The Chemical Imbalance Theory:  Still Being Promoted

Philip Hickey, PhD
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On November 28, Psychiatric Times published an article titled Psychiatric Diagnosis and Treatment of Somatizing Neuropsychiatric Disorders.  The authors are Daniel T. Williams, MD, and Alla Landa PhD, both from Columbia University Psychiatry Department.

The article’s lead-in states:

“Although the somatizing disorders cover a vast array of symptomatic domains across many medical specialties, this article addresses the broad topic conceptually.”

The so-called somatizing disorders have an interesting history in psychiatry.  DSM-III-R (1987) states:

“The essential features of this group of disorders are physical symptoms suggesting physical disorder (hence, Somatoform) for which there are no demonstrable organic findings or known physiologic mechanisms, and for which there is positive evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts.” (p 255)

DSM-IV (1994) states:

“The common feature of the Somatoform Disorders is the presence of physical symptoms that suggest a general medical condition (hence, the term somatoform) and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder (e.g., Panic Disorder).” (p 445)

DSM-5 (2013) states:

“All of the disorders in this chapter [Somatic Symptom and Related Disorders] share a common feature:  the prominence of somatic symptoms associated with significant distress and impairment.” (p 309)

Note that the requirement that the symptoms are not fully explained by a general medical condition has been dropped from DSM-5.  In this latest edition of the manual, the only requirements are that the symptoms are distressing, disruptive, and excessive, the assessment of which is inevitably subjective.

Note also that Drs. Williams and Landa refer to these “diagnoses” as neuropsychiatric disorders, essentially begging the question that they involve neurological pathology.  There is no evidence to support this position.  Nor is there any rational support for the notion that worries and concerns about medical matters should be conceptualized as illnesses, even if the individual’s level of distress and preoccupation is extreme.  But a detailed critique of this matter is beyond the scope of this post.

. . . . . . . . . . . . . . . .

The Williams and Landa article is detailed and comprehensive.  It addresses the phenomenology, epidemiology, and developmental course of the so-called somatization disorders.  Under the heading “Postulated pathogenic influences,” the authors present working hypotheses from psychoanalytic theory, learning theory, behavior analysis, social-affective neuroscience, autoimmune sensitization, and theories of dissociation.

On the topic of social-affective neuroscience, the authors state:

“Recent advances in social-affective neuroscience suggest that early interpersonal environment may interact with genetic predisposition and epigenetic changes to affect the neural circuits involved in interpersonal emotions and physical pain. This type of predisposition makes a person particularly sensitive to emotional stressors and presents difficulties in regulating emotional and somatic distress 12.  This could explain the variable vulnerability to somatization under similar stressors among different individuals. It also points to the need to carefully evaluate these relevant vulnerabilities in psychotherapeutic exploration of each patient’s unique biographical narrative.”

The essential point being expressed here is that people develop “excessive” concern about their health or “excessive” sensitivity to pain, because of neural circuitry anomalies.  These anomalies, in turn, stem from the interaction of a hypothesized genetic predisposition and the individual’s early interpersonal environment.

Aberrant neural circuits are fast replacing the discredited chemical imbalances that constituted the cornerstone of biopsychiatry until effectively debunked by psychiatry’s critics.  At present, the aberrant circuits are being postulated with a measure of caution; note the terms “suggest” and “could explain” in the above quote. But in general, the circuitry hypothesis is being actively promoted, and is gathering a good deal of traction.

Incidentally, reference # 12, cited in the above quote, is to an article by Dr. Landa and two other Columbia researchers.  Here’s the final statement from the abstract:

“Specifically, the proposed theory and research review suggest that psychotherapeutic and/or pharmacological interventions that foster the development of affect regulation capacities in an interpersonal context will also serve to more effectively modulate aberrantly activated neural pain circuits and thus be of particular benefit for the treatment of somatoform pain.”

Note:  “…psychotherapeutic and/or pharmacological interventions…”, and particularly the suggestion, which is also becoming common in psychiatric circles, that psychotherapy and drug treatment have essentially the same effect:  the modulation of “aberrantly activated” neural circuits.

Certainly psychotherapy affects people’s brains.  All human activity affects the brain. But the notion that talking to a person empathically and sincerely (whether in a professional capacity or simply as a friend) is on a par with the ingestion of psychiatric drugs makes a mockery of human interaction.

