On April 15, Ronald Pies, MD, an eminent and widely published psychiatrist, wrote an article for Medscape.com. The piece is titled Nuances, Narratives, and the 'Chemical Imbalance' Debate in Psychiatry.
The main thrust of the article is that:
"…the 'chemical imbalance theory' was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry."
This is not the first time that Dr. Pies has made this claim, On July 11, 2011, he wrote an article for Psychiatric Times titled Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance.” In that article he wrote:
"In truth, the ‘chemical imbalance’ notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists."
And on September 2, 2011, in the comments section of the above post:
"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."
At the present time psychiatry, because of intense pressure from its critics, is retreating somewhat from the chemical imbalance theory. But instead of acknowledging that this notion was flawed, that they knew it was flawed, and that they promoted it for self-gain, they are claiming that they never really said it in the first place.
Dr. Pies is a major spokesman for this particular piece of spin:
"In the narrative of the antipsychiatry movement, a monolithic entity called 'Psychiatry' has deliberately misled the public as to the causes of mental illness, by failing to debunk the chemical imbalance hypothesis. Indeed, this narrative insists that, by promoting this little white lie, psychiatry betrayed the public trust and made it seem as if psychiatrists had magic bullets for psychiatric disorders. (Lurking in the back-story, of course, is Big Pharma, said to be in cahoots with Psychiatry so as to sell more drugs)."
Note the euphemism "little white lie." Great big black whopper would be more accurate. And it was a betrayal of the public trust; and it did create the impression that psychiatrists had magic bullets for depression and other human problems; and it did induce people, who might not otherwise have done so, to take psychiatric drugs; and Big Pharma was, and still is, in cahoots with psychiatry. (69% of the DSM-5 Task Force had financial links to pharma!)
Dr. Pies continues:
"But then, why do antipsychiatry groups and bloggers fail to note the nuances of what psychiatrists have been saying for at least the past decade? My guess is that doing so would undermine the derogatory narrative they wish to promote. And, of course, nuanced statements do not gin up public opinion or sell books."
Note the ad hominem attack. We antipsychiatry groups and bloggers simply want to promote a "derogatory narrative," gin up public opinion, and sell books. This kind of attack is so much easier than actually addressing the issues that we raise.
"…but it's probably true that some psychiatrists did hold a purely biocentric view; and, alas, some undoubtedly used the expression 'chemical imbalance' in their clinical practice, without putting it into a broader context for their patients."
A few bad eggs. Tsk, Tsk!
"That said, I am not aware of any concerted effort by academic psychiatrists, psychiatric textbooks, or official psychiatric organizations to promote a simplistic chemical imbalance hypothesis of mental illness."
In conclusion, Dr. Pies embarks on the daunting task of demonstrating that the biopsychosocial model has been the essential underpinning of psychiatric theory (and presumably practice) since the 1980's. He quotes passages from Theodore Nadelson, MD, Eric Kandel, MD, and from his own writings.
Commenting on Dr. Nadelson's writing, Dr. Pies says:
"Ted Nadelson understood that the brain is the crucible in which all the elements of human life intermingle, including our genetic makeup; our brain chemistry; and the influences of parents, culture, ethnicity, and even diet. Derangements, deficiencies or abnormalities in any of these biopsychosocial elements can lead to what we call, for lack of a better term, mental illness, which often represents the end result of innumerable interacting 'pathogens.'"
Note the truly exquisite piece of spin – "…what we call, for lack of a better term, mental illness…." The primary issue in the present debate is that the various problems of thinking, feeling, and/or behaving that psychiatry labels mental illnesses are not illnesses. That's the kernel of the debate. Dr. Pies is obviously aware of this, but in characteristic psychiatric style, he ducks the issue and pretends that they just call them illnesses "for want of a better term." If he would actually read some of the anti-psychiatry material that he dismisses so perfunctorily, he would come across a great many better terms, e.g.: human distress; painful memories; loneliness; sadness; despondency; feeling overwhelmed; feeling underappreciated; being a victim of abuse; sense of powerlessness; loss of hope; frustration; anger; etc.. Or how about: problems of thinking, feeling, and/or behaving? Or how about just asking the client to describe the problem in his/her own words?
