Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance”
Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance”
“Everything should be made as simple as possible, but no simpler.”
—attributed to Albert Einstein (probably a paraphrase)
“Mind and body do not act upon each other, because they are not other, they are one.”
—Philosopher Will Durant, on Spinoza’s monism1
I am not one who easily loses his temper, but I confess to experiencing markedly increased limbic activity whenever I hear someone proclaim, “Psychiatrists think all mental disorders are due to a chemical imbalance!” In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the “chemical imbalance” trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves.2 And, yes—the “chemical imbalance” image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding.3 In truth, the “chemical imbalance” notion was always a kind of urban legend- - never a theory seriously propounded by well-informed psychiatrists.
Fortunately, recent advances in cognitive psychology and neuroscience are now converging, with the result that psychiatry may be on the brink of a unified model of so-called mental illness. (The term itself, as we shall see, is belied by the new research). As described at the APA’s 2011 annual meeting by NIMH Director Thomas Insel, MD, neuropsychiatric research is pointing to a complex interplay between factors traditionally dichotomized as “biological” and “psychosocial”.4
As Insel describes the new model, conditions such as schizophrenia or bipolar disorder are attributable to rare, but highly potent, genetic variations that lead to dysfunction in multiple, complex brain circuits. However, the particular symptomatic manifestations in a given individual-—the disease phenotype—is partly dependent on the person’s experiences and environment. We may hypothesize (and this is my view, not necessarily Dr. Insel’s) that given developmentally-based “biases” in various neurocircuits, the young boy or girl may be predisposed to the use of certain dysfunctional cognitive strategies; for example, viewing everyone in the environment as uniformly threatening or “rejecting.” These tendencies could easily be exacerbated by, say, childhood traumata or parental neglect.
We can imagine that the “irrational cognitions” so prized by cognitive therapists may develop on this abnormal, biogenetic substrate, and eventually become woven into the very fabric of the individual’s personality and world-view. Thus, rather than remain ensnared by the terms “mind” or “brain”, we would be better served by what Dr. Dan Stein calls, the “brain-mind.” Indeed, “…the two constructs are, in fact, impossible to disentangle.”5 This is essentially what the philosopher Baruch Spinoza (1632-1677) argued more than three centuries ago: “mind” and “brain” are not two substances, but one—variously understood in “mental” terms for some purposes, and in “physical” terms, for others. And, as Dr. Stein observes, the brain-mind “. . .is not a computational, apart-from-the-world, passive reflector, but rather a thinking-feeling-actor-in-the-world…"5
In short, we cannot afford to view our patients’ afflictions in the balkanized terms of “mental” vs. “physical”, “mind” vs. “body”, “psyche” vs. “soma”. Neither can we afford the luxury of supposing that only one type of treatment—medication or psychotherapy—will be effective for the illnesses we treat. On the contrary, the best available evidence suggests that each modality, or their synergistic combination, may be effective—depending on the specific illness. To be sure, as my colleague, Nassir Ghaemi MD, has cautioned, we must not be drawn into a haze of promiscuous eclecticism in our treatment; rather, we must be guided by well-designed studies and the best available evidence.6 Nonetheless, there is room in our work for both motives and molecules, poetry and pharmacology. The legend of the “chemical imbalance” should be consigned to the dust-bin of ill-informed and malicious caricatures. Psychiatry must now confront the mysteries and miseries of the brain-mind.
References:
1. Durant W. The Story of Philosophy. New York: Pocket Books;1953.
2. See, eg, “The cornerstone of psychiatry’s disease model today is the theory that a brain-based, chemical imbalance causes mental illness.” http://www.cchr.org/sites/default/files/Blaming_The_Brain_The_Chemical Imbalance_Fraud.pdf
3. Lacasse JR, Leo J. Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature. PLoS Med. 2005; 2(12): e392. doi:10.1371/journal.pmed.0020392
4. Moran M. Brain, Gene Discoveries Drive New Concept of Mental Illness. Psychiatric News. June 17, 2011.
5. Stein DJ. Philosophy of Psychopharmacology. Cambridge: Cambridge University Press; 2008: x.
6. Ghaemi SN. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. Baltimore: Johns Hopkins University Press; 2009.
Psychiatry in treatment of transgender , have they investigated any possible underlying causes and other treatments other than hormones, and srs surgery
More on the So-called Chemical Imbalance Theory
My usual practice is to ignore crackpot bloggers who misrepresent psychiatric writing in general, or my own writing, in particular. However, when an academician with some influence over public opinion radically misreads-and misrepresents-my views, I find myself with no alternative but to rebut the errors.
