{"id":561,"date":"2012-04-29T15:33:12","date_gmt":"2012-04-29T22:33:12","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=561"},"modified":"2012-05-12T15:57:36","modified_gmt":"2012-05-12T22:57:36","slug":"chemical-imbalance-sloppy-thinking-in-psychiatry-part-1","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=561","title":{"rendered":"Chemical imbalance \u2014 Sloppy thinking in psychiatry 1"},"content":{"rendered":"

\"\"There’s a lot of sloppy thinking in my field. \u00a0This troubles me. \u00a0While psychiatry\u00a0inevitably<\/a> deals with the speculative and poorly understood, this surely cannot excuse faulty logic and intellectual laziness. \u00a0Worse yet, this laxity of thought extends across the field, from biological psychiatry to psychotherapy, and from the general to the specific. \u00a0My next few posts will address what I see as major areas of psychiatric sloppiness.<\/p>\n

“Chemical imbalance” is a phrase used by psychiatrists and laypeople alike. \u00a0When a mental problem seems to arise from within instead of without, it is said to be due to a chemical imbalance. \u00a0 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. \u00a0Historically, whenever chemical or structural abnormalities were<\/em> found to account for abnormal mental functioning, those conditions were no longer considered psychiatric<\/a> and were adopted by another branch of medicine. \u00a0If this trend continues, psychiatry will never include pathophysiology in the usual medical sense. \u00a0It certainly does not at present.<\/p>\n

Like many paving stones on the road to hell, the phrase “chemical imbalance” was sincere and well-intended at first. \u00a0It originally referred to the \u00a0biogenic amine<\/a> model of depression, i.e., the hypothesis that a lack of excitatory neurotransmitters such as norepinephrine and serotonin underlies depression. \u00a0While it’s a fairly compelling concept, it suffers from a lack of solid evidence. \u00a0People who are depressed do\u00a0not<\/em>\u00a0have “decreased serotonin in the brain,” and taking an SSRI does\u00a0not\u00a0“correct” the serotonin level. \u00a0Such drugs may offer benefits as a result of boosting serotonin, but that’s not because serotonin levels were low to begin with. \u00a0Moreover, the fact that SSRIs increase the amount of serotonin in brain synapses says nothing about the ultimate cause of depression. \u00a0A cascade of downstream effects follows from tinkering with serotonin, including receptor down-regulation and probably new protein synthesis. \u00a0If there’s any inherent chemical imbalance being remedied, we don’t know a thing about it.<\/p>\n

Population studies show subtle changes on average<\/em> in the brains of patients with certain psychiatric disorders. \u00a0However, 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. \u00a0(Dr. Daniel Amen<\/a> claims otherwise regarding SPECT scanning of the brain, but many critics<\/a> are<\/a> skeptical<\/a>. \u00a0Likewise, a putative new blood test for depression raises many questions<\/a>.) \u00a0At best, “chemical imbalance” is shorthand for a presumed brain abnormality that no one has yet proven. \u00a0At worst, it is disingenuous hand-waving aimed to add medical legitimacy to the field of psychiatry.<\/p>\n

Why is “chemical imbalance” so often advanced as a pseudo-explanation for mental illness? \u00a0Many psychiatrists confidently\u00a0proclaim 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. \u00a0Suffering a\u00a0“chemical imbalance” implies that proper medication will correct a pre-existing, permanent organic abnormality.\u00a0\u00a0\u00a0The problem here is that the end (patient cooperation) does not justify the means (lying). \u00a0The honest answer is that we psychiatrists believe our medications help relieve psychiatric symptoms and distress \u2014 although even that is hotly debated<\/a>\u00a0\u2014 including maintenance treatment to forestall relapse. \u00a0This belief is based on outcomes research and clinical, aka anecdotal, experience, not on knowledge of biological mechanisms.<\/p>\n

Psychiatry has long been the\u00a0red-headed stepchild of medicine. \u00a0In medical centers we’re often in a separate building across the street from the main hospital. \u00a0Other physicians sometimes don’t understand what we do and make nervous jokes. \u00a0Critics accurately note that psychiatric disorders are never found in standard pathology textbooks, and some claim the field is baseless and harmful<\/a>. \u00a0“Chemical imbalance” gives some psychiatrists the medical bona fides they crave, but at the price of intellectual laziness and sloppy thinking. \u00a0This serves no one. \u00a0Psychiatry must embrace uncertainty, and not seek false security in empty phrases. \u00a0Physicians prescribed aspirin for pain and fever long before we understood the intricacies of these conditions, or the mechanism by which aspirin affected them. \u00a0We simply knew it worked \u2014 no one claimed that a subtle “aspirin imbalance” was being corrected. \u00a0Like it or not, psychiatry is in much the same place now.<\/p>\n

I’m hardly<\/a> the<\/a> first<\/a> to critique “chemical imbalance,” although some still defend<\/a> it. \u00a0I started with this as the prime example of sloppy thinking in psychiatry. \u00a0But as we shall see, there are many others.<\/p>\n

Photo courtesy of Petr Kratochvil<\/a>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[6,7],"tags":[49,45,43],"class_list":["post-561","post","type-post","status-publish","format-standard","hentry","category-medication","category-psychiatric-diagnosis","tag-chemical-imbalance","tag-psychiatric-research","tag-uncertainty","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/561","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=561"}],"version-history":[{"count":11,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/561\/revisions"}],"predecessor-version":[{"id":580,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/561\/revisions\/580"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=561"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=561"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=561"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}