Today, let’s dig into the two extremes of human performance in the workplace – “underperformance” and “overperformance.”  A lot of the credit for this blog and the work that went in behind the scenes for it, should go to my wife, Leigh Ann.  She has dedicated decades of her life to enhancing workplace performance and optimization programs.  It was her recognition that utilizing vagus nerve stimulation techniques and technologies in this setting could offer profound benefits.  Her insights into the parallels between my work in healthcare and hers in workplace performance gave rise to the concept of our joint program called “Treating Corporate Inflammation” that her company and I are pioneering.

Despite all of the media buzz around “quiet quitting” and complaints about the latest generations’ troubles in the workplace, nobody strives to be an “underperformer.” “Overperformance” may not be everyone’s goal, but nearly every human wants to be considered reliable and a good worker.  As will become clearer as you read this blog, better terms to describe these extremes of “overperformance” and “underperformance” are “surviving” and “thriving.”

As these terms suggest, those who are only “surviving” are living with their noses barely above the waterline, typically filled with anxiety or pain (emotional or physical), or challenged with cognitive issues, like brain fog, and are not in a position to succeed because they are living in a perpetual state of emergency.  Underperformance doesn’t fully capture the experience of living with the figurative air raid sirens blaring.  By contrast, those who are “thriving” are living in the opposite state, one filled with confidence, clarity, and comfort in which accomplishment of even difficult tasks seems smooth and easy.  Describing this as overperformance seems inadequate to capture what it means to live in such a state of Nirvana.  For those who are just surviving, new work obligations seem like the final straws that will break the camel’s back.  For the thriving, however, new tasks are motivating opportunities to learn, grow, and prove their worth.

Maslow’s Hierarchy of Needs

Embedded in the more descriptive terms “surviving” and “thriving,” is a hint of Maslow’s Hierarchy of Needs.  The Hierarchy of Needs is typically illustrated as a triangle with five levels.

  1. Immediate physiological needs (e.g., food, water, shelter, clothing, warmth, oxygen, and sleep) forms the base.  Without any one of these, death is a real and imminent possibility.  
  2. Physical safety and security, e.g., having the means to ensure continued safe access to the resources necessary to meet those fundamental physiological needs from level one, is the next level up.  
  3. Emotional safety and security (e.g., friendship, family, love, human connection), which, when viewed through the lens of physical needs, can be defined as the close network of people upon whom one can rely to help acquire the basic physiological needs of level one and the physical safety and security of level two.  
  4. Recognition, status, and self-respect or “esteem”, which is, in a sense, an extension of the safety nets of levels two and three, is the penultimate level.  It ensures the individual with the power to acquire needed resources through the expansion the network of social support of level three across a much broader population.

What about the fifth level?  The triangle shape can be seen as having served a clear purpose up to this point, with each level providing further insulation from the life-threatening risk of not having the capacity to meet basic physiological needs.  It is at the fifth and final level, however, where the triangle shape seems to miss a quantum change of focus.

The top of the Maslow’s Hierarchy of Needs is Self-Actualization.  To me, this is where the progression up the ladder loses at least some of its prior focus on physiological needs.  Self-actualization is about becoming the most one can be.  In fact, many argue that the lower four levels aren’t the steps to the top, but, rather, form a path that actually leads one away from ever reaching Self-actualization.  Perhaps this is why the Tibetan monks renounce all worldly possessions and take a vow of poverty in pursuit of true actualization.  If I can try to make their argument, it goes something like this: “Acquiring recognition, respect, and status from others requires a sacrifice of energy and focus that inevitably blocks one from attaining harmony and peace, which is the ultimate goal of Self-Actualization.”  Debating whether peace and harmony are the endgame of Self-Actualization seems like the subject of a whole separate blog (maybe I’ll incorporate that into a blog I’m working on around “Happiness vs. Pleasure”).

Let’s start back at the first few levels of the Hierarchy of needs and consider them from the perspective of the surviving versus thriving employees.  Pain, anxiety, and brain fog that often afflict an individual who is just surviving are interfering with having their basic needs met.  Not getting out of the base of the triangle is the textbook definitions of a chronic survival emergency.  In a sense, survival is being threatened at all times.  Existing in an endless state of psychological and/or physical crisis has neurological and physiological consequences that preclude any focus on climbing the Hierarchy.  Individuals who living in constant states of threat response and are under relentless stress will inevitably break, and along the way, the warning signs are psychological and physiological.

The Conditions that Travel Together to Torture Us

Kudos to the folks reaching for level five.  It is yours to decide whether the next stage of your journey is a quest for greater power and control over your destiny, or if it is to walk the path of simplicity in search of greater knowledge and enlightenment.  We wish you well and will not analyze you further than to note that you probably aren’t exhausted, dealing with a life of chronic stress, struggling with debilitating physiological ailments, and feeling like you are one false step away from careening down the sheer face of a mountain.

