Mind Affecting Drugs and the Self

By James Gillespie

Abstract
In this paper I argue that the mind altering medication used in treating mental disorders
can cause significant changes in the self, which is often overlooked in the clinical setting.
Furthermore these changes are in many cases not worth the improvement in condition that the
drugs afford. From this perspective I will investigate several of the most common drug types in
psychiatry as well as propose a method of cost-benefit analysis for prescription.

Introduction
Todays psychiatric patient is unprecedentedly medicated. There is just about no
condition for which a drug cannot be prescribed, and if there were it can be imagined that one
would quickly be found to fill the void. This deluge of medication has allowed treatment of
disorders had previously been life ruining and reintegration of otherwise uncontrollable
individuals into society. But the medication used in psychiatry is not the same as that used in
other fields of medicine. The mind is where the essence of a person resides it is who we are.
Medication that alters mental states therefor must provoke unique ethical questions beyond the
typical evaluation of risk of harm and discomfort. And yet this discussion is almost entirely
absent in the clinical psychiatry world. Altering the self is not something to be taken lightly. I
hope to show the significance of this in the following sections

Concepts of the Self

While clinicians may only pay minimal attention to the concept of the the self,
philosophers have no such reservations. At times it can seem like everyone and their mother has
a different theory on the subject. Descartes famously characterized the self as an autonomous

agent independent from the rest of the world I think therefor I am. Avicenna proposed in his
floating man experiment that the self was whatever was left over if a person was totally
deprived of all senses. Hume on the other hand characterized the self as simply a collection of
different perceptions which succeed one anotherin perpetual flux and movement. Daniel
Dennett took that a step further, characterizing the self as convenient fiction whos only purpose
is to be used as a narrative center. Despite these seemingly infinite views, there are some
commonalities. Almost all definitions of the self-include some combination of the following:
memory, personality, beliefs, behaviors, and a center of consciousness that endures over time.
Even Dennetts convenient fiction is the imaginary entity that experiences those phenomena.
Returning to the topic of this paper, we can for now avoid the problem of finding a perfect
definition of the self. Due to the sheer number of drugs now prescribed as well as their wide
range of effects, its not really important which concept of the self one settles on. No matter the
concept, there is sure to be a drug that impacts it. Moving forward I will stick with my
symptomatic list for easy reference.

The Value in a Consistent, Internally Controlled Self

The self is not constant over time, as just about everyone can attest. And yet the self is
still connected. I may not be exactly the same as I was a year ago, but I wouldnt call myself a
separate person either. I would call this phenomenon coherence. Like an unbroken thread, the
self stretches back in time. And this coherence is intuitively important - no one would want to
wake up each morning a different person with completely new beliefs and priorities. People like
predictability in their lives, and being able to predict how one will think and act is perhaps the
most important manifestation of this. The moments when we dont know why weve done
something are unsettling and we constantly act to understand ourselves through self-reflection.

This process is invaluable because it allows for the possibility of internally driven growth. The
reformed criminal, the lazy student turned hard worker, the selfish jerk turned caring friend, all
chose to change themselves and came out better for it. Internally driven self-improvement is a
gradual process that is solely the prerogative of the person undergoing it (although it likely will
impact others) and does not impede coherence. By maintaining a coherent self one is allowed
consistent insight into their own inner workings, which leads to a healthier, more fulfilling
existence. And it affords the individual a good deal of self-control, which is beneficial not just to
them, but to those around them as well.

