No Longer Gage
THROUGHOUT THE HISTORY OF NEUROSCIENCE, mounting evidence of the brain’s pivotal role in modulating an individual’s personality and behavior has been revealed. The most illustrious (*and sensationalist) example of mind-body interaction was reported when 19th century railroad foreman Phineas Gage survived an iron rod propelled through his brain—an accident resulting in striking personality changes that led his friends to say he was “no longer Gage”1.But as our understanding of the brain has driven us from the Cartesian philosophy of a mind/soul/self completely separate from the brain, have we gone too far? Are we, as individuals, just our brains? And if so, does brain damage through disease or injury change the very essence of an individual? I have certainly watched family members suffer from stroke, dementia, and Alzheimer’s disease (i.e. brain damage) who seem to morph into completely different people, never to be themselves again. For this reason, I have always struggled when faced with a decision of whether or not to take medication for my psychiatric problems, the symptoms of which can be partially alleviated with medication, but which I have always resisted. I thought that altering my brain would change who I was.
As a seemingly anxious-born person, I learned to cope with my anxiety and even used that anxious energy to succeed in many personal and academic endeavors. But mostly, my childhood trait-anxiety just led to missed opportunities, dampened relationships, frustration, loss of sleep, and general dread of any and every situation. Still, I always told myself that I would rather be who I was born to be than a product of some billion-dollar corporation selling bottled happiness (if only I could have used a similar dogma for my sexual orientation instead…)
However, when PTSD was thrown into the mix, I finally reached a point where I could no longer cope. Unfortunately, it took over 8 years for a healthcare professional to recognize my PTSD, at which point I was just barely alive. Even though it was much easier for me to rationalize treating my PTSD with medication—that disorder was a result of events that interrupted and disrupted my life—I still refused to take medication during the first year of my recovery, opting for 2-3 therapy appointments per week instead. My argument was this (verbatim what I wrote to my psychiatrist):
“If I’m taking medication, I can never be sure if how I’m feeling is really me or just a consequence of the medication. If I’m unmedicated and have a crippling panic attack or dissociative flashback episode, I at least know that is organically coming from within myself, and I need to learn to navigate it through therapy. But with medication, I never know whether something is my problem or just a side-effect, in which case I would rather stop taking the medication than try to deal with a generic problem that wasn’t even mine to begin with. On the other side of this dilemma lies the question of whether any positive aspects of my life are really me or just a result of medication. If I’m on medication and being a functional human being, I wonder if I’m losing myself to medication by covering up my organic problems and creating false happiness? Are my diseases/disorders/illnesses just as much a part of who I am as are my healthy strengths? Should I be treating my weaknesses with medication or just accepting and coping with who I am?”
But even with extensive therapy, I was struggling to survive with my anxiety and PTSD—I could hardly even talk about anything that had happened to me without having a complete breakdown. So for the past year, I have been taking psychiatric medication, which has allowed me to talk to my therapist without getting overwhelmed and has taught me that my anxiety is not who I am. Just because someone is born with trait anxiety or bipolar disorder or schizophrenia or depression doesn’t mean those disorders are innate parts of who they are. Like PTSD, which is a normal response to very abnormal circumstances (but which becomes unhealthy when there is no longer a threat present and you can’t return to normal life), any other psychiatric illness can arise out of abnormal circumstances that occur in development. Just because something is “in your genes,” doesn’t mean it’s part of the essence of who you are as a person or that it’s a healthy and functional state of being.
What defines me are those things without which I would not be me. If I was unable to give or receive love, I would not be me. If I couldn’t communicate by creating ideas and things and art, I would not be me. If I couldn’t be honest with myself or others, I would not be me. I don’t know if it’s a specific combination of genes, proteins, and chemicals that control the way these attributes present themselves in a uniquely me way—or if it’s something more ethereal—but anything that interferes with my ability to do these things, interferes with my ability to live and be me. My anxiety and PTSD completely compromised my ability to love, communicate, create, and be honest, and they would continue to do so if I were to stop treating those disorders. Even though I might have been born with a genetic predisposition to maladaptive types of behaviors and illnesses, they are not part of who I am as a person. As long as I am able to be me, I know that my medication is doing its job—it’s not changing who I am, it’s allowing me to be who I am.
Unfortunately, many medication regimes can interfere with a person’s ability to be themselves, and it’s the weighing of the side effects of the medication vs. the symptoms of the illness that present a true challenge in treatment. It shouldn’t come to a decision on which course—treatment or illness—causes the least amount of interference with a person’s ability to be themselves, but it often does come to that, and many people choose to abandon medication altogether because it seems “more unnatural” than suffering through an illness with which they were born. Even though medications are made in a laboratory, the illness itself results in abnormal (i.e. “unnatural”) modulation of the optimal functioning of the mind and body.
This isn’t to say that every manifestation of some clinically defined illness is an inherently negative thing that needs to be exonerated with medication—or that people with psychiatric disorders are “abnormal.” There are lesser degrees of severity and aspects of certain “disorders” that may cause less harm than medication or can even be beneficial to a person. A small or moderate amount of anxiety can provide motivation for a person, some autism spectrum disorders allow someone to live a very fulfilling life, and 99% of persons with Down syndrome report being happy with their lives3. Certain “disorders” can be treated so well with lifestyle and behavioral management that I question whether they are really disorders at all.
But when a condition interferes with a person’s functioning and ability to be who they are, that person should receive help, which may or may not include a medication regime. We should use all available resources, beginning with lifestyle changes and therapy/counseling—and then medication if necessary—to help people function optimally. Living with a disorder such as depression or bipolar disorder, which can be life-threatening when untreated, should not be an option because someone was “born that way.” Taking medication is not cheating or giving up, and it is not something to be ashamed of—on the contrary, it says that you are trying to be the best person you can be for the sake of yourself and everyone else around you. People shouldn’t be defined by their illnesses or by the medications they take, but by how they navigate these challenges to live as their best selves.
*It is worth noting that Phineas Gage’s post-iron-stake-through-the-head life was more elusive than we thought2.
1. Harlow JM. (1868). Recovery from the passage of an iron bar through the head. Publ Mass Med Soc.1868(2):327–347.(https://www.countway.harvard.edu/menuNavigation/chom/warren/exhibits/HarlowBMSJ1860.pdf)
3. Skotko, B., Levine, S., and Goldstein, R. (2011). Self-perceptions from people with Down syndrome. American Journal of Medical Genetics, 155A(10): 2360-9.
Apryl Pooley is a neuroscientist at Michigan State University, researching the effects of trauma on the brain and author of Fortitude: A PTSD Memoir