Like any great movie, our main focus will stay on the characters with struggles.  I previously slipped in that these people are simply “surviving,” not out of choice, but because they are disengaged and distracted, dealing with brain fog, mental fatigue, low mood, strain, tension, hyper-reactivity, and are overwhelmed by normal challenges of life.  Executive coaches and human resources executives who are tasked with managing such employees have long recognized that symptoms from this collection are seldom experienced in isolation from one another.  Typically, having one means having many, if not all of these characteristics.  Estimates for the numbers of employees experiencing this state range from 10% to upwards of 25% (especially in the wake of the CoVID pandemic and strains associated with the current economic system).

When my wife first shared these correlations and observations, it reminded me of the groundbreaking work that was done by my team looking at the relative risks of symptoms like migraine, sleep disorders, anxiety and depression, widespread pain, asthma and allergies, and GI distress.  For those of you who have read a number of my prior blogs at, or who have listened to the Health Upgrade podcasts ( my co-host, Dr. Navaz Habib, and I produce, I suspect you have an idea where this is going.  For the rest of the readers, my team and I conducted extensive analyses of de-identified patient medical records over millions of people on multiple continents.  We validated our findings with other datasets of millions of patient records conducted by other institutions, in both Europe and the U.S.  What we discovered was that approximately 10-12% of the adult population has been formally diagnosed with at least 3 of the above 6 debilitating conditions.  More importantly, once we began interviewing these co-morbid patients, we found that most informally reported suffering with many more of the symptoms, even if they had never received a formal diagnosis.

Just as the employees who exhibit symptoms of burnout, irritability, distraction, emotional fragility, tiredness, low mood, disengagement, brain fog, and mental fatigue seldom have troubles with only one of these, patients diagnosed with frequent headaches, breathing difficulties, widespread pain, depression and/or anxiety, GI conditions, allergies, and sleep disorders seldom have only one.  Why does being a person with hayfever and frequent stomach problems make you a person who is more likely to have headaches, not sleep, filled with anxiety, or crippled by fibromyalgia? Kinda fascinating, right?  So, we dug in and tried to figure it out.

Grinding through a mountain of statistical work demonstrated that no single symptom was driving the other conditions.  This means that, while having a diagnosis of depression certainly did make a person more likely to have headaches and asthma, the headaches weren’t the reason why you had the asthma.  Rather, all signs (and here, I guess I mean all mathematical signs, as well) pointed to there being an underlying condition, or physiological state, that generated a high susceptibility to experiencing all the symptoms.  The technical term for this underlying condition is a “latent cause” – which is a fancy way of saying that the reason why it is “underlying” is because it doesn’t have separate symptoms … other than all the flu-like symptoms and more that these people are living with for years on end!  (Note that I choose to use the word “symptoms” rather than “conditions” to describe very different phenomena, e.g., stomach symptoms and sleep disruption, or panic attacks and allergies, because of this relationship.  These ailments are symptoms of the underlying state and are not independent conditions, because there is a common latent cause.)

THE BIG REVEAL!  What we discovered was that the latent cause was an autonomic nervous system dysregulation.  This caused an inflammatory response from the innate immune system coupled with a cellular metabolic problem (oxidative stress and mitochondrial dysfunction).  As I will explain below, these aren’t three different things.  They are three legs of the same stool, and when one gets wobbly, the whole stool becomes unstable and fails.

But first, the most remarkable discovery was that the co-morbidity experienced by these multi-symptomatic patients and the psychological and behavioral issues experienced by the employees who are just “surviving” turned out not to be parallel, because parallel lines are distinct from one another.  These weren’t two separate lines.  What we were each talking about (my wife and her executive coaching team in the realm of psychology, and me and my team doing the epidemiology work on the physiology side) were aspects of the same line, with the same people.  This exposed one of the most astounding truths about human existence that I distilled down to the following:

The Two States of Existence

Each of us has an autonomic nervous system that has two side, or arms: the sympathetic and the parasympathetic.  We also each have innate immune cells, and among these there is a class called macrophages that coordinate a lot of critical activities, from building and maintaining use, to generating inflammatory responses when we are under assault.  They comprise 10-15% of every tissue in the body.  Finally, every cell in the body (other than red blood cells that also don’t have nuclei) has a complement of organelles called mitochondria.  These fascinating little organelles are the power plants of the cell, producing prodigious quantities of the units of energy, called ATP, that our cells use to conduct the billions of chemical reactions that keep us alive.  Rather than use the stool analogy again, the image below shows a triangle that very well may represent the (non-religious) core of our existence.

When we are in a state of calm, where we are not under assault from the outside world (which can be subconscious, like a viral infection, or conscious, like a broken bone, or even emotional, like stress from a job or spouse), we exist in a state of homeostasis, which means that the systems within us are working smoothly and everything is being maintained as it should be.  When we are in this state, the elements of the triangle look like this:

When we are under assault, and we need to battle a pathogen, fend off a physical attack, deal with a wound, or even struggle through an emotionally or mentally stressful experience, the triangle shifts.  This is characterized, first by sympathetic activation (the nervous system is able to react within milliseconds), inflammation (which can respond within seconds to minutes), and changes in energy production (which can take hours or days).  Short term stress responses are healthy, perhaps not insomuch as they don’t cause some damage, but because the recovery process jumpstarts the regenerative processes that ensure we are being maintained properly.  Some great examples of this are muscles getting stronger and better toned when they are regularly exercised, or emotional resilience growing as a result of prior adversity.  The technical term for this is “hormesis” and it is defined as the phenomenon in which a harmful experience stimulates beneficial effects when the quantity or duration of the harmful experience is small.

