Institute For The Future

There Are Problems. And There Are Biological Problems

 

What's the difference between conduct disorder and biplor disorder? A recent NPR story by Alix Spiegel highlights that, even though these terms have been used by psychiatrists to refer to roughly the same behaviors, at least when describing children, the meanings of these two terms have profound impacts on how our social institutions respond. We blame parents for problems, but we accommodate, manage and treat medical problems.

 

Noting that the number of children diagnosed with bipolar disorder has increased by 4,000 percent since the 1990s, Spiegel then goes on to describe the different ways we classify "kids struggling with explosive moods." Prior to that point, "the prevalence of bipolar disorder in children somewhere between 'never' and 'vanishingly rare.'" While there's a significant debate among psychologists about whether the rise in diagnosis of bipolar disorder is justified--in fact, the disorder is slated to be reclassified in the forthcoming DSM--the classification of 1 million American children as bipolar, many of whom used to be diagnosed with conduct disorder, has had profoundly reaching effects.

 

 

 

 

Gabrielle Carlson, a child psychiatrist at Stony Brook University, doesn't agree that the bipolar label took off simply because the diagnosis allowed clinicians to finally categorize children in a way that made sense. She points to a host of other reasons.

 

For example, she says many of the kids now categorized as bipolar were, once upon a time, diagnosed as having conduct disorder. Kids with conduct disorder are seen as very combative, aggressive, and prone to destructive behavior. But the treatments for conduct disorder are woefully limited, says Carlson. "Mostly prayer and fasting," she says. "We don't have good treatments for it. We've got parent-training kinds of treatment, very strict behavioral modification kinds of things, but the evidence that therapy makes a big difference is not wonderful."

 

Which is why when every day psychiatrists were told that they could now think of this set behaviors as manic-depression, not as conduct disorder, they got so excited, says Carlson. "They thought, 'Heck, if that's what it is, we have a bunch of medicines that are supposed to be helpful for mania — maybe I can make it better,' " she says. This has deep appeal to doctors face to face with parents who are heartbroken over the difficult time their child is having.

 

Another advantage to the bipolar label, Carlson points out, is that the insurance industry saw bipolar as a biological or medical problem, while conduct disorder was seen more as a parenting problem, so insurance companies were reluctant to reimburse for it.

 

 

 

 

Elsewhere in the story, Spiegel notes that schools have been more tolerant of behavioral issues among students diagnosed with bipolar disorder. And that's the key lesson of this story, I think. The ability to explain a phenomenon as biological--as a medical problem beyond an individual's control--is a fundamentally different way of explaining behavior that shifts how everyday people and institutions react.

 

A few months ago, I noted that a court in Italy shortened a sentence of a convicted murderer due to a genetic mutation that has been linked, somewhat tenuously, to violent behavior. At the time, I (and others) pointed out that someone could credibly make the reverse argument: That a genetic predisposition to violence could, just as easily, be used to justify harsher prison sentences.

Scientists can now identify when a brain scan indicates that you intend to break a promise, and if your genes suggest you might stutter--some of the early signals of a broader trend to explain virtually everything as a symptom of biology. How people, and institutions, adapt to these explanations will become an increasingly interesting and important question.