In a recent posting on the "Neuroscience Journal Club"website (http://neurojournalclub.com/), neuroanatomy professor Jonathan Leo has a number of critical comments on my "Chemical Imbalance" posting (above), as well as some comments on a piece I did for the New York Times, some year ago [www.nytimes.com/2008/09/16/health/views/16mind.html]
Unfortunately, Prof. Leo seems to have misread and misunderstood my principle claims in both pieces, and attributes to me views that are far removed from my actual positions. (Ironically, I actually cited a paper by Lacasse and Leo in my blog on "Psychiatry's new brain mind").
To dispense with the red herrings first: based on my NY Times piece, Prof. Leo writes that Pies "….boldly states that using antidepressants to treat normal everyday sadness is perfectly acceptable and something that he has no problem with." In truth, I say nothing of the kind, nor do any of my writings reflect such a benighted position. On the contrary, even a cursory reading of the many postings from Dr. Sidney Zisook and me would show that I regard normal sadness as just that-normal-and not the appropriate target of medication or any other kind of "treatment." [see, e.g., http://www.medscape.com/viewarticle/740333]. The debate has been over whether persons presenting with all the symptoms and signs of a major depressive episode should be "exempted" from the diagnosis of major depression if this picture occurs within a few months of a major loss. Readers who want to delve into the debate may see the link above, on Medscape, or read the numerous exchanges on the Psychiatric Times website.
Then, referencing my Psychiatric Times article ("Psychiatry's New Brain-Mind and the Legend of the Chemical Imbalance"), Prof. Leo asserts that I present a "new definition of mental illness." But I do no such thing. Rather, I present a brief sketch of a developing model of how serious psychiatric disorders may arise, based on views propounded by Dr. Thomas Insel. This sketch is not a "definition" of mental illness; rather, it is an attempt at overcoming the reductionism of a simplistic "chemical imbalance theory", and replacing it with a more sophisticated bio-psycho-social hypothesis.
I did not intend to assert as a fact the claim on Dr. Insel' part that there are "highly potent, genetic variations that lead to dysfunction in multiple, complex brain circuits…". I would agree with Prof. Leo that we need more evidence of such genetic variations, though I think it quite likely they exist. I merely wanted to argue that modern models of severe psychiatric illness go far beyond any simple notion of a "chemical imbalance", and invoke a complex interaction of genotype, early developmental issues (such as trauma), biochemical abnormalities, and psychosocial factors. And, yes-I deny the claim that sophisticated, well-informed psychiatrists ever propounded a simple "chemical imbalance theory" of mental illness. I stand by that claim, notwithstanding Dr. Leo's citing an NIMH statement asserting that depression is "linked to decreased serotonin in the brain." There is a big difference between claiming a "link" or association, and claiming that depression is caused by decreased serotonin.
Prof. Leo does raise a legitimate question, and one worthy of comment. He asks, "If the Psychiatry Community knew all along that the [chemical imbalance] theory was not true, then why did they not clarify this issue for the general public? Shouldn't they have pointed out to the general public and patients, that what the pharmaceutical companies were saying about psychological stress was not true? Why did the professional societies not publicly set the record straight?"
Leaving aside the dubious notion that there is a "psychiatric community"-I see it more as a balkanized collection of competing fiefdoms!-Prof. Leo raise a fair question. I would respond by repeating the statement clearly enunciated by the originators of the biogenic amine hypothesis (note: that's hypothesis, not theory!), cited in my response to Prof. Joel Paris. Schildkraut and Kety clearly said more than 50 years ago that
"…Whereas specific genetic factors may be of importance in the etiology of some, and possibly all, depressions, it is equally conceivable that early experiences of the infant or child may cause enduring biochemical changes and that these may predispose some individuals to depressions in adulthood. It is not likely that changes in the metabolism of the biogenic amines alone will account for the complex phenomena of normal or pathological affect."
