Chemical imbalance — Sloppy thinking in psychiatry 1

There’s a lot of sloppy thinking in my field.  This troubles me.  While psychiatry inevitably deals with the speculative and poorly understood, this surely cannot excuse faulty logic and intellectual laziness.  Worse yet, this laxity of thought extends across the field, from biological psychiatry to psychotherapy, and from the general to the specific.  My next few posts will address what I see as major areas of psychiatric sloppiness.

“Chemical imbalance” is a phrase used by psychiatrists and laypeople alike.  When a mental problem seems to arise from within instead of without, it is said to be due to a chemical imbalance.   In truth, however, no chemical imbalance, nor any structural abnormality in the brain, has ever been found to account for anything we currently consider a psychiatric disorder.  Historically, whenever chemical or structural abnormalities were found to account for abnormal mental functioning, those conditions were no longer considered psychiatric and were adopted by another branch of medicine.  If this trend continues, psychiatry will never include pathophysiology in the usual medical sense.  It certainly does not at present.

Like many paving stones on the road to hell, the phrase “chemical imbalance” was sincere and well-intended at first.  It originally referred to the  biogenic amine model of depression, i.e., the hypothesis that a lack of excitatory neurotransmitters such as norepinephrine and serotonin underlies depression.  While it’s a fairly compelling concept, it suffers from a lack of solid evidence.  People who are depressed do not have “decreased serotonin in the brain,” and taking an SSRI does not “correct” the serotonin level.  Such drugs may offer benefits as a result of boosting serotonin, but that’s not because serotonin levels were low to begin with.  Moreover, the fact that SSRIs increase the amount of serotonin in brain synapses says nothing about the ultimate cause of depression.  A cascade of downstream effects follows from tinkering with serotonin, including receptor down-regulation and probably new protein synthesis.  If there’s any inherent chemical imbalance being remedied, we don’t know a thing about it.

Population studies show subtle changes on average in the brains of patients with certain psychiatric disorders.  However, the findings in subjects with psychiatric diagnoses overlap so much with those of normal subjects that no blood test or brain study can diagnose mental illness in an individual.  (Dr. Daniel Amen claims otherwise regarding SPECT scanning of the brain, but many critics are skeptical.  Likewise, a putative new blood test for depression raises many questions.)  At best, “chemical imbalance” is shorthand for a presumed brain abnormality that no one has yet proven.  At worst, it is disingenuous hand-waving aimed to add medical legitimacy to the field of psychiatry.

Why is “chemical imbalance” so often advanced as a pseudo-explanation for mental illness?  Many psychiatrists confidently proclaim that psychiatric disorders “are medical conditions just like diabetes and hypertension” to justify chronic ongoing management and the need for medication even when the patient feels subjectively well.  Suffering a “chemical imbalance” implies that proper medication will correct a pre-existing, permanent organic abnormality.   The problem here is that the end (patient cooperation) does not justify the means (lying).  The honest answer is that we psychiatrists believe our medications help relieve psychiatric symptoms and distress — although even that is hotly debated — including maintenance treatment to forestall relapse.  This belief is based on outcomes research and clinical, aka anecdotal, experience, not on knowledge of biological mechanisms.

Psychiatry has long been the red-headed stepchild of medicine.  In medical centers we’re often in a separate building across the street from the main hospital.  Other physicians sometimes don’t understand what we do and make nervous jokes.  Critics accurately note that psychiatric disorders are never found in standard pathology textbooks, and some claim the field is baseless and harmful.  “Chemical imbalance” gives some psychiatrists the medical bona fides they crave, but at the price of intellectual laziness and sloppy thinking.  This serves no one.  Psychiatry must embrace uncertainty, and not seek false security in empty phrases.  Physicians prescribed aspirin for pain and fever long before we understood the intricacies of these conditions, or the mechanism by which aspirin affected them.  We simply knew it worked — no one claimed that a subtle “aspirin imbalance” was being corrected.  Like it or not, psychiatry is in much the same place now.

I’m hardly the first to critique “chemical imbalance,” although some still defend it.  I started with this as the prime example of sloppy thinking in psychiatry.  But as we shall see, there are many others.

Photo courtesy of Petr Kratochvil.

