Mental Illness Isn't Just About Chemical Imbalances

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I recently heard someone argue that, because the brain, from which we experience things, is biological, that biology is responsible for psychological disorders. Critically thinking, that's like saying because respiratory distress is experienced in the lungs, the lungs are responsible for the illness. Few would suggest that toxic environments have nothing to do with instigating many lung diseases. However, it's still popular to frame mental illness as "brain-based," implying its faulty hardware eliciting the malfunction.

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It's not that simple.

Mental illnesses don’t just germinate from some unfortunate, genetic compromises within brains like a weed might nonchalantly arise in the garden.

There’s usually a bio-psycho-social wellspring.

Consider that psychotic disorders, like schizophrenia, often rely on psychotropic medications for treatment. This suggests a prominent biological etiology, especially when there’s an 81% heritability rate in families where it's established (Lo et al., 2020). It’s thought-provoking, however, that most people with schizophrenia have no known family history of it (American Psychiatric Association, 2013). Then where does it come from?

We know that reducing dopamine can reduce the acuity of psychotic symptoms. Therefore, might the chronic stress of psychosocial issues encourage the secretion of excess dopamine in some, which somehow acts like an accelerant? Attentive therapists will see that delusional and hallucinatory material is often correlated to the sufferer’s pre-illness psychosocial conflicts. The disease is most likely the intersection of the stressors meeting biological vulnerability.

The Case of Jenny

A former patient, Jenny (name disguised), came from a family with no known history of any mental illness. Jenny, however, had a series of stressors that needed defending again that clearly shaped her schizophrenia symptoms.

Jenny’s family had a business everyone worked in, including her, until she began having seizures as a teenager. After this, Jenny didn’t fit the mold, unable to take part in the identifying activity of the family. Her family was loving and attentive, and her mother always took time from the office to assist her in recovering. Jenny felt guilty about it, though. She not only felt she didn’t identify with the family anymore, but she began berating herself for, surely, in her mind, ruining the business given her mother wasn’t able to take as many orders.

Jenny began protecting herself from this self-persecution, though she didn’t know it. If her siblings weren’t being particularly social, she thought, “I bet they’ve had enough of me.” Eventually this was a given in her mind, so she avoided them. They reached out for her to get together, but certainly, she believed, it was merely patronizing of this outsider. Naturally, they eventually left her alone; Jenny created a self-fulfilling prophecy.

Soon, she pictured them wondering, “Was Jenny really ill, or just trying to get out of responsibilities and be catered to?” She just knew they were spying on her and gathering evidence to oust her from the family. Jenny was also certain her parents must be struggling to correct business losses from having to care for her.

Her family assured me and her that the business was healthy. However, Jenny was convinced they discussed the turmoil in whispers in their bedroom each night. “I put a tape recorder outside their door last night, to see if I could learn anything,” she once told me. “I can’t work. What do I do if they lose the business?”

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Eventually, her inner voice of observations and concerns began sounding like they came from outside of her. “Don’t trust what they say. They don’t want to give you seizures with bad news stress.” In conversations, I could watch Jenny become distracted, receiving “guidance” on how much to let me know, from someone that wasn’t in the room.

Despite some periods of therapeutic gains, Jenny would slip back into alternative realities, especially after seizures. The guilt and pain were too much, and her delusions and accompanying hallucinations only got stronger. She must escape, though she couldn’t drive.

The last I heard she was discovered at an airport with as many personal effects which would fit into a cab, and committed to long-term inpatient care.

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Why Jenny's Psychosis Persisted

This pattern was no genetic anomaly. As you can see, her delusions were an elaborate projection of her own self-persecution, making it seem as if everyone else was the problem.

While Jenny’s symptoms would improve somewhat when she took antipsychotic medications, medications can’t resolve an inner conflict. This could explain why, even on medications, the general persecutory thoughts remained, which could reignite into full paranoia whereby she’d become suspicious of the medications, discontinue, and start all over.

Jenny’s schizophrenia was most likely her life experience meeting a genetic profile that, under duress from environmental factors, encouraged her defense to take on a life of its own. In fact, this process, called epigenetics, is gaining recognition as a factor in the development of schizophrenia (Wawrzczak-Bargieła et al., 2023).

The biogenic model is not the last word, even for severe mental illnesses. Ivanov & Schwartz (2021) wrote an article called "Why Psychotropic Drugs Don't Cure Mental Illness- But Should They?" that examines the limitations of psychotropic effects. If it was so biological, wouldn't it seem there'd be better results from the billions of prescriptions for psychotropics written every year? In fact, they wrote:

"It is our position that, given the present limitations of our therapeutic arsenal, both researchers and clinicians would be well-advised to pay closer attention to human specific factors such as the role of language, the creation of personal narratives, and how factors such as these interface with underlying biological diatheses in mental illness."

If anyone needs more convincing that psychosocial material has a heavy influence on mental illness evolution, consider reading I Never Promised You a Rose Garden, a story based on a real patient of psychiatrist Frieda Fromm-Reichmann.

If the first-line medications aren’t working for psychosis and the person doesn’t have a therapist skilled in encountering the sufferer’s thoughts, they may be seen as treatment-resistant. Thankfully, there is an increasing number of psychosis intervention programs for youth and adults that might put an end to the simplified, ultimately harmful, common belief that the cure lies in pharmaceuticals alone.​

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual's provider or formal supervision if you're a practitioner or student.