Psychiatrists call all significant problems of thinking, feeling, and/or behaving illnesses, not for want of a better term, but rather to establish their professional turf and to legitimize their role in the distribution of psychoactive drugs. For the past 60 years this has been their primary agenda, to which they have routinely subordinated considerations of cogency, scientific validity, ethical practice, and human respect.
Dr. Pies' quote from Dr. Kandel is particularly interesting:
"'…all mental processes, even the most complex psychological processes, derive from operations of the brain...as a corollary, behavioral disorders that characterize psychiatric illness are disturbances of brain function, even in those cases where the causes of the disturbances are clearly environmental in origin.'…But in practice, Kandel is no biological reductionist. He is certainly no fan of a chemical imbalance hypothesis! Rather, Kandel paints a picture of the new psychiatry, in which psychoanalytic and biological constructs complement and reinforce one another." [Emphasis added]
It seems to me that the quote from Dr. Kandel refutes Dr. Pies' contention. Dr. Kandel says quite clearly that "… behavioral disorders that characterize psychiatric illness are disturbances of brain function even in those cases where the causes of the disturbances are clearly environmental in origin." [Emphasis added].
Dr. Pies concludes his article:
"It is time for psychiatry's critics to drop the conspiratorial narrative of the 'chemical imbalance' and acknowledge psychiatry's efforts at integrating biological and psychosocial insights."
Response to Dr. Pies
As is often the case in critiquing psychiatric claims, it's difficult to know where to start or, indeed, where to finish. What's perhaps most surprising about Dr. Pies' current paper is that he wrote it at all. Most of psychiatry's so-called thought leaders are just letting this particularly shameful episode of their history die a natural death.
The fact is that psychiatry, at both the organized and individual level, did promote, in characteristically dogmatic fashion, the notion that depression and other significant problems of thinking, feeling, and/or behaving are caused by chemical imbalances in the brain, and are best treated by drugs and other somatic measures. Nor was this an innocent error. They promoted this fiction even though they knew that it was false, because it suited their purposes and the purposes of their pharmaceutical allies.
This falsehood was promoted vigorously by psychiatrists and by pharma, and tragically has been accepted as fact by two generations in western countries and increasingly in other parts of the world. Here are some unambiguous quotes from eminent psychiatrists, whom one might reasonably expect to have been "well-informed."
"In the last decade, neuroscience and psychiatric research has begun to unlock the brain's secrets. We now know that mental illnesses – such as depression or schizophrenia – are not "moral weaknesses" or "imagined" but real diseases caused by abnormalities of brain structure and imbalances of chemicals in the brain." Unlocking the Brain's Secrets, by Richard Harding, MD, then President of the APA, in Family Circle magazine, November 20, 2001, p 62.
"More serious depression, or depression that is quickly getting worse, should be treated with medication. Antidepressants are not "uppers" and they have no effect on normal mood. They restore brain chemistry to normal." About Depression in Women, by Nada L. Stotland, MD, Professor, Departments of Psychiatry and Obstetrics/Gynecology, Rush Medical College Chicago, and subsequently President of the APA. Op.Cit., p 65.
"ADHD often runs in families. Parents of ADHD youth often have ADHD themselves. The disorder is related to an inadequate supply of chemical messengers of the nerve cells in specific regions of the brain related to attention, activity, inhibitions, and mental operations." Paying Attention to ADHD, by Timothy Wilens, MD, Associate Professor of Psychiatry at Harvard Medical School, and Psychiatrist at Massachusetts General Hospital. Op. Cit., p 65
As noted, the three passages quoted above did not occur in peer reviewed journals or in a psychiatry trade magazine. They occurred in Family Circle magazine, with the obvious intention of selling this theory to mothers. This was no accident. The articles in question were part of a "special advertizing feature" and were interlaced with ads for Paxil (paroxetine) and Metadate (methylphenidate). This was a deliberate move to lend psychiatric support to the advertisers, and to dupe the readership. Dr. Harding makes the point explicitly: "Woman, especially, can lead the way in identifying mental disease in their families, friends, and loved ones – and in themselves."
