Social Context, Biology, and the Definition of Disorder.

In recent years, medical sociologists have increasingly paid attention to a variety of interactions between social and biological factors. These include how social stressors impact the functioning of physiological systems, how sociocultural contexts trigger genetic propensities or mitigate genetic defects, and how brains are attuned to social, cultural, and interactional factors. This paper focuses on how both sociocultural and biological forces influence what conditions are contextually appropriate responses or disorders. It also suggests that some of the most obdurate health problems result from mismatches between natural genes and current social circumstances rather than from genetic defects. Finally, it examines how social environments have profound impacts on how much harm disorders create. It shows how sociological insights can help establish valid criteria for illnesses and indicates the complexities involved in defining what genuine disorders are.

The Troubled History of Psychiatry's Quest for Specificity.

Over the course of the nineteenth century, medical disciplines replaced holistic conceptions of body and mind with specific diagnoses that were unrelated to the qualities and circumstances of the individuals who harbored them. Despite periodic attempts from the late nineteenth through the mid-twentieth centuries to implement diagnostic systems based on the principle of specificity, psychiatric diagnoses remained undifferentiated, overlapping, and capacious. The need for medical legitimacy, compatibility with a biomedical model, and conditions that third parties would reimburse led psychiatry to replace the psychodynamically oriented DSM-I and DSM-II with the radically empiricist DSM-III in 1980. This manual emphasized explicit measurement, symptom-based entities, and homogeneous categories that were compatible with the specific disorders embraced in the rest of medicine. Yet the diagnostic system that the DSM-III launched was incongruent with the underlying nature of the continuous, fluid, and intersecting conditions with which psychiatry deals. The widespread institutionalization of the specific diagnostic system in psychiatric practice, however, prevented any thoroughgoing revisions when the DSM-5 was published in 2013. The result is an impasse between psychiatry's classificatory system and the need for scientific progress in understanding the causes of and treatments for mental disorders.

How Did Everyone Get Diagnosed with Major Depressive Disorder?

Psychiatric diagnoses often reflect a matrix of sociological factors associated with professional prestige, economic forces, and cultural fashions. Diagnostic systems conceptualize the same underlying psychosocial problems in very different ways during various time periods. Since the publication of the third edition of the Diagnostic and Statistical Manual (DSM-III) in 1980, psychological distress resulting from social circumstances that previously was viewed as a general problem of nerves, neuroses, and anxiety was transformed into the specific diagnosis of major depressive disorder. Several factors, including the contrasting ways in which DSM-III defined anxiety and depression, the necessity of using explicit diagnoses to obtain professional legitimacy and reimbursement for services, and the marketing practices of the pharmaceutical industry, account for why depression replaced anxiety as the diagnosis most suitable for treated mental health conditions. Beneath the changing veneer of psychiatric labels, however, lies the same mélange of psychic ills that resist the precise labels current diagnostic fashions strive to impose upon them.

The checkered history of American psychiatric epidemiology.

CONTEXT: American psychiatry has been fascinated with statistics ever since the specialty was created in the early nineteenth century. Initially, psychiatrists hoped that statistics would reveal the benefits of institutional care. Nevertheless, their fascination with statistics was far removed from the growing importance of epidemiology generally. The impetus to create an epidemiology of mental disorders came from the emerging social sciences, whose members were concerned with developing a scientific understanding of individual and social behavior and applying it to a series of pressing social problems. Beginning in the 1920s, the interest of psychiatric epidemiologists shifted to the ways that social environments contributed to the development of mental disorders. This emphasis dramatically changed after 1980 when the policy focus of psychiatric epidemiology became the early identification and prevention of mental illness in individuals. METHODS: This article reviews the major developments in psychiatric epidemiology over the past century and a half. FINDINGS: The lack of an adequate classification system for mental illness has precluded the field of psychiatric epidemiology from providing causal understandings that could contribute to more adequate policies to remediate psychiatric disorders. Because of this gap, the policy influence of psychiatric epidemiology has stemmed more from institutional and ideological concerns than from knowledge about the causes of mental disorders. CONCLUSION: Most of the problems that have bedeviled psychiatric epidemiology since its inception remain unresolved. In particular, until epidemiologists develop adequate methods to measure mental illnesses in community populations, the policy contributions of this field will not be fully realized.

Naming the problem that has no name: creating targets for standardized drugs.

