Saturday, March 31, 2018

How the Human Stress Response Explains Away "Bipolar Disorder"

My current diagnosis is "Bipolar I Disorder."  In a few years, that likely won't exist.  I might even be able to sue my clinician for not assessing - or ruling out - known biological markers of stress that overlap with conventional diagnostic features.

Here is how it works.

What we now know about the stress model

For a variety of complicated reasons, some of us develop an overactive stress baseline (sympathetic / fight or flight response) early on in life.  Here's the down and dirty from Robert Sapolsky, world-renowned neurobiologist and primatologist at Stanford University:

Across numerous species, major early-life stressors produce both kids and adults with elevated levels of glucocorticoids (along with CRH and ACTH, the hypothalamic and pituitary hormones that regulate glucocorticoid release) and hyperactivity of the sympathetic nervous system. 32 Basal glucocorticoid levels are elevated—the stress response is always somewhat activated—and there is delayed recovery back to baseline after a stressor. Michael Meaney of McGill University has shown how early-life stress permanently blunts the ability of the brain to rein in glucocorticoid secretion.
(Sapolsky, 2017, pp. 194-95.)

A simple way of thinking about this is that a lot of us start our lives in 'high idle' mode.  The engine is always a little too revved and running a bit fast for its own good.  Plus, it's harder than usual to calm it down. This puts added wear and tear on the system, and that begins to show over the years.

There are a zillion ways the effects of a high rev can manifest. The stress response affects virtually every aspect of human functioning.  Here are some that Sapolsky (2004) discusses in another book:

  1. Functioning of glands, hormones, neurotransmitters
  2. Heart, blood pressure, cholesterol, breathing
  3. Metabolism, appetite, digestion, stomach and gut functioning
  4. Growth and development
  5. Sex and reproduction
  6. Immune system, vulnerability to disease
  7. Pain 
  8. Memory
  9. Sleep
  10. Aging and Death 239
  11. Mental health and well-being
  12. "Depression", motivation, ability to experience pleasure
  13. Personality and temperament
  14. Vulnerability to addiction

In other words, there's practically nothing that happens in human minds and bodies that the stress response doesn't potentially affect.

How the stress response affects us individually is a different matter.  Human beings are incredibly diverse in our life circumstances, experiences, interests and gifts.  There is no manual for life.  Nor is there any one right way of doing things.  Rather, human development is more of a creative endeavor.

Each of us constructs a response to the challenges we face based on what we have to work with (personally, socially, environmentally) at the time.  With time and repetition, some responses start to come more naturally than others.  They start to feel like the essence of 'me.'  And, in all likelihood what I come up with - and ends up feeling entirely natural to me - will end up being entirely different from what you come up with - and what ends up feeling natural to you.

That's the beauty and diversity of life.  It potentially gives us a lot to learn from each other.

So what's going on with 'mania'?

Well, here's a really interesting piece of information.  As it turns out, the human stress response (sympathetic/ fight-flight) is a real swinger.  It plays for both teams.  In other words, the stress response doesn't just get turned on by fear - like if I'm being chased by a bear.  It also turns on if I am the bear and chasing you.  This was discovered by a bunch of researchers at the University of Florida. (Bradley et al. 2001; Bradley et al., in press; Lang et al. 2010; Lang et al. 2013; Schupp et al. 2004.)  Here is one of the diagrams they drew to illustrate what they found:





(Schupp et al., 2004, p. 598.)

As you can see, the upside of the stress response (appetitive motivation) has a lot of overlap with the exciting and pleasurable things that many of us tend to chase after when we're so-called 'manic.'

When you think about it, it makes sense though.

The human stress / survival response (sympathetic nervous system/ fight-flight) developed to help us survive - both as individuals and as a species. Our survival is not just about getting away from threats as fast as we can.  Survival also requires us to be alert and on the ball for potential opportunities.

It's not enough to just know there's an opportunity.  A lot of opportunities are only there for a moment. Like classic cat and mouse, you have to gear up and go after it before it gets away.

Think of bargain shopping at Walmart on Black Friday. I have to be able to mobilize really quickly if I'm going to snatch up that hot deal on a big screen TV.  Fortunately, the survival response is there for me.  It's all over the stuff that matters to human beings the most - thereby enabling me to out-hustle or out-wrestle the next guy who is all over the same Walmart bargain that I am.


Physiology of "Mania":  Symptom by symptom.

So now that we have a basic outline of what's going on, let's take a look at so-called 'mania.'  We'll go through the criteria for a 'manic episode' symptom by symptom so you can see how the stress response is potentially operating here.

DSM 5 Critieria for Manic Episode 

A) A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary. 
B) During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flights of ideas or subjective experience that thoughts are racing.
5. Distractability (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless
non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained
buying sprees, sexual indiscretions, or foolish business investments). 


Let's start with Criteria A first:  elevated, expansive, or irritable moodincreased energy, increased goal-directed activity.  

To really see what's going on, let's go back to that Walmart bargain and take a look at what is happening physically and mentally:  


  • First of all, an opportunity like this doesn't come every day.  
  • In all likelihood, I'm gonna get something I desperately want at a price I can finally afford.  
  • But there's a catch:  I get the bargain if and only if the item I want is still on the shelf  -- which requires me to activate like crazy to beat out the next guy. 


So is my mood expansive or elevated...?  You bet. It's the chance of a year, and I might get it. 

Am I going to get potentially irritated...?  Well, if anything cuts me off or gets in my way, you bet.  

Is my energy increased...?  You bet.  I have to make a dash for it.

Am I goal-directed...?   You bet.  That's the whole purpose.  

Does it last a week...?  Probably not, because it's a one-day sale.  


But it could.  - Like if I had to compete with the other customers in a survivor show for the chance to get the best deal - and that competition went on for a week or a month....  Well then, if I really, really wanted that item, and this was my one chance, I might well stay revved for as long as it took to give myself the best chance I could at landing the prize.   And, just the same as if I was in a war zone and had to stay in high alert, my body would likely rise to the occasion for as long as I needed it to to protect my interests as much as possible. 


Okay, onto Criteria B.   Here's where you have to understand a bit more about the fight or flight response and how it actually affects us.  When I'm chasing the opportunity of a lifetime, this is what my body does: 


  1. Adrenalin surges.  My heart pounds, lungs pump and blood pressure amps.  All of this is in service of getting as much fuel and oxygen to my muscles as possible.  
  2. My hair stands on end, my fists clench, my legs get ready to run.  Everything is primed and ready to pounce at the drop of a hat.  
  3. My digestion shuts down.  My stomach gets queasy and light.  My bladder and bowels empty - just to make sure there's no needless surplus holding me back.  
  4. Higher order thinking (judgment) gets put on hold. That takes energy that my muscles need to move me.  It also takes wayyyyy too long.  This is a time for action!  I can't afford to get bogged down in details.  Once the cat is in the bag, there will be plenty of time for a more careful and reflective appraisal of what could be different.  
  5. With judgment out of the way, out come the fast reflexes and old habits.  The autonomic system takes over behind the scenes and starts calling the plays.  Whatever it is that I do best and know best - whatever comes most naturally - is what that system goes with.  After all, the stakes are high.  This is the Superbowl of my life.  I'm not going to try out a new quarterback or a new play.  I'm also not going to put in the second string.  No way!  It's the stuff I've already done a zillion times over that is going to get done once again in this frame of mind.
  6. Next come the tunnel vision and the tunnel hearing to shut out all the outside distractions.  Attention rivets.  This allows me to hyper-focus and totally zoom in on my vision of what I want to happen.  
  7. I feel no pain.  Literally.   Endorphins, my body's natural opioids, are in full gear now, again making sure that nothing distracts me from the task at hand.  
  8. It gets even better.  The fact that I'm pursuing a highly meaningful personal goal is giving me massive hits of dopamine - which is essentially endogenous cocaine.  In other words, I'm getting encouraged and reinforced by my body's own reward system to whole-heartedly pursue something I care about a lot. 
Ok, now let's go back to Criteria B.  


1. Inflated self-esteem or grandiosity.   Am I feeling pretty powerful here?  You bet.  An opportunity of a life time is within reasonable reach.  My muscles are pumped. I'm feeling no pain.  I'm getting massive internal rewards. Endogenous cocaine is telling me I'm doing great.  Any outside feedback that could discourage me is being shut out.  Yep, this space feels pretty awesome.  And if I weren't pretty awesome too, then why would I be here? 

2. Decreased need for sleep   Let's be honest.  Is there any chance in hell my body is going to let me sleep in these circumstances....?


3. More talkative than usual or pressure to keep talking.  Yep, for sure.  If I care about you or you care about me, you bet I'm talking.  This is the opportunity of a life time.  I want you to know about it.  I want you to get in on it.  I want your support 100%.  This is way, way, way too precious for either of us to miss out on. And, I'm gonna make sure you know that.  I'm also going to make sure you have all the information you need to help this plan succeed.  Heck, you can even carry it out without me if I go down.


4. Flights of ideas, racing thoughts.    You bet.  There's so much to figure out and so many angles to anticipate.  All possibilities must be considered.  All vulnerabilities must be anticipated and addressed.


5. Distractability  Frankly I might never feel this good again.  I'm on a roll and I better take advantage of this energy while it's here. There's not a moment to lose.  I need to make sure that I get everything I can possibly get while the universe is being this generous to me and making me feel this amazingly great.  Yes, I know you might think you have important things to say to me.  But that can wait.  We can talk anytime.  You don't understand.  This is a once in a lifetime opportunity.