Drugs That Impact the Self

Psychiatry utilizes far too many drugs to discuss every relevant medication in detail.
However we can investigate four characteristic categories: antidepressants, benzodiazepines,
anti-psychotics, and mood stabilizers. For the most part I will only be focusing on the effects of
these drugs on the mind, but it should be noted that significant physical side effects often
accompany them. Fortunately the world of biomedical ethics is very diligent when it comes to
physical effects. Review boards subject drug trials to extensive ethical investigations and
psychiatrists are continuously weighing the risk of their medications against the benefits.
Compared to other psychiatric medication, antidepressants are veritable lightweights.
They are modern, clean drugs that have minimal off target effects. And patients rarely if ever
complain. Theyre also so common that their brands have become household named (Zoloft,
Prozac, etc). Most modern antidepressants work by increasing levels of the neurotransmitter
serotonin in the brain by inhibiting its re-uptake or breakdown. Serotonin is involved in the
regulation of sleep, appetite, and most importantly here, mood. Because antidepressants dont
directly cause secretion of serotonin, they really only enhance and prolong existing releases. This

allows for specific, controlled mood uplift with seemingly no strings attached. However, as Paul
Biegler points out, the mood control is itself the string. He explains that antidepressant use
affords the patient no opportunity for insight into how to manage the stressors of their life that
often trigger depressive episodes. In fact, it can harm the patient by reducing their autonomy by
controlling their mood externally.
Unlike anti-depressants, benzodiazepines are broad in effect. They work by enhancing the
effect of GABA, the brains primary inhibitory neurotransmitter. By increasing this inhibitory
action, benzodiazapines effectively depress action across the brain, leading to a host of effects
including sedation, confusion, amnesia, cognitive impairment, depersonalization (a feeling of
watching oneself act without being able to control anything), dissociation (a detachment from
experiencing reality) and many more. Because of their depressive properties benzodiazapines are
most commonly used to treat anxiety disorders, but their wide effects also lend themselves to
many other areas of medication. The list of effects may seem severe, but these drugs are almost
always prescribed short term as an immediate response to anxiety attacks. And lasting effects of
this are very rare. However it cannot be denied that during their short term application
benzodiazapines have major effects on the self. And like antidepressants these can serve as a
crutch rather than treating the underlying cause. In fact, even worse they dont really treat the
fear reaction either. Rather they dampen the response by sedating and dissociating the patient
from the panic theyre experiencing. But the fear is still there and the patient has made no
progress in overcoming it.
Antipsychotics are the classic mental disorder drugs and most have been used for many
decades. Theyre used to treat psychosis, which is usually described as a break with reality
(delusions, hallucinations, etc). Their most common application is schizophrenia. Antipsychotics

work by blocking the brains dopamine (yet another neurotransmitter) receptors. Psychotic
episodes typically involve an excessive release of dopamine in the mesolimbic pathway, so these
drugs suppress those. However this is not even close to the only area dopamine is involved, so it
should come as no surprise that antipsychotics come with their share of off-target effects. They
can cause drowsiness, restlessness, memory loss, sedation of emotion, and behavioral changes.
And unlike benzodiazepines, antipsychotics are usually taken long term because they are
intended to proactively prevent episodes. Antipsychotics also do not always actually treat the
disease, instead blunting the symptoms. In many cases patients will still experience delusions
and hallucinations but lack the motivation to act upon them. So the patient is not really a version
of their healthy self on antipsychotics. Instead the patient is a version of themselves with both a
mental disorder and all the effects of the drugs layered on top. This makes antipsychotics not
only an undesirable method of self change, but also a non-optimal direction to change towards.
Mood stabilizers are a class of drugs not yet fully understood. The exact mechanism of
their action is unknown, but their primary effect is a reduction in the magnitude of mood swings.
Because of this their primary use is treatment of mood disorders like bipolar disorder. Despite the
name, many mood stabilizers will only act to improve manic or depressive episodes, not both.
And the effect of each mood stabilizer varies greatly between individuals, which often leads to a
patient needed to go through several drugs before finding one that works for them. As with
antipsychotics these do not treat the underlying disorder patients still experience mood swings,
theyre just lesser in magnitude. Normal, non-pathological mood swings are also dampened
along with the disorder. Mood stabilizers are also accompanied by a moderate level of off target
effects including impaired memory, fatigue, and difficulty concentrating. I think it is clear that at
least in regards to memory and mood these drugs have a significant effect on the self. By

dampening the effect of the patients moods, both healthy and pathological, mood stabilizers
inhibit the ability of the self to naturally develop through emotional responses. Instead, during
the course of treatment, they artificially shift the self from one of uncontrollable extremes to one
of uncontrollable moderation.

