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I'm overdue for a rant, damn it—I've got intermittent explosive disorder (IED) don't you know? Oh, and while we're on the subject of your knowledge, you do realize it's your fault, doctor, that since you won't give me codeine I have to steal to do drugs? I know I smoke doc, but what are you going to do about my chest? But I don't eat too much. I hit her because I was having some sort of seizure—can you give me something for it? Well, it's like this: I can't afford to keep my house tidy. I've had a bad day; can I have Prozac? Familiar?

When are people going to wake up and take responsibility for their own actions (or lack thereof)?

The BBC is reporting a study suggesting that the entity formerly known as "bad behaviour" be re-classified as a mental illness called "intermittent explosive disorder". This is the latest effort to transmogrify something traditionally considered "non-disease" into something for which you can receive absolution from your doctor. The suggestion is hot on the heels of the rise to stardom of CKD (chronic kidney disease) which, although measuring eGFR is undoubtedly useful, also seems to be about attaching a new medical term to "getting on a bit" (think of eGFR as a percentage measure of kidney function; the percentage naturally gets less as you get older).

What is medicalisation?

I discovered a useful presentation by Richard Smith, a former Editor of the BMJ, given in September 2003 asking "Where are the limits of medicine: are we turning the whole world into patients?" Smith defines medicalisation as:

The process of defining an increasing number of life's problems as medical problems

Reflecting on this it seems this process has gathered pace. The "increasing number" is a relatively recent phenomenon. In his presentation Smith identifies several medicalisation trends:

• intervention with birth (e.g. increasing caesarean rates);
• intervention with death (e.g. inappropriate intensive care);
• intervention with sexuality (e.g. "female sexual dysfunction");
• over-investigation/ over-screening.

The reasons for these trends are multiple and mostly understandable (that's a different choice of word from "justifiable"). Butt-covering and profiteering (patients are now clients) are motivations high up on the list of causative factors, but I think there's a very significant cultural aspect to all of this. It's increasing medicalisation of primarily social problems that is the subject of my rant. For example, in addition to IED:

• Smoking;
• Alcohol abuse;
• Illicit drug abuse;
• "Social phobia";
• Shyness;
• "Normal" life events such as relationship difficulties, childbirth, menopause (it doesn't even exist in some cultures), aging, male pattern baldness,...
• Problems in the education system like bullying and truancy (I do not want to be issuing medical certificates to account for school absences!);
• Is it "disruptive behaviour" or ADHD?;
• Filth;
• Sexual orientation;
• Some cases of "tired all the time" and "I'm depressed".

Many problems on this list, even if social in origin, can of course have significant medical consequences. I have no problem dealing with the consequences... that's what doctors do. But it's society that has to prescribe the cure for the cause.

What are "social problems"?

In the context of "holistic" healthcare it is most difficult to tease out the social elements from the physical, emotional, spiritual, etc. Importantly, deciding someone has a social problem rather than a medical one doesn't automatically make them "normal". To be normal, statisticians would argue, is to be one of the 95% of people that lie within 2 standard deviations from the mean in a distribution curve for the parameter you are measuring. Of the 5% lying outside this range, a few will still be "normal" and the rest "deviants". Outside of this range, a social behaviour may be atypical at best, criminal or self-destructive at worst. Some will be outside social norms because they are ill (mentally or otherwise), and some will be so because they make certain choices of their own free will, or because they are just plain evil.

Yes, that's right, you have choices. And there are evil people out there. Don't be so keen to excuse everyone. A thug doesn't knife a person to death because his doctor didn't prescribe anything to help his violent outbursts: he's just a thug. Period. Heroin addicts don't smash your car windscreen and take the radio because of a medical problem; they do it because they are just criminals. Period.

Am I suggesting that a behaviour is aberrant if practised by 5% or less of the population? It may well be, but that 5% don't have a monopoly. Take smoking; nearly 1 in 3 adults in the UK under 65 years smoke. It would be hard to argue this is an "abnormal" behaviour. One in 10 people are left-handed, an attribute less common than being a smoker, but still considered (nowadays) "normal" nevertheless. But most people likely agree that smoking is a social problem. Why is that? Is it because this is the "traditional" view?

I haven't found a definition I'm happy with. For example, this one:

Social problems are societally induced conditions that harm any segment of the population, and acts and conditions that violate the norms and values found in society.