6. Goal-directed activity, psychomotor agitation.  Yep.  This is here for sure, like we talked about above, for all the reasons above.   


7. Risky activities, high potential for painful consequences (unrestrained buying sprees, sexual indiscretions, or foolish business investments).  


Exactly.  This is where the survival response is really so deadly.


In simple fact, whole purpose of the survival response is to facilitate quick action and fast resolution.  So it's basically telling me that everything is urgent and to run, run, run.  Because after all this is the opportunity of a life time.  So, nail it down, right now.  Once we have it in hand, there will be plenty of time afterward to think about what we did, how we did it, how it might go better next time.  But, says my brain in the survival frame of mind, this is not the time

In these circumstances, my better judgment really doesn't have a chance.   It's under-resourced at the same time that my body is primed for action and my old habits are given a free reign.  There's also very little chance of any outside feedback getting past the fire wall being that is being patrolled by the high intensity tunnel vision/ tunnel hearing hyper-focus system that is keen to insure that 100% of my attention is focused on pursuing this reward.

So that about does it.  Dispensed with the all the symptoms of so-called genetic, chemically-imbalanced 'mania' armed only with the little ole garden-variety human stress response that happens for millions of Americans every Thanksgiving.

If you've been following me so far, and relating it to your own experience, then quite possibly you're beginning to see how all of this might come together to create the 'perfect storm' that gets labelled a 'manic episode.'

But what about that inevitable crash that comes the so-called 'mania'? Where does that come from?

Piece of cake.  The survival response runs on borrowed time and energy.  It requires sacrifice from all sorts of other bodily systems.  At the time, I have no idea this is happening.  The adrenaline, the power surge, the dopamine hits, the pain killers, the hyper-focus frame of mind all converge to keep me chasing short-term gains.

Once I come back to earth, however, it's payback time.  There's a boatload of refueling, replenishing and damage repair that has to be done - at the very least in my own body, quite possibly in my life as well.

Let's talk Biomarkers.


Hopefully by now you can see how most - if not all -  of the so-called 'bipolar' symptoms connect to the human stress (survival) response.   The even better news is that there is a way to test to see if this is what's happening.  There are numerous biomarkers for these kinds of stress states: blood pressure, blood sugar and oxygen levels, blood and saliva tests for hormones (e.g., adrenalin, glucocorticoids), skin conductivity tests, muscle tension or twitching, frequency of movement, whether fine motor or large motor movements are more prevalent, pupil dilation, whether visual perception is biased toward detail or gross impressions, brain scans to see what neural pathways are 'hot' or 'cold'  .... the list goes on.

What about other DSM Disorders...?


Yep, they all potentially have their stress response correlates, with symptoms that match known 'stress signatures'  as well.  It's only a matter of time before we start to map them and do the real/ honest science that so many of us have been calling for all along. 

Stay tuned - we'll be debunking some of these other 'disorders' from a stress response perspective in the near future.


Why this matters

Let's suppose you tell me that the wreckage I create in a 'bipolar' state of mind is due to a genetic or disease condition that renders my brain  structurally defective.  If that's the case, then any hope I have of effective treatment is logically the purview of brain scientists, doctors and surgeons.  My major role is to pray that they figure out a cure and soon.

On the other hand, suppose the problem isn't that at all.  Suppose, what's really driving my so-called 'mania' is that my stress/ survival response is firing wildly.

Then the solution is a lot more within the realm of something I can work with.  Yes I have some learning to do.  I need to understand the basics of how the survival system operates.  I need to learn what turns it on - and even more importantly, what turns it off.

But if I have that basic knowledge (which the average person can be taught in a few hours) then I have a tremendous amount I can work with through my own observation and trial and error.


Working with 'Mania'



Here are some basics that I've found useful for me.

What turns me on?


The survival response turns on from fear.  Predator fear and prey fear look a little different.  Predators get scared of losing opportunities. Prey get scared of becoming them.  But fear is still the basic trigger that activates the system.

What turns me off?

I used to think there was no way to shut this thing down.  It had been a part of me - and basically running my life - for long as long as I could remember.  I couldn't imagine how I could work with it.  I had tried so many things, none of them really seemed to work.  The drugs shut me down, but killed everything I enjoyed about myself along with it.  I felt stuck.   

Things started to change when I began to see my body as my ally, rather than my enemy.

The simple fact is this:  My body basically hates being in survival mode.   The survival system burns up energy and resources like they are going out of style.  It's simply not sustainable.

There are 300 trillion cells in the human body.  The survival response oversupplies a few of them, but leaves the vast majority high and dry.  For the rest of these cells, life in survival mode is pretty dismal.  Their needs are all basically getting ignored and going unmet while the survival system is off and running.  They are not happy about this at all.  Nothing would make them happier than to exit survival mode and go back to the other option (happy, sustainable, relaxed) that every human body has to offer.

This other option is the rest and refresh mode of the parasympathetic nervous system.  You don't hear much about this system.  It's considered boring, compared to fight or flight.  It's basically involved in repair and maintenance.

But, when you think about it, there is tremendous wisdom and potential in this restorative bodily system.  It's what lets us digest food, keep a steady heart beat, not forget to breath,  replenish resources and sleep at night.  It's what allows us to grow, heal injuries, defend against infection, reproduce - and love and connect with ourselves, each other and whatever is beyond.

Better yet, this restorative (parasympathetic) part of us has been with us since the womb.  It knows our needs and how to meet them better than anyone else could.  No cell in the body is even more than 5 cells away from the capillary network it manages.  It literally does brain surgery on us every night while we sleep to heal the damage of the day.

Put another way:  The ‘dumbest’ one of us on the planet has a parasympathetic nervous system that is smarter than any neuroscientist who ever lived.  If that weren’t the case, none of us could be alive right now.


Turning Off 'Mania'


If I want to function in this world, my body basically gives me two choices:

1. A survival (stress) response that revs me up and keeps me running and chasing.

2. A restorative system (parasympathetic) that offers less excitement but the option of real serenity and sustainability (well-being).

My personal belief is this:  I have to decide ‘which wolf I want to feed.’

For me, that means actively choosing which bodily system I want to live in and relate to life from as human being.  Is it the body of trust and connection - of sustainability, restoration and well-being?  Or is it the body of excitement, ambition and hot pursuit...? 

Setting my mind to go for the trust and connection body is about half the battle.  Here are some other tips I've found useful:

  1. The survival (stress) system goes on for a reason. It is signalling me that something I care about feels unsafe or at risk. Once that risk is addressed, the system has no reason for stay on.  It turns off naturally once I start to feel secure.  As a result, I generally approach my activation with an eye to restoring a sense of safety and well-being.  I ask myself what I'm scared of and try to listen honestly for the answer.  Sometimes just doing this much - honestly owning that I'm scared of something and facing the truth of what that is - can help a lot. 
  2. There’s a bit of a trick to making conscious contact with the body of well being (restorative system).  I can’t access this part of me by trying harder or forcing myself to feel something.  The harder I try, the more my survival (stress) system revs up.  The restorative (well-being) system turns on when I make a decision to let go and allow myself to be helped.  I consciously shift my focus from trying to fix it to actively cultivating my capacity to trust and be cared for.  This parallels the wisdom of many religions (and also Twelve Step programs).  My personal belief is that this is not an accident, but more on that another time.  
  3. As someone with a boatload of social trauma, and a really bad relationship with my body historically, making this shift this has not come easily.  Nevertheless, I’ve found it possible with practice.  Over time, the internal motor has begun to slow down.  Everything is not always a crisis any more.  It doesn't always have to get fixed right away - and sometimes not at all!  There is now a frame of mind that I can access where everything really is ok just the way it is.  
  4. In trying to lessen the amount of time I spend in survival reactivity, it helps to learn to recognize the signs of amping up. I can then use that ‘biofeedback’ as a mindfulness bell to return to the body of well being.  Once back in that state of relative well being, I can begin to gently inquire into what is scaring me and allow possibilities for addressing it to bubble up.
  5. The long and the short of it is that there’s a zillion ways to feel scared, but also a zillion resources for feeling safer.  There’s also a zillion options for finding something or someone I can potentially put my trust in.  That’s where the diversity of life and experience on planet earth is a huge asset.
  6. It can also help to do things that physically reassure my body and the cells in me that we are not in crisis. I try to find ways to be with myself that are totally different from how my body would act if I were running from a bear. This includes moving slowly and intentionally, activating my curiosity about small things, doing stuff that takes fine motor coordination instead of large muscle groups, making tiny gentle touching movements one finger at a time, wiggling my toes one toe at a time, doing something familiar and easy like making my bed or washing a dish, playing my guitar…  The possibilities are endless.
  7. It’s important to be patient.  As Sapolsky points out, the transition from survival (sympathetic) activation to restorative well being (parasympathetic) is a delicate one.   It’s bad for the body to have both systems firing at the same time (like heart attack bad).  Also, it takes awhile to clear one set of hormones from the bloodstream and introduce new ones.  Thus, the body needs to time to make a safe transition.  This takes a while – a minimum of 10-20 minutes - and more likely an hour or two.   Sometimes, I even find it happening slowly over several days when I've been on a real emotional bender. 
  8. Waiting out this transition can feel really uncomfortable.  The more activated I am, generally the harder it is to sit tight.  But, if I’m able to keep trusting in the process (instead of panicking and ratcheting myself back into stress reactivity), my body gets progressively more comfortable.  My muscles relax as my cardiovascular and endocrine systems stop pumping and priming them for action.  The circulatory system starts re-routing oxygen and glucose to my stomach, intestines, pancreas, kidneys and prefrontal cortex.  Queasiness, cravings and gut discomfort dissolve as my digestive system reboots into a context of relative calm. Rational capacities return, and big picture perspective and judgment radically improve as my brain has increasingly more to work with.  The end result is that I become progressively interested in – and capable of enjoying – rest, relaxation, sleep, healthy food, recreation, mundane social interactions and life management tasks. My body repairs and restores.  