Dr. Wilens continues the theme: "Contrary to what most parents think, medication is one of the most important treatments for ADHD and is essential for long-term success of these kids."
But let's hear from another eminent promoter of the chemical imbalance theory, Jeffrey Lieberman, MD:
"…the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated. And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate. So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion." Causes of Depression, a video by Jeffrey Lieberman, MD, Psychiatrist-in-Chief at NewYork Presbyterian/Columbia University Medical Center, and then President-elect of the APA. Video made by The University Hospital of Columbia and Cornell. (June 19, 2012)
The chemical imbalance theory was also given clear and forceful expression in Nancy Andreasen's book The Broken Brain: The Biological Revolution in Psychiatry (1984). Here are some quotes:
"When we talk, think, feel, or dream, each of these mental functions is due to electrical impulses passing through the complicated and highly specialized electrical circuits that make up the human brain. The messages passed along these circuits are transmitted and modulated primarily through chemical processes. Mental illnesses are due to disruptions in the normal flow of messages through this circuitry, and these 'breaks' in the brain can occur in many different ways. The nerves forming command centers may become ill or wear out and die. The wires may lose their insulation. Some neurons may in a sense become 'overheated' and send or receive too many chemical messages. Short circuits may occur so that new connections are formed that should not be there, or command centers may become disconnected from one another through the loss of the wiring between them." (p 219) [Emphases added]
"The various forms of mental illness are due to many different types of brain abnormalities, including the loss of nerve cells and excesses and deficits in chemical transmission between neurons; sometimes the fault may be in the pattern of the wiring or circuitry, sometimes in the command centers, and sometimes in the way messages move along the wires." (p 221) [Emphasis added]
And psychotherapy is relegated to the task of helping people adjust to the consequences of having a brain illness:
"While the patient may require a somatic therapy to correct an underlying chemical imbalance, he may also need psychotherapy to deal with the personal and social consequences of his illness. He may need help with his marriage, with learning to find a new type of work, or simply with learning to live with the fact that he has had an episode of mental illness." (p 256)
Nancy Andreasen, MD, PhD, is an eminent psychiatrist. She is currently Chair of Psychiatry at the University of Iowa. She served on the DSM-III and DSM-IV Task Forces, and reportedly wrote the definition of PTSD for DSM-III. She is past president of the American Psychopathological Association and the Psychiatric Research Society. She has received numerous awards and, according to Wikipedia, is "one of the world's foremost authorities on schizophrenia."
The Broken Brain was well received by psychiatry. In May 1985, a book review written by Hagop S. Akiskal, MD appeared in the American Journal of Psychiatry. This review was extremely positive. Here's a quote:
"Dr. Andreasen's brilliant exposition effectively counters those who believe that psychiatric illness represents moral turpitude, inadequacy, eccentricity, or social marginality, as well as the lay belief to the effect that the professionals who treat such ills lack moral fiber. The accuracy of her analysis of the history of ideas and current trends, coupled with her compelling prose, renders The Broken Brain the most cogent single work on what psychiatry is about. It should be required reading in high schools, colleges, and medical schools." [Emphasis added]
Dr. Akiskal is also an eminent psychiatrist. According to his bio, he was Professor of Psychiatry and Psychopharmacology at the University of Tennessee from 1972 to 1990, and was the Senior Science Advisor to the Director of NIMH from 1990 to 1994. He is currently Professor of Psychiatry at the University of California at San Diego, and since 1996 has been Editor-in-Chief of the Journal of Affective Disorders. He has received several awards, including the Jean Delay Prize for international collaborative research from the World Psychiatry Association.
Morris Lipton, PhD, MD, wrote an opinion piece for the American Journal of Psychiatry (September, 1970, p 133). The article is titled Affective Disorders: Progress, But Some Unresolved Questions Remain. Here's a quote:
"Since the pharmacological agents that ameliorate depression and mania appear to act upon and alter the concentration and metabolism of the biogenic amines in what are presumably corrective directions, it may be inferred that in the affective disorders there exists a chemical pathology related to these compounds…positive evidence is slowly accumulating and negative evidence is thus far lacking." [Emphasis added]
The late Dr. Lipton was a psychiatrist who had served on the faculty at both the University of Chicago and Northwestern University, and at the time of writing was Professor and Chair of Psychiatry at the University of North Carolina at Chapel Hill.
