I don’t know about you, but for me, the lines between trauma, stress and suicidal depression can get pretty blurred. Whatever you call it, I feel like I’m being attacked from all sides. The universe is out to get me. Nothing I do can make any difference. My mind and body have betrayed me.
- Family and friends become suspects or spies.
- Help degrades to force or manipulation.
- Reassurance mutates into lies.
- Neuronal connections to happy, hopeful memories drop like flies.
I once spent four years of my life like this. The lion’s share of it I was praying to die. Life was a prison camp with no future. Just torture or death in a hold so deep and dark no sunlight made it to the walls.
The last fight left was with myself. Conscience in chains, I watched my integrity slither away and disappear through a gap in the bars.
I tried to describe what was happening to my doctor: Are you sure this is depression? Because it feels like abject terror to me. It’s as if some portentous wraith showed up, hijacked my body and opened a refuge for underworld drifters. Now, they’re all hanging out, making themselves at home, feeding on my energy and laughing at what a goner I am. It’s no use trying to kick them out. The next day they’re back in force with a new pack of goons, mocking me for trying and tormenting me all the more.
Doctor: You’re depressed. Your symptoms are classic. Your mother had depression. Your grandmother had depression. It’s genetic. Take your medicine. Eventually you’ll come out of it. Most people do.
Maybe he was right. I did come out of it. Meds probably played a role.
But I think I was righter.
Nailing Jello to the Wall
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5®)1 devotes 34 pages and a host of symptoms and diagnostic specifiers to the various permutations and combinations of human despair (pp. 155-88). When you look at it, these criteria are all over the map. There’s no rationale for why certain things cluster. It’s like nailing jello to the wall. As a diagnosed person, it spawns an almost overwhelming urge to throw up my hands, stick my head in the sand, and turn over my future to someone else.
This is what makes the stress response so exciting to me. All I have is a lay understanding of stress. I’m pretty much totally self-taught at the level anyone can get by reading a bit of popular science. But if I combine that with a survival/trauma paradigm called “the defense cascade” that’s emerging in the clinical literature, I can make sense of every symptom and subtype of depression based on my own experience of what happens in my own body. In fact, I can pretty much do this with the entire DSM.
This raises, for me, some important, troubling questions. By and large, most of society agrees we have a depression epidemic that affects millions of people each year. Everyone also pretty much agrees that suicide rates are disturbingly high. Yet, by and large, the mental health industry is still seeing and treating these concerns as biochemical and genetic in origin.
But the fact is, my body can turn this kind of stuff on and off, practically on command. Just in the course of writing this blog, I got to see, time and again, how all of this stuff eased or passed as the stress equation in me changed. Sometimes on, sometimes off. Sometimes many, sometimes just a few. On and on, over and over, in various patterns, depending on how, for me, the stress-cookie crumbled.
And, over the course of three months, I cycled through pretty much all the so-called symptoms of DSM depression. Just based on how stressed I was or wasn’t, while writing this blog.
So what does that say about the biogenetic, chemical imbalance theory, where depression is a lifelong illness and all I can do is take my meds?
In other words:
- What if we don’t have a depression epidemic at all? What if we have a stress epidemic that’s reaching traumatic/survival proportions…?
- What if the reason a lot of us aren’t getting any better or feeling any better is we’ve been taught to believe we have a lifelong, incurable disease?
- What if we’ve been steered away from exploring our minds and bodies—learning how they actually work—and into believing that our attempts to survive and respond to traumatic, threatening real-life circumstances are “symptoms of mental illness”?
- What if a huge part of our distress is that we’ve been advised, by professionals, society and everyone else in our known world, to just sit still and wait for “the experts” to fix us—and until then we’re out of options?
As we will see in just a few hundred words, that kind of thinking—in and of itself—is a recipe for a state of “traumatic immobility” that explains away all the major indicators of DSM depression. Yep, no real disease needed. Just an effed up brain loop sold to us by Pharma, payola government, and the mental illness industry.
Introducing the Defense Cascade
The defense cascade is this framework that trauma therapists have been working on. I have a really cynical theory as to why.
Obviously, recalling trauma can be upsetting. So upsetting, apparently, that some of us become unresponsive.
It turns out that this can create quite a crisis. You might guess for the client, but it’s actually the clinician that I suspect the concern is mostly about.
