Tuesday, September 6, 2011

On Chemical Imbalances in the Brain

Maybe it’s not such a bad theory after all.

The brain, as always, bats last. It compensates, reregulates, and adjusts. One of the major ways it accomplishes this is through the neuroadaptive phenomenon called downregulation. When we take drugs continuously, the brain compensates for the artificial flood of, or sensitivity to, serotonin, dopamine, and other neurotransmitters by cutting back on its own production, and the receptors on the cell surfaces ultimately degrade. This is, in fact, what can happen in a case of active addiction, or with the habitual use of any receptor-active drug. The phrase “chemical imbalance,” as a means of describing this process, fell out of favor as soon as Pfizer started using the analogy in its television advertising for zoloft.

Call it a receptor imbalance, then. Call it neuronal dysregulation, if that helps. The concern with downregulation is that, over time, chronic use of serotonin reuptake blockers or dopamine-active drugs of abuse can lead to both a decrease in the number of receptors and a desensitization of existing receptors. The brain does not stay idle during these artificial rains of neurotransmitters. As explained by Peter Kramer in Listening to Prozac: “The chronic, constant, reliable presence of high levels of neurotransmitter causes the cell to downregulate—reducing the number of receptors, by drawing them back into the cell membrane, where they become inactive, or by otherwise uncoupling them from further events.”

The brain adjusts to the constant bombardment of addictive drugs. Downregulation and upregulation are not well understood. If significant downregulation takes place, then conceivably, there could be a rebound effect. Even withdrawal from non-addictive drugs can be difficult and stressful, as the brain upregulates to account for the new biochemical dispensation. Drugs of abuse, and the drugs used against them, share one important trait—they both illustrate the adage that too much of a good thing is a bad thing.

The entire field of addiction medicine has its detractors, of course. In particular, the SSRI medications have been a prominent target since their inception. Dr. Peter Breggen, Dr. Joseph Glenmullen, and other critics have been particularly vocal in their objections to the use of serotonin-active drugs. They argue that psychoactive drugs cause assorted brain dysfunctions, and that such medications do far more harm than good. But these jeremiads aside, there are legitimate issues surrounding the use of many of the receptor-active drugs that addicts and alcoholics may encounter, or may request—whether treatment consists of a formal in-patient clinic or an informal arrangement with a family practitioner. Since addiction and mental illness overlap, a percentage of addicts are likely to encounter antidepressant and other psychoactive drugs during treatment. Drawing on work by Robins, Kessler, and Regier, Dr. Lance Longo, Medical Director of Addiction Psychiatry at Sinai Samaritan Medical Center, wrote as far back as 2001: “Approximately half of individuals with bipolar disorder or schizophrenia and approximately one third of those with panic disorder or major depression have a lifetime substance use disorder. In general, among patients with alcoholism, nearly half have a lifetime history of coexisting mood, anxiety, and/or personality disorders.”

The optimistic view of anti-addiction drugs says that depressive and addictive episodes feed on themselves. The more you get that way, the more you get that way, so if you can somehow give the brain a giant holiday from being serotonin- and dopamine-impaired, it will naturally adjust, compensate, rewire. It will teach itself. It will learn how not to be addicted and depressed all the time. In this view, what the addict/depressive needs is normalcy, a period of feeling better, a chance to sort things out, adjust behavior, become productive, and build confidence. While all of this is happening, under the influence of an antidepressant or an anti-craving drug, the patient learns to experience a different kind of world on a daily, even minute-to-minute basis. Like training wheels, the medications give the brain its first chance in a long time, possibly ever, to operate within the normal parameters of serotonin, dopamine, norepinephrine, and GABA metabolism.

Okay, “chemical imbalance” is a very imprecise description of all this. But branding it as a “myth” has the potential of doing far more damage, by discouraging active addicts from seeking medical treatment.

Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction by Dirk Hanson.

Graphics Credit: http://bentobjects.blogspot.com/2007/11/slight-chemical-imbalance.html


Kenneth Anderson said...