Issues with Self Altering Medication

I have touched on some of the problems with each of these medications separately, but
here I will focus on features they all share. First of all in the clinical setting the changes brought
about by these drugs are externally driven. They are prescribed by the doctor and the effect
comes from the medication itself, not the patient. Because the patient is not changing his or
herself there is a loss of both control and understanding that comes with this. Recently
neuroethicicists have begun to invoke the term cognitive liberty, which is the right of an
individual to think independently and autonomously. And I think it could be argued that mind
altering drugs violate this. Even in the cases where a patient initially is able to consent to the
medication, by changing the self it is no longer the original patient that continues to consent.
Another issue with most medications is their lack of specificity. While the patient may be
perfectly willing to change the pathological portion of themselves with the drug, most of the time
this will be accompanied by significant off target effects. While the schizophrenic may be eager
to end his delusions he would likely be less than thrilled to see himself becoming apathetic and
forgetful as well. The method of change from the drugs is also problematic. Unlike natural,
healthy change, medication is neither gradual nor reflective. Rather they abruptly turns the self in
a completely different direction with the patient in the passenger seat. This breaks coherence and
may leave the patient wondering who am I? And will I be the same person tomorrow? And
because of this method of change the patient will also lack the insight that usually accompanies

reflective and leads to a more fulfilling life. Beyond even the method of change, there is also the
risk that the patient may not like the destination. If a patient is unhappy with who the medication
turns them into, what was the point of the self change in the first place?

Considerations in Evaluating Prescriptions

Obviously I am not claiming abandoning all use of psychiatric medication. In spite of
their problems, these medications do a great deal to improve the lives of many patients and their
loves ones. First of all it is clearly acceptable to use medication to alter the self when without
such medication the patient is a danger to themselves or others. Its better to have a different self
than to lose oneself all together. Similarly there is the case of the patient whose disorder is so
severe that he or she is unable to attain any of the previously benefits of a natural self. If a
patient is perpetually in the grip of psychotic episodes theres not really going to be any
meaningful reflection of self-improvement anyway, so in this case nothing is lost from a mind
altering prescription. Another possibility for evaluation is if the patient endorses the prescription
upon reflection. This is of course imperfect because the self that is endorsing the prescription is
not the same as the self that was first treated, but it at least provides a measure of the patients
satisfaction. Finally there is the case of a patient that fully understands all the effects of the drug
and makes the conscious informed decision to proceed. This still carries the problem of abrupt
change, but as David Degrazia points out can be a method of internally driven change that stays
true to oneself. To Degrazia mind altering drugs, in particular anti-depressants, are another
pathway for patients to become who they want to be.
However there are also flags for avoiding treatment that I do not think are always
adequately considered. First of all is the problematic assumption that a person with a mental
disorder cannot live a fulfilling life without treatment, which is contradicted by the testimony of

many mentally ill patients. Autistics in particular often report being just as satisfied with their
lives as non-pathological individuals. It is even possible for a disorder to become a valued part
of the self. Consider an artist who suffers from moderate manic episodes. Theyre not strong
enough for his life to be in danger, but it does allow him bursts of creativity and productivity.
Over time the artist, even between episodes, comes to value and even rely on his disorder. I think
it is clear in both of these cases that the subjects (they cant really be called patients) would not
benefit from medication, but would in fact suffer from the self change it would force upon them.
For the most part I have ignored physical side effects, but it should be noted that is severe
enough they can also have a mental impact through the trauma they inflict. When combined with
the mental side effects often the treatment can be as bad or worse than the disease, which I think
makes treatment unacceptable. Finally, while considering all of the positive benefits of the drug,
one must weigh this against the magnitude of self change that the drug will impart. All of this
varies between drugs and individuals, so there is no clear answer. But the general idea is that if a
drug is changing the core of who a person is their beliefs, personality, priorities, etc then it
ought to be offering a lot of relief from a severe disease.

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