The authors discuss the treatment implications of these various “postulated pathogenic influences,” including the need to restructure learned patterns and the establishing of therapeutic rapport.  Under the heading “Approach to treatment,” the authors stress the importance of psychosocial factors:

“…do the symptoms serve to avoid a constellation of stressors with ensuing functional impairment, by allowing the patient to retreat into ‘the sick role’? Moreover, might the symptoms be the body’s reaction to overwhelming stress?”

“Many patients may not be able to articulate the complex environmental stressors that produce feelings of shame or inadequacy. They may cling to the identity of the medically ill patient as a ‘safer’ refuge from life’s adversities. Therefore, the psychiatrist should present the diagnostic hypothesis of SSD tentatively and supportively, noting that it is not mutually exclusive of coexisting physical illness.”

Under the heading “Treatment options,” Drs. Williams and Landa list and discuss:

  • Reassurance, placebo, suggestion and psychoeducation
  • Individual or family psychotherapy
  • Psychodynamic strategies
  • Behavior modification
  • Cognitive-behavioral therapy
  • Group psychotherapy
  • Mindfulness, meditation, progressive relaxation, deep breathing

All of this, apart from the unwarranted implications of neurological illness, sounds fairly encouraging.  But then there’s this:

“Psychopharmacological agents may have specific therapeutic benefit for comorbid psychiatric disorders, including anxiety, depression, obsessive-compulsive disorder, and psychosis, all of which may coexist with and complicate SSDs. In addition, these agents may have nonspecific (placebo) benefits. For patients who have difficulty in grasping the concept of somatization, who have discomfort with psychotherapy, or who want a ‘medicine’ to legitimize the validity of their physical illness and recovery, a supportive discussion of the role of these medications in normalizing brain neurotransmitter function can be helpful. The medicine can be the needed aid that helps the psychotherapy go down.” [Emphasis added]

The fact is that there are no psychiatric drugs that normalize brain neurotransmitter function.  Indeed, the opposite is the case.  Every psychiatric drug on the market today produces abnormal brain function.  So either Drs. Williams and Landa aren’t aware of this, or they are advocating that therapists should deceive their clients on this very fundamental issue.

Unfortunately, but perhaps inevitably, this kind of patronizing disrespect is still widespread in psychiatry, and is fundamentally incompatible with the lofty rapport-building and therapeutic sentiments expressed earlier in the article.  Therapeutic rapport and systematic deception are mutually exclusive.

The very eminent psychiatrist Ronald Pies, MD, has written that the chemical imbalance theory is a kind of “urban legend” – never promoted by well-informed psychiatrists.  Well, Dr. Williams, according to his bio, has been on the faculty at Columbia University for forty years!  He has authored more then 60 publications in peer-reviewed journals and standard textbooks in the fields of psychiatry and neurology.  I think it is reasonable to suppose that he would meet Dr. Pies’ standards for being well-informed, and yet here he is advocating the promotion of the spurious chemical imbalance theory!

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30 COMMENTS

  1. Hi Philip,
    firstly I’d like to thank you for all your incredibly informative reports – thank you!

    What is postulated in this article is thoroughly abhorrent: it merely re-brands all psychiatry’s past lies and adds the new dimension/name/veneer of neuropsychiatry!!!!

    That is an extremely interesting evolution of the DSM definition of somatizing disorders. It would appear that psychiatry is not just intent on increasing its own power but wants to be able to legitimately take over the rest of medicine as well.

    I note that the tone of the pieces you quote also much of the responsibility back onto the patient, even more blatantly than the old “chemical imbalance” positions did.

    WOW, I am almost speechless when he says,
    “…do the symptoms serve to avoid a constellation of stressors with ensuing functional impairment, by allowing the patient to retreat into ‘the sick role’? Moreover, might the symptoms be the body’s reaction to overwhelming stress?”

    “Many patients may not be able to articulate the complex environmental stressors that produce feelings of shame or inadequacy. They may cling to the identity of the medically ill patient as a ‘safer’ refuge from life’s adversities. Therefore, the psychiatrist should present the diagnostic hypothesis of SSD tentatively and supportively, noting that it is not mutually exclusive of coexisting physical illness.”
    …and basically, then drug them.

    Obviously the paradigm shift being promoted needs to be countered before it takes wider hold, as I see it as something psychiatry will very enthusiastically embrace.