Many of the most common types of mental health problems that are found in outpatient psychiatric and general medical practices are diffuse, undifferentiated, and amorphous. Before the 1970s this lack of specificity did not conflict with the dominant theories and treatments of the American psychiatric profession or the demands of third party insurers and regulators. However, since that time the legitimacy and solvency of the psychiatric profession has come to depend on the perception that it treats specific disease entities. The establishment of the DSM-III in 1980 provided American psychiatry with many standardized disease entities that could be precisely measured, quantified, and abstracted from their particular contexts. In the late 1980s, these entities became the targets of the new class of psychoactive drugs, the Selective Serotonin Reuptake Inhibitors. Professional, political, economic, and cultural forces that arose in a particular historical era account for the standardization of mental illnesses.

How an age of anxiety became an age of depression.

CONTEXT: During the 1950s and 1960s, anxiety was the emblematic mental health problem in the United States, and depression was considered to be a rare condition. One of the most puzzling phenomena regarding mental health treatment, research, and policy is why depression has become the central component of the stress tradition since then. METHODS: This article reviews statistical trends in diagnosis, treatment, drug prescriptions, and textual readings of diagnostic criteria and secondary literature. FINDINGS: The association of anxiety with diffuse and amorphous conceptions of "stress" and "neuroses" became incompatible with professional norms demanding diagnostic specificity. At the same time, the contrasting nosologies of anxiety and depression in the Diagnostic and Statistical Manual of Mental Disorders III (DSM-III) extended major depressive disorder to encompass far more patients than any particular anxiety disorder. In addition, antidepressant drugs were not associated with the stigma and alleged side effects of the anxiolytic drugs. CONCLUSION: Various factors combined between the 1970s and the 1990s to transform conditions that had been viewed as "anxiety" into "depression." New interests in the twenty-first century, however, might lead to the reemergence of anxiety as the signature mental health problem of American society.

Sequencing and its consequences: path dependence and the relationships between genetics and medicalization.

Both advocacy for and critiques of the Human Genome Project assume a self-sustaining relationship between genetics and medicalization. However, this assumption ignores the ways in which the meanings of genetic research are conditional on its position in sequences of events. Based on analyses of three conditions for which at least one putative gene or genetic marker has been identified, this article argues that critical junctures in the institutional stabilization of phenotypes and the mechanisms that sustain such classifications over time configure the practices and meanings of genetic research. Path dependence is critical to understanding the lack of consistent fit between genetics and medicalization.

Transforming normality into pathology: the DSM and the outcomes of stressful social arrangements.

The sociology of stress shows how nondisordered people often become distressed in contexts such as chronic subordination; the losses of status, resources, and attachments; or the inability to achieve valued goals. Evolutionary psychology indicates that distress arising in these contexts stems from psychological mechanisms that are responding appropriately to stressful circumstances. A diagnosis of mental disorder, in contrast, indicates that these mechanisms are not functioning as they are designed to function. The American Psychiatric Association's Diagnostic and Statistical Manual, however, has come to treat both the natural results of the stress process and individual pathology as mental disorders. A number of social groups benefit from and promote the conflation of normal emotions with dysfunctions. The result has been to overestimate the number of people who are considered to be disordered, to focus social policy on the supposedly unmet need for treatment, and to enlarge the social space of pathology in the general culture.

Distinguishing distress from disorder as psychological outcomes of stressful social arrangements.

Some studies in the sociology of stress conceptualize their outcome variables as distress, while others treat the same outcomes as mental disorder. This article focuses on the importance of distinguishing between the two. It argues that there are fundamental differences between distress that arises in non-disordered persons and genuine mental disorder but that studies of stress typically fail to distinguish between these conditions. The article outlines the historical developments that led the field to conflate distress and disorder. Finally, it indicates some advantages for research, treatment and policy that can accrue when distress that is initiated and maintained by social conditions is distinguished from mental disorders that are dysfunctions of internal psychological mechanisms.

Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey.

CONTEXT: Symptoms of intense bereavement-related sadness may resemble those of major depressive disorder (MDD) but may not indicate a mental disorder. To avert false-positive diagnoses, DSM criteria for MDD exclude uncomplicated bereavement of brief duration and modest severity. However, the DSM does not similarly exempt depressive reactions to other losses, even when they are uncomplicated in duration and severity. OBJECTIVE: To test the validity of the DSM exclusion of uncomplicated depressive symptoms only in response to bereavement but not in response to other losses. DESIGN: Community-based epidemiological study. PARTICIPANTS: From the National Comorbidity Survey (NCS) of 8098 persons aged 15 to 54 years representative of the US population, we identified individuals who met MDD symptom criteria and whose MDD episodes were triggered by either bereavement (n = 157) or other loss (n = 710). Intervention We divided the bereavement and other loss trigger groups into uncomplicated and complicated cases by applying the NCS algorithm for uncomplicated bereavement to the reactions to other losses. We then compared uncomplicated bereavement and uncomplicated reactions to other losses on a variety of disorder indicators and symptoms. MAIN OUTCOME MEASURES: Nine disorder indicators, as follows: number of symptoms, melancholic depression, suicide attempt, duration of symptoms, interference with life, recurrence, and 3 service use variables. RESULTS: Episodes of uncomplicated depression triggered by bereavement and by other loss have similar symptom profiles and are not significantly different for 8 of 9 disorder indicators. Moreover, uncomplicated reactions, whether triggered by bereavement or other loss, are significantly lower than complicated reactions on almost all disorder indicators. CONCLUSION: The NCS data do not support the validity of uniquely excluding uncomplicated bereavement but not uncomplicated reactions to other losses from MDD diagnosis.