9 comments to Chemical imbalance — Sloppy thinking in psychiatry 1

  • Ryan

    I find it interesting how assumptions about the nature of mental illness and receptors such as dopamine can make it into literature that excess dopamine is responsible for psychosis and schizophrenia I think originates from drug company propaganda. Interesting and disgusting that many of the symptoms are the result of low dopamine levels and perfectly match what is known by scientific investigation of dopamine that rarely relates anything to do with hallucinations and delusions but accounts for the negative symptoms of medication treated subjects such as low motivation cognative deficits, working memory problems which can present as thought disorder in some cases [personally. but I can see that the error could be made since psychiatrist lack scientific credability in identifying symptoms] and changes in personality from extraverted to introverted and apathy (probably the main thereapuetical advantage of suppressing agitated subjects based on theory of dopamine)

    Working memory problems form medication and cultural bias of psychiatrist who preferred to treat me as pathological and alienating method in diagnostics and my frustration with the inadequacy these ‘professionals’ who have a delusion of granduer which in my case lead to a diagnosis of thought disorder and disorganized thinking that possibly directly relating to the effects of medication and of course relativity and lack of insight lead to my projection of understanding my condition made them consider that I had granduer issues and flight of ideas in relation to cultural and scientific perspective being in contrast that I seemed to not make any sense, medication only worsened my communication ability and leads to apathy [another therapuetical advantage of lowering dopamine and seeming to suppress psychotic symptoms or give false illusion dopamine imbalance was responsible]

    my point mainly is it is despicable that psychiatrist don;t even consider the effects of inducing a chemical imbalance of too low dopamine has on cognative ability and is the root cause of many of the recognised symptoms of schizophrenia especially all the negative symptoms since dopamine is necessary for functional social personality goal driven attributes and behavior and the ability to feel pleasure and fluent communication through working memory [how come noone else realizes this I have been searching for credible information on how faulty diagnostics in schizophrenia really is] I will be treated aloofly and with lies and ignored when bringing my concerns up with a practitioner who is convinced by drug companies selling drugs of and attempt at brain washing for compliance and projecting that I have insight by eating all of what is presented and practiced based on psychiatry theory and limited understanding the nature of mental illness especially prognosis as 60-90percent naturally recover global functioning as seen with mosher studies open dialogue of finland and John weir Perry using jungian psychotherapy.

    the therapuetic benefit of lowering dopamine in psychotic individuals I believe is effective only to induce a personality change that the patient become less interested or less able to focus on hallucinations or ruminations, Personally I have a link to lucid dreaming and sleep disorder that lucid dreams and meditation creap into my waking world, I also become very focused on physical performace of moving meditation which kept me well for years leading up to moving to a very small unit which allowed for me to develop chi-gong deviation[a culture bound syndrome presenting with psychotic like symptoms psychiatrists in the west neglect to consider or talk on an even playing field with me since they consider me defective and defective intellectually because I disagree with notions of psychiatry from a valid scientific perspective, without them picking apart my nature and dopamine deprived cognition and communication to label me of throw out notions that my motivation level problem is because of the post psychotic syndrome not that they a validified this with scientific investigation to confirm it is actually the medications psychotics are too often put on also withouut identifying people like myslelf who have ver short episode and have positive attitude to recovery, functional psychosis, life changing and positive effort into disolving issues and self esteem from history of trauma like the psychotic process is part of transformational episode and part of effort in meditating on repressed memories a therapist would prefer to call delusion and false memory

    Feel free to reply to my email provided. sorry it is so long and rambling

    • Hi Ryan,
      You make a good point that dopamine-lowering antipsychotics can produce unwanted side-effects. (These are called Parkinsonian side-effects, as Parkinson’s Disease is caused by a lack of dopamine in the brain.) As you wrote, such effects may include low motivation, cognitive impairment, and memory problems. They may also include a slow, shuffling gait, lack of emotional expression, and even depression. A competent psychiatrist should always watch for treatment side-effects, and always weigh the benefits of a treatment against its risks.

      On the other hand, “negative symptoms” were described long before antipsychotics were discovered. The meds can’t be blamed for all of it. Also, the newer atypical neuroleptics have less effect on dopamine, and thus produce fewer Parkinsonian side-effects. (They have other side-effects instead.) Simplistic “chemical imbalance” language overlooks this complexity: Obviously, schizophrenia is not a simple dopamine imbalance.