Even so prominent an advocate of "organic psychiatry" as Prof. W.A. Lishman stated, in his classic text, Organic Psychiatry [preface to the second edition] the following:
"The study and treatment of those psychiatric disorders deriving from brain malfunction must capitalize on all that psychiatry has to offer. There are psychodynamic, social, and cultural aspects of neuropsychiatry to be considered; exploration of conflict must take its place alongside the physical examination in differential diagnosis, psychotherapy alongside pharmacotherapy in treatment."
As for professional organizations, I would agree that more could have been done over the years, on the part of the professional leadership, by way of dispelling the "chemical imbalance" slogans of the pharmaceutical industry. Nonetheless, here is a recent statement from the American Psychiatric Association's "Health Minds" website:
"The exact causes of mental disorders are unknown, but an explosive growth of research has brought us closer to the answers. We can say that certain inherited dispositions interact with triggering environmental factors. Poverty and stress are well-known to be bad for your health-this is true for mental health and physical health. In fact, the distinction between "mental" illness and "physical" illness can be misleading. Like physical illnesses, mental disorders can have a biological nature. Many physical illnesses can also have a strong emotional component."
http://www.healthyminds.org/Main-Topic/Mental-Illness.aspx
This doesn't strike me as an endorsement of the "chemical imbalance theory".
If Dr. Leo cares to take the time to peruse the 10th edition of the influential textbook, Kaplan & Sadock's Synopsis of Psychiatry (2007), he will find this observation on the monoamine hypothesis of mood disorders (p. 529):
"A progressive shift has occurred from focusing on disturbances of single neurotransmitter systems in favor of studying neurobehavioral systems, neural circuits, and more intricate neuroregulatory mechanisms. The monoaminergic sytems, thus, are now viewed as broader, neuromodulary systems, and disturbances are as likely to be secondary or epiphenomenal effects as they are directly or causally related to etiology and pathogenesis."
In other words, psychiatry recognizes that alterations in brain chemistry may sometimes be effects, rather than causes, of psychiatric illness; or else signify some deeper, underlying etiology. The authors go on to discuss social, cultural, cognitive, and psychological factors in the etiology of depression.
Yes, this kind of holistic message should have come earlier and stronger from psychiatry's academic and professional leadership. I am sure I could have done more in this regard. But I stand by my claim that no respected representatives of the profession seriously asserted a simple, "chemical imbalance" theory of mental illness in general.
Ronald Pies MD
I am not sure I understand Sally Feldman's question. However, I address these concerns to a hypothetical patient in a blog that will soon appear on the Psychiatric Times website. It may now be viewed at the link below. I hope that this will be of help in answering the reader's query. --Ron Pies MD
http://psychcentral.com/blog/archives/2011/08/04/doctor-is-my-mood-disor...
How would you describe this concept to the patient experiencing the process??
I thank Dr. Johnson for his cordial observations. It is indeed difficult to find the right
vocabulary for what we are trying to express with terms like "bodymind", "brain-mind",
"embodied mind"(a la Merleau-Ponty and some cognitive theorists), etc. I think Dr. Dan
Stein puts it well in his book, Philosophy of Psychopharmacology, when he writes (citing
Schechtman, 1996), "Persons need to be understood both as objects (with crucial biological
underpinnings) and as subjects (intentional agents with thoughts and emotions)..."
I suspect most experienced psychiatrists make this integrative assumption as a result of
trying to "do what works"; e.g., combining psychotherapy with medication in appropriate
cases.