Eventually I feel human again.

Below are some steps that I use to help me make the transition.  I practice them daily, often by setting a timer and doing them as a meditation (e.g., 1-2 minutes per step).





It actually really works, if I’m willing to try it.


REFERENCES:


Bradley, M. M., Codispoti, M., Cuthbert, B. N., & Lang, P. J. (2001). Emotion and motivation I: Defensive and appetitive reactions in picture processing. Emotion, 1(3), 276-298. https://pdfs.semanticscholar.org/cd1a/a512069ea32d00bba9e2d9e62f172304652f.pdf.

Bradley, M. M. & Lang, P. J. (in press). Motivation and emotion. In J.T. Cacioppo, L. G. Tassinary, and G. Berntson (Eds.), http://brain-mind.med.uoc.gr/sites/default/files/aaaaEmotion_0.pdf, Handbook of Psychophysiology (2rd Edition). New York: Cambridge University Press, http://brain-mind.med.uoc.gr/sites/default/files/aaaaEmotion_0.pdf

Lang, P. J., & Bradley, M. M. (2013). Appetitive and Defensive Motivation: Goal-Directed or Goal-Determined? Emotion Review : Journal of the International Society for Research on Emotion, 5(3), 230–234. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784012/pdf/nihms452994.pdf

Lang, P. J., & Bradley, M. M. (2010). Emotion and the motivational brain. Biological Psychology, 84(3), 437–450. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612949/pdf/nihms-164194.pdf

Sapolsky, R. (2017). Behave: the biology of humans at our best and worst.   New York : Penguin Press, https://www.goodreads.com/topic/show/19107284-d0wnload-behave-pdf-audiobook-by-robert-m-sapolsky  (pages 194-95).

Sapolsky, R. (2004).  Why Zebras Don't Get Ulcers, 3rd Edition (New York: Holt Paperbacks), https://www.mta.ca/pshl/docs/zebras.pdf.

Schupp, H., Cuthbert, B., et al. (2004). Brain processes in emotional perception: Motivated attention, Cognition and Emotion, 18:5, 593-611, http://wwwtest.kch.uiuc.edu/Research/Labs/neurocognitive-kinesiology/files/Articles/Brain_processes_in_emotional_perception_Motivated_attention.pdf

Sunday, March 25, 2018

Reality In a Nutshell: How the Normal Stress Response Explains Away 'Mental Illness"

(in progress)

A troubling fact of the medical model of mental illness is that the lion’s share of psychiatric
diagnoses lack inter-rater reliability and fail to specify a coherent theory as to actual causation.
In recent years, both the NIMH and the British Psychological Society have given the current
diagnostic system a vote of no confidence and called for re-examination. Post by Former NIMH Director Thomas Insel: Transforming Diagnosis (April 29. 2013), https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml; Johnstone, L. (May 13, 2013), UK Clinical Psychologists Call for the Abandonment of Psychiatric Diagnosis and the ‘Disease’ Model, https://www.madinamerica.com/2013/05/uk-clinical-psychologists-call-for-the-abandonment-of-psychiatric-diagnosis-and-the-disease-model/.

The question remains how to explain behavioral health phenomena that many people find troubling in a coherent, comprehensible way. The Social Justice Model of Fundamental Human Needs was proposed for this purpose in 2016.  Einstein, Social Justice and the New Relativity, https://www.madinamerica.com/2016/02/einstein-social-justice-new-relativity/.  In January 2018, the British Psychological Society went on record with a highly similar model - the Power Threat Meaning Framework - recognizing the importance of individual experience, trauma, culture and social justice considerations in the phenomena that are currently labeled and treated as 'mental illness.   Johnstone, L. & Boyle, M. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society,  https://www1.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/INF299%20PTM%20Main%20web.pdf.

The Power Threat Meaning framework proposed by the British Psychological Society model does an incredible job of articulating the research and rationale for moving beyond the medical model of mental illness.  It also clearly articulates the problematic nature of biomedical research, as well as why this research falls far short of giving us satisfactory explanations and meaningful information about the phenomena at issue.  A question left open by the Power Threat Meaning framework, however is this:


  1. What actually is the role human biology in the phenomena we are calling 'mental illness'?
  2. What part does human biology play in affecting how important life experiences (like threat or trauma) and their personal, social and cultural meanings are expressed in real time in living breathing human beings

This purpose of this paper here is to address that gap.  Here we propose that the human stress response - if understood in the level of detail that modern stress research is now making possible - holds promising explanatory power:


  1. It is fully capable of providing a physical mechanism by which individual and social meanings of great personal importance are expressed.  
  2. It likely evolved in animals and humans, in part, to serve this purpose.
  3. It potentially functions as the driving force behind nearly all of the somatic 'symptoms' - and contributes to many to many of the subjective experiences - that are labeled 'disorders' by the  DSM.  
  4. It explains not only aversive responses to threat or pain (e.g., anxiety, depression), but also excited responses to opportunities and pleasure (e.g., mania, addiction). 
This way of understanding also has important implications for those interested in social justice, equality and dignity for those labeled 'mentally ill.'  The stress model is universal and applies to all human beings.  Its fundamental operations are something that all human beings experience and have personal experience with.  The information related to the stress model - and how to relate to ourselves and others skillfully when in excited or distressed - is thus universally relevant.  All human beings, everywhere, can benefit from knowing more about it. 

The universality of the stress model is a great leveler.  Everyone experiences stress or excitement.   Everyone has experience with trying to manage stress and excitement in themselves.  Everyone has been impacted by the stress or excitement of others.  Everyone has had some successes and probably many failures in trying to contain the personal and social damage when stress or excitement goes too high and powers up to levels that feel subjectively 'unsafe.'  

This first hand knowledge potentially makes all of us 'experts.'  It potentially empowers us as individuals, families, allies and people of goodwill to take meaningful action and offer meaningful assistance to resolve crisis situations.  The major requirement is that we learn what is known about the human stress response, how it operates - what brings it up and what helps to tone it down.  From there, the task is simply to be begin to observe the stress response in ourselves:  

  • How do I respond to threats and opportunities?   
  • What happens in me when I feel threatened or excited? 
  • How do I treat myself and others when something I care about a lot is at stake?
  • How does that tend to work out for all of us in the end? 

From there, the task is simply to use imagination and empathy.  My first effort is usually to try to relate to relate to others in ways that would work for me in a similar situation.

PLEASE NOTE: There is a crucial distinction here.  I really have to put myself in the other's shoes and ask what I would want in their shoes.  This is very different from just following conventional advice about what to say or do when someone 'gets out of line."

Most of the time this works.  The more in touch I get with myself the better I do.  The more in touch I get with what stressed me out (instead of just blocking it out of my mind) the more experience I have to work with.  The more in touch I get with myself during the times I'm really stressed out more I can empathize with how hard it is to be in a given situation.  The more in touch I get with what I really need or want from others when I'm stressed out better my intuition becomes about what I might be able to offer -- and just as important how to offer it in a respectful rather than degrading way.

But, suppose that doesn't work. My best efforts have failed me and I'm still really striking out.  In other words, what if someone seems to me to be getting more rather than less stressed or extreme as a result of my actions.

Well, then, now I'm stressed right?  

That leads to option #2.  If I'm just trying to be a good samaritan to a random citizen, at this point, I might give up and walk away.  I tried to do what I know how to do, but it didn't work.  I offered what I had, it wasn't enough.  Win some, lose some.  I got a life to live.

But what if this person is my life?   What if we our lives overlap or are inextricably intertwined in some important way?

Now we're at option #3.

I own my own stress and ask the other person for help to manage it.

  • I honestly tell them what I'm looking for:  I want to understand.  But I feel like I keep missing you.
  • I try to verbalize what that experience might be like from their side:  I'm guessing it might be really frustrating for you to be experiencing something you care a lot about and have someone seem to be trying really hard, but still not be able to understand.  
  • I own my stress:  I worry that I might be making your life worse rather than better right now - and I totally don't want to do that.  
  • I own what my stress is about for me:  I think I'm scaring myself here.  I'm used to being able to relate in really difficult situations.  I don't like feeling like I'm failing you.  
  • I ask for help in finding a workable direction for both of us:  Do you have any ideas how we could go forward?  Is there anything I should be doing differently here? 
  • I ask for the practical support I need to hang in there with the conversation:  I'm having trouble following so many points at once. Can we get a paper and make a diagram so I can see what relates to what? 

It's about that simple. It works 90% of the time - with 90% of people.  And I spend a lot of time with stressed out people.

OK so onto the model....