Daniel Amen, MD, is a very successful American psychiatrist. He is the author of more than 30 books, five of which have been on the NY Times bestsellers list. Here are two quotes from Change Your Brain, Change Your Life (1998), one of his bestsellers.
"Depression is known to be caused by a deficit of certain neurochemicals or neurotransmitters, especially norepinephrine and serotonin." (p 47)
"Through the SPECT [single photon emission computed tomography] research done in my clinic, along with the brain imaging and genetic work done by others, we have found that ADD is basically a genetically inherited disorder of the pfc [pre-frontal cortex] due in part to a deficiency of the neurotransmitter dopamine." (p 117)
Dr. Amen is certified by the American Board of Psychiatry and Neurology in both General Psychiatry and in Child and Adolescent Psychiatry. He is CEO and Medical Director of the six Amen Clinics. Dr. Amen has had many critics, including some psychiatrists. But these criticisms have focused on his use of SPECT scans to confirm psychiatric "diagnoses" and to monitor treatment progress. I have not been able to find a single psychiatrist who criticized Dr. Amen for the kinds of chemical imbalance claims quoted above. Indeed, when psychiatrist Andrew Leuchter wrote a book review for the American Journal of Psychiatry (May 2009) on Dr. Amen's book Healing the Hardware of the Soul, he criticized what he felt was unwarranted use of SPECT scans, but also stated:
"Dr. Amen makes a good case for the use of brain imaging to explain and medicalize mental disorders." [Emphasis added]
"While these imaging studies undoubtedly educate patients and families about the fact that psychiatric disorders are bona fide medical illnesses, it is not clear how the SPECT image provides reliable information that informs clinical decisions." [Emphasis added]
In addition, it should be noted that Dr. Amen is a Distinguished Fellow of the APA.
It should also be noted that Dr. Leuchter is a Psychiatry Professor at the University of California at Los Angeles. According to his UCLA bio, he is a frequently published author, and is a reviewer for a number of scientific journals.
Although the great majority of psychiatrists adopted the chemical imbalance theory enthusiastically, there were a few dissenters, and some of these expressions of dissent provide a telling contrast to Dr. Pies' claim.
Elio Frattaroli, MD, Assistant Clinical Professor of Psychiatry at the University of Pennsylvania, spoke at the APA's 52nd Institute on Psychiatric Services (October 2000). Here's a quote from the printed summary on page 66:
"Over the last quarter century there has been a dramatic erosion of psychotherapeutic training and practice in psychiatry, caused largely by a change in our philosophical beliefs. Psychopharmacology has replaced psychotherapy because brain has replaced soul - i.e., chemical imbalance has replaced inner conflict – as the philosophical basis for psychiatric explanation. We no longer consider it important to trouble ourselves with the inner lives of our patients - the nuances of thought, feeling, impulse, and imagery in their minds and souls. We consider these private experiences that are of such deep concern to our patients to be largely irrelevant to their symptoms and personality problems, which we believe are caused directly by chemical imbalances in the brain." (p 66) [Emphasis added]
And the late Loren Mosher's 1998 letter of resignation from the APA contains the following:
"No longer do we seek to understand whole persons in their social contexts - - rather we are there to realign our patients' neurotransmitters."
Loren Mosher, MD, (1933-2004) received his medical and psychiatric training at Harvard. He taught psychiatry at Yale. He was Chief of NIMH's Center for Studies of Schizophrenia. He founded the journal Schizophrenia Bulletin. He was a Professor of Psychiatry at Uniformed Services University, Bethesda, and at the University of California, San Diego.
And Steven Sharfstein, MD, President of the APA (2005-2006), writing in Psychiatric News on August 19, 2005:
"As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the biopsychosocial model to become the bio-bio-bio model." [Emphasis added]
It is clear that all these psychiatrists quoted above are confirming and lamenting the fact that psychiatric practice is dominated by exclusively biological perspectives.
