Sense of Self & non-self in health and disease: a literature review

Introduction

Our sense of Self defines the experience from referencing sensory information in relation to my egocentric ideas and beliefs that form the core structural stability that is my anchor. This is achieved by how we individualistically actively manipulate the processing of bland slices of sensory information and then tie it all together to inform (or not) our preconceived notions. It is the individualistic ways we do this that allows our self-awareness to experience the abstract, not literal truth, that is our story comprised of the stereotypical caricatures that enable us to understand our self and the world.

“The stereotype is like the door-keeper at a costume ball who judges whether the guest has an appropriate masquerade. There is nothing so obdurate to education or to criticism as the stereotype” - Walter Lippman

The enormity of such a topic ties together such diverse subjects ranging from neurology, biochemistry and endocrinology to evolutionary perspectives on cultural identity to name but a few. It is therefore not a subject that is close to home, but by literal definition of what our sense of Self is, fundamentally is home. For this reason it is beyond the scope of myself and such an article to give a complete review of such diverse subjects but to extrapolate the overall meaning of common trends in the literature. For example, the Default Mode Network (DMN) has received prominent attention regarding how we self-referentially process our sense of Self, but obviously it doesn’t function independently from all the other neurological centres that aren’t mentioned here. So not only are there broader complexities and interpretations to all the subjects, pathologies, analogies and quotes in this text, but with no background in such a vast subject I could only derive stereotypical meaning from a lot of the terminology e.g. ‘self-narrative’ ‘sense of belonging’ “give anything a name and very quickly its more obvious elements will be plundered by the plebs” (-John Cooper Clarke). Only being able to ‘plunder the more obvious elements’ of the generic terminology I had to interject biological rationales, pathology, analogies and other interpretative cultural references, in the context of the subject, to derive any real world meaning from these concepts with the hope it would also do so for others of a similar disposition!

Sense of Self

Our sense of Self: when ideology attempts to makes sense of reality

“How can I accept a limited definable self when I feel, in me, all possibilities?... I never feel the four walls around the substance of the self, the core. I feel only space. Illimitable space” - Anaïs Nin

Individuals need a structural stability, something that defines and differentiates them from all others and their environment, but being different, standing out from the crowd, leaves the individual vulnerable to trauma (Lanius et al 2020) and open to uncertainty, risk, and emotional exposure (Bruk et al 2022) from, for example, being judged. Therefore, to cope with this emotional exposure our structural stability, our sense of Self, must have a comforting familiarity in its first-hand narrative, a constant stream of verbal thought that processes self-related information (Frewen et al 2020). This provides a self-assuredness and confidence (Martial et al 2021) by validating ones individuality and identity, as they strive to matter, to be of value and add value, for security (van Gordon et al 2018) in their self-esteem or significance (Shiah 2021).

But the structural stability forming our sense of Self is constructed by a speculative fiction derived from how an individual’s evaluative and judgmental stance embodies the ideas and beliefs that form their mental constructs. By aligning themselves to these ideas and beliefs in a way that they cease to pass through the mind as mere thoughts, but instead, become fixated on makes them intrusive as they swallow an individual by forming a self-identity encaged by a well-defined, inflexible self-narrative (Soler et al 2021), the “four walls around the substance of the self”. Although this narrative limits the individual’s behavioural and cognitive flexibility it obtains, retrieves, processes and responds to information about life, relationships, and mental states (Dubey et al 2022) in a way that provides an anchor, the internal stability needed for a secure base from which an individual can look beyond present difficulties thrown up by an ever changing world (Fingelkurts & Fingelkurts 2018). Feeling the weight of this anchor provides clarity by supporting comforting, familiar, decision making, motivation, emotional coping strategies and overall quality of life (Piotrowski 2020) to keep the individual on course towards a stable, safe, individualistic, self-prioritising, enduring reality.

Losing a sense of Self: worry, catastrophisation & fibromyalgia, Depersonalisation Disorder & meditative experiences

Worry, catastrophisation & fibromyalgia

It is the characteristic ideas, beliefs and prior experiences of the individual that determines how they derive a meaning from assembled pieces of sensory information to conceptualise both whether worry, in a “what if … happens?” style of thinking is warranted, and how to construct our own unique experience of worry (Satpute & Lindquist 2019). This individualistic, tailor made, experience of worry, rightly or wrongly, stresses the importance of an upcoming situation as to find solutions, and from how them solutions fare, enable us to learn about ourself and our environment (Meeten et al 2016).

This may entail experiencing worry to certain things in a way that fosters greater cognitive flexibility characterised by a mindset open to a broader range of “what if … happens?” expectations whilst being curious to any unpredictabilities or contradictions to those expectations. Using cognitive flexibility and feeling less overwhelmed by the unpredictability of emotions engages more of a challenge stress response to worry. Feeling accepting of, but detached from a greater diversity of emotions, in the form of raw, untainted sensory information, encourages self-compassion and activation of reward systems (Dowling 2018). How this sensory information, as pieces of a jigsaw, is contextualised and intertwined (Dubey et al 2022) into the overall puzzle that is our self-narrative to promote growth and opportunity (Chen & Jackson 2019) reflects how we make sense of a worrying situation as it unfolds (Yeshurun et al 2021).

Consequently, towards other things, it may entail experiencing worry with more cognitive inflexibility using catastrophisation characterised by a blinkered, avoidant mindset that can only experience a narrow range of well-defined expectations that is intolerant to any unpredictabilities or contradictions. In contrast to a challenge response, this excites a threat and fear stress response (Brunzli et al 2017) which, as an avoidance strategy, is preoccupied with an anxiety driven desire to overgeneralise and misshape perspectives as not to confront the complexity of a problem (Flink et al 2013). Actively manipulating (or suppressing) sensory information in this way, through active inference, is akin to misshaping and discolouring a jigsaw piece. Forcibly manipulating the jigsaw piece so it fits nicely into the overall puzzle fulfils the self-fulling prophecy of a pre-determined inflexible self-narrative targeted to maintaining safe and predictable boundaries (Bohlen et al 2021).

But sometimes sensory information from an event is so overt and overwhelming that no matter how much we try to manipulate it or be flexible in our mindset towards it we just can’t self-referentially process it in a way that it becomes contextualised and intertwined with other sensory information that forms our self-narrative. For instance, that initial moment when standing at a cross roads trying to process whether a joke, as a piece of sensory information, should be intertwined with how our self-narrative experiences and expresses humour or disgust.

In such a case all the sensory information from this overwhelming event becomes clumped together to form a fragmented stand-alone monstrous, traumatic caricature or representation. Drawing our attention to this monstrous representation so it is not observed using a third-person perspective but is recursively lived as a first-hand traumatic experience can be seen, for example, when a patient is so blinkered by living out representations of their spine crumbling with ensuing disability that they can’t integrate into their self-narrative other sensory information from healthcare professionals that tell them this is not the case. Having their nose fixed to a wall in this way makes them feel trapped by repeatedly living out their traumatic representations e.g. “I just keep dwelling over and over on what if my spine keeps crumbling and I’m permanently disabled’. I just can’t get past that”. This causes the individual to become alienated and retreat into a world whereby their traumatic ‘spine crumbling-disabled’ representations swallows up and re-defines their entire narrative identity to become, for example, “me as my illness” . This restricts their sense of Self’s ability to detach from their problem, to step back from their wall, and self-referentially process a broader range of sensory information, including that from their illness representations, into a broader self-narrative, e.g. “me as a problem solver” or “me as being proactive” that would have helped them successfully navigate this impasse imposed by their illness representations (Fingelkurts & Fingelkurts 2018). When the entrenched neural circuits that self-referentially process a sense of Self (refer sense of Self: sense of agency and ownership) are deemed detrimental “I know all the tests show my spine is strong enough, but I know my own body, I just know I’m going to end up disabled some way” psilocybin therapy has been shown to open a window of neural plasticity during which improvement can be facilitated (Doss et al 2021).

