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.)1
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)2 discusses in another book:
- Functioning of glands, hormones, neurotransmitters
- Heart, blood pressure, cholesterol, breathing
- Metabolism, appetite, digestion, stomach and gut functioning
- Growth and development
- Sex and reproduction
- Immune system, vulnerability to disease
- Aging and Death
- Mental health and well-being
- “Depression,” motivation, ability to experience pleasure
- Personality and temperament
- 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 what 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;3 Bradley et al., in press;4 Lang et al. 2010;5 Lang et al. 2013;6 Schupp et al. 2004.7) Here is one of the diagrams they drew to illustrate what they found:
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 Criteria 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
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 mood, increased 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 in order to protect my interests as much as possible.
Okay, on to 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:
- Adrenaline 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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 wholeheartedly pursue something I care about a lot.
Okay, 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 lifetime 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 lifetime. 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, the 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 lifetime. 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 firewall 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 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 after 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., adrenaline, 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 that 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’re 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 heartbeat, 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 five 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:
- 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 to 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.
- 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.
- 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 anymore. 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 okay just the way it is.
- 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.
- 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.
- 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.
- 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 a while 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.
- 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.
- 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. ↩
- 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.), 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. (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 ↩
- 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 ↩
- 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 ↩
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.