The Stress Model of Human Survival Reactivity

(in mostly outline form, in progress) 

The following comes out of my own lived experience (which includes numerous personal diagnostic labels - bulimia’, ‘anxiety’, ‘psychotic NOS’, ‘OCD’, ‘OCPD’, ‘depression’, ‘bipolar’…), a law degree, former clinical practice as a therapist, completing the coursework for a doctorate in pastoral counseling, and subsequent disability pension due to mental extremes. I basically have been trying to find a way to honestly and accurately describe what is going on for me – and the DSM / medical explanations don't help or seem to fit.  Some of the treatments I tried helped in small ways, but none of them was a complete answer.  Many things I was told to do made things worse instead of better, or created new problems of their own.   Even worse, the advice of mental health experts put me in conflict with my own knowing.  This made me more confused and drove the truths I believe my mind and body were trying to get across to me even further underground.

For many years, I gave up my own agency.  I relied on the advice of mental health professionals, increasingly ceding my own authority.  I hoped beyond hope that someday all my hard work would pay off.  Eventually, I would experience the promised 'break though' and all would be well with myself and my future.  At last, I could have the life I saw others having and was working so hard to deserve!

At some point I realized the process, for me, was never going to end.  There was always going to deeper aspect of myself to pathologize.   No matter how hard I tried to do it their way, the simple fact was this:   If I kept being honest about what I found, no one in the mental health profession was ever going to pronounce me well.

The realization was utterly demoralizing.  I really was 'mentally ill' and no escape was possible.  Those were my initial thoughts. 

Then I decided to take my future into my own hands.  I knew people who had used the same techniques I had, and got better.  What were they doing differently?   Why did it work for them and not me?

I applied to graduate school in a mental health program and started trying to figure this out.   In some ways, the experience was a failure. I never found an answer to my initial question.  I never learned how to make the mental health work for me.  Even as a practicing therapist, I kept getting worse instead of better.

But I did get exposed to some new ideas, and set on a new path of inquiry, that (for me) has made a huge difference.  This, in turn, led me to develop this following model (Stress Model of Survival Reactivity) that I'm about to share with you.  It's the first thing I've come across that has allowed me to make sense of - and productively work with - the intense inner world I've been experiencing since childhood.  It also seems to make sense to quite a few others I’ve shared it with.

I. Preliminary Question: What biology are we actually seeing in DSM ("mental illness")diagnoses? 

The basic premise is this:

  1. We can potentially explain the nearly the entire medical model/ DSM just based on the human stress (survival) response.   
  2. In a word, it’s just the human condition.

II. The Role of Biology in Troubled/ Troubling States 

Concept A: Dual Threat/ Opportunity Stress Response Activation

The human stress / survival response (largely the sympathetic nervous system, ‘fight-flight-freeze’) developed to help us survive - both as individuals and as a species. It is activated both by threats and opportunities, as both have important survival implications.  I.e., it might be more fun to be predator than prey, but there are stress and survival implications for both.  Thus, the stress response is not just about avoiding getting eaten.  Even if you’re a predator, and even if you enjoy hunting, it is still stressful to need to eat and find ways to feed yourself.  So the survival system is there for you, to satisfy animal appetites – as much as it is for your potential meal-mates lower on the food chain.

Here's how it works:



Another way to think of the stress/ survival response is that it is about power.  It helps us power up, marshall our resources and exert power in ways that protect the needs and values we care about the most.  There are 4 archetypal (autonomic) power roles crucial to animal survival:

  1. Predator – you exert power to expand the scope of your territory
  2. Prey – you exert power to protect yourself from intrusion
  3. Protector – you exert power to protect others.  Can be motivated by self-interest (shepherd), altruism (Jesus), or both (most family relationships)
  4. Protected - you don't have to exert power. You feel safe, protected and free to appreciate existence just as you are.
The different power roles have some significant differences in the way they use the stress response.  Here's an overly simplistic model for their different physical and mental experiences.  The information about specific hormones and how they function is based on Sapolsky reference, infra.


Predator (fight)

This is the way the business world and most of the modern culture operates

Profile:
  1. Mental = power up with intention of destroying all resistance.  
  2. Physical = sympathetic: adrenaline (power and control) + dopamine (hope/ optimism, activates to helps us chase our goals).  
The Predator profile supports active chasing/ aggressive behavior.  It potentially explains ‘symptoms’ related to excitement, activation, hyper-focus, high energy, obsession, dominance, grandiosity and the like.   It is behind the predatory, expansive or appetitive ‘disorders’ like 'mania' addiction, violence, sexual predation, some kinds of spirituality.

The Predator response can stand alone, e.g., I like feeling powerful so I'll make you vulnerable (much of sadism).  It can also be compensatory, e.g., I feel vulnerable and scared and I need something to feel better - what can I chase or catch that will do that? (Much of addiction).  Often, I experience some of both. (E.g., the boss threatened to fire me, so now I’m picking a fight with you to feel more powerful.)


Prey (flight, freeze)

This is what it feels like to me as a small cogs in the big and grinding wheel of modern culture.

Flight profile:
  1. Mental = power up with intention of escaping destruction
  2. Physical = sympathetic + adrenaline (power and control)
Notice here that the prey profile has no dopamine.  In other words, there is no anticipation of reward -- only the stress of being chased and deterred from enjoying more meaningful activities.  This is hallmark trait of pure anxiety - heart and lungs pumping, blood pressure through the roof; muscles tense, shaking, jumpy); digestive system shutting down (lump in throat, nauseous, gut cramping, bowels loose, weak bladder); hair trigger reactivity; mind blank or racing).  For me, it explains most of the anxiety-related 'disorders / symptoms' in the DSM.

Freeze profile:
  1. Mental= power off with intention of escaping detection
  2. Physical (most commonly) = sympathetic (readiness) + parasympathetic brake (holding you back or still) 

Freeze often looks like a uniform phenomena to outside observers.  But it serves a variety of functions.  Freeze itself is posited to have several unique stress profiles of its own:

  1. freeze to appraise
  2. freeze to play dead
  3. freeze to become unconscious
  4. freeze to heal
The freeze response potentially explains a variety of disorders and related symptoms.  It is what anxiety, depression, and dissociative and/ or altered perceptual states feel like to me.  Common features include:  indecision, immobility, paralysis, black and brown outs; leaden limbs, waxy flexibility, attention that is either riveted or totally out of it, low blood pressure, low heart rate, locked muscles).

Protector (tend and befriend) 

It is the archetypal ideal of family where others have your back when you're in trouble.

Profile: Tend/ Befriend

  1. Mental = power up with intention of creating safety
  2. Physical = sympathetic -> parasympathetic: adrenaline (power and control) + oxytocin (relational bonding) + dopamine (hope and reward) 
The Protector profile energizes and gives meaning to human connection and bonding.  It's the relatively pleasurable physical state that gets created when human beings use our power to walk each other to safety.  I suspect that the pleasurable nature of the oxytocin at least partly contributes to the data on relationships as a protective factor in resilience.

The Protector archetype points to the healing potential of both natural and service relationships - families, friends, neighbors, mutual aid, volunteering, professional helpers. It's probably behind the healing power that many of us experience with really good 'therapeutic alliance.' It likely explains the popularity and success of modern peer support movements.

Notably, data from addiction recovery is that cocaine spurs a 1000-FOLD increase in the release of dopamine.  So, if humans were only about self-interest or euphoric experiences, there would be no hope for recovery following initial exposure. Our fight response would have all of us, invariably, chasing drug-driven dopamine discharge until we die.  But, every day, people overcome this largely though the power of peer support relationships. Something in the chemical mix of the human bonding experience apparently is more rewarding than cocaine.  (See Hari reference, inpra.)

I suspect Twelve Step programs capitalize on this. For myself, it's been a useful way to combat addictive cravings.  My initial tendency under starts is to go with the 'fight response' but that often has me chasing stuff that is harmful in the long run.  Instead, if I'm able to connect with another person, even if it involves doing something for them instead of me, I start to feel a little better.  I'm guessing this the the power of oxytocin rising up to aid the human bonding experience and moving both of us to parasympathetic safety.

Protected (rest/ refresh) 


This is the Archetypal ideal of unity/ oneness/ 'all is well.'

Profile: Rest/ Refresh
  1. Mental = natural easeful experience, no added power needed
  2. Profile = totally parasympathetic
Essentially, this is the parasympathetic nervous system taking care of us.  It is about trust and connection with ourselves, others and possibly beyond.  I suspect it's the place in human beings that longs for (and possibly facilitates) contact with something greater than ourselves.  It is what spirituality and unconditional well-being feel like to me.  In this state, generosity of spirit and appreciation of things as they are seems to flow naturally. 

REFERENCES:

Bradley, M. M., Codispoti, M., Cuthbert, B. N., & Lang, P. J. (2001). Emotion and motivation I: Defensive and appetitive reactions in picture processing. Emotion, 1(3), 276-298. http://dx.doi.org/10.1037/1528-3542.1.3.276, https://pdfs.semanticscholar.org/cd1a/a512069ea32d00bba9e2d9e62f172304652f.pdf.

Bradley, M. M. & Lang, P. J. (in press). Motivation and emotion. In J.T. Cacioppo, L. G. Tassinary, and G. Berntson (Eds.), http://brain-mind.med.uoc.gr/sites/default/files/aaaaEmotion_0.pdf, Handbook of Psychophysiology (2rd Edition). New York: Cambridge University

Hari, J. (2015). Chasing the Scream: The First and Last Days of the War on Drugs. Bloomsbury. ISBN 978-1-620-408902.