By the way, Dr. Johnson, Tom Szasz is very much a man of our own time, and, like me, still
engages in spirited debates at Upstate Medical University, where he was one of my teachers
over 30 years ago! --Best regards, Ron Pies
A useful compliment to this conversation is the article, "Getting It From Both Sides: Foundational and
Antifoundational Critiques of Psychiatry,"by Pies, Thommi and Ghaemi, in the July 2011 issue of Psychiatric
Times, as it adds a philosophic dimension. When I began my residency in psychiatry at the Washington
University School of Medicine in St. Louis, the study of bodymind--a term I prefer to brain-mind--was just
beginning to incorporate somatic modeling of psychological disease. Psychoanalysis predicated pure
psychological, ie psychosocial, etiologies at the time. The pendulum has obviously swung its distance
today, as we understand the 'disconnect' between extremist biological arguments and common sense.
In Woody Allen's recent film, "Midnight in Paris," the protagonist is allowed to move from the Paris of today
back in time to the Paris of the twenties, a charming fantasy. Would we so lucky to hear Foucault and
Szacz opine with Pies, Thommi and Ghaemi?
I appreciate Dr. Paris's concerns and observations, and I would note that his own work on Borderline Personality Disorder exemplifies an integrated, "non-reductionistic"approach to psychiatric diagnosis and treatment (1). I believe that most well-trained psychiatrists embrace a similarly broad-based model of mental illness and its treatment, even though our model of practice has been constrained and distorted by various economic and social forces buffeting psychiatry in recent years (2). Indeed, I believe we need to distinguish between what "prominent psychiatrists really think" about the nature of mental illness, and how some psychiatrists are now conducting their practice. Moreover, while I acknowledge that psychiatric practice relies much less on psychotherapy than it did in past decades (2), I do not believe the best available evidence supports Dr. Paris's contention that "…psychiatrists hardly ever do psychotherapy these days…" or that "reductionism rules" in psychiatry.
And, while I don't presume to speak on behalf of Dr. Insel or Dr. Quirion, I believe a careful reading of the Insel & Quirion (2005) paper does not support the view that their position is reductionistic. On the contrary, I think it gestures toward an "integrationist" view (perhaps not fully articulated), in which clinical neuroscience is able to embrace and reformulate-not eliminate-- traditional psychodynamic concepts, such as motivation and ego defenses. I believe Insel and Quirion's position is fully consistent with Dr. Paris's point that "…people have lives, and that life events can make a difference in symptoms…"
First, though, on the matter of psychotherapy as a component of psychiatric practice: many people have misconstrued or selectively interpreted some recent findings in that regard (2). To be sure, Mojtabai and Olfson (3) found a decline in the number of psychiatrists who provided psychotherapy to all of their patients - from 19.1% in 1996-1997 to 10.8% in 2004-2005. The study also found that the percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005, which "…coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications." But the very same study found that almost 60% of psychiatrists were providing psychotherapy to at least some of their patients.
Moreover, Reif et al (2010) found that, in a managed care psychiatric practice setting, two-thirds of claims involved medication management, and two-thirds involved psychotherapy - with an overlap of about 30%. The authors concluded that
"Despite potential financial disincentives for psychiatrists to conduct psychotherapy, our findings show that billed claims for psychotherapy by psychiatrists were common… [and] it appears that the broader skill set of psychiatrists is still being tapped, with provision of both medication management and psychotherapy."(4)
Regarding the 2005 paper by Insel and Quirion (5) it is true that their position is that "mental illnesses are brain disorders"; but this claim does not necessarily entail "reductionism" in any pejorative sense of that term. On the contrary, Insel & Quirion clearly state that "…mental disorders need to be addressed as disorders of distributed brain systems with symptoms forged by developmental and social experiences…." (italics mine). They go on to consider "…how environmental factors during critical intervals of development exert long-term effects on gene expression…(italics mine)" and suggest that, "…studying unconscious processes, motivation, or defenses, while at one time the sole province of psychoanalytic therapies, are now also in the domain of cognitive neuroscience." None of this points to a blinkered "reductionism", but rather, to an incorporation of traditional developmental and psychodynamic constructs into the content and purview of neuroscience. I believe all this is consistent with what Dr. Paris wrote in the same year as Insel & Quirion, regarding Borderline Personality Disorder:
"As with most mental disorders, no single factor explains its development, and multiple factors (biological, psychological and social) all play a role…" (1)
Insel & Quirion go on to advocate the following:
"… ideally the psychiatrist will increasingly be part of a team that provides culturally-valid, psychosocial rehabilitation along with medications to help those with mental disorders recover and return to a productive and satisfying life."(5)
Finally, it is ironic that the "chemical imbalance" metaphor-arguably, a bowdlerized version of the catecholamine hypothesis developed by Schildkraut & Kety in the 1960s-completely ignores what Schildkraut & Kety themselves had to say on the matter of "reductionism":
"Whereas specific genetic factors may be of importance in the etiology of some, and possibly all, depressions, it is equally conceivable that early experiences of the infant or child may cause enduring biochemical changes and that these may predispose some individuals to depressions in adulthood. It is not likely that changes in the metabolism of the biogenic amines alone will account for the complex phenomena of normal or pathological affect." (6)
I believe psychiatry is best served by recalling what our best scholars have actually said, rather than playing into the hands of psychiatry's uninformed critics. I'm sure Dr. Paris would want to join me in that effort.