For example, when a patient’s fibromyalgia illness representations swallows their narrative-identity defining their sense of Self as “me as my illness” it starts to muscle into their other narrative-identities such “me as a friend”. This leads to poor pain acceptance (Tenti et al 2022) characterised by sacrificing a full and meaningful life (as a friend for example) in order to fulfil the blinkered need to avoid any unpleasant, painful experiences (Varallo et al 2021) irrespective of intensity or fear of pain (Tenti et al 2022). This loss of sense of Self leads to a reduced sense of ownership giving rise to a sense that their body part no longer belongs to them and is ‘alien’ or ‘strange’, illusionary movements and a low level of acceptance which correlates with a morbid dislike for a body part (Scandola et al 2022). Therefore, improving pain acceptance by integrating a broader range of emotions, beyond pain, beyond their illness representation, into their narrative-identity mediates a reduction in physical and psychological symptoms (van Gordon et al 2018) and redefines their narrative-identity as “me and this illness” (‘refer sense of non-self; Example: non-attachment based coping strategies, fibromyalgia and catastrophisation’)

How to remove patents from their self-narrative in light of their personal and cultural identities was pondered by David Ponka on his return to his Canadian practice having just returned from Chad and Sudan having treat malaria, malnourished infants, shrapnel wounds, “and worse”“I wonder what our role should be with patients whose very attitude toward disease has become a disease itself. I wonder what we can do about an all-too-common undercurrent in the modern medical visit, at least in the West: a sense of entitlement and a never-ending search for perfection” - Patient-centred care in a self-centred world (2008).

Depersonalisation Disorder (DPD)

DPD is not only associated with a disconnect between what sensory information is actually being experienced and what sensory information was predicted to be experienced, but also a cognitive inflexibility that fails to breach this divide. This results in an incapability to integrate a broad range of subconscious and conscious movements (Ciaunica et al 2022) and cognitive functions, such as perceptions and memories (Levin et al 2022), into the first-hand narrative. Feeling out of synch, incapable of living out a symphonic orchestration of coordinated movement and cognitive functions renders individuals feeling, at their core, ‘fundamentally wrong’.

Sensory information is processed in a way that any subconscious or conscious deviations from what was expected to be felt (“that’s hotter than I thought it would be”) gets flagged up in light of what was initially predicted (“I thought it was going to be more tepid”); this error in our predictions is called a ‘prediction error’. This subconscious and conscious processing of sensory information, and their prediction errors, takes place so what we perceive, and live out, as a first-hand experience, is a compromise between (Paulus 2019):

i. Actively changing sensory information through motor action, reappraisal, suppression or distraction (Khoury et al 2018) making it fit what we always anticipated and predicted to be true. For instance, if an unexpected subtle sensory input from a slight change in foot pressure whilst walking were deemed unimportant we can actively suppress the sensation, by for example corrective motor action so the subsequent sensations meets our expectations and a more normal foot pressure is registered in lower levels of conscious processing. But if this same subtle unexpected change in foot pressure was deemed important “this is going to jolt my pelvis out” we can actively magnify the sensation, by for example motor actions, and register the event in higher levels of conscious processing to fulfil, once again, a self-fulfilling prophesy in light of the individual’s expectations.

ii. Passively allowing perceptions to be moulded by the processing of raw, untainted, sensory information (including prediction errors) in high levels of conscious processing in order to attempt to see beyond superficial impersonal generic prejudices to underlying specificities (Ho et al 2021). This involves mindful, contemplative techniques such as equanimity, curiosity and acceptance (Khoury et al 2018), as for example, when feeling that a foot pressure may “jolt my pelvis out” appraising such anticipative sensations with an objective curiosity as to inform and update our perceptions.

In what way our sense of Self juggles the active and passive processing of different pieces of sensory information determines how effectively it integrates, not just the sensory input from motor actions, but all our perceptions and memories into the first-hand narrative. It does this by deciding to what degree, and in what way, different sensations, memories and perceptions are bought to the forefront into higher levels of conscious processing, or kept more subconsciously in the background in lower levels of conscious processing. This enables us to describe, perceive and live out the experience of things in an integrative way that is characteristic of ourselves as individuals (Levin et al 2022).

In DPD unsuccessfully integrating sensory information, comes from waves of sensory information, and their prediction errors, bypassing the lower (more subconscious) levels of conscious processing and flooding the higher (more conscious) levels of conscious processing. This bombardment of sensory information, that doesn’t represent the expected response, is then appraised with a cognitive inflexibility that can’t relate to this unexpected information as being ‘mine’ so therefore, by default, must be someone else’s. This keeps the individual in their ‘observing self’, being consciously pre-occupied with streams of unrelatable sensory information that paints a picture with no resemblance to themselves, and out of the ‘experiencing self’, that would have, otherwise, took all that observed, third-hand, relatable information and lived it out for that first-hand ‘me being me’ experience. This disconnect promotes feelings of being outside of their body observing at a distance, through dense fog, their actions, feelings, thoughts and sensations so they feel as though they are ‘not fully real’, ‘dead inside’, emotionless, living on ‘automatic pilot’ (Ciaunica et al 2022).

For instance, it would entail, whilst walking, every single little sensation and their prediction errors from e.g. motor actions, memory, emotion and sound passing straight through the lower levels of conscious processing and overwhelming higher conscious self-referential processing. Being curious to the wave of higher order conscious processing experienced by DPD patients an individual may recreate this but the bizarre sensory input, from a perceived alien way of walking, would be appraised with a cognitive flexibility that aims to match the novel sensory information with new enlightened perceptions that gives a clarity of understanding. But in DPD this doesn’t occur and these sensations are appraised with a rigid inflexibility that clashes with, and can’t be informed by this tsunami of sensory input bringing even more attention to how this sensory overload is out of synch with their expectations. This conscious awareness of the disconnect between what they’re feeling and what they expected to feel means not only can they no longer ‘switch off from themselves’ and experience themselves ‘in the moment’ just strolling down the road but at their core they have no sense of personal control or ownership over their body making movements feel alien. By observing themselves with a heightened self-focus and intellectualisation they become hypersensitive to information they have no control or ownership over precipitating a hyper-reflexive response and suboptimal motor action that yields further less intended results and a sense that their actions are ‘outer worldly’ and beyond their control (Ciaunica et al 2022).

This is why simply experiencing reality in the present moment using detachment, non-judgmental and non-reactive mindfulness techniques facilitates the integration of a broader range of sensory experiences into a more flexible broader self-narrative (refer above ‘worry, catastrophisation and fibromyalgia’) as to reduce a heightened sense of interpretative awareness and self-focus (Levin et al 2022). 