Suppose you’re a therapist and the 50-minute hour is over. So you say to the client, “Your time is up.” But they don’t move. So you say it again, but they still don’t seem to hear you. So now you muster your most firm, directive clinical voice, “Your time is up. I’ll see you next week.” Still nothing. Just dead air. It gets even worse because ethics prevent you from even patting the laggard’s arm to get their attention.
Given that there is usually a client #2 in the waiting room whose session can’t start until #1 is removed, you can imagine how many therapists this may have traumatized.
Eventually, this phenomenon recurred enough times that it couldn’t be written off. It had to be more than pathetic, Hail Mary, end-of-session attention-seeking by said client #1’s. At that point, the professional world took some interest and some measurements.
What they found was fascinating:
(Schauer & Elbert, 2010, p. 111)2
As it turns out, the phenomenon we are talking about has a real name (#4 in Figure 1 above: Fright / tonic immobility). It also has measurable, observable physiological characteristics (Kozlowska, Walker, McLean, & Carrive, 2015;3 Schauer & Elbert, 2010; see also Roelofs, 20174).
Not only that, but it seems that there is a logical progression—and clear reasons in mind and body—for when and why this phenomenon appears:
[W]e propose that defense reactivity is organized to account for battlesomeness (chances to win a fight) of the threatened individual, that is, the appraisal of the threat by the organism in relation to its own power to counteract (age, gender, physical condition, defensive abilities, etc.) and, not least, for the threat-specifics (type of threat, type and speed of approach, context, threat involving blood loss, etc.). Whereas the dynamics of the defense cascade progresses in gradients of alternating ascending and descending activation, the various defense responses can be categorized into two general forms, namely active defense and immobility. (Schauer & Elbert, 2010, p.110.)
In other words, my body offers me two basic types of defenses (active/immobile) when I feel threatened. After a preliminary appraisal, I go with the approach I think offers me the best chance to survive.
The type of defense I choose (active or immobile) depends on how threatened I feel. In addition, both types (active, immobile) give me some sub-levels to choose from as the degree of threat changes. Different body systems are brought into play, in different combinations, based on the defense level I end up going with:
Our model … suggests six defense responses, notably Freeze, Flight, Fight, Fright, Flag, and eventually Faint, whereby during the two Fs Flight and Fight bodily responses are mainly regulated via the sympathetic branch (‘‘uproar reactions’’) and the following three Fs, the second half of the cascade, are dominated by parasympathetic arousal, determining the spectrum of dissociative responding (‘‘shut-down’’ reactions: Fright, Flag, and Faint). We thus may arrange the stages of the defense cascade in form of an inverted u-shaped arousal function with the alarming flight-fight responses on the ascent of the curve and the set of dissociative variants on the descent (see Figure 1). (Schauer & Elbert, p. 111, 2010)
A simple way of thinking about this is like a car. The active defenses—Fight and Flight—are controlled by the Gas Pedal (sympathetic) system. This system gets energy to my muscles and allows me to move. From there, it is a simple matter of direction:
- Fight is like barreling forward into the stuff I’m afraid of.
- Flight is like backing up and trying to get away.
Most people try to get away from scary stuff if they think that’s an option (Schauer & Elbert, 2010).
Freeze, Fright, Flag and Faint are all dominated by the Brake (parasympathetic) system of the car. If a Brake response comes on, it means that, for one reason or another, my body has decided that it’s smarter to slow down or not move at all.
What is this thing called Fright?
Fright is a state of intense distress, equivalent to what my car would probably feel if I floored the Gas Pedal and slammed on the Brake at the same time. Like my car, the engine is all revved up and raring to go, but the energy it produces is totally jammed and blocked from taking me anywhere.
In humans, this dual activation of both the Gas Pedal (sympathetic) and Braking (parasympathetic) systems of our bodies is called ‘Fright.’ It typically occurs when intense fear or threat combines with a sense of being trapped or constrained. (Schauer & Elbert, 2010) Essentially, a threshold is reached where mental and physical arousal are sky-rocketing. But there are no good options and thus, no viable strategy for unleashing all that energy. It is no longer adaptive to run or fight (active defenses), so the body changes tactics and begins to shut down (immobile defenses). In the prodromal period before complete shutdown, “[g]eneral fear symptoms are experienced, including dizziness, nausea, palpitation, drowsiness, lightheadedness, tension, blurred vision, feelings of irreality, numbing, and tingling appear” (p. 112).