Dr. Pies is correct on one specific matter: psychiatric textbooks generally don't endorse or promote a simplistic chemical imbalance theory. Textbooks, by their very nature, discuss controversial subject matter from various aspects, and seldom come down heavily in favor of a specific theory. However, I did find this passage in Tasman, Kay, and Lieberman (eds.), Psychiatry (2003). It's on page 290, Volume 1. The chapter was written by Robert Freedman, MD, Professor and Chairman, Department of Psychiatry, University of Colorado.
"A final reason for studying the mechanisms of psychopathology is to inform our patients, their families, and society of the causes of mental illness. At some time in the course of their illness, most patients and families need some explanation of what has happened and why. Sometimes the explanation is as simplistic as 'a chemical imbalance,' while other patients and families may request brain imaging so that they can see the possible psychopathology or genetic analyses to calculate genetic risk."
The passage is not very clear, but does seem to suggest that it's OK to tell clients and their families the chemical imbalance falsehood, if they ask for an explanation,
. . . . . . . . . . . . . . .
In the light of all of which, it's difficult to afford credence to Dr. Pies' contention that "…the 'chemical imbalance' theory was never a real theory, nor was it widely propounded by responsible practitioners in the field."
And I need to stress, firstly, that it did not take a great deal of searching to find the passages quoted above, and secondly, that I limited my search to psychiatrists who had achieved a measure of eminence or stature within their profession. A less stringent search would have uncovered a great many more proponents of this theory. I constrained my search in this way because that was the challenge that Dr. Pies laid down. But in fact it's a pointless restriction. A psychiatrist who is irresponsible, ill-informed, or unrespected can disseminate falsehoods as readily and as effectively as psychiatrists of standing.
And further, it should be mentioned that psychiatry's promotion of this theory was never any secret. I have personally heard it proclaimed by many psychiatrists, both in private conversations and in public speeches. I have also heard literally hundreds of clients say that they had been assured by their psychiatrists that they had a "chemical imbalance" in their brains, to remediate which they needed to take psychiatric drugs. Fred Baughman, MD, retired neurologist, critiqued the Family Circle articles mentioned above in June 2005.
Another way that organized psychiatry has promoted the chemical imbalance notion is through the so-called consumer groups. In a 2014 brochure under the tab "links for more information," the APA lists a number of "Resources" including the following:
- Child & Adolescent Bipolar Foundation (CABF, now known as The Balanced Mind Foundation/Parent Network)
- Depression and Bipolar Support Alliance (DBSA)
- Mental Health America (MHA)
- National Alliance for the Mentally Ill (NAMI
Each of these organizations has endorsed the chemical imbalance theory wholeheartedly.
Here are some quotes from documents on their webpages:
"Depression is a medical illness caused by a chemical imbalance in the brain." (here)
"Antidepressant medications work to restore proper chemical balance in the brain." (here)
"Bipolar disorder is a chemical imbalance, which means someone with bipolar needs medicine to regulate his or her moods." (here)
The Balanced Mind Parent Network Scientific Advisory Council consists of 26 psychiatrists, including:
- Joseph Biederman, MD, Professor of Psychiatry at Harvard Medical School, Chief, Clinical and Research Programs in Pediatric Psychopharmacology Massachusetts General Hospital and McLean Hospital
- Gabrielle Carlson, MD, Professor of Psychiatry and Pediatrics, Director of Child and Adolescent Psychiatry, Stonybrook State University
- Kiki Chang, MD, Associate Professor and Director of Pediatric Bipolar Disorders Program, Child and Adolescent Psychiatry, Stanford University
- Melissa DelBello, MD, MS, Professor of Psychiatry and Pediatrics, Vice Chair of Clinical Research, Co-Director, Division of Bipolar Disorders Research, University of Cincinnati
- Robert L. Findling, MD, Director Child and Adolescent Psychiatry, University Hospitals of Cleveland; Professor of Child & Adolescent Psychiatry, Case Western Reserve University
- Janet Wozniak, MD, Director, Pediatric Bipolar Disorder Research Program; Assistant Professor of Psychiatry, Harvard Medical School and Massachusetts General Hospital