 Meditative experiences

Out of body experiences in psychedelic meditative (and drug and near death) experiences, are again characterised by a loss of one’s ego-centric sense of Self (Martial et al 2021). However, this time instead of a loss of sense of Self resulting in rumination around higher-levels of self-referential processing (i.e. fixating on illness representations and “where’s all this sensory input coming from”) the individual ‘escapes from themselves’ to experience a low-level awareness of themselves as a mere body experiencing sensations (Bastion et al 2014).

Losing their sense of Self in this way the individual blurs the boundaries that differentiate themselves from all others creating a sense of belonging, or unity, to a larger whole. This loss of self-identification over whether they actually have a body or not and what their body is, as well as a sense of location of where they are, and from where they experience things creates a ‘dissolving into the ether’ effect. This effect is more prone in individuals inclined to feelings of belongingness, of a connection that is not bound or defined by their perceptions or imagination, but by a non-defensive unanticipatory openness that promotes long-term well-being (Martial et al 2021).

Sense of Self: sense of agency and ownership

“When ‘my toy’ is broken or taken away, intense suffering arises, not because of the intrinsic value of the toy, but because of the thought of “‘mine’” - Eckhart Tolle

An ‘all-encompassing oneness’, how my sense of control allows me to feel grounded in my own body and the world is experienced by how our self-consciousness actively manipulates, relates to, integrates, interprets and regulates divergent information from a sense of agency and ownership which is then related to prior expectations:

• Sense of agency: a robust, slowly learnt (Ishikawa et al 2021) experience of being in control. That based on my context, my knowledge, beliefs and values that form my judgements and intentions that I am the author, and can predict the consequences of, my own actions to change the external world. It is therefore dependent on top-down predictions being confirmed by valued bottom-up processing of sensory information derived from either motor actions, or social, or environmental cues (Braun et al 2018). This sense of authorship can be reduced, such as when working in a group, as there is a difficulty, or disfluency, in foreseeing how one’s individual decision-making fits in with the unpredictable nature of a group’s actions. This difficulty in formulating top-down predictions as to what the group will do, and in turn, uncertainty over the bottom-up consequences of the individual’s actions within that group, leads to a loss of sense of control and responsibility resulting in anonymity, as seen for example in ‘bystander apathy’. This makes group outcomes feel insignificant in providing feedback on how to improve individual behaviour, for instance, a joint grade for a group project can feel less important in providing feedback on an individual’s contribution (Beyer et al 2017).

  Therefore, a reduced sense of agency is like skidding uncontrollably all over the road in a car. Trying to regain control by making top-down predictions that moving the steering wheel one way will correct the course of the skid, is shown to be wrong, as bottom-up processing of sensory information shows the car failing to meet these predictions as it veers in the opposite way leaving the individual with no sense of control and feeling vulnerable to catastrophe.

  Making an individual with a reduced sense of agency, of control, feel vulnerable and intimidated in their perceived ‘dangerous’ environment is associated with (i) anxiety (Wei & Qian 2018); (ii) Checking OCD whereby learning from prior experience “when I checked the door once it didn’t open” to create a sense of certainty, is riddled with difficulty, or disfluency, making the ‘checking’ feel irrelevant. An anxiety fuelled cognitive inflexibility creates rigid top-down predictions, “unless the pressure of my hand on the handle feels just right, the door might not be shut and someone may break in and burn the building down”, that requires nothing less than highly precise bottom-up sensations (e.g. just the right hand pressure on the door handle) to feel the certainty required to avoid impending catastrophe (Sharp et al 2021). Feelings of uncertainty and a loss of control (Beyer et al 2017) creates a need to check in a way that floods the individual with high value, anxiety quenching, bottom-up information (pressure of the hand on the door handle, verbal reassurance, etc ) whilst becoming hyper-responsive to any imperfections by flagging up even slight unexpected sensory variations (Fradkina et al 2020). This when compounded with disorders of self-referential thinking associated with excessive self-awareness, obsessive thinking about an uncertain future, perfectionism, and behavioural and cognitive rigidity (Dubey et al 2022) reflects how OCD represents a broader disorder in brain regions associated with processing of a sense of Self (refer below).

• Sense of ownership: is a quickly learnt adaptable (Ishikawa et al 2021) feeling. It is largely dependent on integrating highly manipulable bottom-up processing of sensory information that anchors us in the current moment (Ataria 2013) into a unified perception of ‘my body’ (Kilteni et al 2015). The processing of these bottom-up signals are derived from visual, somatosensory (Braun et al 2018) and proprioceptive, as an innate self-reference of where ‘my’ body is in space (Liesner & Kunde 2021), input that is then integrated with more stable, consistent top-down predictions (Ataria 2013). This allows us to reflect upon, and relate to our first-hand narrative that integrates diverse experiences into a single awareness creating care, affection and empathy (Jing & Wei 2018), a sense of belonging and being grounded (Wang et al 2021) by the familiarity of being ‘Me’ in the world. Therefore, our sense of ownership attempts to make sense of reality by tying together bland slices of sensory information in a way that it jazzes it up to form a caricature that represents my embodied ownership over the world as I see it, my body parts, my personality, my qualities, my values and the characteristic ways in which I engage with myself and others. This constructed caricature also gives ownership over an illusional continuous identity by forming a conveniently cracked lens through which the ‘present me’ can see a persistent, stable, identity with the ‘past me’ and ‘future me’ (Wang 2021).

  How a sense of ownership integrates different ideas and beliefs into the first-hand narrative determines if a strong sense of ownership over-identifies with ideas and beliefs that align with superficial impersonal generic prejudices (Ho et al 2021) as to entrench or further contract our self-identity; or, if being free from a sense of ownership allows one to develop compassion (Dowling 2018) to novel underlying, independent, specificities (Ho et al 2021) so that challenges activate reward circuits (Dowling 2018) promoting growth and development of a self-identity (Chen & Jackson 2019). An example of this is how deeply a sense of ownership over political ideologies (Chen & Urminsky 2019) or illness representations (Scandola et al 2022, Tenti et al 2022) dictates and moulds an individual’s self-identity and fundamental belief systems.

Our sense of agency and ownership are processed through the integration of multisensory (visual, bodily, motor, and interoceptive) signals. But information for information sake is useless, it has to be processed, as to predict what it means, and what will happen as a result of our actions. For instance, visual information from seeing nothing on a stretch of road whilst driving predicts a series of motor actions, e.g. positioning of the hands on the steering wheel and feet on the pedals will result in me driving safely to the end of the stretch of the road. These successful top-down predictions when confirmed by bottom-up processing of sensory information, e.g. I haven’t crashed yet, allows for a sense of agency (e.g. I have successfully predicted how I can control my car) and a sense of ownership, for instance, proprioceptively I have successfully predicted how I feel orientated in my car, the seat, steering wheel, pedals, etc i.e. nothing feels unexpected or ‘a bit off’. This makes driving more of a subconscious action where I can switch off and let my mind wander as I am at ‘one’ with my car and the environment. However, when unexpected sensory stimuli flags up something, e.g. a deer running out in front of me, and that my predictions of getting safely to the end of the road are wrong, I am suddenly no longer ‘at one’ with my driving and have to instigate a series of motor responses that will predict a successful outcome, e.g. braking.