Lang, P. J., & Bradley, M. M. (2013). Appetitive and Defensive Motivation: Goal-Directed or Goal-Determined? Emotion Review : Journal of the International Society for Research on Emotion, 5(3), 230–234. http://doi.org/10.1177/175407391347751, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784012/pdf/nihms452994.pdf

Lang, P. J., & Bradley, M. M. (2010). Emotion and the motivational brain. Biological Psychology, 84(3), 437–450. http://doi.org/10.1016/j.biopsycho.2009.10.007, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612949/pdf/nihms-164194.pdf

Sapolsky, R. Why Zebras Don't Get Ulcers, 3rd Edition, https://www.mta.ca/pshl/docs/zebras.pdf.  


Schupp, H., Cuthbert, B., et al. (2010). Brain processes in emotional perception: Motivated attention, Cognition and Emotion, 18:5, 593-611,DOI: 10.1080/02699930341000239, http://wwwtest.kch.uiuc.edu/Research/Labs/neurocognitive-kinesiology/files/Articles/Brain_processes_in_emotional_perception_Motivated_attention.pdf

Concept B: The Defense Cascade.


This is where the research is heading in trauma-informed care:

The fight-flight-freeze model is becoming increasingly elaborated.  Many nuances are now understood.  While sympathetic activation tends to dominate, the parasympathetic system collaborates with it at crucial junctures.  Here is the general idea:




As you can see from the diagram (reference below), higher levels of threat lead to increasingly extreme stress response activation.  Different appraisals (meanings) of threat result in different 'stress signatures.'   The particular stress signature is closely related to subjective appraisal (meaning) and self-assessment of relative power.  In other words, if something has the power to hurt me and might use it, then it is threatening.

Here is how this plays out:

(1) Freeze

  • The first step in activating the defense cascade
  • Attentive immobility
  • An orienting response 
  • The parasympathetic nervous system acts as a brake and puts the flight-or-fight response put on hold.
  • This keeps you perfectly still (and hopefully imperceptible) while allowing time to assess your next move

(2) Flight

  • Active defense response for dealing with threat
  • Response of choice for most people
  • Hope is to get away unscathed (and possibly unnoticed)
  • Some of us don't run.  We skip directly to fight


    (3) Fight
    • Active defense response for dealing with threat
    • Almost never arises without some level of pre-existing fear. 
    • Used when cornered or being attacked seems relatively certain
    • Response of choice for about 1/3 of us
    • Hope is to put an end to the threat - once and for all.

    (4) Fright
    • A response to inescapable threat
    • Tonic Immobility 
    • A strategy of last resort when active defenses are futile
    • Parasympathetic system puts 'brake' on heart rate, breathing and muscles
    • Fully conscious and alert but physically paralyzed and unable to respond voluntarily
    • 'Involuntary' (sympathetic) capacity to respond is maintained. (Just release the parasympathetic brake!)
    • Appear dead so predator may lose interest or loosen grip
    • Muscle tone is maintained, making a quick get away possible (release brake!) if escape opportunity presents itself
    • Frequent irregular heartbeat because parasympathetic and sympathetic systems are both active
    • High chance of heart attack for same reason
    (5) Flag
    • A response to extended captiviy
    • Collapsed immobility
    • Heart and breathing remain slowed for extended period
    • Brain doesn't get much oxygen
    • Consciousness is often lost
    • Muscle tone is then lost (waxy flexibility)
    • No ability to respond either voluntarily or involuntarily 
    • Effs with memory
    (6) Faint

    • Result of body's natural disgust response
    • Turned on by exposure to contaminants like bodily fluids
    • Frequent response to rape.
    • Effs with memory

    (7) Quiescent immobility

    • A state of quiescence that promotes rest and healing. 




    coordination are recognized and understood. Additional stages (-fright-flag-faint) have been added. They are hypothesized to progressively express overwhelming levels of distress/ intensity that trigger dissociative bodily states.


    The research in the prior section (on human motivation) suggests that the same basic physical capacities should be available to aid us in pursuing our appetites not just in escaping our fears. the more dangerous the threat or valuable the opportunity, the more I tend to exert my power to ensure that things turn out okay for me.

    Here’s the basic outline of how it works:

    Level 1: NO CHALLENGE 

    Societal archetype:  Rest

    Appraisal: No threat, no critical opportunities.

    Signature: Parasympathetic activation.

    What it looks and feels like:  Good ole R & R (rest & relaxation)

    Practical outcomes ('symptoms'): optimal digestion, immunity, healing, sleep, sex


    Level 2: MILD CHALLENGE

    Societal achetype: Play

    Appraisal:  “I got this.  This is gonna be fun.”

    Stress signature:  Optimal sympathetic activation

    What it looks and feels like:  Fun! Flow, Happiness, "High Functioning"
    • activity is engaging and rewarding in itself
    • experience is voluntarily sought out
    Practical outcomes ('symptoms'):

    Naturally rewarding experience leads to:

    • optimal attention, energy, learning
    • natural desire to repeat experience 
    • increases in learning and competence over time 


    Level 3: MODERATE CHALLENGE

    Societal archetype: Work

    Appraisal: “This takes more effort than I would like.  It's not my preferred way to spend my time.

    But it's necessary in order to have the life I want to have.”

    Stress signature:  Moderate sympathetic activation

    What it looks and feels like:  Effort

    • Requires self-control to stay on task and keep good attitude
    • Activity is not rewarding in itself
    • Motivation comes from secure expectation of rewards


    Practical outcomes ('symptoms'):

    Repeated task-relevant expenditures of effort and energy result in:

    • Objectively valued productivity 
    • Reliable rewards
    • Need for physical and mental restoration
    • Increasing levels of competence



    Level 4:  MAJOR CHALLENGE 

    rchetype:  Trauma/ "Rite of Passage"

    Appraisal: “This is really hard. I'd give anything to escape it. But I don't have a choice.”

    Stress signature:  High level sympathetic activation

    What it looks and feels like: learning to build the airplane while you're flying it

    • high pressure, stressful, challenging, 
    • frustrating due to numerous setbacks, 
    • emotional rollercoaster due to one step-forward ('growth opportunity!') two steps backwards (punished by god)),
    • physically and emotionally exhausting due to massively steep learning curve  


    Practical outcomes ('symptoms'):
    Due to steep learning curve and massive investment of energy, attention and effort required:
    • Intense feelings, psychomotor activation, digestive shutdown, limited sleep
    • One track mind, tunnel vision, tunnel hearing, 'obsessed' 
    • High alert and hair trigger for danger/ opportunity/ relief
    • Intense perceptual sensitivity (skin sensitivity, noise, smells, light)
    • Cold hands & feet  - or sweating
    • Foreshortened future - all that matters is now!
    • Impatience, intolerance, trying to force resolution
    • Analgesia (don't feel pain) or hyperalgesia (feel pain intensely)
    • Big picture and long-term needs sacrificed
    • Fast foods, sugar and drugs used to sustain energy
    • Stress valves (addictions, compulsions, anger, crying) used to prevent shutdown from overwhelm (see level 5).


    Level 5:  OVERWHELMING CHALLENGE (Overwhelming threat/ Unattainable opportunity).

    Archetypes:  Grief/ Breakdown/ Death

    Appraisal:   ‘There’s no hope. I can’t do this.  It’s all over. I’m a failure.  I lose. I might as well quit and turn in the towel right now.”

    Stress signature:  Parasympathetic responses override sympathetic activation resulting in mental and physical shutdown.

    What it looks and feels like: Total systems failure, abort mission

    Practical outcomes ("symptoms"):

    Variable sympathetic and parasympathetic activation lead to extreme, erratic or collapsed presentations, including: 

    • Psychomotor shut down/ frozen or leaden limbs, waxy flexibility, catatonia
    • Digestive shutdown (anorexia, incontinence, nausea, cramping)
    • Altered perceptions, perceptual shutdown, paralyzed perceptions where you can see and hear everything but can't do anything about it
    • Hypersomnia, unconsciousness, blank or frozen consciousness, waking dream state, out of body experience
    • Low blood pressure, heart rate, respiration, fainting
    • Analgesia (don't feel pain) or hyperalgesia (feel pain intensely)


    7) Notably, these various stages – and their hypothesized psychological meanings - have a huge overlap with the symptoms of what are considered diagnoses of ‘severe mental illness’ in the DSM.  For example, freeze, fight and flight (stages 1, 2 and 3) seem to coincide with ‘acceptable mental illness’ (anxiety, phobias, bipolar II, dysthymia, cyclothymia, mild ptsd, milder addictions/ obsessions/ compulsions).  They lead to the kind and level of symptoms that are typically seen as treatable on an outpatient basis without neuroleptics or shock.  The higher stages (fright, flag and faint - stages 4, 5, 6) seem to overlap with the symptoms of ‘severe mental illness’ – major depression, bipolar I, dissociative and psychotic experiences and chronic treatment resistant everything else.