One could even argue that tolerance for alcohol rising if we drink regularly is hormesis.  (That is NOT a license to drink more!)

As the definition of hormesis suggests, chronic or severe harm does not provide benefit.  In fact, the effects of enduring chronic harm or existing under a continuous perception of threat shifts the triangle toward dysfunction as shown below:

I don’t think it will be a surprise to anyone that the trajectory of homeostasis is the one traveled by those who are thriving, and the chronic stress trajectory is the one of those who are just surviving.  Now, these trajectories define the extremes of human possibility, and most of us spend our lives drifting between them.  Finding a way to remain on the homeostasis trajectory, through establishing habits (sleep and work), lifestyle commitments (family and social engagement and positive attitude), daily decisions (about exercise and diet), and treatments and supplements (for example, probiotics, vitamins, anti-inflammatories, and vagus nerve stimulation), is critical to remaining happy, healthy, and smart.  It is also the key to living longer and healthier.  To be clear, regulating your autonomic  nervous system will regulate the immune system, and preventing inflammation can have critical benefits for metabolic functions.  Remember, that the goal is to keep your “triangle in the green”.

The Dangers of the Modern World 

These medical and performance problems are far more prevalent in Western Societies than they are in less “advanced” nations.  This is a very interesting phenomenon, given that there are far fewer chronic physical threats, like malnutrition, disease, and trauma in the Modern World.  Culprits, including highly processed foods, constant connectivity through our smart devices, sedentary lifestyle, the removal of human personal social interactions, and circadian dysregulation have been identified, and they appear to be far more dangerous than high levels of bacterial and viral particles in the environment, or hard physical labor.  Ensuring that people recognize these risks and have the tools to enable them to remain on that homeostasis trajectory is the goal of the health and wellness community (i.e., integrative and functional medicine, chiropractic, and the like).  It is also the goal of the executive and/or health coach, if not specifically with respect to the physiological health, certainly with respect to ensuring that employees have the tools they need to exist on the overperformance side of the scale.

One of the most remarkable and influential physicists of the 20th century was a man by the name of John Archibald Wheeler.  To give you a sense of the influence he had, Wheeler’s name for what Robert J. Oppenheimer once called “frozen stars” became the darling of science fiction story tellers ever since.  He called them “Black Holes”.  He once said, referring to the search for the grand unified theory (also called the TOE, or the Theory Of Everything) that once it was discovered, its physical meaning would be so simple that all who were exposed to it would marvel and exclaim, “Of course! How could it be anything else!”  The same must be said of the discovery that the autonomic nervous system influences the innate immune system and metabolic function.  While being one of the greatest advances in our understanding of how life works, the discovery of how the autonomic nervous system coordinates and controls metabolism and immune function is, in fact, the culmination of ten thousand years of human medical study, and the discovery that modulating the autonomic nervous system can regulate metabolic function and inflammation are the most natural conclusions to millennia of mankind’s quest for medical treatments.

In terms that John Wheeler would have appreciated, what this discovery tells us are things that we already know.  Taking a deep breath (to activate stretch receptors in the lungs that activate the parasympathetic nervous system) can relax you and clear your mind.  Literally “chilling out“ with a cold shower or a walk outside in the winter makes you feel awake and alive (and reduces inflammation as it activates thermal triggers for the parasympathetic).  Sleeping on it makes for better decisions and helps you understand what you have learned (sleep affords the innate immune cells of the brain, the microglia, the chance to properly remodel the network to better process new concepts and experiences).  Even taking a walk around the block helps to settle your stomach, emotions, and even help lower your blood pressure (movement and rhythmic breathing are powerful signs to the nervous system that there is no emergency).  Each of these are daily expressions within our own language that we use to help ourselves and others to manage stress and prevent inflammation, and now we know the why – the nervous system controls the immune system, which in turn can critically influence mitochondrial metabolic function.

Modern Technology: Heal Thyself

The invention of vagus nerve stimulation, originally as an implanted device for the treatment of epilepsy, has enabled very important work in this area of autonomic nervous system regulation. The requirement for surgical intervention, however, relegated this therapy to the far end of the continuum of care, and certainly precluded its use as a cure for performance challenges among employees with burnout and other challenges.  The recent advancement of vagus nerve stimulators that are hand-held and non-invasive, first as prescription devices to treat migraine and other severe headache conditions, and now as a wellness device that can be purchased for a few hundred dollars online, have made this therapy accessible to everyone.  The United States military has begun deploying it for their most stressed soldiers and civilian consultants.  Top executive and health coaching firms are beginning to suggest it to their best clients.  What individual or organization in today’s modern culture that induces sympathetic overdrive individuals, shouldn’t use it?  It is, after all, one of the greatest advances in health and wellness, and will improve also enhance personal performance and employee productivity!