However, most of the time we don’t live on tenterhooks and we can successfully predict the consequences of our actions and are defocused and detached from the outside world allowing our mind to wander and drift off on to other things. When this ‘mind wandering’ occurs voluntary movement, bridges a gap allowing the multisensory processing from a sense of agency and ownership to activate the Default Mode Network (DMN) (Harduf et al 2022). The DMN forms a central hub that actively shapes and integrates information from a range of sensory modalities so it can be properly symbolised, coded and conceptualised (Fingelkurts & Fingelkurts 2018) into a first-person meaningful narrative (Fingelkurts et al 2021). It does this by filtering sensory information through a lens that is clouded by our memories, conditional responses, beliefs and emotions (Yeshurun et al 2021) and by making the brain believe that events from a sense of agency and ownership have occurred in the same time-line and has a causal relationship (Ishikawa et al 2021).

This sensory processing by the DMN’s emotional filter allows for more enhanced levels of perceptual self-representation (Harduf et al 2022) by running simulations, stories, shaped by our memories and beliefs (Yeshurun et al 2021), of past, hypothetical, and future events (Dohmatob et al 2020). By using prior experiences to contextualise and intertwine bland fragmented sensory input into ‘our’ story the DMN gives it meaning (Dubey et al 2022) enabling us to make sense of situations as they unfold (Yeshurun et al 2021) as to successfully predict how we should respond to life’s ‘plot twists’ (Dohmatob et al 2020). Therefore, the DMN allows us to observe ourself as we experience our self-consciousness (Fingelkurts et al 2021) by creating a familiar illusion that allows us to learn about our sense of Self (Ishikawa et al 2021) in the world whilst simultaneously activating our reward circuits (Dohmatob et al 2020).

When functioning normally the DMN should connect freely with other parts of the brain. This permits cognitive flexibility so that when these simulations, that try to predicts life’s ‘plot twists’, receive sensory stimuli that shows things didn’t pan out quite as it expected we can evaluate and correct distorted beliefs and misinterpretations by volitionally switching between different parts of the brain. This promotes a less blinkered and more lateral self-referential processing when defining our sense of Self in the world.  

In contrast to a brain that facilitates cognitive flexibility, disorders of self-representation processing leads to cognitive inflexibility. This is characterised by stress induced changes in the DMN that creates a more blinkered perspective on our sense of Self, including our self-identity. When negative thoughts about ourself are perceived to be in accord with negative views on our self-identity it leads to a heightened self-focus, an inflexible blinkered perspective, and repetitive inflexible thinking in the form of rumination (van Oort et al 2022). Ruminating, being detached and defocused from the outside world so we dwell on things means running never ending simulations in the DMN about ourself. Being stuck on this hamster wheel by repeatedly filtering sensory information through this inflexible repetitive negative thinking style makes these thoughts become over-identified with. This redefines the individual’s self-identity and dictates their actions (Zhang et al 2018) resulting in hopelessness, resignation and a lack of motivation (Cook & Artino 2016) which is then reflected upon in light of how our social and cultural norms transmit back to us the manifestation of their sense of Self (Shiah 2021).

Could this be a mechanism by which mindfulness principles, by increasing connectivity and volitional switching between the DMN and other parts of the brain, evaluate and correct distorted beliefs and misinterpretations, restore cognitive flexibility, aid creativity (King et al 2015), address ruminative tendencies (van Oort et al 2022) and create a more harmonious balance between active and perceptual inference? Within this context could therapeutic active movements, by allowing the multisensory processing sites of a sense of agency and ownership to activate the DMN, also help in restoring a more functional sense of Self?

Sense of Self and evolutionary biopsychology: implications of stress, status and belonging

Sense of Self: ‘Me’ and ‘We’

How areas like the DMN self-referential process and respond to stimuli in specific reference to ourselves is not just individualistic, defining the Self as ‘Me’, but can be collective, defining the Self as ‘We’ (Frewen et al 2020) allowing us to infer and draw conclusions in order to gain insight into our own condition and that of others (Lanius et al 2020). This underlying need for affiliation, belonging, and community, to connect deeply with other people and secure places, to be aligned with cultural and subcultural identities and feel a part of a system is buried deep inside our biology, all the way down to the genome (Allen et al 2021) and is why social rejection carries a 21.6% increase in risk for onset of major depressive disorder (Salvich & Irwin 2014).

However, what if we perceive we can’t cut it in our group? That we’re out of our depth and hold no significance? In evolutionary terms being rejected from, or demoted within our tribe would have resulted in a loss of resources, status, access to mates, physical protection, and ultimately survival. Therefore, even anticipating that we may soon have less available resources and be vulnerable to threat, injury and illness, meant a sole reliance on our innate stress-immune response to evade threat and nurse ourself back to health. This makes a pre-mediated stress induced immune response essential for our survival in reaction to any hint, even a symbolic one, of our demise within, or from our group; for example, from cues such as social conflict, evaluation, rejection, isolation, or exclusion (Slavich & Irwin 2014) and is why group ostracisation elicits the same mechanisms of pain and stress as physical pain (McDremott & Hatemi 2018).

Therefore, an awareness of our thinking processes (e.g. “I cannot control my worrying; worrying about my appearance means I can be prepared”) can lead to social anxiety and negative social cognition (e.g. “people think I’m boring; if I show anxiety people will think I’m foolish”) (Nordahl et al 2022). This social trauma, in the form of rejection and humiliation, living a life under a constant perceived threat from a sense of powerlessness and inadequacy, can lead to post-traumatic stress disorder (PTSD) and social anxiety disorder (SAD), possibly, as one integrated condition (Bjornsson et al 2020). Indeed acts of humiliation that erodes the individual’s psychological autonomy rendering feelings of vulnerability and of being ill equipped to deal with any further unpredictable, unexpected and arbitrary attacks leads to a loss of agency and mental defeat which can be a stronger predictor of severe PTSD symptoms than a perceived threat to life (Leask 2013). Therefore, the effects of feeling powerlessness and of being ill equipped to ward off hostility and navigate a hostile environment, be it through social anxiety and negative cognition (Nordahl et al 2022), humiliation (Leask 2013) or PTSD and SAD (Bjornsson et al 2020) results in social fear/avoidance mediated through the autonomic nervous system and hypothalamic–pituitary–adrenal (HPA) axis (Simons & Tung 2019).

Hypothalamic-Pituitary-Adrenal axis: social status & ostracisation

Sustained activation of the HPA axis from a perceived lower social status, especially when associated with regular harassment or high levels of social uncertainty (Simons & Tung 2019), threat of ostracisation from our ‘tribe’ (Slavich & Irwin 2014) and trait specific rumination (Gałecki & Talarowska 2018) leads to chronic social stress. Triggering top-down changes in the HPA axis and autonomic nervous system (e.g. high glucocorticoid, particularly cortisol levels) this chronic social stress (Simons & Tung 2019) results in up-regulation of proinflammatory pathways (e.g. proinflammatory cytokines and CRP), and down regulation of anti-inflammatory pathways (e.g. 5-HT and melatonin) (Figure 1). Sustained activation of the HPA axis can result in depression (Correia & Vale 2022), vascular inflammation and atherosclerosis, obesity, type two diabetes (Liu et al 2020), tumorigenesis (Simons & Tung 2019), chronic pain, fibromyalgia, asthma (Adler-Neal & Zeidan 2017), reduced brain plasticity, neurodegeneration (Bourgognon & Cavanagh 2020), adverse outcomes in perinatal women with a lower socioeconomic status and adverse outcomes in perinatal women with a reduced meaning in life and higher levels of repetitive negative thinking (Mitchell & Christian 2019).