    8) A large part of someone’s personal ‘stress signature’ is dependent upon an autonomic (instinctive/ reactive) appraisal of what the most successful strategy in the repertoire is likely to be for the threat or opportunity in question.
    9) The relevant autonomic appraisal is highly affected by past experiences with this kind of threat/ opportunity.  Thus, a war veteran or assault survivor will respond differently than a bull rider in her first rodeo.
    10) Also, if the first exposure is traumatic enough, there is a high likelihood that the person will do what they did the last time they were in a similar situation (or what they saw someone else do at home or on tv).  This is because:
    a) The autonomic nervous system is rapidly recalling our past emotionally relevant experience and how it was survived. (Thereby explaining why I hear my mother’s words coming out of my mouth in times of stress even though, as a kid, I couldn’t imagine anything lamer to say. Or why my first thought when facing intellectual challenge is always to secure a ready supply of chocolate – even when I’m fully aware that sugar is bad for me or I need to lose a few pounds.)
    b) At high enough levels of distress/ intensity the autonomic system bypasses the frontal cortex and simply proceeds to action.  Here, the system is basically saying: “There’s no time to waste. We barely got out of here alive last time.  We know what worked then.  Just do it.”  As a result, there is little conscious awareness of the response – or even the stressor that prompted the responding.  (Ergo, ‘autopilot’, unconscious behavior, black outs, brown outs, fragmented memories, …)
    c) The automaticity inherent in this way of responding wreaks havoc on subsequent efforts to recall experiences and responses or make sense of them.
    REFERENCES
    Kozlowska, K., Walker, P., McLean, L., & Carrive, P. (2015). Fear and the Defense Cascade: Clinical Implications and Management. Harvard Review of Psychiatry, 23(4), 263–287. http://doi.org/10.1097/HRP.0000000000000065, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495877/
    Roelofs, K. (2017). Freeze for action: neurobiological mechanisms in animal and dhuman freezing. Philosophical Transactions of the Royal Society B: Biological Sciences, 372(1718), 20160206. http://doi.org/10.1098/rstb.2016.0206, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5332864/pdf/rstb20160206.pdf
    Sapolsky, R. Why Zebras Don't Get Ulcers, 3rd Edition, https://www.mta.ca/pshl/docs/zebras.pdf.
    Schauer, M., & Elbert, T. (2010). Dissociation following traumatic stress: Etiology and treatment. Zeitschrift für Psychologie/Journal of Psychology, 218(2), 109-127, http://dx.doi.org/10.1027/0044-3409/a000018, http://mandaladesign.com.au/startts/winter2011/schauer-elbert-dissociation.pdf
    Generic research on the human stress response:
    I’ve found the following book by Stanford researcher Robert Sapolsky incredibly helpful in trying to understand how the human stress response potentially translates into biological impacts that the DSM is labeling ‘mental illness.  (I think his stuff on depression is overly influenced by the medical model, but most everything else he says about how the human body functions has been tremendously helpful to me in deconstructing various DSM diagnosis/ symptoms I've experienced and translating them into their underlying biological correlates.)

    REFERENCE

    Sapolsky, R. Why Zebras Don't Get Ulcers, 3rd Edition, https://www.mta.ca/pshl/docs/zebras.pdf.

