Thursday, January 5, 2017

Treat Autonomic AND Cognitive Conditions in Psychopathology?

A student of such experts on the stress response as Herbert Benson, Joseph Wolpe, Hans Selye, Bruce McEwen and Robert Sapolsky as I have become in recent years, a new concept hit me while answering a post from a person with bipolar + CPTSD a bit ago: I'll call it "autonomic dieseling," at least for the time being. 

I did some hunting on the Internet, but was not able to locate anything that fit either the experience or the physiology of the syndrome I experienced for eight, then eleven, then two, then eight, then one (for a total of thirty) months across nine years from 1994 to 2003. 

All of the "AD" took place on the heels of long periods bipolar hypomania and job- or financially-driven, environmental stress driving increasing anxiety and panic attacks. Once in the "dieseling," however, the panic no longer subsided. My autonomic nervous system had shot past "fight-flight-or-freeze" into "freak and fry" that commenced like an electrical shock upon awakening and only abated in a state of exhausted passing out at night. Every. Single. Day. 

Back then, I called it the "terror tunnel." It was like having a panic attack that could not be stopped for days, weeks, months, and even almost a year. The emotional engine would not shut off... even with combinations of both "major" and "minor" tranquilizers like Risperdal risperidone, Geodone ziprasidone, Klonopin clonazepam, Ativan lorazepam, Xanax alprazolam or Valium diazepam. (In time, we figured out why: I was being dosed with anti-depressants, as well. Bad idea. Really bad.) 

I am beginning to sense that this syndrome or something very similar is what I am reading about in the reddit posts of many with CPTSD, BPD and/or BSDs of one sort or another. And because the education I got as the result of someone else paying for the mistake of mis-medication over those years, I tracked down over the past 14 years what is now increasingly common knowledge about the misuse of anti-depressants for BSDs... but still not so common knowledge about the role of chronic and/or re-triggered stress -- and allostatic load -- in "AD." 

The remainder of the article here was posted just about a year ago. I was struggling with a whole bunch of concepts that were much newer to my experience then. I have attempted to re-edit the original post substantially to make it more understandable to lay people. Bear with it if you can, and the result may well be pretty rewarding.

After reviewing the email posts of several hundred people who inquire about and describe their various symptoms of complex post-traumatic stress disorder -- including depression, anger, mania, anxiety and panic attacks, as well as their cognitive orientations -- I am pretty much convinced of the following:

CPTSD is an ongoing condition of autonomic pendulum-swinging from relative homeostasis into either 

1) extreme parasympathetic pitch -- or "freeze -- as the result of the cognitive triggering of Seligman's learned helplessness (depression), or 

2) extreme, sympathetic pitch -- "fight or flight" -- as the result of attempts to cope with cognitive triggers (everything but depression, meaning... mania). 

The "pendulating" CPTSD patient (temporarily) stuck in parasympathetic freeze will be "learned helpless" and unable to take meaningful action, and "fry" (neurologically) in a state of frozen anxiety and/or depression. The CPTSD patient (temporarily) stuck in sympathetic fight-or-flight will be "learned dysfunctional" (in mania), and "freak" (behaviorally in an attempt to discharge the intolerable energy) and "fry" in so doing. Excitotoxicity and resulting synaptic and neural degeneration are expectable results. (See Heller, Levine, Lupien, Ogden, Sapolsky and van der Kolk.)

Cozzolino's and others' functional brain mapping demonstrate that such "heterostasis" -- which is not the same as (though not quite exactly the diametric opposite of), but nevertheless very relevant to McEwen's & Lupien's allostasis -- looks to be the result of cognitive distortions affecting neural transmission from the insula through the amgdala and onto the pre-frontal cortex, hippocampus, hypothalamus, pituitary and adrenal cortices, also know as the HPA. It is well-know that the HPA is the driver of sympathetic and parasympathetic pitch in the autonomic nervous, as well as the primary neural force back of "allostatic loading" in the feedback from and to the entire limbic system. (With respect to all this, I had originally intended to at least list all of the lead authors in the references below, but there were so many...)

I may be re-inventing the wheel here, of course, but I do not recall "getting" this in lecture or seeing it in any of my biological psych textbooks. And I didn't begin to "get it" until I dug into Bessel van der Kolk's, Bruce McEwen's, Sonya Lupien's, Patricia Ogden's, Peter Levine's and Robert Sapolsky's excellent texts, all listed in the references hereto. But I now suspect that DBT inventor Marsha Linehan had her mind at least somewhat wrapped around all this with respect to psychotherapeutic treatment, as well as Ogden after some period of time using Ron Kurtz's HBCP. Growing grasp of ANS function and role in psychiatric disorders began at least with Joseph Wolpe and Hans Selye in the 1950s. Herbert Benson got in on it in a significant way in the 1970s. But a complete connection of the dots by any of the above-named has somehow eluded me for 15 years. 

Linehan's approach rests on four basic sets of skills, including mindfulness and emotion regulation. Having learned them from the books (including her own, Marra's, Dimeff & Koerner's, Chapman & Gratz's, Pederson's and van Dijk's) it is clear that they are all directed toward Margaret Mahler's and Daniel Stern's notions of self-soothing and integration of maternal attunement from Donald Winnicott's "good enough mother." (One must also give major credit to Alan Schore, who, along with Stern and Daniel Siegel at UCLA, have been making a loud noise about all this since the late '90s.)