  2. I strongly believe this Psychiatry guys are out of order. Psychiatry is a ”science” which doesn’t even act according to its name, uses neologisms and theories meant for description in literature, neologisms that have no match with reality; it lacks of Elementary Logic and destroyed the evolution of humanity. It’s just a coercion form, a worst than Middle Age and Nazism history regarding human nature, and who doesn’t subscribe to it has probably ”a chemical imbalance”. I really wonder when will it finish, when will we be free to not believe these things and we will speak in our own facts, when will we evolve and won’t listen this cheap philosophy that Psychiatry makes?

  3. I wanted to caution people that even though psychiatry deserves all the intense criticism directed towards it as the result of this article that Philip has referenced, it is important to not let primary care physicians off the hook since they prescribe 80% of psych medications.

    And in reading this article, many of the issues with somatic disorders have occurred due to primary care physicians pawning off their patients onto psychiatrists because they couldn’t be bothered to investigate why a complicated medical condition was causing a patient problems. Alot easier to blame it on psych issues.

    And as MIA author Richard Lawhern as commented on the Psychiatric Times Website, once a patient is referred by his/her PCP to a psychiatrist, he/she is no longer seen as a credible member of any experienced health conditions. The effect on the type of care this person receives is devastating.

    • Thanks again, Philip, for continuing the good fight against psychiatric fraud.

      AA, “A lot easier to blame it on psych issues” is the truth. I’m your perfect example that a primary function of the psychiatric industry today (and historically) is covering up easily recognized iatrogenesis via psychiatric defamation, tranquilization, and major drug interaction poisonings. I had no mental health problems until after a “bad fix” on a broken bone was treated with a dangerous and ineffective “safe smoking med” / antidepressant, then the known withdrawal effects of the antidepressant were misdiagnosed as the “life long, incurable, genetic mental illness,” bipolar.

      It’s time to put an end to “the dirty little secret of the two original educated professions.” Covering up easily recognized medical mistakes by defaming, torturing, and poisoning patients is immoral and evil, doctors.

  4. Thanks for your informative exposures of the very biased speculations of psychiatry.

    I’ve been fascinated at how neuron-science would assail the whole notion of human liberty and moral agency through this manner of theorizing humanity some sort of predetermined mechanistic machinery. B. F. Skinner’s Walden II, I think utopia is the wrong word to use, but society governed by a managerial class with a scientific, or pseudo-scientific, background, is an example. One could call it scientism at its worst.

    One Somatic Symptom Disorder (SSD) that doesn’t get as much mention as it might once have received is Hypochondriasis because we’re actually talking about a house of cards here. Give a person a pill for thinking they are sick, when they are not actually sick, and automatically you’ve altered that person’s chemistry, and perhaps introduced what could be called a negative change. Changing their chemistry is never going to make them well when they weren’t sick to begin with. It might, though, have the opposite effect, injuring them, and ultimately serve as a justification for the pretense. The thing is, as in the WIlliams Landa Psychiatric Times piece, you can’t get there without a heck of a lot of deception, and perhaps even a great deal of self-deception.

    Link Hypochondria to what have you “disorder”, and what have you “disorder” to Hypochondria, and you only give the drug companies further reason to celebrate.

  5. Philip,

    IMO, it’s a wise thing for a person to “listen to their body.”

    Our bodies are pretty intelligent, and can warn us if we are in bad relationships, under too much stress, not getting enough sleep, need to exercise, need to relax, take a break, make a move, be still for a while, get something to eat, etc.

    And when we have very real “symptoms” from any of these, it doesn’t mean we have a mental disorder; in fact, it these may be the first clues in helping prevent more emotional distress, or a physical illness.

    Also, just because a brief exam by a doctor shows no clues that nothing appears to be physically wrong, doesn’t mean that an underlying physical illness is not the culprit. Thyroid problems, diabetes, sleep disorders, and many other conditions are routinely ignored by psychiatrists and GPs. Ironically, the drugs they prescribe often cause or exacerbate these conditions.

    I still say, listen to your body. Even when docs say ignore it.