Cortisol released from this sustained HPA activation shifts tryptophan metabolism from 5-HT to Kyn production (Figure 1). As well as inhibiting 5-HT (and the metabolism of 5-HT into 5-HIAA/melatonin) which disturbs the circadian rhythm, Kyn metabolises into QA. QA not only reduces levels of dopamine, choline, BDNF and GABA as well as disturbing glutamatergic pathways, but also, along with NA from the sympathetic nervous system (Slavich & Irwin 2014) and decrease vagal activity (Tatsios et al 2022), stimulates the production of proinflammatory cytokines (Correia & Vale 2022).

The activation of macrophages (microglia) to produce proinflammatory cytokines can be specifically in response to social stress characterised by social evaluation and the possibility of social rejection (Slavich et al 2010), lowered meaning in life and repetitive negative thinking (including worry and rumination) (Mitchell & Christian 2019). By self-sustaining activation of the HPA axis, in response to any hint that we maybe cast out from the safety of our group and into the wild (Slavich & Irwin 2014), proinflammatory cytokines switch the HPA axis on, and prevent corticosteroids from switching it back off again (Correia & Vale 2022), in order to mobilise cortisol for metabolic energy and accelerate wound healing to limit infection (Slavich & Irwin 2014).

By being activated in anticipation of rejection and the need for survival proinflammatory cytokines induce adaptive sickness behaviours. This is achieved by (i) self-sustaining HPA axis activation so cortisol shifts tryptophan metabolism from 5-HT to Kyn production; (ii) having negative specific effects on 5-HT metabolism; (iii) over-activating the Kyn pathway, to favour the 3-HT (neurotoxic) arm, which influences microglia and astrocyte function in regulating neural activity; (iv) causing breaches in the BBB, allowing non-CNS infections to impact social behaviour (Delvin et al 2022). These sickness behaviours that can be manifested in a variety of ways, depending on environment, sex, and type of infection (Delvin et al 2022) but can include a lack of broader engagement with others and a greater desire for supportive figures (Devlin et al 2021) with an avoidance of additional conflict (Slavich et al 2010).

“[it is] trying to search for a fixed sense of identity that can often propel people to seek refuge inside an object or state of mind” - Ricky Emanuel

Proposing a link between social anxiety and negative social cognition and avoidance behaviour (Nordahl et al 2022) this biological process may provide one rationale for using avoidance behaviour to obtain a sense of belonging. This may involve a sense of personal belonging through isolated individualism, e.g. retreating within oneself to make individualistic moral decisions; or, retreating within a group to create a social belonging through relationships which may, if group expectations supersede personal integrity (Vu & Burton 2021), blur self-other boundaries to deplete dopamine levels and create ‘empathy fatigue’ (Dowling 2018). However, when avoidance, as a self-preservation response, is taken further still it not only cuts the individual off from the outside world, but as attention is turned more inwards the haze from ruminative self-awareness can cloud vision leading to a loss of sense of Self (Cianunica et al 2022).

By losing their sense of Self’s egocentric generic ideologies and beliefs that are expected to navigate real world specificities (Ho et al 2021) the individual loses not only the very definition of themselves but also their understood significance. Losing their significance, that encapsulates how they are ranked and valued based on their own sense of fairness (Scarpa et al 2021) results in further feelings of a loss of control and disassociation (Cianunica et al 2022) as well as stress induced changes to the HPA axis (Simons & Tung 2019, Correia & Vale 2022).

This is why a value is placed on strategies that elicit that comforting, familiar, embodied ‘sense of Self’ experience as either ‘Me’, i.e. a sense of ownership (Shiah 2021) over a personal identity, or ‘We’, i.e. a sense of belonging to a group identity (Wang et al 2021), on a recursive loop (van Gordon et al 2018). Pain, as one of these strategies, enables the individual to experience themselves, their significance and ‘place’, by signalling their personal virtues and sense of entitlement by virtue of their fortitude in ‘soldiering on’, or, pain catastrophisers can experience secure attachments and empathy, by strategically communicating the effects of their pain (Bastion et al 2014).

In contrast to this pain is not just used to repeatedly live out our sense of Self’s same old ruminative tendencies but can be used to switch our brain off, so we can ‘escape from ourselves’, to achieve a state of non-self, and come back stronger. By grounding the individual with an immediate low-level awareness of themselves as a mere body experiencing sensations, pain restores the individual to ‘factory settings’, allowing them to re-emerge with a new higher-level conceptual representation of themselves. This is how initiation ceremonies uses pain to separate the individual from their current status allowing for a redefinition of the Self and a more genuine transition to a new higher status (Bastion et al 2014).

Figure one: stress —> metabolism of tryptophan into Kyn & simultaneously inhibiting 5-HT; neurotoxic effects of QA; proinflammatory cytokines sustaining the HPA axis, inhibiting production of 5-HT, promoting Kyn pathway & sustaining inflammation. Exercise promotes Kyna over 3-HT pathway; BDNF promote 5-HT & Kyna (>3-HT).

Our sense of Self’s attachment to doctrines: how our ideological social identity plays out the goodies and baddies

“A radical is a man with both feet firmly planted - in the air” - Franlklin D Roosevelt

Therefore, in us all, it can be seen evolution has not produced ‘neutral truth seekers’ but loyal tribal members of competitive groups. When a self-identity centred around ‘Me’ or ‘We’ has a strong hold on conditioned thoughts, emotions, behaviours (Soler et al 2021) and unyielding perceptions (Ho et al 2021), that can only align with a well-defined reality, what ensues is inflexible, poor critical thinking (Hill & Garner 2021) which is linked to extreme ideological identities (Zmigod 2022) and feelings of vulnerability (Bruk et al 2022). This makes any perceived attack on our fixed personal beliefs and identity trigger protectionist decisions (McDermott & Hatemi 2018) that are aligned with our self-constructed, self-idealised identity (Vu & Burton 2021) to mitigate against this security threat and establish superiority (Zmigrod 2022). This is why individuals are less inclined to counter the group’s narrative and risk their status within the group, or the protection that being a member of the group offers, when ‘under attack’ (McDermott & Hatemi 2018).

The result is an overzealous, subjective, egotistical fixation on a self-manufactured unique and stable identity (Vu & Burton 2021), especially when there is a need for personal meaning, certainty and self-esteem (Zmigrod 2022), making us more authoritarian (McDermott & Hatemi 2018) and inclined to find flaws in contradicting perspectives. The resulting polarisation, resentment, anger and radicalisation (Hill & Garner 2021) is why simply more education or the “right” information, that doesn’t fit with an individual’s inflexible self-narrative, does little to change one’s opinion (McDermott & Hatemi 2018).