As the lack of options is confirmed and hopelessness sets in, distress and activation jointly peak in a “peritraumatic ‘panic-like’ dual autonomic activation” (p. 112). This is the tipping point: “sensation, perception, motor abilities, and speech behavior are dramatically altered” (pp. 112-13, emphasis supplied). A “‘shut-down’ reaction” occurs (p. 112):
- The Braking (parasympathetic) system powers on—forcing heart rate and blood pressure down and making active defenses all but impossible.
- The Gas Pedal (sympathetic) system goes into overdrive—muscles become “overly tense and rigid,” and movements are “slow and difficult”—to the point where “overt behavioral actions are not an option” (p. 115).
- Normal channels of awareness and perception are blocked, and endogenous opioids flood the system.
In this dual Gas Pedal/Brake state, “various forms of dissociation appear” (p. 112):
- “Memory retrieval deficits” occur (p. 113).
- Consciousness alters, with a prevailing sensation of “alienation of oneself or the external world” and “a flattening of emotional experiences” (p. 113).
- There is failure, of both mind and body, to “deliberately control processes and take actions that can normally be influenced by an act of volition” (p. 113):
As a result, previously accessible information does not reach conscious awareness, and voluntary movements are not attempted. (p. 113)
Why would I ever opt for Fright?
Fright is basically a strategic surrender when I’m overwhelmed and out of options. It buys me time to regroup, and I also hopefully get hurt less:
Tonic immobility [fright] is almost always displayed when the person is overwhelmed by threat and not allowed and not able to act aggressively against the threat. Thus immobility functions to suppress anger in the victim and acts bidirectionally to inhibit aggression. (Schauer & Elbert, 2010, p. 116.)
To grasp what’s going on, let’s take a look at how this plays out in the wild.
Suppose I’m a rabbit trying to avoid becoming a foxy meal. I’ve run my fastest, fought my hardest, but I’ve lost. So now the fox has me down by the neck, and it looks like I’m done for.
Not so fast! I still have one trick left up my sleeve: Play Dead. Next thing I know, the Brake slams on and overrides the Gas Pedal. Instant immobility.
Surprisingly, Fright may save my life. The Braking system so completely subdues me that I give no appreciable signs of life. The fox thinks I’m dead and loses interest or his appetite. The moment the fox is out of sight, the Brake lifts, and I floor the Gas Pedal back to my hole.
Time for the Spoiler
As you may have guessed, the Fright response is a big part of what I’m referring to here as “traumatic immobility.” It’s not the only factor, however.
Traumatic immobility also extends to stages 5 and 6 (Flag and Faint) of the defense cascade (see Figure 1 above). Flag and Faint largely result when Fright goes on too long, or when distress continues to rise. At that point, awareness of suffering loses adaptivity, so the Braking (parasympathetic) system shuts down consciousness even further, and Gas Pedal (sympathetic) arousal fades away. I end up just laying around—a sort of floppy, semi-comatose, helpless blob. That’s Flag. If I become wholly unresponsive, that’s Faint. Either way, no more faking it—this is true surrender. My mind and body have conceded defeat, and we’re just waiting for the end.
Each of these variants on traumatic immobility has something to add to our discussion of depression. As we will see in a later piece, Fright, Flag and Faint all meet the DSM criteria for a Major Depressive Episode in their own right. In addition, they each neatly correlate with a specific depressive subtype (i.e., anxious, melancholic and catatonic features, respectively).
There’s some ground work to lay before we get to that. Right now, it’s time to dive deeper into traumatic immobility and the paradigm shift it points to.
It’s not all in my head
When I came across the defense cascade, I could have kissed the researchers who wrote the article. Finally I had some answers. Finally, I could explain experiences and deep moral conflicts that had been dogging me for 20 years. Finally, it wasn’t all in my head.
Here are the basic components of traumatic immobility (Fright, Flag, Faint on the defense cascade).
