Questioning the Disease ModelYears ago as a doctoral candidate for a mental health degree, I asked my then-psychiatrist what I thought was an important question. In class, we’d been studying the biology of trauma and learning about the fight-flight-freeze response.
I had writer's block at the time and was tremendously anxious about the papers that were required for my coursework. I noticed that every time I had a paper due, I got ‘manic':
I became obsessed with how I was going to get it done. I found myself hyper-focused and way way way geared up in both my mind and my body. I was restless, jittery, constantly on the move. I couldn’t stop thinking or worrying about it. I was so paralyzed by anxiety that I had tremendous difficulty getting started at all. But once started, it was like a switch flipped and I'd work on the paper nonstop until it was done. Often I barely ate or slept for days. I got irritated if anything interrupted me.
In the early stages, when the task seemed insurmountable, I was practically despondent about the prospect of finishing. But later on, as the ideas started flowing, my thinking would get more grandiose. I’d start feeling like I was making new discoveries and saying something really important. Heck, who knew, potentially these connections might even change the world.
Another thing I noticed was even more striking. The moment I finished the paper - the moment it was safely off to school and handed in, the entire 'geared up' phenomenon went away. The huge intensity and associated 'symptoms' that had been so real while the paper was in progress either evaporated into thin air or progressively continued to fade.
Something in me relaxed. The next thing I knew, I was eating, then sleeping. I was able to slow down, get comfortable, take a look around me and appreciate what was happening in the world. Not long after, I’d re-read my paper and realize that it wasn’t nearly as brilliant as I thought. Just another paper by another college student for another class. Maybe a few good insights. But, hey, a lot of people have said it brighter and better.
To my psychiatrist, the paper-writing phenomena was clear evidence of mania. It fit all the standard assessment criteria. - And I had to agree with the outward appearances:
There was the initial irritability, distractibility and psychomotor agitation. There was the sense of being flooded with ideas -- literally overwhelmed by the number of directions I could pursue that would materialize and then move on faster than I could write them down. There was continual pressure to keep thinking and moving, as well as the lessened ability – and then need- for sleep. There was an intense, extended hyper-focus on goal-directed activity. There was often excessive sugar and caffeine consumption. It was almost impossible to pull away to fulfill other life obligations, so I ignored or cancelled whatever I could. If I had relationships, significant others would feel really annoyed at how unreachable I was and for how long. Often these kinds of stress responses around academic and professional performance interfered with having relationships at all.
However, from the inside it felt very different. I would start out literally in terror of failing and having no future as a human being. Every time I looked into the computer screen, I could see this stern face frowning back at me, telling me I was a fraud and a liar who would say anything to pass this course. That wasn’t entirely true, I was sincerely trying to be as academically honest as I knew how. On the other hand, I had a significant psych history that I was afraid to disclose, and our papers required a lot of self-disclosure. I didn’t know how to put those experiences into words that wouldn’t get me labeled and tossed from the program and still speak honestly about my life.
The whole experience was incredibly traumatic. I felt like I was fighting for my life and my right to have a meaningful future, even though only a school paper was involved. Eventually, when I progressed far enough in the writing to gain some confidence, the balance of power would start to shift. Before long, I would be laughing at my imagined persecutors and picturing myself in a victorious role, making some important contribution that would secure my place in humankind once and for all. Yeah, in retrospect it was silly. But the optimism helped me keep the momentum going so I could stay out of reach of the mean-eyed bully.
In other words, it really felt inside like I was experiencing a fight-flight-freeze survival response. So, in therapy, I wanted to explore the possibility of a PTSD diagnosis. For me, the basic PTSD paradigm fit:
You face a high-stakes situation. Your body gears up. You activate to meet the challenge. You stay activated and intensely focused on the challenge at hand until the threat goes away. Once the challenge is overcome and you feel safe again, however, the fight-flight-freeze system turns off. The threat has passed, the system is no longer needed, so you can go back to the normal routine and take life as it comes.
My psychiatrist was an incredibly kind compassionate man. He has helped me in countless ways. But, still, he didn’t buy it. He said something like:
Yes, the fight-flight-freeze system is involved in PTSD. But that only applies to life threatening circumstances. You’re not in a war, you’re in graduate school. There’s a big difference. It’s not PTSD, it’s bipolar spectrum. Please don’t stop taking your meds.
I have great respect for the man, his integrity and the way he related to me as a patient. But I still think he was wrong. The following chapters of this guide are my attempt to explain why.