So, whether defining the Self as ‘Me or ‘We’, it is our sense of Self’s egocentric first-hand tendency to encourage hormonal responses to psychosocial stress that needs to be balanced with a third-person perspective (Ho et al 2021). This enables us to be independently self-reflective (Hill & Garner 2021) promoting a more concrete curiosity to thought processes whilst impeding more reflex, abstract, blinkered emotional responses that skewers memory and, by feeling more distant from the specificities of events, shifts blame and casts unjust moral judgements (Kyung et al 2010). But disassociating from a sense of belonging to either a group identity or personal identity involves not feeling the weight of the anchor that characterises our sense of Self's internal stability (Tsakiris 2017) that successfully predicts how the consequences of our actions will integrate with prior expectations. This results in a greater cognitive cost (Ho et al 2021), a loss of control and feelings of being uprooted by a reduced sense of ownership over an embodied self (Atari 2013) or group identity.

But, expending the effort to use cognitive flexibility to both reduce the need to distort the bottom-up processing of sensory information to fit with an idealised identity aligned with ‘Me’ or ‘my tribe’ and become accepting of contradictions that threaten to overwhelm the individual’s sense of belonging by ‘bringing into the fold’ uncomfortable emotions broadens our sense of Self’s narrative-identity (Fingelkurts & Fingelkurts 2018). This enables us to see beyond more reflex, convenient, unyielding egocentric stereotypes and replaces them instead with more new, life like perceptions, with less impersonal generic prejudices and more independent specificities (Ho et al 2021) that weakens the attachments to the conditioned thoughts, emotions, and behaviours that define our sense of Self’s current self-narrative (Soler et al 2021). Exposing underlying truths in this way uses a “see what others see, find what others don’t” (- Greg Hoffman) ethos to develop compassion and empathy to reduce feelings of animosity, polarisation and vulnerability to expression (Bruk et al 2022) and foster post-conflict resilience that may possibly account for the one-third of individuals that having suffered from childhood adversity developing greater resilience than their low-adversity controls (Ho et al 2021).

“You expose who you are, your emotions and you learn to deal with them, that’s what resilience is…it is about taking on the challenges that will challenge you and test you.” - Ant Middleton.

Sense of non-self

“People make the mistake of thinking the people on the stage here are defining something … you couldn’t say anyone that was ever in Oasis, me included, were the best at anything, but when it all came together we made people feel something that was indefinable. We were practically the same band that was playing at the Boardwalk, we were virtually wearing the same clothes, all that’s happened is that it’s caught fire and all these people have got on board …. There’s a chemistry between the band and the audience that’s something magnetic drawing the two to each other, the love, the vibe and the passion and the rage and the joy that comes over from the crowd” - Noel Gallagher on Knebworth (2016)

Through the lens of Self and non-self Noel is describing the mistake of clinging on to the notion that an individual, as a separate entity, valuing and attributing meaning to themselves, radiates out their embodied sense of Self, this ‘thing’ that’s meant to signal their brilliance to the masses “people make the mistake of thinking the people on the stage here are defining something”. Instead he describes the bands rise in popularity not due to some ‘independent, intrinsic existence’ that they formulated to magically transform themselves into a success “we were practically the same band that was playing at the Boardwalk” but by ‘a union of dependent origination’, everything effecting everything else as a collective whole “all that’s happened is that it’s caught fire and all these people have got on board” with success simply following as a by-product of that.

All in all what he describes is an individual’s self-identity and the embodied caricatures that represent their perceptions dissolving into a collective effervescence, a ‘coming together’ “you couldn’t say anyone that was ever in Oasis, me included, were the best at anything, but when it all came together we made people feel something that was indefinable” . This ‘ego dissolution’ is an abandonment of any ownership over an individual’s being, so they experience a low-level awareness of themselves as a mere body experiencing sensations (Bastion 2014). By losing the distinction and relationship between ‘Me’ (Self) and everything else (non-self) they immerse into a psychedelic mosh pit, that feels in-synch as a collective whole allowing for feelings of profound peacefulness, a belongingness defined by a connection that is not shaped to an individual’s perceptions or imagination, but by an unanticipatory openness (Martial et al 2021). With no goals, demands, preferences, habits or aversions feelings of vulnerability from uncertainty, risk, and emotional exposure melt away (Bruk et al 2022). Nullifying the stress response (Correia & Vale 2022) that would ordinarily kick in when not feeling the weight of our anchor from the internal stability provided by our sense of Self (Tsakiris 2017), allows for a non-fearful, unanticipated openness that is related to a sensitivity towards feelings and experiences, seeking out new ideas and values, a motivation for novel, unpredictable experiences, cognitive flexibility, creativity and intellectual curiosity (Dubey et al 2022) “there’s a chemistry between the band and the audience that’s something magnetic drawing the two to each other, the love, the vibe and the passion and the rage and the joy that comes over from the crowd”, however this openness can, when negatively appraised, lead to addiction (Dubey et al 2022). This is in contrast to the previous section whereby feeling in-synch and an all-encompassing oneness was achieved more by actively manipulating the bottom-up processing of sensory information to meet the familiar top-down perceptions aligned with a more self-manufactured, stable, egotistical identity of the Self.

However, it is not practical in day to day life to live like you’re in a ‘psychedelic mosh pit’. This state of ‘ego dissolution’ achieves a total state of non-self in more extreme circumstances such as near death, drug-induced and meditative psychedelic experiences (Martial et al 2021). In reality, we live second by second edging back and forth along a continuum, rarely existing in either a total state of ‘Self’ or ‘non-self’. Where we are on the continuum determines how far we can edge away from our ‘anchor’ whilst feeling comfortable enough to decide how we admit to fear or shortcomings without blame or embarrassment, ask for help, share the results of creativity (Bruk et al 2022) or feel open to moving on after pleasant experiences end (van Gordon et al 2018). The two ends of this continuum are:

• State of Self: a first-hand narrative from self-referentially ruminating on a stable, predictable self-awareness. This self-awareness centres around the world being referenced in relation to an egocentric Me and my story. This can be likened to a drunk karaoke singer embodying the first-hand experience of their performance as exemplifying excellence. This makes the perceived experience egocentric by bringing the individual’s self-identity (of being a top class singer) in-line with them taking centre-stage as a top class entertainer. Existing at that moment separate and distinct from the masses that they are entertaining with their brilliance this creates a clear distinction between the individual (Self) as the centre-piece and all others (non-self) on their periphery.

• State of non-self: the experience from a third-person’s perspective allowing for a lower-order perception about the Self that is more open to passively experiencing sensations. This lower-ordered passivity is characterised by not feeling the need to actively manipulate sensory information so it falls in line with the ideas and beliefs that anticipate events based on an individual’s perceptions and imagination. This can be likened to achieving a third-person’s perspective by the individual watching, whilst sober, the drunken karaoke video footage of their performance. Providing a less blinkered, more panorama view, presents a real world perspective of a woeful performance, the experience of which at the time, being only possible due to the shared interaction of the individual with others, their environment and of course the beer! By virtue of the sum being more than its parts this shared interaction blurs the distinction between the individual (Self) and all others (non-self). Whilst this may simplify the individual’s identity to being one ‘cog in the machine’, a cog shaped by a true, not perceived identity, the collective experience is defined by what it feels like when all the cogs, the whole machine, represented by every member of the crowd, the singer and their environment, feels like when it’s in action i.e. everyone creating and everyone sharing the same atmosphere and the same experience. This allows for a more authentic experience that exceeds the limitations of any one person’s imagination and perceptions.