How do you "violate the norm" when the behaviour could be considered the (non-exclusive) norm? How do you "violate the values" if a large proportion of society is not clear anymore what it's core values are?

It's important to note that "normal" is not fixed—not in time, place, or any other context. No wonder it's so hard to define.

The importance of disease

Is it easier to give up trying to define social problems, and move on to the definition of medical problems instead?

You can't have a medical problem unless you have a disease.

Do you agree? It sounds reasonable at first, until you mull it over. Smoking (a.k.a nicotine addiction) is widely held to be a disease. I hear myself not infrequently telling a patient "You have smoking-related lung disease". I am, of course, referring to the consequences—but the point is that some states of being can be both social problems and medical diseases. You don't just get disease when the choice is not yours (e.g. diabetes, coronary heart disease). Sometimes you get a disease via your conscious choices and social behaviours (e.g. diabetes, heart disease). Many conditions can be had both with or without self-responsibility.

In the same presentation, Smith also asks "What is a disease?" and rather elusively says:

A disease is a social and medical construct—and as such a very slippery construct.

On that we can agree, having gone through the above reasoning. There's not even an answer to the simpler-sounding question of "What is not a disease?"

Perhaps a disease is simply a non-exclusive state that the majority perceive to be addressable in a medical context, within the context of the attitudes prevalent at a given time in a particular society or sub-culture.

Social or medical? Who is to blame?

The medical profession, at least in part. From empire-building to self-promotion, there may be several reasons for the rise of medicalisation:

Patients and their professional advocacy groups can gain moral and financial benefit from having their condition defined as a disease. Doctors, particularly some specialists, may welcome the boost to status, influence, and income that comes when new territory is defined as medical. Advances in genetics open up the possibility of defining almost all of us as sick, by diagnosing the "deficient" genes that predispose us to disease. Global pharmaceutical companies have a clear interest in medicalising life's problems, and there is now an ill for every pill. Likewise companies manufacturing mammography equipment or tests for prostate specific antigen can grow rich on the medicalisation of risk. Many journalists and editors still delight in mindless medical formulas, where fear mongering about the latest killer disease is accompanied by news of the latest wonder drug. Governments may even welcome some of society's problems within, for example, criminal justice being redefined as medical, with the possibility of new solutions.

In his presentation Smith also (and importantly) highlights:

The decay of cultural, particularly religious, ways of managing difficulties.

I don't think we can under-estimate the importance of this last suggestion. Medicine is the recipient of societal ills because, well, there is nothing else to pick up the pieces.

Conclusion

The BMJ cites Ivan Illich:

In a morbid society the belief prevails that defined and diagnosed ill-health is infinitely preferable to any other form of negative label or to no label at all. It is better than criminal or political deviance, better than laziness, better than self-chosen absence from work. More and more people subconsciously know that they are sick and tired of their jobs and of their leisure passivity's, but they want to hear the lie that physical illness relieves them of social and political responsibilities. They want their doctor to act as lawyer and priest. As a lawyer, the doctor exempts the patient from his normal duties and enables him to cash in on the insurance fund he was forced to build. As a priest, he becomes the patient's accomplice in creating the myth that he is an innocent victim of biological mechanisms rather than lazy, greedy, or envious deserter of a social struggle over the tools of production. Social life becomes a giving and receiving of therapy: medical, psychiatric, pedagogic, or geriatric. Claiming access to treatment becomes a political duty, and medical certification a powerful device for social control.

Wooh! That's one scary paragraph. Some insight for 1976.

Too many folks are just plain unwilling to accept personal responsibility for their individual actions, and look to others (such as the medical profession) to defer responsibility. Doctors cannot solve your social and political problems, so please don't ask us to (*). On the other hand, we would be pleased—as learned human beings trying to grasp the big picture—to help empower you to recognise your role in working towards solutions by means of advice, encouragement, and support.

So, are people labelled with "explosive disorder" sick, because they hit their wife or throw bricks through the neighbour's window? I suggest an alternative, non-disease taxonomy: "jerk".

Those are my thoughts. What are yours?

* This doesn't mean doctors can't contribute, as expert members of society, to helping solve problems as individuals or in groups e.g. IPPNW, environmental concerns, etc.

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