Media portrayals and health inequalities: a case study of characterizations of Gene x Environment interactions.

OBJECTIVES: This article examines how genetic and environmental interactions associated with health inequalities are constructed and framed in the presentation of scientific research. METHODS: It uses the example of a major article about depression in a longitudinal study of young adults that appeared in Science in 2003. RESULTS: This portrayal of findings related to health inequalities uses a genetic lens that privileges genetic influences and diminishes environmental ones. DISCUSSION: The emphasis on the genetic side of Gene x Environment interactions can serve to deflect attention away from the important impact of social inequalities on health.

DSM-III and the revolution in the classification of mental illness.

A revolution occurred within the psychiatric profession in the early 1980s that rapidly transformed the theory and practice of mental health in the United States. In a very short period of time, mental illnesses were transformed from broad, etiologically defined entities that were continuous with normality to symptom-based, categorical diseases. The third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was responsible for this change. The paradigm shift in mental health diagnosis in the DSM-III was neither a product of growing scientific knowledge nor of increasing medicalization. Instead, its symptom-based diagnoses reflect a growing standardization of psychiatric diagnoses. This standardization was the product of many factors, including: (1) professional politics within the mental health community, (2) increased government involvement in mental health research and policymaking, (3) mounting pressure on psychiatrists from health insurers to demonstrate the effectiveness of their practices, and (4) the necessity of pharmaceutical companies to market their products to treat specific diseases. This article endeavors to explain the origins of DSM-III, the political struggles that generated it, and its long-term consequences for clinical diagnosis and treatment of mental disorders in the United States.

Rethinking twins and environments: possible social sources for assumed genetic influences in twin research.

A central sociological problem is the extent to which genetics and the environment influence human behavior. Studies of twins are a core method in attempts to disentangle and to determine the comparative strength of genetic and environmental influences on psychosocial outcomes. A critical assumption of twin studies is that both monozygotic "identical" twins and dizygotic "fraternal" twins share common social environments. Therefore, any greater similarity of monozygotic than dizygotic twins is attributed to genetic influences. This paper tests the equal environment assumption by examining the extent to which greater concordance of adolescent monozygotic compared to dizygotic twins results from social, as well as genetic, influences. Bivariate comparisons indicate that monozygotic twins show greater similarity than dizygotic twins in socially-based characteristics including physical attractiveness, time spent in each other's company, the overlap in friendship networks, and friends' use of alcohol. Multivariate analyses indicate that measures of the social environment sometimes reduce or eliminate apparent genetic effects. In comparison with genetic indicators, social variables are usually stronger predictors of depression and alcohol use and abuse. These findings suggest that past twin studies could overstate the strength of genetic influences because some similarities in behavior among monozygotic compared to dizygotic twins stem from social influences.

Double vision: reply to Freese and Powell.

Freese and Powell make a number of critiques of the theoretical assumptions, statistical methods, and use of variables in our paper, which raises questions about the typical use of the equal environments assumption in twin research. We do not find that any of their critiques modify our conclusion that the equal environments assumption cannot be taken for granted but must be subjected to empirical testing. We hope that our paper and the resulting exchange will lead sociologists to become more actively involved in the debate regarding the extent of genetic and environmental influences on social behaviors.

Outcomes in the sociology of mental health and illness: where have we been and where are we going?

Sociologists of mental health and illness have traditionally used outcome measures that they have obtained from other disciplines, especially psychiatry and psychology. These include official statistics, symptom scales, and diagnostic measures. Answers to the central sociological question of how social arrangements affect mental health might require the development of explicitly sociological outcome measures. This introduction provides an overview of several issues that arise in grappling with this question. These include whether symptom scales or diagnoses best capture the mental health consequences of social arrangements; when single or multiple outcomes are necessary to compare the consequences of social arrangements across different groups; if sociologists should explore the positive as well as the negative consequences of social forces; and when sociological attention should be directed toward social-level as well as individual-level outcomes. The papers in this symposium that follow provide more detailed analyses of each of these issues.