There is quite a body of evidence to suggest that giving antidepressants to most people with alcohol dependence or excessive drinking problems will lead them to drink more, not less. Antidepressants seem to benefit only alcoholics with severe depression, not those with mild or moderate depression or with no depression.

I have written a popular article on this topic:
as well as a more scholarly one:

Dirk Hanson said...

The effect on drinking appears to be slight, and in fact the early Prozac research was sparked by an interest in these compounds as treatments for alcoholics and overeaters.

But you are right to point out that antidepressants are only likely to benefit severely depressed alcoholics. Unfortunately, there are plenty of those alcoholics to go around.

SleepRunning said...

One of our go-to sources on all things clinical and brain is Psychiatric Times, here is a nice piece on evidence-based treatment. We have a long way to go. Decades, not years, likely. http://www.psychiatrictimes.com/print/article/10168/1945722?printable=true

Dopamine Receptor Deficits -- Our understanding is that family deficits in dopamaine receptors, likely D2 ones, leads to impulsive and compulsive addictive and hyper-seeking behaviors.

A person is born with defective DA receptors so their brain is constantly getting signals that it is "starving" thus the hyper-seeking. This is slightly, but perhaps significantly, different from the "reward" model of addiction and DA.

Comments and disagreement welcome.

Dr Hulda Clark said...

In my opinion chemical imbalance is due to the medicine because we are now very useful-to the medicines and they are disturbing our mental rest and affecting our potential to deal with diseases..

www.habilitat.com said...

This is exactly why short term rehabs don’t work for most people. All the evidence clearly shows that. Why then, are most of the addiction centers in our country short term? After 30 days of abstinence the brain is still not functioning properly. Long term treatment for addiction seems to be the answer. Why are 30 day treatments the trend?

Dirk Hanson said...

Treatment is typically 30 days because that's the length of stay insurance companies are prepared to cover.

www.habilitat.com said...

so length of treatment is driven by 3rd party payment rather than need and level of treatment.

Its just hard to understand why they pay at all if the success rates are so low for short term treatment.

We have witnessed many cases of former meth (ice) users who exhibit slight psychosis like behavior for many months after complete abstinence. In most cases these symptoms seem to go away around a year to 18 months. Surely there is some data on this that is accessible by the people who run these 30 day programs.

It seems to me they are making a lot of money billing insurance companies for treatment that they know is very likely to fail. They even tell people that relapse is part of recovery. That’s like saying drowning is part of swiming…

The american medical community has cashed in on this addiction issue. Billions are wasted and my insurance keeps going up! The money is in the comeback… not the cure… If you ask me, millions have been brainwashed into believing a bunch of lies that addiction is a disease and they can’t be cured.

Those that do recover fully… where did they addiction go. Nobody seems to be able to answer that question!

jen h said...

I disagree. Im am a recovering drug addict that has been clean for 5 years. My drug of choice was opiates and benzos. I was an active addict for over 15yrs. I had to get detoxed in a hospital because w/o constant dr supervision and medication i could have died from withdrawals. I experienced a severe depression apon discharge from a 90day treatment facility. So depressed I attempted suicide. I didnt get clean to be so miserably depressed.
Thats when I found help from a psychiatrist. I have been on an SNRI and moodstabilizer for almost 5yrs and w/o that crutch I know I wouldnt have made it this far. How can I go to NA and work the 12 steps if I cant get outta bed no matter how hard I push myself. The antidepressants helped me get to where I am today. Everyones journey is so different you cant compare them. Just because they are alcoholics doesnt mean theyve got it the worst. .

A friend of Bill W.

Shelby said...

I believe that the 12 step program and attending meetings works. U have to really WANT a new way of life. Wether or not u believe in God, believe that a higher power can bring u to sanity. U have to be open minded. Get a sponsor. I am trying to do this 12 step program myself, yes I have relapsed alot, yes I been told relapse is normal, but I have so much faith, I keep trying.i always return to the na meetings when I relapsed. It's my home. They are all there to help. But it's truly YOU who has TO WANT IT and there are so many people there to help if u ask. I love being clean! I love God! I personally could not do this without him

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