Stanley and Carolyn Block developed a much simpler schematic for cognitive restructuring or emotion processing in the early 2000s. Their MBBT rests on grasp and utilization of a combination of four quite simple concepts (the ego as "I-dentity system," ego ideals or "requirements," Seligman's learned helpless "depressor," and the compensatory "fixer"). I have observed this mindfulness-grounded, meta-cognitive system in use by more than 30 people and have come to think that it works because of its relative simplicity.

Stephen Hayes's ACT is another of the Asian-inspired, mindfulness-based, awareness-inducing, post-CBT (or mindfulness-based cognitive therapy) systems. And it works almost diametrically opposite to the Blocks' MBBT. While it seems to me from several years' observation that MBBT appeals to the more verbal-symbolic left brain hemisphere of most right-handed patients, ACT works better with those whose "doors" to recovery are in their more sensory-affective right brain hemispheres. (And respectively somewhat more male vs. more female, as well.) I suggest that this is the case because of the mountain of work done on hemispheric function weighting and trans-corpus-callosul connectivity by Michael Gazzaniga and Iain McGilchrist -- as well as Ogden's and Levine's observations --  with which one would have to be familiar in order to make such an assertion in the face of some of the currently popular, pseudo-scientific belief to the contrary. That and the fact that Shapiro's EMDR is one of the very most successful psychotherapies for trauma resolution. 

Jon Kabat-Zinn at U. Mass. Medical road in on the horse of Tibetan Buddhism at about the same time. And punched a hole in a dam against Asian solutions that is now pretty much gone in the flood of empirical-research-authenticated literature on mindfulness meditation by Seigel, Daniel Goleman, Stephen Hayes, Mark Williams, John Forsyth, Thomas Marra, Victoria Follette, Antonio Damasio. Charles Tart, et al. As well as heaps of well-intended -- and often functional -- but sometimes crassly commercial and plain old "pop-psych," mass-market material by the likes of Eckhart Tolle, Deepak Chopra, Wayne Dyer, Sam Harris, Thich Nhat Hanh and the usual list of suspects. 

Fortunately, the tsunami has induced some publishers to dust off decades old work by some of the real experts on this stuff like S. N. Goenka (whose vipassana style of meditation is really the methodological grandpa of this entire movement), Ramana Maharshi, Chogyam Trungpa, Pema Chodron, Tara Brach, Jean Klein, Stephen Levine, Stephen Batchelor, Arthur Deikman, Joel Kramer, Anthony de Mello, Richard "Ram Dass" Alpert, Alan Watts, G. I. Gurdjieff, and even the redoubtable Jiddu Krishnamurti (though JK was ostensibly anti-method). 

I want to make a quick note here: Psychotherapeutic mindfulness meditation is not TM or any other form of "thought suppression," or escapism by means of "awareness exclusion." MM is about seeing, hearing, smelling, tasting, feeling and otherwise sensing what is in the present moment. Anything that is escapist may produce stress response symptom reduction in the short run, but will not serve the purposes of cognitive restructuring or emotion processing in the long. 

To that end, and after having studied and experimented with the post-CBT psychotherapies I described above, as well as several others (including the CBTs, Albert Ellis's REBT, collegiate critical thinking and Jeffrey Young's schema therapy as upshots of Alfred Korsybski's, S. I. Hayakawa's and Noam Chomsky's essential work on semantics), I devised a distillation called the 10 StEPs of Emotion Processing several years ago. I have taught it to several people, who have in turn taught it to several others. The system was not designed to be a psychotherapy so much as a distress tolerance and emotion regulation mantra. But it has turned out to be psychotherapeutic for some because it promotes inter-hemispheric communication that appears to integrate fragments of sensorimotor experience similarly to Levine's SEPt and Ogden's SP4T.

More relevant to the combination of topics here, the 10 StEPs appear to impact both the autonomic and cognitive components of the depression, anger, mania, anxiety and panic attacks as they are experienced in the present moment. Familiarized use of the mantra appears to reliably bring autonomic imbalance back to homeostatic balance, as did Benson's "relaxation response," as well as (to some extent) Wolpe's earlier "reciprocal inhibition." But what the 10 StEPs seems to do -- at the same time -- is reorient the practitioner to reality on both the sensorimotor and verbal-symbolic (or cognitive) levels, thus integrating the experiences of what is with what is believed... and that brings the functions of both brain hemispheres out of cognitive dissonance or conflict into agreement, allowing autonomic homeostasis to be sustained over time. 

Further -- and on the level of behavior modification via positive experiential feedback -- as result of using the mantra and getting relief via homeostatic rebalancing, the practitioner has the direct and memorable experience of managing his or her own emotions with a simple device that can be summoned at any time he or she is agitated or depressed. 

One can look into the use of the 10 StEPs for various psychotherapeutic objectives in the following articles:

Critical Thinking, Logical Fallacies & the 10 StEPs

Romantic Love, Being with What Is, and The 10 StEPs

The 10 StEPs to Freedom from Emotional Blackmail

The 10 StEPs for Recovery from the Consensus Trance

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