"Depression is caused by a chemical imbalance in the brain."(here)
"Scientists believe that depression and bipolar disorder are caused by an imbalance of brain chemicals called neurotransmitters."(here)
"People with depression have an imbalance of certain brain chemicals known as neurotransmitters."(here)
DBSA has a Scientific Advisory Board, the membership of which includes the following eminent, and presumably "well-informed" psychiatrists:
- Gregory E. Simon, MD, MPH, Psychiatrist and Senior Investigator, GroupHealth Research Institute, Seattle
- Michael E. Thase, MD, Professor of Psychiatry. University of Pittsburgh
- Mark S. Bauer, MD, Associate Professor of Psychiatry, Brown University School of Medicine
- Joseph R. Calabrese, MD, Professor of Psychiatry and Director of Mood Disorders Program, Case Western Reserve University
- David J. Kupfer, MD, Professor & Chairman Department of Psychiatry, University of Pittsburgh (and Chair of the DSM-5 taskforce)
- George S. Alexopoulos, MD, Professor of Psychiatry, Cornell University
- Gary Sachs, MD, Director, Bipolar Research Program, Harvard University
- Mark A. Frye, MD, Professor of Psychiatry, Mayo Clinic
- J. Raymond DePaulo Jr. MD, Professor of Psychiatry, Johns Hopkins
- William Beardslee, MD, Psychiatrist-in-Chief, Children's Hospital, Boston
"People with schizophrenia have a chemical imbalance of brain chemicals (serotonin and dopamine) which are neurotransmitters."(here)
"The presence of bipolar disorder indicates a biochemical imbalance which alters a person’s moods."(here)
"…the disorder [ADHD] is genetically transmitted and is caused by an imbalance or deficiency in certain chemicals that regulate the efficiency with which the brain controls behavior."(here)
"Scientists believe that if there is a chemical imbalance in these neurotransmitters [norepinephrine, serotonin, dopamine], then clinical states of depression result." (here)
"A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain."(here)
"…despite the knowledge that most mental illnesses are caused by chemical imbalances…there is a stigma surrounding mental illness." (here)
The most recent list of NAMI's Scientific Council includes the following eminent and presumably "well-informed" psychiatrists:
- Nancy Andreasen, MD, PhD: Chair of Psychiatry and Director of the Mental Health Clinical Research Center at The University of Iowa College of Medicine.
- Ellen Frank, PhD: Professor of Psychiatry and Psychology at the University ofPittsburgh School of Medicine; member of the Mood Disorders Workgroup of the DSM-5 Task Force.
- David Kupfer, MD: Professor of Psychiatry and Professor of Neuroscience, University of Pittsburgh School of Medicine; Chair of the DSM-5 Task Force.
- Jeffrey Lieberman, MD: Chair of Psychiatry, Columbia University; Director of the New York State Psychiatric Institute; Psychiatrist in Chief at NewYork-Presbyterian Hospital - Columbia University Medical Center; immediate Past President of the APA.
- Henry Nasrallah, MD: Associate Dean; Professor of Psychiatry and Neuroscience, Director of the Schizophrenia Program, University of Cincinnati.
- Charles Nemeroff, MD: Chair of Psychiatry and Behavioral Sciences and Director, Center on Aging, University of Miami Health System.
- S. Charles Schulz, MD: Professor and Chair, Department of Psychiatry, University of Minnesota Medical School.
NAMI's Medical Director is Kenneth Duckworth, MD, Assistant Clinical Professor at Harvard University Medical School.
Is it not reasonable to assume that all these eminent psychiatrists endorse the chemical imbalance illness theory so clearly set out in the above quotes? If these psychiatrists were as skeptical of this theory as Dr. Pies implies, shouldn't they have taken steps to have the brochures changed? Or was this just a "little white lie?" What's the point of having a scientific advisory board, if it doesn't provide scientific advice?
And remember, all four of these organizations are on the APA's "Links for more information" tab. If the APA does not, in fact, endorse the chemical imbalance theory, wouldn't it be more appropriate to label this tab: "Links for disinformation"? The chemical imbalance theory, as Dr. Pies so rightly states, is simplistic nonsense. So why does the APA promote these organizations on its website? Isn't it, at the very least, a reasonable conjecture that the APA leaves these links in place from considerations of self-interest? Has there ever been an attempt by the APA or any of its members to educate these organizations on these matters?