    What the book covers:
    “There has been a revolution in medicine concerning how we think about the diseases that now afflict us. It involves recognizing the interactions between the body and the mind, the ways in which emotions and personality can have a tremendous impact on the functioning and health of virtually every cell in the body. It is about the role of stress in making some of us more vulnerable to disease, the ways in which some of us cope with stressors, and the critical notion that you cannot really understand a disease in vacuo, but rather only in the context of the person suffering from that disease.
    This is the subject of my book. I begin by trying to clarify the meaning of the nebulous concept of stress and to teach, with a minimum of pain, how various hormones and parts of the brain are mobilized in response to stress. I then focus on the links between stress and increased risk for certain types of disease, going, chapter by chapter, through the effects of stress on the circulatory system, on energy storage, on growth, reproduction, the immune system, and so on.
    Next I describe how the aging process may be influenced by the amount of stress experienced over a lifetime. I then examine the link between stress and the most common and arguably most crippling of psychiatric disorders, major depression. As part of updating the material for this third edition, I have added two new chapters: one on the interactions between stress and sleep, and one on what stress has to do with addiction.”
    What Sapolsky says (in a nutshell):
    1) The subjective meaning of various life events have everything to do with how human beings respond.
    2) The stress response activates in a broad variety of contexts depending on the meaning they have for human beings.
    3) The short and long term consequences of real life events, their subjective meanings and the autonomic responses they evoke affect every aspect of human functioning - attention, memory, capacity to learn, energy, outlook, sleep, health, digestion, breathing, heart rate, high blood pressure, life expectancy.
    4) Human beings have created a society that is intensely stressful for those who are low on the totem pole. Plus we have taken intentional othering to a level previously unknown in the animal kingdom.  Such uses of social power are profoundly affecting the health of all concerned – both haves and have nots.
    RELATED REFERENCE:
    Sapolsky, R. (2017).  Behave: The Biology of Humans at Our Best and Worst. By Robert M. Sapolsky. New York: Penguin Press.
    Inferences from Sapolsky’s work:
    Concept C: The more activation the worse the ‘symptoms’
    1) The higher the level of stress response activation the more urgency there is to get immediate results.  The sympathetic system is basically spending energy on credit.  The needs of most cells in the body are being put on hold while the ‘hero’ functions (muscles, circulatory system) get the lion’s share of attention and resources.  This includes the prefrontal cortex which loses about 20% of its normal blood supply.
    2) Suffice it to say, the system is not sustainable, leading to a lot of physical discomfort with attendant pressure to act, get it over with, act now think later. – Plus, you have an under-resourced cortex that basically just goes along for the ride.  This potentially explains a lot of the impulsiveness and ‘poor’ judgment associated with ‘mental illness’ – especially the more appetitive ‘disorders’ – like those involving drugs, sex, ‘mania’, food, dominance, addiction.   In a word, once the fight response activates and the dopamine reward system start fueling the chase, the anticipation of reward itself becomes a reward.  This can create a vicious upward spiral as increasingly high ambitions are set to release increasingly more dopamine – ending only when utter physical depletion or some external catastrophe shuts it down.
    Concept D: High level stress activation potentially explains differing perceptions of reality
    1) As noted above, the stress response is turned on by the perception that something is threatening (or exciting). Perception can become primed by past experience leaving parts of the autonomic nervous system perpetually on high alert (amygdala pathways).  Essentially, we end up with autonomic antennae that are constantly on the lookout for anything that might resemble important prior experiences.
    2) According to Sapolsky, these antennae are 'fast but faulty.' Also, if activation is high enough, they can trigger reactions that bypass the parts of our biology (frontal cortex) that are 'accurate but slow.' – This leads to situations where people react first and think later.
    3) Although automated responses can be changed, they actually have to be ‘unlearned.’ In other words, new learning has to occur where you actually experience the feared input as not dangerous.
    4) This, potentially explains individual responses that look ‘crazy’ to others: Something resembles a serious past threat that I experienced – but no one else in the room has.  My antenna pick up the potential threat and I react before my frontal cortex has a chance to separate wheat from chaff.  No one else sees anything threatening.  Plus, their cortexes have plenty of time to carefully assess incoming data.  Next thing I know, I’m ‘sure’ I saw something deadly, while everyone else is sure I didn’t – and also sure I’m crazy.
    5) This also potentially explains why these responses are so difficult to change:  Suppose I’m walking on a path and mistake a stick for a snake.  After I jump to safety, I can look back and see if it was a stick or a snake.  If I do that, I can potentially get better at distinguishing sticks from snakes.  I also get the opportunity to recognize that sometimes my first impulse is wrong and I actually mistake sticks for snakes.  On the other hand, if I’m sufficiently terrified of snakes, then there’s a high likelihood that I may not even go back to see if it was a snake.  Instead, I keep running from sticks, so my perception stays inaccurate.  Also, it may never occur to me that my perception could be inaccurate.  I might just go about life thinking about how unfortunate I am to see so many snakes – or how great I am at not getting bitten by the zillions I see everyday.
    6) Also, if I keep running these same brain circuits, I make them more alive and increasingly attuned to looking for things that resemble snakes.  The more ‘practice’ these brain circuits get at looking for potential snakes, the more I end up seeing signs of snakes everywhere.  Eventually, tons of things -- pencils, dental floss, string, power cords -- all put my autonomic ‘early warning’ system into high alert.
    7) As Sapolsky notes, however, if I’ve been sufficiently traumatized by my first encounter with snakes, much of this autonomically detected information never reaches my prefrontal cortex.  It bypasses that stop on the route, and goes straight to threat activation.  The result is I’m repeatedly setting off sympathetic reactivity (and potentially in a continual state of fear and panic) with very little conscious awareness of why that just happened.  This is a possible explanation for how some kinds of panic, anxiety, phobic responses get so entrenched and hard to change.
    8) Just as important: most important life events happen in real time.  They are not on camera, and there is no instant replay.  So I rarely get to see when my intuition is right and when it’s wrong.  The best I can do is try to reconstruct what happened with the help of others.
    9) This highlights the importance of trusting and trustworthy relationships. In other words, if I trust you, this social reconstruction can often be helpful in establishing a consensual reality.  Alternatively, it can raising flags for both of us that something outside of our shared awareness just occurred that we need to pay attention to.  Then maybe the next time something similar happens, we can pay more attention and have more to work with in figuring out why our perceptions disagreed.
    10) But, if we don’t trust each other, this can’t happen.  I don’t believe you, you don’t believe me.  In this case, usually, the ‘reality’ with the most social power behind it wins.
    11) This exacerbates the distrust and entrenches us both in our positions.  It makes our interactions increasingly ‘high stakes’ (stress charged).  This, in turn, decreases the likelihood that either of us will learn anything useful from our differing perceptions.
    Concept E:  The ‘otherness’ of intrusive experiences (voices, visions, thoughts) is potentially explained by the independent functioning of the autonomic system
    1) Sapolsky argues that ‘surprise’ is a key factor in feeling like something is coming from self or others.  It’s basically why you can't tickle yourself -  you’re not surprised.
    2) But, there is an exception to the ‘can’t tickle yourself’ rule.  You can tickle yourself IF you devise a tickle machine that delays 3 seconds before it executes your command to tickle.  It turns out that a delay of about 3 seconds from conscious awareness is all it takes for something to seem like it's coming from outside of us instead of inside.
    3) The autonomic nervous system functions independent of conscious awareness and largely outside of our conscious awareness and control.  It therefore possesses the power to 'surprise' our conscious brain.
    4) This element of surprise potentially could explain at least some of the mysteries of the voice hearing experience.  This includes the sensation that perceptions are coming from outside the body.  Also: why voices seem foreign to us but also seem to know all about us.
    5) Important to note:
    a) This ‘autonomic surprise’ theory doesn’t rule out spiritual, ESP or other explanations for the voice hearing experience.
    b) It merely suggests a possible explanation for these phenomena.
    c) The fact is, the autonomic system IS operating outside largely of our conscious awareness and control.
    d) So potentially there are zillions of phenomena that the autonomic system is aware of and managing behind the scenes without our conscious knowledge.
    e) To get a sense of how potentially wise the autonomic system is:
    i) This system co-ordinates the activity of 300 trillion cells that support our lives.
    ii) It keeps them hydrated, nourished, temperature controlled, in good repair, defended from external threats – AND working in a collaborative, coordinated fashion to sustain our lives.
    iii) It has been with us since the womb and knows us better than anyone could.
    iv) It literally does brain surgery and sophisticated healing processes on us every night while we sleep to heal the damage of the day.
    v) Thus, in a very real way, the ‘dumbest’ person on the planet has an autonomic nervous system that is smarter that any neuroscientist who ever lived.  If that weren’t the case, we couldn’t be alive right now.
    f) This suggest the wisdom of trying to listen and make sense of autonomic phenomena, even if they are painful or distracting.
    g) It also points to the potential danger of drugging, shocking or finding other ways to merely override this system for the sake of shutting it up.  We may be, literally, killing the messenger.
    Following are some ideas that makes sense to me based on my own experience of my own mental and physical responding:
    Concept F:  My ‘high stakes’ are diverse, habitual and based on my greatest gifts
    1. When the stakes are really high, I find it incredibly hard to use – or even recall – that really constructive strategy sounded so great when I talked about it in therapy.  I think this is because the stress response (especially at high levels) is about survival. So, in the metaphoric equivalent of a Superbowl or Worldcup, my autonomic ‘coach’ isn’t going to let me put in the “B’’team.  It just goes with the tried and true strategy of doing what I’ve always done (e.g., losing my temper, or eating more brownies).  After all, that’s kept me alive up until now.  Thus, my past experiences with a given challenge heavily influence my current autonomic responding.
    2. In deciding what strategies to use, my autonomic ‘coach’ looks at my gifts, strengths and available resources, including what comes most naturally and reliably to me in the moment. It’s a highly individual assessment that varies from individual to individual. Thus, if I’m strong, I amp up physically.  If I’m smart, I amp up mentally.  If I’m loud, I amp up my volume.  If I’m social, I amp up my relationships.  If I’m rich, I throw money at it.  If I ‘know somebody’, I ask for information or a favor.
    3. This explains some of the diversity in the way that ‘mental illness’ is expressed.  We are literally taking the stuff we, personally, know the best or are the best at, and amping that up as high as we need to to survive whatever is stressing us out.
    4. This also highlights the damage of many medical interventions like drugs and shock.  All too often, our gifts and strengths are the so-called ‘symptoms’ that they target for eradication.
    Concept G:“Safety” and/or “trust” turn off the stress response.
    1) High stakes activation turns on because something important to survival feels at risk.  Maybe a lion or the tax collector is chasing me.  Maybe there’s an incredible bargain, meal, or cosmic secret that I can’t afford to miss out on.  Either way, it’s hard to rest or give up the chase unless the situation is resolved.
    2) Resolution, for me, usually means that what I care about most feels safe and/or that I trust that the ultimate outcome is in good hands.
    3) If the situation is resolved:
    4) Once I feel relatively safe or trusting, then I can relax.
    5) At this point, the sympathetic system starts to dampen down and restorative functions of the parasympathetic system naturally and progressively return.
    6) This takes a while – often 10-20 minutes, sometimes more.  As Sapolsky points out, the transition from sympathetic activation to parasympathetic restoration is a delicate one.  It’s bad for the body to have both systems firing at the same time (like heart attack bad).  Also, it takes awhile to clear one set of hormones from the bloodstream and introduce new ones.
    7) Waiting out this transition can feel really uncomfortable.  It may explain the popularity of the Twelve Step slogan: ‘Don’t quit before the miracle.”
    8) If I’m able to keep trusting in the process (instead of panic and ratchet myself back into stress reactivity), my body gets progressively more comfortable.  My muscles relax as my cardiovascular and endocrine systems stop pumping and priming them for action.  The circulatory system starts re-routing oxygen and glucose to my stomach, intestines, pancreas, kidneys and prefrontal cortex.  Nausea and gut cramping dissolve as my digestive system reboots. Rational capacities return, and big picture perspective and judgment radically improve as my brain has increasingly more to work with.
    9) The end result is that I become progressively interested in – and capable of enjoying – rest, relaxation, sleep, healthy food, recreation, mundane social interactions and life management tasks. My body repairs and restores.  Eventually I feel human again.  (It actually really works, if I’m willing to let it.)
