The Chemical Imbalance Theory:  Still Being Promoted

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!

  • Dr Hickey, thanks for this needed article.

    I have written in multiple forums concerning the medical and ethical hazards of so-called “Somatic Symptom Disorder” in the DSM-5 and its precursors. I consider the entire field of psychosomatic medicine to be an elaborate mythology reinforced by the financial self-interest of medical and psychiatric practitioners. The medical doctors use SSD as a throw-away diagnosis to remove difficult or time-consuming chronic disorder patients from their practices for whom insurance companies refuse to adequately reimburse. Psychiatrists want to get paid for delivering “therapy” that has results no better than placebo and which may actively endanger the patient. The two groups combine in an often-deadly dance which further disables and marginalizes patients with rare or subtle medical issues, and places millions of others at risk who present with common but difficult-to-confirm medical problems such as early stage cardiac disease, MS, and Lupus.

    Three additional references may serve to reinforce the points you have offered above.

    Angela Kennedy has written a ground-breaking book, available on Amazon: “Authors of Our Own Misfortune? The problems with psychogenic explanations for physical illnesses”. It can be tough reading. But in my opinion, any psychiatrist who is damn fool enough to believe in psychogenic illness should be forced to do so.

    “It’s NOT All In Your Head” is an editorial piece that I contributed to Mad In America.

    “Psychogenic Pain and Iatrogenic Suicide” was published at the Global Summit for Diagnostic Alternatives, sponsored by the Society for Humanistic Psychology. See dxsummit.org/archives/1002 . In this article I offer evidence that by the act of assigning a diagnosis of so-called “psychogenic pain”, medical doctors directly increase the risk of patient suicide by 250%. This risk is independent of the nature of the presumed co-morbid — but in fact ONLY — underlying pain disorder that actually creates the patient’s chronic pain. This evidence is grounded upon results of the largest survey of suicide and chronic pain ever conducted, among 4.8 million patients.

    Other articles on this theme occur on Dr. Allen Frances’ blog on Psychology Today, and on “Living With TN”, a patient peer support website serving 6,000 chronic face pain patients in 117 countries. I am a senior moderator on that site.

    Thanks again for your continuing efforts to force mainstream psychiatry to confront its gross folly and maltreatment of millions of people.

    Best Regards,
    Richard A. Lawhern, Ph.D.
    Resident Research Analyst,
    Living With TN – an online community within the Ben’s Friends group.

  • cledwyn bulbs

    I tend not to bother reading the articles you discuss, nor the quotes you select, because I find the the style impenetrable, and the waters within which their insights (if there are any) reside, turbid. Trying to wend one’s way through the throng of code words and the most diffuse abstractions that crowd their sentences is an endeavour that yields few, if any, emotional and intellectual rewards, and the rewards would need to be great and plentiful to justify the mental toil required to make it through the arid figurative landscape of their prose.

    There’s also nothing to recommend it aesthetically either, and beauty sweetens the love of learning and is a wonderful digestive aid, that serves to awaken the faculties from their customary repose. Conversely, prose as dry, prosaic, and insipid as is to be found in most scholarly writing, disturbs digestion, and acts like a narcotic on the faculties, so that it requires a great exertion of the will and a mostly useless expenditure of mental energy to take anything in. Alas, most men are philistines, so this applies to few. Perhaps this explains why there are people who can make it to the end of the DSM without blowing their brains out, assuming such a person exists.

    My brain just switches itself off reading this stuff, a precautionary measure it reflexively takes to forestall the likelihood that my thoughts will become as confused as those of the writer. Even the tools of the cryptologist wouldn’t suffice to prize the meaning out of much of what passes as “scholarly” writing on this issue.

    The origin of such confusion and diffusion, as is regularly encountered on this issue, is manifold.

    For one, when an idea is held in an inchoate form, trying to find the right words is difficult.

    Secondly, because all specialties have their own code language, and the function of code language is generally to obscure meaning and elucidate it (and specifically in this case, to guard against trespassers and preclude criticism and democratic discussion), even the people using the terms are not entirely sure of what the hell it is they are talking about, because the language is so imprecise, drawing a veil of obscurity over that which it refers to. This leads to people writing things they know not the precise meaning of, in the hope that the reader won’t notice, a hope usually well founded when the writer’s status and prestige, as well as the other trifles and extraneous details that prepossess human judgment in his favor and surround him with a halo of glory, lend an appearance of wisdom and intelligence to words in which neither inhere.