At the foot of the 2014 Resources document, the APA have inserted the disclaimer: "These links are provided as a convenience and do not imply endorsement." But if they are not endorsing the various organizations' stance on the chemical imbalance theory, why in the world would they list them as a resource for "more information?" And isn't it obvious that a person clicking on the "Links for more information" tab will likely go to these links, and will likely not go to the bottom of the page to read the disclaimer? If the APA genuinely wanted to disavow the spurious chemical imbalance theory, wouldn't they have put the disclaimer at the top of the page, or removed the links altogether?
Dr. Pies has not himself, as far as I can tell, ever promoted the chemical imbalance theory. He recognizes it as nonsense, and is anxious to distance his chosen profession from this deception. And this perhaps understandable human desire is blinding him to some unsavory realities. What he is doing essentially, is cherry-picking references to support his contention, while ignoring the very large body of contrary evidence.
But he's also doing something else. By drawing us into a debate as to whether or not psychiatrists promoted the chemical imbalance lie, he is deflecting attention from the much more fundamental lie: that all problems of thinking, feeling, and/or behaving are illnesses. In comparison with this monstrous falsehood, the specifics of the putative illness are trivial.
Dr. Pies has not only promoted this monstrous falsehood, he has insulated this falsehood from any possibility of rebuttal by the simple expedient of redefining the word disease. In his paper Context Does Not Determine 'Disorderness' or Normality, (April 2013) he states:
"Regardless of context, once a certain threshold of suffering and incapacity is crossed, physicians justifiably apply the term 'disease' (or 'disorder') to the person’s condition. (For purposes of this discussion, I am using the terms 'disease' and 'disorder' more or less synonymously, although the medical literature is remarkably inconsistent in how these terms are applied.…) This is also true of maladaptive symptoms attributed to the patient’s developmental context…. It is of course true that temper tantrums in a 2-year-old—or moodiness and impulsivity in an adolescent—are very often developmentally normal. But once a certain threshold of suffering and incapacity is crossed, we rightly impute disorderness to the child’s condition, make a diagnosis, and offer appropriate treatment. That the child’s symptoms occur in an understandable context does not render our diagnosis a 'false positive.' Context helps explain pathology—it does not annul it."
And in case there might be any residual ambiguity, in April 2013 in Psychiatry and the Myth of 'Medicalization', he wrote:
"So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease…."
So if a person is significantly suffering and incapacitated, from any cause - not just physical pathology - he has a disease. Dr. Pies acknowledges that all three terms – significantly, suffering, and incapacitated – defy definition and measurement. But he promptly dismisses these concerns, and focuses instead on "…the first duty of all physicians is to relieve pronounced or prolonged suffering and incapacity."
But what he ignores entirely is that this is not the normal meaning of the word "disease." In its normal usage, the word "disease" implies physical pathology. Indeed, even psychiatrists acknowledged this implicitly when, for decades, they told their clients that depression was an illness "just like diabetes." The phrase "just like diabetes" makes it perfectly clear that they were not using the word "illness" in Dr. Pies' arbitrary and esoteric sense, but rather in the conventional sense of organic pathology – and this is how psychiatric clients and the public generally interpret this statement.
Dr. Pies' statement above that "…the first duty of all physicians is to relieve pronounced or prolonged suffering and incapacity" is seductively convincing, but in fact is false. It is a physician's business to relieve suffering and incapacity that is caused by organic pathology. I think this is how the great majority of non-psychiatric physicians would conceptualize their role. I'm not saying that physicians shouldn't be allowed to branch out into other areas. Plumbers can do carpentry work. In fact, most plumbers have to do some carpentry to expose pipes and tidy up afterwards, etc… But a plumber who conceptualized all carpentry problems as leaks, and tried to fix these problems with copper pipe and solder, would not be very successful. In the same way, physicians who conceptualize non-medical problems as illnesses do more harm than good.
Dr. Pies' definition of disease is just one more attempt on the part of psychiatry to prolong the destructive deception: that all problems of thinking, feeling, and/or behaving are illnesses.
