With Obesity, A New Disease is Born: Its Profound Implications for Psychiatry

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World of Psychology

With Obesity, A New Disease is Born: Its Profound Implications for Psychiatry

A new disease was discovered the other day — or rather, one was created.

There is no “lab test” for this disease, nor is there an X-ray, MRI, or CT scan that can detect it. It is diagnosed on the basis of a mathematical formula that many believe is simplistic and poorly-validated.

Sometimes this “disease” results in metabolic abnormalities, sometimes not.

Many clinicians view the decision to recognize this disease as another example of “medicalizing” a problem stemming from the person’s “life-style” — not from a specific pathological process. In fact, the declaration that this condition is a “disease” was the result of a vote among a group of doctors at a medical meeting in Chicago.

In effect, this condition became a disease through a show of hands.

And many believe that the “disease” in question will merely amount to a “stigmatizing label” for millions of otherwise healthy Americans.

No, I’m not talking about Disruptive Mood Dysregulation Disorder, or Premenstrual Dysphoric Disorder — two new disorder categories created by the recently-released and intensely controversial DSM-5, psychiatry’s new diagnostic manual. Nor am I talking about long-established psychiatric disorders like schizophrenia or major depression.

Instead, I’m talking about obesity. And while the move by the American Medical Association to recognize obesity as a disease is proving controversial — after all, it contradicted the conclusion of the AMA’s own Council on Science and Public Health — I predict that the AMA’s decision will not generate anything like the vitriolic attacks directed against the DSM-5 and the profession of psychiatry.

Why might this be so?  

First, the general public tends to single out psychiatry for a failure to use “objective” measures and definitions of “disease”. Many in the popular media and the general public have bought the misguided notion that the term “disease” has a universal and uncontroversial definition in general medicine.

Yet, as Andrew Pollack pointed out in the June 18, 2013 New York Times, “…the question of whether obesity is a disease or not is a semantic one, since there is…[no] universally agreed upon definition of what constitutes a disease.”¹ Indeed, the concept of what is a “disease” or “disorder” has been a matter of dispute among physicians since the time of Hippocrates.

Second, many in the general public may believe that there are “objective” tests for obesity — such as biochemical measures of lipid or sugar metabolism — whereas they do not believe such tests exist for psychiatric disorders. This, too, is largely incorrect.

Obesity is defined by a measure called the BMI, or body-mass index — basically, a person’s weight divided by height. There is no single metabolic measure or laboratory test that validates a diagnosis of obesity — though marked obesity may result in very serious metabolic and cardiovascular complications for some individuals.

Indeed, I would argue that the biological correlates of schizophrenia are at least as well-established as those for obesity. When DSM-based criteria are used to identify persons with schizophrenia, we find numerous brain abnormalities highly (though not invariably) correlated with the diagnosis. As one recent review put it, “Neuroimaging studies have linked structural and functional [brain] abnormalities [in schizophrenia] to symptoms; and progressive structural changes to clinical course and functional outcome.”²

Finally and perhaps most important for many critics of psychiatry: people are not hospitalized against their will for being obese — but they may be so hospitalized when a psychiatric disorder creates a substantial danger to the patient or others.

In general, this means that a person diagnosed with a psychiatric disorder may be hospitalized involuntarily for up to 72 hours, if the person is found to be suicidal or homicidal — the exact standards vary from state to state.³ But such an emergency hospitalization may be instituted, in most states, by any physician — not just by psychiatrists. And, contrary to a popular myth, psychiatrists do not “commit” people to mental institutions for weeks, months or years — only judges can do that, under due process of law.⁴ These legal issues arise because of policies enacted by duly-elected state legislatures and approved by the courts — not because of anything intrinsic to psychiatry’s diagnostic system.

Nevertheless, the widely-perceived link between psychiatric diagnosis and involuntary hospitalization will inevitably color the debate about whether psychiatric disorders are “real diseases.”  And, this same link will raise questions about psychiatric diagnoses that will not arise with regard to obesity.

The general public will continue to hear the simplistic claim that, “Unlike in general medicine, psychiatric disorders are merely invented by committees” — even though the American Medical Association just declared obesity a disease, by means of a simple vote.*

 

*I am not opposed to the AMA’s decision, and, despite some disadvantages of applying the “medical model” to obesity, the net result may be more intense and effective treatment for this condition.

 

Footnotes:

1. A.M.A. Recognizes Obesity as a Disease, New York Times
2. Ahmed AO, Buckley PF, Hanna M. Neuroimaging schizophrenia: a picture is worth a thousand words, but is it saying anything important? Curr Psychiatry Rep. 2013 Mar;15(3):345
3. Personal communication, Prof. Amanda Pustilnik (Associate Professor of Law, University of Maryland School of Law), 3/5/13
4. Personal communication, Prof. Amanda Pustilnik (Associate Professor of Law, University of Maryland School of Law), 3/5/13

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