Example: maladaptive perfectionism, non-self and self-compassion

Maladaptive perfectionism

Perfectionist exhibit maladaptive behaviours, such as “all or nothing” thinking, making them feel as though their failures are catastrophic and humiliating (Pia et al 2020). Measuring their self-worth against achieving ‘perfection’ (Ferrari et al 2018) maladaptive perfectionists are destructively self-critical (Woodfin et al 2021) in order to meet, what is perceived to be, their own, or other people’s impossibly high standards as to ensure their approval. Feeling personally to blame for the distress of failing to meet these impossibly high standards, that is predicted to permeate through every aspect of their life (Rubenstein et al 2016), they experience shame (Piotrowski 2020), rejection, self-criticism, feelings of being overlooked (To et al 2021), self-doubt (Woodfin et al 2021) and through measuring their self-worth against achieving the impossible, perfection, an overall self-worthlessness as being imperfect makes them undeserving of love or wellbeing (Pia et al 2020).

Worrying and ruminating (Piotrowski 2020) on these emotions causes the individual to align themselves to them in a way that they become not just passing thoughts, but over-identified with, turning them into a ‘truth’. Over-identifying with these emotions allows this ‘truth’ to swallow up and redefine their self-identity so that it dictates not just who they are, but their actions (Zhang et al 2018) leading to hopelessness, resignation and a lack of motivation (Cook & Artino 2016). As this negative self-image becomes re-enforced they feel inferior, hopeless and helpless with a desire to hide these flaws (Velotti et al 2017) by either escaping or disappearing (Cȃndea & Aurora 2018) or pursuing perfectionism (Ferrari et al 2018) leading to low self-esteem and a vulnerability to other negative emotions such as shame (Velotti et al 2017).

Non-self

In contrast, a state of non-self decentres the individual from their blinkered first-hand narrative using a third-person’s perspective. Fostering cognitive flexibility enables the individual to purposively experience and accept an emotion by aligning themselves to it in a way that they don’t over-identify and embody an ownership of it, allowing it to become an absolute truth that defines them, but instead, it becomes a simple learning tool (Chen & Jackson 2019). Not over-identifying with emotions is essential in order to not feel isolated in times of adversity when a sense of belonging, of feeling connected to a larger whole (Berardini et al 2021) makes the individual feel grounded with other people and secure (Wang et al 2021) in showing their vulnerability (Bruk et al 2022) which is a pre-requisite to developing self-compassion. Self-compassion enables the individual to be more supportive and friendlier toward oneself, more aware of being too hard on oneself, feeling less alone when having painful feelings, more accepting of painful feelings, and feeling more stable and peaceful. Therefore, self-compassion helps address the exaggerated self-criticism, self-doubt and fear of vulnerability from making the mistakes that comes from not being perfect (Woodfin et al 2021).

Self-compassion

“I’ve missed more than nine thousand shots in my career. I’ve lost almost three hundred games. Twenty six times, I’ve been trusted to take the game winning shot and missed. I’ve failed over and over again in my life. And that is why I succeed” - Michael Jordan

In maladaptive perfectionism self-compassion directs a ‘forgiving loving acceptance’ inwards reducing the perceived vulnerability to fear, anxiety, stress and shame from being looked upon unfavourably by others (Bruk et al 2022). It enables the individual to help themselves as they would another, by not avoiding or disconnecting from distressing emotions, but by being (i) kind (instead of critical and self-judgmental) as not to feel frustrated by inadequacies and failures; (ii) caring; (iii) understanding; (iv) mindful (as opposed to overly identifying with emotions) towards the self.

“In that moment one has a choice whether they want to fall into the problem and become the problem and become consumed by it, or, if they want to hold it out in front of them and deal with it there” - Steve Bartlett

This allows self-compassion to foster a broader panorama view that shows that by virtue of us all belonging to a humanised network, we see a reflection of ourself in others, recognising, and empathising, with others perceived failures and imperfections as an unavoidable part of life for us all. This renders a redundancy in feeling isolated by these feelings or trying to gain acceptance by concealing them, or trying to compensate for negative social comparisons by proving self-worth through achievement or by obtaining a ‘higher social rank’ (Ferrari et al 2018). Therefore, self-compassion activates an individual's soothing system, related to feeling safe, connected and cared for (Kotera & van Gordon 2021) reducing the fear of negative evaluations and increasing perceived controllability and optimism (Bruk et al 2022). This helps regain control over first-person self-referential processing that obsesses on negative emotions and self-criticism promoting an identity around “I failed” rather than “I’m a failure” fostering resilience, wisdom (Al-Refae et al 2021), social connectedness, optimism, overall happiness, satisfaction (Berardini et al 2021) and an authenticity whereby a non-constrained, open, self-compassionate inner self can be outwardly expressed (Zhang et al 2019). Therefore, self-compassion can help the perfectionist clearly differentiate between what ‘I feel I should want to be and do’ based on their perceived expectations of others, and, who ‘I truly am and what I truly want’. But separating oneself from their emotions to develop self-compassion to increase activity in dopaminergic and oxytocin-related processes that enhances positive emotions in response to adverse situations (Dowling 2018) can be experienced as threatening in individuals that are highly self-critical, with insecure or avoidant attachment styles, or have experienced abuse, neglect or shame by caregivers (Woodfin et al 2021).

Attachment & Non-attachment

Attachment

Attachment to the ‘delusional me’, a definitive sense of Self causes an individual to become stuck or fixated on things feeling an internal pressure to manipulate circumstances and experiences (Solen et al 2021). When this attachment is to a sense of Self as ‘Me’, with an ego-centric focus on self-other differentiation, it can cloud objectivity, compassion and encourages selfishness (Vu & Burton 2021) just as an attachment to a sense of Self as ‘We’, blurring self-other distinction, can lead to ‘empathy fatigue’ (Dowling 2018).

But an unhealthy attachment to this need to constantly self-prioritise how ‘I’ self-appraise, integrate and relate external and internal stimuli to ‘Me’ by valuing and attributing meaning to ‘Me’ (Northoff et al 2009) is a hedonistic derived pleasure that can predispose to other hedonistic derived pleasures and substance addiction (van Gordon et al 2018). As a close attachment to any hedonistic derived pleasure only yields temporary happiness due to its non-sustainable nature it inevitably results in the need for more happiness when it ends, ‘happiness rebooted’ (Shiah 2021). This makes any suggestion of transcending selfhood to break this endless cycle seen as a threat that ultimately results in mental illness, fatigue, sleep impairment, ruminative thinking, resentment, stress, functional impairments and addiction (van Gordon et al 2018).

