Who are we?
The difficulties on withdrawal from antidepressants link to some of the most profound mysteries both philosophical and pharmacological.
In the West, we have grown very used to identifying ourselves with our brains. The first thing to note here is a difference between our brains and consciousness – or what we usually feel is our self, the bit of us that can see things in our memory and imagine ourselves doing things. A whole range of physical states can lead this imagining consciousness to seemingly be transported out of our body – we can be significantly misled.
A book by Thomas Metzinger called The Ego Tunnel is not an easy read but tackles some of these matters head on.
But even in this philosophically cutting edge book, the sense is that our selves might not be in that bit of us that seems to generate images and memories, but they are in our brains.
The phenomena of withdrawal and Post-SSRI Sexual Dysfunction (PSSD) however suggest that a great deal of us, maybe most of us, lies outside our brains in our bodies.
The loss of libido that is central to PSSD offers one of the clearest examples. Several of us have spent some years thinking about this and working out how to research it – where in the brain to look for some libido center that is malfunctioning. But the more we thought about it, the more it began to look like this apparently central loss of libido was being driven by a peripheral genital numbness.
If they pay close attention to it, most people who take their first dose of an SSRI will be aware of some degree of reduced genital sensitivity within 30 minutes of taking the dose. It takes weeks or months of numbing before libido begins to drain away and in those with permanent numbness after the drug is removed, libido is a pale shadow of what it used to be. Fix the numbness and everything else will begin to wake up.
In the same way, depersonalization is a huge feature of protracted withdrawal. We don’t feel right. We feel 2-D, almost as though we are looking at ourselves or that we are a cardboard cut-out of ourselves. In this case it makes sense to think that disruption to the constant stream of sensation coming in from C-fibers in skin and other organs and especially from caress fibers is responsible. Restore these to normal and we will inhabit our own bodies properly again.
This is only semi-revolutionary. The same ideas were put forward over a century ago by Boston’s William James and Copenhagen’s Carl Lange, quite separately, and have since been termed the James-Lange Theory of the Emotions. The idea which was shocking then and grew even more shocking since, was that our emotions happen in our body and our brains interpret them. This is the wisdom of the body or of the heart, the murmurs within that it’s worth listening to.
In the middle of the 20th century, before the psychopharmacological revolution took off there was a lot of experimental support for the James Lange idea from research on adrenaline and other hormones. When adrenaline was infused into people or animals, it causes hearts to race, breathing to get shallow and other features of arousal to be manifest. Depending on the context the person or animal is in, they decide whether they are anxious or stimulated and excited. The key thing is the bodily change comes first and the brain then tries to make sense of it.
The many things that go wrong in protracted withdrawal from depersonalization to asexuality to memory problems can all be interpreted in these terms. Psychologists have real problems with these ideas applied to memory – they find it very difficult to think that the body might remember even though musicians and athletes are all familiar with the idea of muscle memory.
So those with Protracted Withdrawal and PSSD have been put in a concentration camp. The conditions are pretty awful and may lead some to suicide, and we don’t know if any rescuers are going to turn up but there are no gas chambers.
For those who can manage it, there is an horrific opportunity. You are being given a view through a window into how the brain and body work. Find a cure to withdrawal and PSSD and you may find a lot more as well – you may shed light on some fundamental aspects of who we are.
The pharmacological mysteries of complex withdrawal
For most doctors and even pharmacologists, the idea that a drug can be causing problems long after it has left the body or indeed might only start to cause problems after it has left the body is a long way removed from what they learnt in university. They will often feel more comfortable telling you that this is all in your mind.
While some are fortunate to have doctors who are knowledgeable about withdrawal, many of those who engage with this site will have had the experience of encountering doctors who dismiss real issues outright or who look mystified and say something to the effect of
“But the drug has been out of your system for a long time – it can’t be doing things now”.
A peripheral neuropathy model helps answer this in part. If there is a dysfunction, it can be expected to endure.
A peripheral neuropathy model can maybe explain why the problems might only start happening on withdrawal, even in some cases the problems only start happening several weeks or longer after withdrawal.
Even less explicable at the moment is the fact that there is an on-off response to treatment. This is most clear in the case of PSSD. There are a number of treatments that can reverse parts of the problem to a modest degree. This is what you expect of most treatments.
But another regular finding is that a number of drugs like benztropine or Maca roots when taken for a week or two seem to reliably produce a benefit, in some cases a dramatic benefit, in the week after stopping. But the effect vanishes again.
The hopeful message from this is that the damage may not be permanent. There is a switch that can be toggled. We need to find out what the toggling does if we are going to get precise effects.
To do this, we need someone, possibly a pharmacologist or physiologist, to explain this “Look No Hands” effect.
But before that, we need those of you who are having experiences not covered in any pharmacology book to help us put those experiences on the map.