by Peter R. Breggin MD
Why do so many individuals persist in taking psychoactive substances, including psychiatric drugs, after adverse mental and behavioral effects have become severe and even disabling? The author has previously proposed the brain-disabling principle of psychiatric treatment that all somatic psychiatric treatments impair the function of the brain and mind. Intoxication anosognosia (medication spellbinding) is an expression of this drug induced mental disability. Intoxication anosognosia causes the victim to underestimate the degree of drug-induced mental impairment, to deny the harmful role that the drug plays in the person’s altered state, and in many cases compel the individual to mistakenly believe that he or she is functioning better. In the extreme, the individual displays out-of-character compulsively destructive behaviors, including violence toward self and others.
Anosognosia is defined as unawareness or denial of a neurological deficit or, more broadly, ignorance of the presence of disease. The concept originated in the observation that individuals with nondominant parietal lobe lesions (e.g., stroke)sometimes fail to recognize an associated paralysis on the other side of the body. In an enlightening essay, Fisher (1989) enlarged the concept of anosognosia and described it, along with memory dysfunction, as one of the constant features of brain damage and dysfunction. Defining anosognosia as “the capacity of brain damage to cause denial of lost function,” I have previously used the concept to explain aspects of the brain-disabling principle of psychiatric drugs—that all physical treatments in psychiatry work by causing brain dysfunction and disability (Breggin, 1997, p. 10). In this article I want to examine a specific brain-disabling effect that I have labeled medication spellbinding or intoxication anosognosia.
THE IMPORTANCE OF MEDICATION SPELLBINDING
A huge percentage of the population uses legal recreational drugs such as caffeine, nicotine, and alcohol despite considerable public health efforts to warn about their harmful effects. Another large percentage uses illegal drugs such as marijuana, methamphetamine, cocaine, and heroin despite concerted efforts to alert the public about their dangers.Finally, another significant percentage of the population uses psychiatric drugs—includingstimulants and antidepressants—whose safety and efficacy have become increasingly controversial and subject to Food and Drug Administration (FDA) review.
Why do so many people take psychoactive medications, even in the face of obviously harmful effects and often despite questionable benefits? There are of course many potential explanations why human beings have such a strong tendency to use drugs that impair the function of their brains and minds. Here I want to focus on one specific biological mechanism that encourages and even at times seems to compel drug taking.
If all psychoactive drugs possess qualities that tend to encourage, facilitate, or compel usage, then it may help to explain the widespread use of psychiatric drugs as well as recreational drugs. In the past, most warnings about the beguiling or seductive effects of drugs have focused on recreational and illegal substances—but can the same or similar effects be found in the action of all psychoactive agents, including prescribed psychiatric medications?
Some psychiatric drugs, such as the stimulants and benzodiazepines, cause changes in the brain that lead to dependency and withdrawal problems. There is increasing evidence that most or all psychiatric drugs cause sufficient withdrawal problems to interfere with efforts to stop taking them (Breggin, 1997; Breggin & Cohen, 1999). Dependence and withdrawal problems in themselves, however, do not fully account for the widespread use of a broad array of psychoactive agents, including nonaddictive psychiatric drugs, such as the antidepressants, lithium, and neuroleptics.
REVIEWING NUMEROUS CASES
I have reviewed several dozen cases, selected from many years of clinical and forensic practice in which I have evaluated individuals who developed suicidal, violent, or criminal impulses or behaviors while under the influence of psychiatric drugs. The most common medication offenders have been the newer antidepressants, benzodiazepines (antianxiety sedatives), and stimulants, but all categories of psychiatric drugs have been involved, including mood stabilizers and neuroleptics.
One of the most frequent and serious offenders has been the combination of selective serotonin reuptake inhibitor (SSRI) antidepressants and benzodiazepines, especially alprazolam (Xanax). In one case, a man with no prior criminal history began taking fluoxetine (Prozac) and alprazolam to reduce the strain before starting a new and exciting job. He began to watch videos of the movie The Saint and decided it would be fun to mimic him. He robbed his wife’s bank, his mother’s bank, and his local drugstore wearing a minimal disguise. Before one of the robberies, he stood outside discussing his vintage automobile with a passerby. He was easily apprehended and seemed to have no idea what the fuss was about until the medications wore off. He was mostly worried about making an upcoming business appointment. He thought he was doing fine—or better than ever.
During the robberies, this man was suffering from a substance-induced mood disorder with manic features. He had no history of any violent or criminal activity and denied any fantasies about committing crimes before being placed on the medications. In my report in his criminal case, I emphasized that he suffered from an organic, drug-induced neurological disorder (substance-induced mood disorder with manic features) and not from an ill-defined mental disorder. Due to my report and a corroborating report from an expert hired by the state, he was found not guilty by reason of insanity caused by psychiatric drug intoxication.
In another case involving the same two drugs, fluoxetine and alprazolam, administered over a longer period of time in higher doses, a businessman became dependent on the alprazolam and also developed manic-like symptoms. After he was charged with insider trading, he was unable to adequately defend himself and was in my opinion wrongly convicted. While incarcerated he underwent a severe withdrawal from alprazolam. He too had failed to perceive what was happening to him until he was removed from the drugs. In fact, he thought he was performing on an especially high level.
Another man became psychotic shortly after starting to take sertraline (Zoloft) and believed that his wife had been taken over by a dangerous alien from another world. In order to destroy the alien inside her, he drove their car into a barrier. She was thrown from the car, and he tried to beat her to death as she lay helpless be the roadside. Fortunately, she survived. In a case in which I played no role, he was found not guilty by reason of insanity. Only after he began to recover, over the subsequent weeks of psychiatric incarceration, did he begin to suspect that medications might have caused his psychosis. He was released after several months of commitment to a mental hospital and allowed to remain in the community under supervision. His therapist recommended that I take over the psychiatric portion of his treatment. I gradually removed him from a cocktail of medications and he has done very well during a several-year follow-up. He suffered from a substance-induced mood disorder with mixed manic and depressive features, and psychosis. He did not experience a manic euphoria but he did believe he was on a mission to save himself and the world.
The above cases all had manic features. In other cases, compulsive suicidal or violent behaviors developed without associated manic-like features. A 16-year-old girl was begun on fluoxetine (Prozac) to relieve the stress she was undergoing while being diagnosed for an obscure gastrointestinal disorder that eventually went away. Shortly after starting on the fluoxetine, she felt compelled to stab her mother to death but experienced no otheradverse drug effects. At the last moment, she confessed her intentions to her mother, and she recovered completely when removed from the antidepressant. She was, however, left with years of wrestling with how she could have done such a thing. Now in her 30s, she felt relief after talking with me about what had happened to her and how frequently other good people have developed bizarre impulses on these medications. She had no prior history of suicidality or violence, and she has not experienced any since coming off the medication years ago. There were no legal ramifications to the case.
In another case, a man who had recently been begun on paroxetine (Paxil) for mild chronic depressed feelings became obsessed with killing himself. He drove his car into an unsuspecting policeman in order to knock him down and obtain his gun. Fortunately, he did not kill the officer, and a bystander prevented him from obtaining the gun. He was agitated but not manic during the episode. After my report in his case, the police officer agreed that drugs must have driven his impulsive action, and an agreement was reached that led to only a brief incarceration. On follow-up, he has done well for several years. Although there are numerous references in the literature to compulsive suicidality, there are fewer that describe compulsive violence.
In all cases the suicidal, violent, or criminal behaviors were unprecedented in the individuals’ lives and seemed in retrospect to be very alien and inexplicable to them. Read original article.