    10) All good!
    Concept H: Non-resolution leads to prolonged stress response activation and subsequent breakdown.
    1. If the challenge remains unresolved (unsafe) and I can’t find a way to trust that all will turn out ok in the end, I tend to stay in a state of high alert (vigilance, anxiety, intensity, ‘hypomania’, hyperfocus, obsession, compulsion, insomnia, impatience, irritability, high sugar and caffeine consumption,… ).  This continues until I physically can’t keep it up any more.  Or I cycle in and out of high alert  -- hope, fear, hope, fear, hope, fear…  (‘rapid cycling’, ‘labile’, unstable, ‘cyclothymia’, ‘bipolar’).
    2. During such times, the tunnel vision and tunnel hearing of sympathetic activation remain in full force. Thus, I’m typically pretty obsessed with the little picture of fixing what I see as the problem.  I therefore tend to miss the big picture (and often possible solutions). Essentially, it’s a stress-induced war of attrition.
    3. If the lack of resolution goes on long enough for a given significant stressor, I eventually find myself experiencing a state of break down / collapse.  For me, the effects of this state are indistinguishable from classic ‘symptoms’ of ‘depression’ – no motivation, no energy, no enjoyment, no hope, no memory, no focus, no ability to learn, agitation, digestive and eating issues, leaden limbs, sleep issues …
    4. The exhaustion and lack of resolution take their toll on my self-worth and self-esteem.  I feel like a failure, start wondering what’s wrong with me that I can’t fix it, or why this is happening to me, or if the universe is out to get me...
    5. It’s also not a very long step for me from here to ‘suicidal ideation’, ‘addiction’, ‘dissociation’, ‘delusions’, certain kinds of ‘psychosis.’  Suffice it to say, at this point, I’m keenly motivated to escape or find relief – and all of the above work on some level.  So suicide, ‘forgetting’, ‘spacing out’ and addictive consolation all become highly appealing.
    6. Occasionally, there are rare bursts of energy, where I try to blast or demand my way out (over-power my circumstances).  A lot of time this looks like ‘manic symptoms’ - frenetic activity, high intensity, impatience, ‘irrational’ optimism, rage, dominance, ‘grandiosity’.
    III.  A Potential Solution
    For me, the theory points to its own solution.
    Concept I: For a multitude of reasons, many of us habitually use high levels of stress activation to navigate garden variety life issues.
    1) The sympathetic system (and thus my ‘symptoms’) turns on when something important feels unsafe to me.  It turns off when the things I care about feel safe or in good hands.
    2) I’ve spent my life with a lot of stuff feeling unsafe to me a lot of the time. I’ve also felt on my own to protect many of the things I care about the most.
    3) Not surprisingly then, I’m pretty accustomed to living life with my stress response in high gear.  I can go from zero to 100 in no time.  For as long as I can remember, this pretty much has been my go-to strategy for dealing my life. (My family called me the “little engine that could.”)
    4) As a kid, this level of ambition was seen as an asset. I was a go-getter who ‘exceeded expectations.’ Over the years, however, my body tired of this perpetual deficit spending. I started to exhaust myself and burn out – first in my late teens, then again in my early 30s. This was interpreted as dysthymia and anxiety by the medical profession.  SSRI’s boosted my mood and allowed me to abuse my body for several more years, until the fatigue broke through again – this time with unimagined vengeance.  It happened in my late 30s with the onset of a ‘cant get out of bed, praying to die’ kind of break down. It lasted 4 years, and was the first of many.
    5) From that point forward, I had a new mind and a new body.  I was no longer able to bounce back from set backs or proactively plan my future.  Anxiety and overwhelm became persistent and unbearable.  Motivation and concentration degraded.  Withdrawal and collapse become every day occurrences.
    6) My personal belief is that this huge shift might never have occurred but for the anti-depressants that allowed my to keep ignoring the warning signs my body was trying to give me.   As Sapolsky notes, human bodies were not designed to use the stress response in the way I was using it.  This way of living is simply not sustainable.
    7) If I could do it all over again, I would vastly prefer to have found a healthcare providers who was aware of this dynamic.  I also would have appreciated active help understanding what was happening in my body (where all these ‘symptoms’ were coming from), as well as help to change my relationships with my mind, body, and relevant community so that the operative dynamics were more workable and sustainable for all concerned. Instead, I spent thousands of dollars on conventional mental health services, $70,000 on mental health graduate school.  There were many kind people who encouraged me and helped me keep going.  But the reality is that I still had to connect the multidisciplinary dots that led to a solution on my own.
    Concept J:  Parasympathetic ‘contact’ can make a big difference.
    1) I tried to work with my broken-down mind and body in countless ways for decades.  There were brief periods of hope, but nothing really helped in a permanent sort of way.  The long-term trajectory was consistently downward.
    2) In the fall of 2016, I reached a new low point that I thought I would never recover from.  It was then that I landed on the idea of working actively and daily to shift the sympathetic-parasympathetic balance of activity in my mind and body.
    3) There was very little downside to trying this because most of my modern life involves mental and social threats/ opportunities rather than physical ones.  (I have to escape paperwork disasters, not cougars.  I chase ‘likes’ on facebook, not my dinner.) Thus, as Sapolsky points out, there is almost no situation in my life the stress response is going to improve – as well as tons of potential for it to make many things worse.
    4) I attended a boatload of Twelve Step meetings to complement this process.  Initially, the reason was that I was unemployed and isolated. I remembered that, in the past, I had managed to pull myself out of several very deep mood holes by returning to work, where I could feel like a meaningful part of other people’s lives (the oxytocin effect). Since I could no longer work this wasn’t an option.  But there was a Twelve Step meeting that met daily just down the street.  It was my best option, so I went for it.
    5) The more I study Twelve Step recovery, the more it confirms for me that there is something to the ‘parasympathetic contact’ concept. The talk of ‘surrender’, ‘turning it over’, ‘easy does it’, finding a ‘power greater than ourselves’, and advice to ‘cease fighting anything or anyone” all seem directed at cultivating our capacity to increasingly access parasympathetic well being. The same is true of the emphasis placed on putting serenity first to the point where you can find and maintain it no matter what the external circumstances. In contrast, the effects of sympathetic activation (impatience, urgency, need for quick relief, motor activation, prefrontal cortex off-line) are basically a recipe for literal or emotional relapse.
    6) There’s also a huge overlap with the experience of making parasympathetic contact and the teachings of major religions.  Take Buddhism, for example.  The problem is suffering which is caused by attachment (sympathetic activation).  The solution is to let go of attachments (thereby removing all barriers to parasympathetic well being), leading to a perpetual feeling that all is well, aka nirvana. And, if you can’t do that by yourself, there’s also mahayana buddhism, where you vow keep being reborn until every being gets enlightened (oxytocin/ tend-befriend leading to parasympathetic well-being).  Or Christianity:  1. Trust and love god above all else (total reliance on the parasympathetic system); and 2. Love your neighbor as yourself (transitional oxytocin).  Also compare the effects of high-stress activation to the seven deadly sins (pride, greed, lust, envy, gluttony, wrath and sloth) and the natural effects of parasympathetic well being with the seven virtues: prudence, justice, temperance, courage, faith, hope and charity.  It’s a pretty close match.
    7) I’m not trying to be religious here.  What I’m trying to say is that, in my experience, there a human biology that supports connection and well-being – and a human biology that is really hard on it.  Essentially, we have two different bodies. People throughout the ages have known this: Nirvana-Suffering, Old Man-New Man, Jeckyl-Hyde, Serenity-‘Dry Drunk’. Certain ways of living and relating to ourselves and others simply aren’t sustainable.  DSM diagnosis (Normal-Mentally Ill) is just another way of targeting the stuff that mostly doesn’t work in human interactions.
    8) My personal belief is this: As individuals, families, communities, a world – we have to decide ‘which wolf we want to feed.’  For me that means actively choosing which body we want human beings to live in.  If you map out the consequences of continuing to perpetuate a social order that puts massive numbers of us continually in high levels of stress reactivity, it’s devastating.  It’s only a matter of time before we destroy ourselves and our world.  -- Which would be a shame because the body of peace is just as accessible to us, and just as much a part of us, as the body of fear, conflict and greed.
    Concept K: Making conscious contact with parasympathetic well-being
    1) There’s a bit of a trick to making conscious contact with parasympathetic well-being.  I can’t access this part of me by trying.  This parallels the wisdom of most religions and also Alcoholics Anonymous.  The more I try (exert power), the more my sympathetic system revs up.  Parasympathetic well-being turns on by trusting.  So, I need to actively cultivate my capacity to trust.
    2) As someone with a boatload of social trauma, and a really bad relationship with my body historically, making this shift this has not come easily.  Nevertheless, I’ve found it possible with practice.  This, in turn, has greatly lessened my anxiety, fear, bitterness, rage, and massively improved my ability to listen, think, self-reflect and care about for myself and other human beings.
    3) In trying to lessen the amount of time I spend in sympathetic reactivity, it helps to learn to recognize the signs of amping up. I can then use that ‘biofeedback’ as a mindfulness bell to return to parasympathetic well being.
    4) Once back in a state of relative well being, I can begin to gently inquire into what is scaring me and allow possibilities for addressing it to bubble up.
    5) The long and the short of it is that there’s a zillion ways to feel scared, but also a zillion resources for feeling safer.  There’s also a zillion options for finding something or someone I can potentially put my trust in.  That’s where the diversity of life and experience on planet earth is a huge asset.
    6) It can also help to do things that physically reassure my body and the cells in me that we are not in crisis. I try to find ways to be with myself that are totally different from how my body would act if I were running from a bear. This includes moving slowly and intentionally, activating my curiosity about small things, doing stuff that takes fine motor coordination instead of large muscle groups, making tiny gentle touching movements one finger at a time, wiggling my toes one toe at a time, doing something familiar and easy like making my bed or washing a dish, playing my guitar…  The possibilities are endless.
    7) It’s important to be patient, because, as mentioned above, the body needs to time to make a safe transition from sympathetic activation to parasympathetic well being.
    8) There’s other stuff I could say about this, but this is probably far more than you were hoping for so I’ll stop here.
    IV. Research Directions
    One benefit of the stress / human condition model is that there are established biomarkers for determining when the stress response is activated and how strongly.  Thus, it is now theoretically possible to prove that models like PTM and the defense cascade are scientifically more valid ways to understand what is happening than the 'mental illness'/ 'symptom' formulations of the DSM. The vast majority of symptoms in the DSM have potential observable biological correlates with the stress response. This includes things like digestion, attention, focus, level of physical activation, energy, memory, appetite, sleep. There are other correlates of sympathetic activation that can be measured as well - like blood pressure, blood/ saliva hormone levels, heart rate, skin conductivity, muscle tension, urinary volume/ frequency/ bowel motility, etc.
    A possible research design is this: You take a bunch of people who come fresh into the ER in activated states and get labeled by psychiatry as 'depressed' or 'manic' or 'psychotic' or whatever. Then you take the assessment a step further and do a reading on the stress response correlates. If the research shows a match between so-called 'disorders' and indicators of stress response activation to p<.05 , then you have evidence that strongly favors PTM/ human condition/ stress-related interpretations of phenomena that are currently being labeled and treated as “mental illness”.
    In suggesting using biomarkers to validate this new model, I'm not meaning in any way to diminish the importance of the social and subjective meanings the PTM model articulates. For me these are crucial in understanding the behavioral responses and why they are happening. Also, behavior IS communication - as are the bodily responses that underly stress response activation. This seems especially true in the survival context where words so often fail us.  Or in contexts where words take a second seat to other types of communication - such as the way we express ourselves and the feelings that evokes in others - moreso than the particular verbiage used.
    ADDITIONAL REFERENCES (MY OWN STUFF)
    Einstein, Social Justice and the New Relativity, https://www.madinamerica.com/2016/02/einstein-social-justice-new-relativity/
    Not Broken Biology: Getting Beyond the Disease Model Paradigm of 'Mental Illness', https://peerlyhuman.blogspot.com/2017/03/not-broken-biology-getting-beyond.html.
    Lived Experience Survey:  A Survey To Assess the Impact of Trauma, Human Needs and Community Response on Mental/ Behavioral Health,  https://www.facebook.com/groups/WellnessRecoveryRights/permalink/923647694390461/.
    “Human Rights Theory of Mental and Social Wellbeing”, https://www.facebook.com/groups/159307817434833/permalink/1003056879726585/.  (an earlier version of this work,  similar to PTM, which proposes some ways to understand, assess and diagnose these issues from a social justice perspective.