The Punch Line
Less so today, there used to be a stream of people coming through my office who would say, “I have a chemical imbalance.” Of course, most were applying for Disability payments and would demonstrate their lack of balance by getting angry when I would question their beliefs, which would interfere with the possibility of them getting government money.
“How do you know you have a chemical imbalance?” I would ask.
“My doctor told me. He said I have mood swings.”
The idea of chemical imbalance began with the Dopamine Hypothesis of schizophrenia, which postulated that schizophrenia was caused by an excess of dopamine in the brain or an over-sensitivity to dopamine because of the high reactivity of dopamine receptors and there were other versions of the theory. Brain studies on deceased patiensts gave the theory a scientific basis and, happily, there were positive effects, such as for Henry, which would indicate that the work was headed in the right direction. After that it became fashionable to attach the idea of chemical balance to other psychiatric diagnoses and eventually to most, if not all behavior. With this understanding, Bipolar Disorder, formerly known as Manic Depression, was balanced by mood stabilizers, ADHD by amphetamine and its derivatives, Mood Disorders, such as depression, by SSRIs, MAOI etc, Anxiety Disorders by anxiolytics, and so forth, all with the goal of balancing something that was presumed to be out of balance and that could be corrected with chemical balancing.
To most people this translates to, “I didn’t do it. My chemicals did.” Pretty soon, mothers and fathers were dragging their kids to psychiatrists to fix their difficult children because, it was believed, with a little balancing the behavior would be eliminated and the child in question would miraculously become an Einstein or Shakespeare, someone rich, admired, clever, with the brains of a doctor without ever having graduated high school. Until we arrived at what we see now, a diagnostic system that lets those who reap the rewards of diagnosing and treating determine what is a true diagnosis and how best to treat it, democratizing the system for the diagnoser, a system that under other circumstances should be more systematically controlled to protect the consumer.
What is chemical balance?
The only way chemical balance could be successfully studied would be if researchers knew what chemical balancing was in the first place. Remember, most research compares subjects of interest to normals. It should be no different in this case. First, they would have to identify the subjects, then they would have to identify “normals”, then they would have to poke around in the brains of normals to find out what “normal chemicals” are, then do the same with abnormal subjects to see how they differ.
If this doesn’t sound practical or doable-guess what?-it isn’t. Why not? Well, start out by looking at yourself in the mirror and ask yourself this question, “Am I normal?” If for some reason you think of yourself as normal and you become part of the study, they would have to give you a battery of tests to prove your normalcy. What would be in that battery? Beats me. But, I am sure they would know what was in it and they could explain why it was there to somebody, an oversight committee presumably. Then, when they would determine that you were wrong about yourself being normal, you would likely want to know why not. And as they looked gravely at the floor, avoiding eye contact, they would say, “We can’t tell you because it would violate research protocols.” Then, you would be sent back to the ranks of would-be normals with the rest of us with the knowledge that you were never as good or as normal as you thought you were and, therefore, you were not interesting enough. Better learn tap dancing or portrait art or, like me, take up the piano.
Assuming this could even be done, they would have to come up with a protocol to study potential treatments to bring the out of balance into balance, which would mean that they would have to start with the above again only this time with the experimental treatment. Welcome to the world of medication development!
Is this what they do? Of course not. It’s not practical. Instead they start on the outside of your skull and work in. They may start with rats or guinea pigs, work their way up to still higher primates before they investigate to see whether the treatment works on humans. When researching humans, the protocol would have to investigate personality factors to more objectively identify what it is that is to be changed and whether the chemicals effectively do that.
In a way, the physician who interviewed me for an hour before prescribing the wrong medication was doing just that. The problem was he did not know what to look for when he was interviewing me. The real problem, as I now understand it, probably had to do with our cultural differences. Being from NY originally, I express myself more emotionally than a typical mid-westerner and, therefore could be perceived as abnormal or even (to the treating doc) suicidal despite the fact that in my part of the world my behavior wouldn’t even raise a small bump on a radar screen. Who was more normal, I, the patient, or he, the doctor? He had the credentials and the license. If he thought I was that bad off he should have tried to get me admitted to a mental hospital. Truth is he did not know what he was doing and I was still learning to do what I now do and have done for more than two decades. But, how many physicians take an hour to interview nowadays? Most take 15 minutes. Someone recently said that one cannot diagnose in an hour. To which I replied, you can in many, not all, cases if you know what you’re doing. But how many can diagnose in 15 minutes? I would say, no one, because reasonably accurate diagnosis is done through hypothesis testing using the information provided by a person, through observation, and, yes, some thought, including curiosity. No heads are unscrewed to look at content because it can’t be done. Even if it could, no one would know what they were looking at.
Given all of this, what is chemical balancing? It isn’t balancing at all. Even in the case of Henry from two postings back, successful treatment was done through trial and error and observation. Chemicals are altered, true, but what are really being treated are symptoms. “One shot in each cheek” to manage uncontrollable behavior is just that, for symptom relief, your symptom, my relief. The request to balance chemicals is otherwise meaningless, except it does lead to an unfortunate reliance on medications.
And for a final twist, I will offer another source of confusion coming out of research, that is, that combat veterans’ brain chemistry is altered as a result of trauma (PTSD). Do I believe this? Yes. But it raises a much broader question. Do all our experiences change brain chemistry? Does a child raised on violent TV shows have chemical alterations affecting behavior? Does the act of love making heal or hurt when our chemistry is altered? How about psychotherapy? Does that alter chemistry as well?
Which brings us full circle because, if life experience changes chemistry, then we may not need to alter chemistry at all to relieve symptoms and effect positive change in some people? To which I can now answer, if you want to balance your chemistry, you may not need medication. Medication is for symptom management. Instead, you might want to investigate and to learn about yourself and the world in order to make life a more fulfilling experience. That could balance your chemicals and make you a better person without having to do anything else, certainly without the possibility of irreparably altering what is inside you. Some of what you discover about yourself may feel bad, but it may have a purpose that makes your experience here on our beleaguered planet more meaningful.