Ronald Pies MD
1. Paris J: Borderline personality disorder. CMAJ. 2005 June 7; 172(12): 1579-1583.
2. Pies R: Has psychiatry really abandoned psychotherapy? http://psychcentral.com/blog/archives/2011/04/03/has-psychiatry-really-a...
3. Mojtabai R, Olfson M: National Trends in Psychotherapy by Office-Based Psychiatrists. Arch Gen Psychiatry. 2008;65(8):962-970
4. Reif S, Horgan C, Torres M, Merrick E, Types of Practitioners and Outpatient Visits in a Private Managed Behavioral Health Plan Psychiatric Services. 2010; 61:1066-1068.
5. Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. JAMA. 2005 Nov 2;294(17):2221-4.
6. Schildkraut JJ, Kety SS. Biogenic amines and emotion. Science. 1967 Apr 7;156(771):21-37.
I greatly appreciate Dr. Paris's thought-provoking observations, and I will respond substantively within the next few days. In the mean time, I would very much like to hear from other readers as well. --Ronald Pies MD
Dr. Pies is right in one sense--no expert is willing to admit that they believe in a chemical model of mental disorder, and many offer lip service to a biopsychosocial model. But what do prominent psychiatrists really think? Insel and Quirion (2002) suggested 9 years ago that psychiatry join neurology and commit itself to being a clinical application of neuroscience. Insel's (2009) current proposal that all diagnosis and future research should be based on spectra rooted in neuroscience is not different.
The concept that people have lives, and that life events can make a difference in symptoms, is barely acknowledged by some experts. This ideology is one of the reasons why psychiatrists hardly ever do psychotherapy these days, and why some do not even know how to talk to patients. Whether our current theory is based on chemistry or neural networks, reductionism rules.
Joel Paris, MD
Professor of Psychiatry, McGill University
References: Insel, T., & Quirion, R. (2005). Psychiatry As a Clinical Neuroscience Discipline. JAMA: the journal of the American Medical Association, 294, 2221-2224.
Insel, TR (2009): A Strategic Plan for Research on Mental Illness: Translating scientific opportunity into public health impact. Archives of General Psychiatry.66:128-133
from Ron Pies MD:
With respect to my comments dated Sept 1, 2011, I would like to clarify one statement. My allusion to "crackpot bloggers"was not intended to apply to anyone in particular. Rather, I wanted to contrast such predictably irresponsible bloggers with established academic writers, such as Prof. Jonathan Leo. I regret any confusion or misunderstanding arising from my wording.
And, to reiterate a point I have made on numerous--bordering on "innumerable"! --occasions: I do not advocate, and never have advocated, the use of antidepressant medication for ordinary, "adaptive" grief or sadness, as typically encountered with uncomplicated bereavement. For further review of the bereavement exclusion controversy, please see the recent publications by Zisook at al, in :
Depress Anxiety. 2012 May;29(5):425-43; and Lancet. 2012 Apr 28;379(9826):1590
Best regards,
Ronald Pies MD