. Is this medicalization?

  4. No doubt there are many occasions when professionals prescribe medicines for conditions where they may not be that useful. Some are quite expensive, some have undesirable side effects, and some might disguise the need to search for non-medical remedies. Nor is it that clear that there are non-medical remedies, though there are always those who will make such claims.

5. Also, there are questions about non-medical approaches: Some require a commitment of time, energy, and often professional (expensive!!) time that is far greater than what benefits may be obtained far easier and less expensive through the use of a pill. I say this because it seems that some folks feel an almost a moral obligation to avoid pills, and this bias can make life far more difficult than it needs to be for many people who suffer from a lack of what that pill provides.

6. This moral opprobrium of course spills over into the use of alcohol, marijuana, other drugs, and so forth. While some are “legal,” that clearly doesn’t make them “right”—but what is and is not okay is very much part of the culture shift that is going on today. As new pills or drugs with fewer side effects evolve; or in the other direction, more highly concentrated drugs—which has happened not only with alcohol, but also fat, salt and sugar (!), all this may continued to evolve as a theme in our culture.

7. The boundary between the freedom of recreation and the need for government regulation again is part of this. Some claim that the right of owning a gun is different in essence from the right to choose a romantic or sexual partner that differs from societal norms, or from using certain drugs that may be far less addictive than more legal types (i.e., cigarettes and alcohol), etc. Clearly, these differences are not just about the pros and cons of the issues themselves, but are bundled with complexes of other political, religious, and sub-cultural loyalties.

  8. Indeed, all this teeters on the edge of another fuzzy realm, the “cosmetic” use of surgery. What is elective and what is necessary for health?

  9. All these converge in arguments about what medical insurance or Medicare or prison medical care and so forth should or should not cover. Erectile dysfunction? (Don’t minimize the impact of this on the people involved—it’s not a small matter to them!)

10. If the criterion is the enhancement of life and reduction of disability, who then decides what counts as valid or invalid examples of these abstractions? It’s clear that what one person calls a disability another would say is a natural condition. For example, should kids who have trouble concentrating be stopped from using stimulant drugs while studying for exams? Or athletes competing? “But this gives them unfair advantage.” Well, what then if “everybody” is doing it?

11. The fact that a “condition” is quite common—like nearsightedness—doesn’t mean that it might deserve to be recognized (and treated) like a problem. That’s what hygiene (preventive medicine) is about! Dental floss, good sewage management, pure food, vitamin fortification of staple foods, the list is extensive.

12. Another part of medicalization is the attachment of a “diagnosis” where none existed before. Sometimes diagnosis is one of the better things we can do as physicians, answering the feeling-filled question, What’s wrong with me? Am I just lazy? Oversensitive to my body? Making a big deal about nothing? Self -doubt is a form of mild pain. Should I have done something to prevent this? Am I weird, bad? No, no, this is a recognizable condition, happens sometimes. What will happen? Will I have this forever, will it get worse? What should we do? What will it cost me? Diagnosis is a major therapeutic gift.

13. Secondly, diagnosis sometimes helps doctors to think about, explore further, and then effectively treat various conditions. A good part of the history of medicine has involved improvements in diagnosis. (Example: Oh, this? This isn’t an infective disease: this is a nutritional deficiency.)

14. The fact that some approach gets overdone, overdiagnosed, over-treated, is not in itself a reason we should avoid that procedure or medication. It’s not either-or, but how to find the right balance. Some medicines that have now been standardized were in the early years of their use unreliable—some preparations far stronger than others. Digitalis for heart failure is an example. Finally, we learned to assess and regulate the dose delivered. This is one of the challenges of pharmacology.

15. All these relate to the word “medicalize,” and show why this (and many other words) are terribly complicated. There is a seduction in having a word: It suggests that having named something means that it’s known, when in fact a category may have as many mis-uses as uses. Words are tools and often can be mis-used. This mini-essay shows the many facets of a single seemingly simple word, “medicalize.”

16. Psychiatric conditions have in the past and still to some extent with many plans are either not covered or covered at a different rate. This is not altogether arbitrary, because there are hundreds of times more episodes of people earning a diagnosis of anxiety disorder, depression, or some other ambiguous label for what are problems of living—far less clearly a “medical” condition than, say, schizophrenia. It’s unclear whether the more common diagnoses do merit third party payments, it must be admitted.
       That is to say that we need to re-examine the assumptions behind the socioeconomic use of diagnosis. Should medical insurance be used to cover which psychiatric conditions? Many depressions are milder but some are extremely severe and indeed may well be attributable to neurological or neurophysiological changes.
       What about becoming angry with one’s spouse? No big deal? But what about doing this habitually or going out of control and becoming violent?
       And what about the behavior representing a significant change in function! That’s what brain tumors do, or sever PTSD, or head injuries. “Well, I was never like this before, doc. Ever since that head injury…” or “…coming back from Afghanistan…”

  17. We cannot just refuse to diagnose in many cases, especially if we are pursuing a more organic underlying disease. On the other hand, for most outpatient treatment, most people seeking help really are not benefitted by being saddled with a label and may even be harmed.

  18. Then there’s the problem of various kinds of criminality, in which the proposal of mental illness is called upon to reduce the quality of accountability. This is most complex, but certainly there should be a spectrum of reactions in-between full guilt and maximum punishment and getting off scot-free.

  18. What are some other examples of situations in which we are “medicalizing” that which should not be medicalized?

Well, that’s it for now. Alas, many situations in culture, many abstractions have equivalent complexities, different viewpoints. My real goal is to stimulate more nuanced thinking.

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