- Overwhelmed by threat
- Out of options
- Gas pedal (sympathetic) activation or shut-down
- Brake (parasympathetic) shut-down
- Reduced capacity to respond, mentally and physically, to compelling life circumstances
Here’s how I applied that to make sense of my last major depression/DSM symptoms two years ago:
- Felt constantly threatened (repeated job loss, poverty, homelessness, out of sync with mainstream & workplace values, relationship failure, social pariah): low mood, worry, mental and physical activation, weird appetite and sleep
- Felt out of options (low physical, material and social resources; tired all the time, brain not functioning): hopelessness, sadness, despair, indecision
- Gas pedal/sympathetic (constant pressure to do something to fix it): worry, activation, insomnia, eating for energy
- Brake/parasympathetic (no clue how to fix it, where to turn or if it would ever get better): Low energy, low mood, low appetite and low interest in life; digestive troubles, stomach cramps, poor thinking and concentration; leaden limbs, sleeping a lot
- Life indefinitely stalled by Brake (wasting my life, leaving a legacy of suffering and pain, letting myself and others down): Worthlessness, emptiness, guilt, indecision, crying a lot, preoccupied with death and suicide
Again, this is just a first offering. In a future piece, I will go deeply into the DSM definition of depression and really deconstruct it—subtype by subtype, symptom by symptom, line by line. But right now, I have bigger fish to fry. Because for me, the DSM criteria didn’t come close to capturing the distress I was feeling. And they certainly didn’t give me a clue as to why. So I want to take some time and go into that now.
Where did I go?
For me, depression was like being in a constant state of grief over someone who was lost—except it was me. The person I had known myself to be wasn’t there anymore, and, for all I could tell, was permanently gone. All that was left for me was to wait in bed and hope she would return. So I just sat there watching as life passed me by and everything and everyone I had once cared about slipped away or left.
Then there it was—the reason in print:
In order to enable a maximal defensive and ‘‘dead’’ appearance (‘‘as if dead,’’ ‘‘playing possum’’), which provides survival advantage by complete giving in and cessation of fighting, moving, perceptions and later emotions need to be switched off or deactivated. To guarantee motionlessness in these highly perilous situations, the organism should be unable and unwilling to use voluntary muscles and should feel neither anger nor pain, be finally emotionally numb, as if anesthetized (Schauer & Elbert, 2010, p. 113, emphasis supplied).
I found this weirdly reassuring. Knowing what was happening and why made me feel so much safer: I’m not actually dying. I’m not even lost. Rather, a part of me is so scared—so in over my head about something gone wrong in my life—that my own body has shut me down. My very aliveness is being hidden from me (and others), deliberately, in response to the situation I am in.
But how does my body make all of this seem so convincing?
As it turns out, the way we perceive ourselves as being alive—and as actually present in our bodies—probably has something to do with the continual sensory feedback that our bodies give to our minds:
A person’s sensory processing (sight, hearing, smell, taste, and touch), of kinesthetic (perception of movement and muscular sense) and somesthetic (sensory data derived from skin, muscles, and body organs) stimuli normally continuously serves the perceiving self as evidence that it resides ‘‘in’’ the physical body. (Schauer & Elbert, 2010, p. 117)
It probably also has a lot to do with our experiences of thinking and feeling. This is not just awareness of sensory information, but also the associations, emotions and memories they generate, and all the mental processing our minds do about them. (p. 117)
During traumatic immobility, the Brake system progressively shuts this down:
Kinesthetic, somesthetic, nociceptive stimuli no longer seem to reach the central processing units, causing changes in body awareness and loss of control (depersonalization). Numbness prevails…. Conscious processing of the events becomes limited, making meaning seems irrelevant…. emotional involvement fades away, that is, no action dispositions are assembled and memory consolidation becomes weak and later rehearsal more difficult. (Schauer & Elbert, 2010, p. 118)
Thus, access to the thoughts, feelings and sensations that I experience as the essence of me is blunted or blocked. And so is my motivation and ability to address that. (p. 117) The resulting internal silence is deafening. I literally feel like I am dying—that the essence of “me” is gone, probably for good.
Am I Just Faking It?
The “Play Dead” response explains another thing that has really tortured me. I had this nagging sense, at the height of my depression, that actually I am faking it. There was this odd internal turf war: Something deep inside me has dug in its heels and insists it will not move, while something else is whispering in my ear: You could do better if you tried.
Well, there’s an answer for that too. Traumatic immobility isn’t called the ‘Play Dead’ response for nothing. A part of me knows there’s still life inside somewhere. At the same time, the physiological changes that are taking place totally convince me otherwise. With heart rate capped, digestion cramped, and righting reflex pulled out from under me, instinct commands that I lie down. Endogenous opioids (endorphins) swoop in. Communications crash, and it all gets very, very heavy. The rest is history.
Am I Morally Weak?
