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Published On April 25, 2019

CLINICAL RESEARCH

The Neuroscience of Giving Up

Why do some people react poorly, even catastrophically, in emergency situations?

In the face of severe trauma, why do some people die without any explainable physical cause? That is a frequent topic in the field of survival psychology, a relatively new subspecialty that explores the behavior of people in life-threatening situations. Psychologist John Leach is conducting research in this emerging field as a visiting senior research fellow with the Extreme Environmental Medicine and Science Group at the University of Portsmouth, England, which also studies how people cope with extremes of heat and cold, and in high altitudes and the open seas.

Before Leach took his current post, he worked for 15 years as a regular and reserve Royal Air Force officer in the United Kingdom, specializing in SERE—survival, evasion, resistance and extraction. His research has looked at human adaptability and cognitive function under duress, and he continues to teach survival psychology to the military, including how to cope in extreme environments such as the polar ice caps or the middle of the desert.

Q: Can you explain the term “give-up-itis” (GUI)?

A: Major Henry A. Segal, a medical officer in the U.S. Army, first used that term in 1954 about men held in prisoner-of-war camps in Korea. It describes an extreme apathy that, in its final stages, leads to psychogenic death, which stems from mental defeat rather than from an organic cause. Within just a few weeks, these prisoners began to refuse food and became mute and unresponsive before they “turned their faces to the wall” and died. There have been similar stories throughout history. There was the ill-fated Jamestown settlement in Virginia, which lost some 90% of its inhabitants to starvation, disease and “hopelessness” in the early seventeenth century. Victor Frankl, survivor of Auschwitz, and other witnesses of the death camps, observed that some people would “simply vegetate.”

Q: What do we know about the biological mechanisms behind this phenomenon?

A: I’ve recently published a hypothesis based on my research into historical cases and clinical parallels. Psychological trauma seems to induce a progressive syndrome in which a normal coping response goes awry. Typically, in a traumatic situation, the prefrontal cortex, which is involved in planning and thinking, and the nucleus accumbens, which is associated with motivation, produce higher levels of the neurotransmitter dopamine to help people take steps to resolve the situation.

When some people perceive there is no escape from the trauma, however, their prefrontal cortex puts out more dopamine than it should, which inhibits its release in the nucleus accumbens to below-normal levels. This prompts passive, energy-saving coping behaviors such as withdrawal and apathy. Unless the situation changes, dopamine levels can sink ever further. Death, which feels like the only means of escape, may be a last attempt to cope—although we don’t yet know its exact physical mechanism.

Cases in which the brain is impaired in other ways support this theory. One woman seemed to suffer from GUI, but her care team found that microlesions in the brain were affecting dopamine production. So dopamine-based treatment, either pharmacologically or through physical activity or other means that naturally increase dopamine levels, may hold possibilities for alleviating GUI.

Q: So is this distinct from depression, or do the conditions overlap?

A: Depression has never been observed among GUI victims, whose speech and behavior do not indicate it. GUI also doesn’t depend on personality—we can’t predict or explain which people will be affected, which we would be able to do if it was strongly correlated with depression.

Q: Much of your work looks at how people perform in high-threat, emergency situations. Some people seem to rise to the occasion, while others give up immediately. Is this another manifestation of GUI?

A: It’s a different phenomenon. Many people do act in counterproductive ways, but this is often because of cognitive malfunction. For example, a fire on a Boeing 737 in 1985 cost 55 lives, even though the plane was grounded and people had been told to evacuate. Many sat frozen in their seats instead. It takes between 8 and 10 seconds for higher-order cognition to create a new response or initiate unplanned behavior. It is impossible to think ahead when events unfold faster than we can process them, so people freeze.

Another classic mistake in these situations is called stereotypy, or falling back on routine behaviors. For example, people in the World Trade Center on Sept. 11 made phone calls and collected handbags right after the planes hit. The prefrontal cortex is involved in slow, energy-intensive higher-order functions—the kind of thinking you want in a situation like that. When you perceive an immediate threat, however, the brain channels resources to regions more driven by habit and instinct, taking the prefrontal cortex offline. People may respond by falling back into the well-learned, stereotypical behaviors stored there.

Q: But some people handle emergencies well. Why is that?

A: Experience and training help. For example, when you’re learning to fly an aircraft, you spend 10% of the training time learning to fly and the rest learning how to handle mishaps. Once you’ve established those responses, they’re stored in the subcortical regions and become automatic. Survivors often say, “I must have done the right thing, but I don’t remember doing it.” It’s a phenomenon that many high-stress workers—including emergency department doctors—know well.