Non-attachment

“Until you truly let go, until you truly form humility, can you find empathy and in that empathy you find contact and in that contact you find out who you truly are, and who the people are around you” - Jimmy Nelson

Transcending and truly letting go of selfhood as to develop non-attachment releases the fixation on perceptions leaving the individual free to effortlessly explore, from a third-person’s perspective, beyond their self-narrative by passively integrating diverse experiences into a single awareness. By letting go of the internal pressure to conform to a sense of Self, the individual can de-centre, step back, and from this third-person perspective ‘watch the show from the stands, not from centre stage’, observing, in a detached manner, passing thoughts and feelings. By not over-identifying with thoughts and feelings in a way that they become self-defining reduces an ownership over them so that ‘my thoughts’ and ‘my feelings’ become ‘just thoughts or ‘just feelings’. This lightens the anchor imposed by their sense of Self, releasing the constraints imposed by their imagination and perceptions, to improve their cognitive flexibility (van Gordon et al 2018). Improved cognitive flexibility allows the individual to evaluate and correct distorted beliefs and misinterpretations by shifting attention, changing focus and being flexible when updating their working knowledge. This allows them to activate their reward circuits by developing compassion to feel for someone, as opposed to empathy that makes them feel with someone (refer ‘Attachment’) (Dowling 2018) and encourages a less egocentric, more collective experience. By promoting care, affection, empathy (Jing & Wei 2018) and a less fixed, more malleable belief in human character (Hong et al 2004) non-attachment reduces feelings of animosity, polarisation and vulnerability (Bruk et al 2022) whilst fostering resilience (Ho et al 2021).

Therefore developing non-attachment to the emotional significance of thoughts and feelings means that they cease to act as competing impulses that are prioritised based on their predicted rewards (Matias et al 2017). By existing under a single umbrella these emotions orchestrate themselves into a symphony that allows for a deeper sense of satisfaction and contentment (Frewen et al 2020). This can be seen when experiencing a sense of fulfilling satisfaction by carrying on working, whilst exhausted, as a non-attachment to exhaustion enables a precognitive clarity that envisions a far greater reward of pride once the job is completed. This is in contrast to a more egocentric state of attachment to exhaustion that prioritises, and isolates this emotion based on its predicted reward of inducing a state of rest even if the reward from completing the job would have exceeded that of quitting. When an attachment to negative emotions becomes fixated on and embodied a value is placed on it forming a self-identity around “I can’t do it, it’s just not in me” that can, when it becomes a habit, predispose to apathy and broader ill-health.

Example: non-attachment based coping strategies, fibromyalgia and catastrophisation

Non-attachment-based coping strategies may alleviate symptoms of fibromyalgia by addressing how ‘pain chronification’ primes the neurological circuitry to anticipate, observe, emotionally evaluate, and sensory discriminate pain (Adler-Neal & Zeridan 2017). The association between catastrophisation and cognitive inflexibility and negative mood leading to feelings of disability and depression (Petrini & Arendt-Nielsen 2020) determines how patients interpret and contextualise their pain-related ruminations and feelings of helplessness to facilitate the whole process of ‘pain chronification’, but, more specifically, how pain is emotional evaluated (Adler-Neal & Zeridan 2017). This occurs by how catatsrophisers appraise their pain as being catastrophic and harmful which increases levels of attention and awareness to painful sensations leading to protective behaviour in the form of fear of movement and aversion to activities that precipitates a cycle of avoidance, reduced mobility and disability (Varallo et al 2021). Therefore, mindfulness principles, by mediating how a patient aligns themselves to their relationship with pain, themselves (Adler-Neal & Zeridan 2017) and their illness representations, decreases the affective salience of these painful sensations through:

• Non-attachment to concepts related to Self, symptoms and environment. This is the most effective strategy in improving fibromyalgia-related pain and psychological co-morbidities (Adler-Neal & Zeridan 2017) by reducing the allocation of cognitive and emotional resources towards an illness representation and experience. By making these emotions mere momentary and fleeting thoughts, such as the need to avoid pain at all costs, reduces the extent to which patients over-identify with them allowing them to stand back and decenter from them (Soler et al 2021). Decentering prevents their illness representations and self-identity, as two separate entities, from moving ever closer together and merging into one. In contrast, high levels of attachment to these emotions, and an over-identification with the need to avoid pain at all costs allows their self-identity and illness representation to move ever closer together so that their illness representation swallows up and re-defines their self-identity. This leads to poor pain acceptance (refer below, ‘pain acceptance’) (Tenti et al 2022), a blinkered defensive need to avoid pain at all costs, a loss of their individual identity as they become defined and encaged by their illness representations and a cognitive inflexibility that leads to low levels of acceptance and self-compassion (Ferrari et al 2018).

• Pain acceptance. Having a non-defensive openness to the full experience of a painful sensation, experiencing it ‘as it is’, with no goals, demands, preferences, habits or aversions and without attempting to avoid it (Varallo et al 2021) or actively change it into something else (Soler et al 2021) requires cognitive flexibility. Cognitive flexibility allows for a more developed sustained attention to arising sensory, affective, and cognitive events (Adler-Neal & Zeridan 2017) allowing them to pass through the mind without clinging on to them. This cognitive flexibility allows the individual to accept undergoing an unpleasant, painful, experience in order to adaptively change and persist with important value-orientated behaviours in pursuit of personal goals for a full and meaningful life (Varallo et al 2021) whilst allowing a flexible cognitive reappraisal to be directed inwards, in the form of self-acceptance, to promote self-compassion (Ferrari et al 2018). Using acceptance to build resilience, in response to catastrophisation’s tendency to cause feelings of risk and vulnerability, can reduce day-to-day pain interference and perceived levels of disability, but not actual improve performance in these daily activities. However, as fibromyalgia patients report worse subjective physical function, in comparison to their less impaired objective performance, acceptance can be used to improve their quality of life (Varallo et al 2021) (refer above, ‘non-attachment’).

• Non-judgmental awareness of sensory experiences. Developing self-compassion as to not be destructively judgmental and self-critical leads to less frustration by attenuating their reactions and judgments to their illness associated experiences (Adler-Neal & Zeridan 2017).

• Help patients engage in social activities and relationships to help alleviate depression and stress that can promote high levels of proinflammatory cytokines (Adler-Neal & Zeridan 2017).

Barriers to full treatment engagement with this process are (i) a perceived threat to transcending selfhood (van Gordon et al 2018) which would abandon the comforting clarity and familiarity that has a perceived value to managing and preventing the ‘impending doom’ associated with their condition. For instance when maladaptive perfectionism complicates a fibromyalgia presentation a fear of failure, feeling inadequate and trying to appear perfect to others leads to worry and rumination (Sanchez-Rodriguez et al 2021) promoting avoidance and self-sabotaging behaviours (Randall et al 2021); (ii) an inhibited Behavioural Activation System (BAS) tending to a lowered responsiveness to reward (Petrini & Arendt-Nielsen 2020); (iii) a perceived threat to developing self-compassion through self-acceptance in individuals that are highly self-critical, with insecure or avoidant attachment styles, or have experienced abuse, neglect or shame by caregivers (Woodfin et al 2021); (iv) fibromyalgia can be characterised by lower levels of cortisol (Ubeda-D’Ocasar et al 2020) which is associated with low motivation and a tendency to become passive and withdrawn lending itself to disengaging from problems denying they exist (Loeb et al 2021) and using defensive behaviour to compensate for this and ‘fire back up’ their cortisol in order to feel fearless (Oberle 2018 & Miller et al 2011).

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