One of the hardest things about this state of mind and body was having to face myself: Where did my integrity go? Why was I groveling in fear?
There was no physical predator standing over me. I was being stalked by paperwork, bureaucracy and poverty, not a lion or the Huns. I knew I was being irresponsible. I knew there was business to attend to. I knew there would be no rescue unless I created one.
But still I couldn’t do it.
Why, why, why?
Here’s at least a partial answer:
Tonic immobility guarantees negative or quiescent behavior even in the presence of massive aversive stimulation, a stilled organism that makes no attempt to struggle for freedom or fight. (Schauer & Elbert, 2010, p. 115, emphasis supplied)
The implication: In this state of mind and body, survival instincts override the impulse toward ‘recuperative behavior’. (p. 113) I remember being hypnotically suggestible to some internal whisperer—Stay still. Don’t move. It’s not safe enough yet. Getting up now will be certain disaster. It seems ludicrous in retrospect. There were deadlines to meet, rent to pay, taxes to file, phone calls to make, forms to complete. But I just lay there waiting. Desperately hoping for the odds to change.
Again, it helps to understand the physiology. The same ‘decoupling’ we talked about above between body and brain likely affects our capacity for executive functioning—the ability to plan, prepare, and be disposed for action. (p. 119) It also affects the mirror neuron region of our brains, which helps us reflect and connect ourselves to the behavior of others. (p. 119) The joint effect is a vastly reduced ability to appreciate consequences, care about them, or mobilize the resources needed to address them.
The dis-ease of being human
I don’t know about you, but all of this helps me feel a heck of a lot more hominid and a heck of a lot less pathological or creepy. Instead of thinking of myself as having a brain disease, abnormal, defective, mentally ill, chemically deranged, mentally unscrewed, at the mercy of mysterious factors, randomly firing, totally out of my control—I can just say to myself: Oh, I’m having a rough time and my stress is too high. What do I need to change? That shift alone brings the stress down several notches.
Imagine what that could do for other people too. Instead of those around me looking at me and saying: Oh, what a weird freak. She’s got this crazy, deranged brain thing going on that could make her flip out on me at any moment for no reason at all, they can go: Oh look, she’s having a rough day and her stress is too high. How can I be helpful?
Suffice it to say, the stress response is a great leveler. It’s vastly different that we’re talking about something all of us can relate to—a genetic endowment we’re all born into by virtue of being human. Call it the “human condition” if you will.
In a lovely, quirky way, it’s both reassuring—and threatening—for everyone:
- We’re all in this together.
- We’re all genetically predisposed.
Now that we’ve come full circle, I’ll happily concede this one to my doctor. After all, my mother was a mammal. My grandmother was a mammal. Their ancestors were mammals. They all got stressed too. Aw shucks. I suppose I got it from them.
Time to Brake
All of this can be a lot to digest. But I hope there’s some good news just around the corner. For me, beginning to view these issues through the lens of stress has opened up a whole new way of working with them.
- If depression is a stress response, then it’s potentially reversible. There’s stuff I can do for myself, with or without the medical profession.
- If depression isn’t a stress response, that still isn’t the end of it.5 6 Stress affects virtually every system in our bodies. So maybe I can free up some energy for coping or healing simply by learning more about how the stress response works and then tipping that balance in my favor.
The next offering in this series will propose a framework for understanding where all this stress response is coming from. It’s always tempting to blame the identified patient, e.g., you’re not resilient enough, so work harder on your wellness tools. But I’d like to push back a little. When you look at the research, there’s a really good case to be made that “stress” is actually driving depression. If so, this begs the question:
- Why are so many people in modern society stressed to the point of incapacity?
- Why are we feeling so helpless and hopeless that our bodies are concluding the best we can do is just lay down and die?
- What about modern society—and the options we are giving each other—is generating such resoundingly lethal impressions?
If you’re like me, you may be surprised to realize how much you’ve been up against. Understanding that has helped a lot. I no longer feel like I’m doing something wrong or that breaking down is all about me.
Also, forewarned is forearmed. Now I can think more strategically about the defenses I use to protect myself and my future from some of the pitfalls of mainstream thinking and modern living.
If you don’t want to wait until then, let’s start talking and working on these issues together. How about Sundays at 4 PM Eastern? The join-up information is below:
REVERSING THE STRESS RESPONSE
Sundays 4-5 PM Eastern
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.
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