Is the Problem Chemistry or Character?

In the mental health field, broadly speaking, there are two general types of conditions that are often a focus of treatment. The first is sometimes simplistically referred to as “chemical imbalances,“ but are more precisely characterized as neurochemical and electrophysiological disturbances of the brain, usually caused by a mix of biological, psychological, and environmental factors.

The second type of diagnostic category includes what is referred to as “character pathology” or “personality disorders,” as well as congenital or pervasive developmental difficulties such as autism and intellectual disabilities. Of course, there are some conditions such as ADHD that occupy a murky space between developmental disorders and so-called chemical imbalances. For the purposes of this post, however, I will limit my discussion to typical imbalances and character pathology.

Basically, chemical imbalances trifurcate into depressive disorders, anxiety conditions, and psychoses such as schizophrenia. What gives rise to them isn't always fully understood, but they all seem to involve what can be thought of as rhythm disturbances of the brain due to what appears to be faulty communication among some of its regions.

These illnesses can often be very effectively treated with psychotropic (literally, “mind turning“) medication and/or some therapeutic approaches such as CBT and its derivatives (e.g., dialectical behavior therapy, acceptance and commitment therapy, and EMDR, to name a few). This is because in these conditions, for a variety of reasons, the brain’s rhythms and equilibria shift from its natural state to a “disordered” one. Thus, through the use of appropriate medication and some methods of psychological treatment, the brain’s natural rhythms and balances can often be restored. Other treatments like transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) are also often able to “reboot“ the brain’s baseline rhythms.

Character pathology includes a cluster of personality traits that are almost always present from a young age and seem to be more akin to “faulty wiring“ than a more easily correctable neurochemical or physiological disturbance. Common types of character pathology include the now very well-known narcissistic personality disorder, and nine others recognized in the DSM-5: antisocial, borderline, histrionic, paranoid, schizoid, schizotypal, avoidant, dependent, and obsessive-compulsive.

The etiology or cause of personality disorders is even less understood than chemical imbalances but seems to track to neurodevelopmental processes—that is how the brain grows and matures. For example, in cases of antisocial and narcissistic character pathology, it seems the brain actually lacks the equipment necessary to experience the full range of emotions and to form healthy attachments with other people. Specifically, these individuals appear to be devoid of complex emotions such as empathy, remorse, compassion, and guilt—feelings that are necessary for forming and maintaining healthy human relationships.

A useful analogy is color blindness. Colorblind people actually lack the optical or neurological processes that are necessary to perceive the full spectrum of colors in the visible wavelength. It's not their fault; they just can't see certain colors, hues, or tones. Similarly, pathological narcissists and sociopaths simply can't experience the full range of human emotions that define psychologically healthy people because they seem to literally lack the neural structures or processes necessary to experience it.

Given the limited effectiveness of pharmacotherapy (and other so-called somatic interventions like TMS and ECT) in the treatment of personality disorders, therapy essentially comes down to skills acquisition and intellectual compensation. For instance, helping people with these psychosocial complications learn methods to control impulses, regulate emotions, tolerate frustration and distress, improve reality testing (i.e., understand the personally aversive consequences of their actions), and intellectually compensate for their emotional deficits. Indeed, one of the best treatments for some personality disorders, especially borderline personality disorder, is Marsha Linehan’s dialectical behavior therapy (DBT), which emphasizes teaching most of these skills (e.g., Linehan, 2015).

Unfortunately, people who have significant narcissistic and antisocial character pathology almost never seek treatment themselves, but may instead be coerced or compelled into treatment by family members or a judge. But many people suffering from other personality disturbances do seek assistance and, due to newer CBT approaches like DBT, can be significantly helped.

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It is important to note, however, that while medical therapy is often minimally effective in reducing the severity of personality disorders per se, people are complex and rarely suffer from a singular, encapsulated problem. Indeed, people with personality disorders often suffer from concurrent mood and anxiety conditions, and a significant number of people with treatable conditions like depression also have characterological problems.

Of course, as is the case with most human ailments, early detection and rapid intervention are perhaps the best way to go. This is because the younger a person is, the more changeable their brain is, and what might otherwise end up as “bad wiring" can often be minimized to a greater or lesser extent. But how to successfully detect and intervene as early as possible is a topic for another post.

Remember: Think well, act well, feel well, be well.

To find a therapist, please visit the Psychology Today Therapy Directory.

Copyright 2022 Clifford N. Lazarus, Ph.D. This post is for informational purposes only. It is not intended to be a substitute for professional assistance or personal mental health treatment by a qualified clinician. The advertisements contained in this post do not necessarily reflect the author's opinions nor are they endorsed by him.