This is emphatically not an academic debate. The illness/disease concept is the fundamental underpinning and justification for the administration of drugs and other somatic "treatments." If the illness lie collapses, then psychiatrists are exposed as the frauds and drug pushers that they are. The "illness" lie is actually a mechanism that psychiatrists use to overcome clients' resistance to taking psychoactive chemicals, and as a marketing tactic it has been extraordinarily successful. The fact is that psychiatric drugs distort and impair neural functioning. But if people can be convinced that the opposite is the case – that the drugs actually correct a neurochemical imbalance, or a neural circuitry anomaly, or whatever, then consumer resistance diminishes, and the marketing battle is as good as won.
Fortunately, the neurotransmitter imbalance deception has been so discredited in recent years that, as mentioned earlier, it is being quietly slipped to the wings, but the notion that all problems of thinking, feeling, and/or behaving are illnesses is alive and well, and is still being actively promoted by psychiatry. In 2005, the APA published an "educational" brochure titled Let's Talk Facts About Depression. Here's the opening sentence:
"Depression is a serious medical illness that negatively affects how you feel, the way you think and how you act." [Emphasis added]
In 2014, nine years later, they produced another brochure, this one titled simply Depression. Here's the opening sentence:
"Depression is a serious medical illness that negatively affects how you feel, the way you think and how you act."
Apparently not much had changed between 2005 and 2014. Incidentally, there's a truly delightful piece of psychiatric side-shuffle in the closing paragraph in the 2005 paper mentioned above.
"This brochure was developed for educational purposes and does not necessarily reflect opinion or policy of the American Psychiatric Association."
Why in the world would a professional association put a disclaimer of that sort on an educational brochure? What are they saying? Our educational material does not necessarily reflect our opinion or our policy? We know that there are some lies in here, and we will repudiate them in the future if it becomes expedient to do so?
Psychiatrists' Links to Pharma
In one of the passages quoted earlier, Dr. Pies mockingly rejected the notion that psychiatry was "in cahoots" with Big Pharma. In fact, of the 31 psychiatrists mentioned in this post as promoting the chemical imbalance theory, or of being on the advisory boards of consumer organizations that promote this theory, 19 (61%) have, or had, financial ties to one or more pharmaceutical companies. (Sources: Dollars for Docs and journal article disclosures.)
So to recap, Dr. Pies' insistence that the chemical imbalance theory was never "…widely propounded by responsible practitioners in the field of psychiatry" is simply false. (unless, of course, the statement is meant to reflect the paucity of responsible psychiatrists).
But it is also a red herring. The central issue is psychiatry's spurious assertion that all problems of thinking, feeling, and/or behaving are illnesses. Whether these putative illnesses are caused by an excess of "black bile," a serotonin imbalance, or a neural circuitry anomaly, or whatever the next fad will be, is very much a secondary issue.
We have seen how the APA endorses the illness notion, as does Dr. Pies himself. Dr. Pies even manages to define disease in such a way that psychiatry's subject matter must always be considered illness, regardless of any future empirical findings. For Dr. Pies, any condition or circumstance that entails significant distress and impairment is a disease. Dr. Pies offers no arguments or proof in support of his position. He simply – in the best psychiatric tradition – proclaims it to be true. And within the framework of psychiatric logic, that makes it true. He defines disease in such a way that it embraces virtually all significant problems of thinking, feeling, and/or behaving, and then proclaims, as if it were a significant fact or discovery, that all these problems are diseases.
But Dr. Pies is by no means alone. The notion that all significant problems of thinking, feeling, and/or behaving are illnesses is an integral part of psychiatric dogma, and has been enshrined in the APA's definition of a mental disorder since DSM-III. But there is no coherent or convincing statement of pathology to support this contention. Like so much else in psychiatry, it is considered true because psychiatrists say so. And they say so because it's good for business. The chemical imbalance theory is arguably the most destructive hoax ever perpetrated.
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This article first appeared on Philip Hickey's website
Behaviorism and Mental Health
Behaviorism and Mental Health: Philip Hickey is a retired psychologist. He has worked in prisons (UK and US), addiction units, community mental health centers, nursing homes, and in private practice. He and his wife, Nancy, live in Colorado, and have four grown children. His posts can also be seen on his website, Behaviorism and Mental Health.