    For the foregoing reason, confusion reigns in our age under the guise of superior wisdom, and the utterances of experts, which are often nonsensical, are accorded the same measure of veneration as was once the exclusive property of supposedly divine revelations.

    Another factor is the penchant for jargonistic, sesquipedalian prose common in academic journals. Now there’s nothing wrong with using big words, but when allied to their imprecise usage and used without moderation, so that almost every word in a sentence seems to be vying with the other to be the longest and most impressive sounding, then you’ve got a problem.

    An example of this can be found in the article referred to;

    “Specifically, the proposed theory and research review suggest that psychotherapeutic and psychopharmacological interventions that foster development of affect regulation capacities….”

    Orwell once rightly pointed out that the great enemy of clear language is insincerity, so it is hardly surprising that in professions where sincerity is in limited supply, clarity of language is also.

  • cledwyn bulbs

    That should be “and serves to awaken” in the second paragraph, not “that”.

  • cledwyn

    And that should be “not elucidate it”.

  • Phil_Hickey

    Red,

    Thanks for coming in, and for the references.

  • Sjpickles

    Wonderful article. I have been following your posts as a sufferer rather than a professional in the mental health field. I have posted the link to your website in a uk mental health support website with the hope it will show sufferers who are at the end of their tether with medication that they are being treated with the wrong prescription and give them back power and control over their own circumstances. Please keep doing what you are doing. Because of you I began to overcome sever trauma.

  • Phil_Hickey

    Sjpickles,

    Thanks for your encouraging words. I hope that things continue to go well for you.

  • Deirdre Oliver

    …`the chemical imbalance theory is arguably the most destructive hoax ever perpetrated’. The next best is `God is love’. My problem is that we all know all this, we see it every day -I’m seeing people killing themselves because of the despair at the helpless & hopeless feeling of being trapped in the psychiatric system. Whatever `Illness’ they may or may not have had is totally overwhelmed by their treatment. These people are killing thousands of people every day, quickly & slowly, wrecking their brains, families and lives and the lives of their children who don’t inherit a `disease’ but are terribly damaged by proxy. So we have a total and growing disaster, we know that. But what are we going to do to help them. To actually STOP the destruction? We have a population that don’t know what is happening until it happens to one of their own, and until it does they don’t care. We have politicians and bureaucrats who don’t want to know, escalating costs to the public health service that supports these draconian treatments and actually also escalates the number of people who can no longer work or contribute so that government itself will have to start turning the costs back on the taxpayer as is happening here in Australia, and still nothing happens. People are still dying! Little kids are being electrocuted, 16 year olds are having brain surgery, 21 year-olds face a lifetime of disfigurement from Tardive Dyskinesia, adolescents are still killing themselves and others in shootups because of drugs that should never be being used. Worse, these guys are moving into the 3rd world taking this religion, this sect and selling it to the ill-educated as science, the flagship of civilisation. Reading so many of the paragraphs written by the psychs, burying nonsense in jargon and convoluted crap is pasting a skin over a rotting chancre that has to be burst. How to expose them publicly? Obvious, public research? Constant pressure on them to justify the costs to the health services? Round up the various social agencies who rarely know what each other are doing at the best of times and force the links? I don’t know, but can we please get down to it and make realistic plans on how to STOP them not just EXPOSE them to each other. I’ve written a new ECT Info Brochure – I WILL distribute it – I will constantly write to the press pointing this stuff out – I will get people to COME OUT – somehow. Help!

  • cledwyn bulbs

    Excellent comment.

  • I find it disconcerting that not a single medical professional has been sufficiently discomforted by this paragraph to leave a comment on the Williams and Landa article

    (Original source URL, Psychiatric Times Special Report)

    http://www.psychiatrictimes.com/special-reports/psychiatric-diagnosis-and-treatment-somatizing-neuropsychiatric-disorders

    “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.” [Dr Hickey’s emphasis]

    Wrong on so many levels – as they say.

  • Phil_Hickey

    DxRevision Watch,

    Yes; it is a particularly condescending statement with serious ethical implications.

    Traditionally physicians don’t criticize other physicians publicly, but psychiatry’s foundations and practices have become so patently absurd in recent years, that this tradition is showing signs of strain. Hopefully over the next few years, we’ll see more real doctors speaking out against the medical travesty that psychiatry has become.