      Your last line makes me wonder if you wanted me to publish your comment — your email is only visible to me, not to the reading public. Anyway, thanks for your thoughts.

      • Ryan

        thanks for your reply. There is also theory that Glycine is a factor in schizophrenia based on the effect of PCP and other chemicals that sometimes make there way to marajuana

        I guess it is just a theory like is the big bang theory which has a political power in physics to sway research and what we think we know about the universe more importantly future developments in science

        Psychiatry needs to go on a shift in its self acclaimed superiority over more spiritual understanding and shaman experience for instance. All the historical figures and saints etc could have been considered psychotic, yet they served a purpose and some who have experienced spontaneous altered states of consciousness have prognosis of becoming healers and growing in wisdom undertaking social change and revolutionary thinkers

  • “Psychiatry must embrace uncertainty, and not seek false security in empty phrases”.
    That’s a quote that resonates in my current professional moment.I’m a psychiatry resident, I think my interest in neuroscience attracted me to psychiatry. However, when interviewing a patient, it’s very difficult to see the person and the situations around her as a “pure chemical imbalance”.

    The complexity of the human experience and the biopsychosocial model in my opinion are often overlooked in mainstream biological psychiatry. I think it’s more comfortable to choose to believe in something (faith in pure biological explanations) that help us feel “real” doctors.

    Thank you for your thoughts!

  • [...] does not exist, that we are driven by biological programs adapted to the Pleistoscene, or that mental disorders are caused by brain imbalances? Are these ideas not also likely to cause harm if they are permitted to influence cultural [...]

  • NeuroMSc

    It is evident from a lot of studies that mental illness is biological and it is possible to induce OCD like behaviour in rats. How does one explain that? Apologies first off for my lack of referencing, these can be provided.

    Do you not think that the problem with psychiatry is in categorising sets of symptoms into disorders (however helpful it is to both; the physician to treat, and; the patient to gain validation for these symptoms). But, instead of psychiatrists and physicians seeking to diagnosis when a patient comes to them and presents with symptoms, we should be targeting this in a more personalised, individualised approach by investigating these symptoms as mechanisms in a network of symptoms or indeed ‘chemical imbalances’ in a network of systems.

    I was always against the idea of chemical imbalances as it frustrates me that people think that disorders are of a biological cause as that is just ridiculous and it frustrates me when I see umpteen studies that show similar brain alterations in imaging studies that helps categorise specific disorders. Until I thought about it this way. Of course there would be similarities in brain structures in certain disorders. They are characterised, cognitively and behaviourly in the same way so why wouldn’t they share similar structural and functional ‘abnormalities’ in a brain scan? Well, abnormalities I would choose to instead call, ‘alterations’ to others.

    What if our environment, our psycho social experience was inducing the brain imbalance or brain ‘alteration’ for use of a better term. I think it is vital for Physicians and psychiatrists to look at patients in a way thats different to disorders and symptoms but more in terms of a) Immune dysfunction, b) hormone imbalance, c) nutritional imbalance, d) digestive system, e) detoxification

    and also b) what psyhcological, social, environmental and cogitive factors cause these imbalances that lead to various mechanisms we call schizophrenia, OCD, and BPD etc

    Sadly, all of these things get ignored when we live in a world of pharmaceutical companies, strict time constraints , and categorisation of mental disorders.

    • Hello, and thanks for writing. I have to disagree with you that “a lot of studies” show that mental illness is biological. Which mental illnesses are we talking about? Dementia following traumatic brain injury is clearly biological. Nicotine dependence is clearly biological (if we want to call that a mental illness). Schizophrenia certainly looks biological, but there’s no real proof. Its genetic heritability is about 50%; we don’t know what accounts for the other 50% of the variance. The fact that OCD-like behavior can be created biologically in rats is a useful finding for research, but it doesn’t prove anything about the etiology of OCD in humans. We can also make rats highly anxious or enraged biologically, but that doesn’t mean all anxiety and anger in humans is biological in origin. (We can induce all of these psychologically in rats as well.)

      The later part of your comment echoes a more recent post of mine. I’d add that while immune dysfunction, hormone imbalance, nutrition, digestion, and toxins are all possible contributors, it’s important that physicians don’t make assumptions until the evidence is in. This is also true of putative psychological, social, environmental, and cognitive factors, although “evidence” here is harder to study and assess.

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