    Duane

  6. The notion of somatoform (a.k.a. somatizing) disorder has a long, sad but interesting history. Part of it resulted from efforts in the United Kingdom to avoid public and private insurance compensation, to sufferers of ‘invisible illnesses.’ Here is a focussed conceptual history of the work of Gordon Waddell and its effects in the UK. I wrote this in my own capacity, but am a member of the organisation you will see. The full story is quite complex. http://dpac.uk.net/2014/09/gordon-waddells-biopsychosocial-attack-on-disabled-people/

  7. I’m confused Dr. Hickey. The chemical imbalance theory isn’t a theory at all – it is actually a hypothesis, is it not? We often hear theory and hypothesis used interchangeably in an attempt to simplify a complex topic to more easily dismiss disagreement. We see causation and correlation confused. We see someone say they’ve debunked findings, when it is more accurate to say the findings have been “scaled back” in importance, depth, relevance, etc. We aren’t just talking about semantics. These are important distinctions. It is a common 1-2 punch strategy to mischaracterize then marginalize. (Do we not see this in at least some anti-psychiatry critiques of research and findings?) Because a hypothesis in itself doesn’t prove anything, it can’t be disproven. Wouldn’t a legitimate criticism of the chemical imbalance HYPOTHESIS be that it is far more limited in its ability to explain ‘mental illness’ than we are often lead to believe. We are often lead to believe chemical imbalance is an iron-clad ‘theory’ by folks using the same strategy that is used to refute it. The strategy isn’t fair, no matter which side of a debate uses it. I’ve heard it said that there is no evidence of a biological or genetic basis for ‘mental illness’. Is this not improperly conflating evidence and proof? Certainly there is a significant body of evidence supporting the theory that some mental health issues do have some basis in biology and/or genetics. (of course this does not exclude other factors, and certainly does not constitute proof) I’d say that a general message to anyone trying to find the closest thing to truth in a debate: look into every side with skepticism and recognize when arguments attempt to paint with a simplicity brush. See what important information got brushed over in that process. Attempting to expose supposed ‘pseudoscience’ using a method that can just as easily be labeled pseudoscience is a failed enterprise. Am I completely off my intellectual rocker?

    • Probably not completely, and needn’t get too worried. But the instances that Dr. Hickey refers to do constitutend the deployment of theoretical explanatory claims. All of your semantic and conceptual concerns are issues of relevance for making our ideas clear, although the specific questionable usages are most problematic for foreign translation, and usually we get the gist despite minor inconsistencies in terminology. As far as thoughts of brain deficits and brain dysfunctions go, this personally doesn’t offend me, but no sort of therapeutic intervention for brains are on offer from psychiatry.

      • “no sort of therapeutic intervention for brains are on offer from psychiatry.”

        Not in my personal experience. Now of course it wouldn’t be fair to extrapolate that and make some kind of broader statement, just as it isn’t fair to do the same based on instances where interventions using psychiatric medication have failed, or worse – caused harm.

        When talking about science, I don’t see the inconsistencies as minor. If someone presents something as proven when it is only considered to be supported by evidence, or if someone presents causation where there is only correlation, that person has opened themselves up to criticism for being misleading and dishonest. Psychiatrists have opened themselves up in this way and been on the receiving end of such criticism. I don’t see why it should be different for someone pushing certain anti-psychiatry positions in a way which mischaracterizes what they are criticizing.

          • Your statement is less black and white, but I’d still contest it, as would the perhaps millions of others who have benefited from pharmacotherapy and/or psychotherapy. Are you really going to speak for the scores of people whose mental health issues have been at least in part alleviated by talking with a therapist and/or psychiatric medications? I’m not trying to speak for the scores that haven’t been helped or worse, harmed at the hands of prescription-happy psychiatrists who manipulate information in a misleading way.

            Therapeutic interventions aside, a common strategy for dismissing psychiatry is to throw out evidence because it doesn’t pinpoint a cause, which is ridiculous and creates a standard that other fields are certainly not asked to meet in order to be respected.

            “We all know that diabetes is caused by the failure of the pancreas to secrete normal amounts of insulin. But what causes that? We say it’s an autoimmune condition — the body attacks its own insulin-secreting cells. Why does that happen? We don’t know.”

            “The New England Journal of Medicine some years ago published a paper demonstrating that far fewer than half the treatments used for cardiovascular diseases are supported by good scientific evidence. Psychiatric treatments work about as well as other medical treatments.”

            -Nada Logan Stotland, M.D.

            (http://www.huffingtonpost.com/nada-logan-stotland-md-mph/psychiatry-myths-and-myst_b_840852.html)