Dr. Victor Carrión: How to Heal From Post-Traumatic Stress Disorder (PTSD)

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.240 | where we discuss science

00:00:03.720 | and science-based tools for everyday life.

00:00:05.860 | I'm Andrew Huberman,

00:00:10.240 | and I'm a professor of neurobiology and ophthalmology

00:00:13.440 | at Stanford School of Medicine.

00:00:15.400 | My guest today is Dr. Victor Karian.

00:00:18.040 | Dr. Victor Karian is a professor

00:00:19.840 | and the vice chair of psychiatry and behavioral sciences

00:00:22.880 | at Stanford University School of Medicine.

00:00:25.240 | He is one of the world's foremost experts

00:00:27.100 | on post-traumatic stress disorder,

00:00:29.040 | in particular, the treatment

00:00:30.420 | of post-traumatic stress disorder

00:00:32.040 | in children and adolescents.

00:00:33.660 | Although his knowledge and today's discussion

00:00:35.680 | certainly extends to adult PTSD as well.

00:00:38.920 | Dr. Karian is also the director

00:00:40.760 | of the Stanford Early Life Stress and Resilience Program.

00:00:43.840 | And today's discussion focuses on the psychological

00:00:46.680 | and the neurobiological underpinnings of PTSD,

00:00:49.800 | and which treatments are most effective for PTSD.

00:00:53.380 | We focus heavily on a particular therapy

00:00:55.260 | called Q-centered therapy

00:00:56.620 | that was developed by Dr. Karian and colleagues,

00:00:59.060 | that has been shown to offset the triggering

00:01:01.660 | by words or events or memories

00:01:03.300 | that often are the precursors to PTSD episodes.

00:01:06.620 | And this has been shown to be effective

00:01:07.820 | in both children and adults.

00:01:09.960 | Today's discussion explores the difference

00:01:11.800 | between anxiety, stress, and trauma.

00:01:14.700 | We talk about how those things of course are related,

00:01:16.920 | but how they can be separated out to better understand

00:01:19.700 | if indeed somebody has trauma

00:01:21.340 | and how to best approach the treatment of that trauma.

00:01:24.220 | As you'll soon see what makes Dr. Karian's work

00:01:26.260 | so unique is that it combines the psychological,

00:01:29.140 | the neurobiological, but also practical tools,

00:01:32.000 | such as mindfulness.

00:01:33.460 | It relates mindfulness and cognitive behavioral therapy

00:01:37.060 | to the underlying biology and what's known

00:01:39.340 | about the psychiatry and psychology of PTSD

00:01:41.780 | at its different stages,

00:01:43.140 | depending on the trauma, the age of the person, et cetera.

00:01:45.740 | Today, Dr. Karian clearly explains all of that

00:01:48.420 | so that by the end of today's conversation,

00:01:50.400 | you'll really understand what PTSD is and is not.

00:01:53.980 | And of course, the best ways to treat it.

00:01:56.400 | Before you begin, I'd like to emphasize

00:01:58.220 | that this podcast is separate from my teaching

00:02:00.140 | and research roles at Stanford.

00:02:01.740 | It is however, part of my desire and effort

00:02:03.900 | to bring zero cost to consumer information about science

00:02:06.500 | and science-related tools to the general public.

00:02:09.160 | In keeping with that theme,

00:02:10.260 | I'd like to thank the sponsors of today's podcast.

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00:03:41.840 | Today's episode is also brought to us by BetterHelp.

00:03:44.980 | BetterHelp offers professional therapy

00:03:46.780 | with a licensed therapist carried out entirely online.

00:03:49.740 | I've been doing weekly therapy for well over 30 years.

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00:04:59.160 | that offers hundreds of guided meditation programs,

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00:05:05.000 | I started practicing meditation

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00:06:13.820 | to access a free 30-day trial.

00:06:15.860 | And now for my discussion with Dr. Victor Carreon.

00:06:19.180 | Dr. Victor Carreon, welcome.

00:06:22.220 | - Thank you.

00:06:23.060 | Thank you so much for having me.

00:06:24.900 | - I'd like to talk today about PTSD,

00:06:27.180 | post-traumatic stress disorder,

00:06:28.680 | in particular in young people, but also in adults.

00:06:32.120 | But before we do that,

00:06:34.020 | can you educate us on the definition of stress

00:06:37.860 | and maybe distinguish between short-term stress

00:06:40.980 | and long-term stress?

00:06:42.780 | And then perhaps we can segue into PTSD.

00:06:46.300 | - That's a very good way of starting

00:06:47.660 | because in reality, my main interest

00:06:50.780 | was the role of stress and the role of stressors

00:06:54.100 | and how stressors really would activate the gene makeup

00:06:59.100 | and make us vulnerable to things

00:07:01.100 | that we might be vulnerable.

00:07:03.000 | But at the time when I was training,

00:07:06.820 | everything psychiatry as a field was very diagnosis-based.

00:07:12.100 | So you needed an anchor.

00:07:14.140 | And hence, I used PTSD to communicate

00:07:17.980 | what I was really referring to.

00:07:20.340 | But the reality is that the experience of stress,

00:07:23.360 | as we now know, is a spectrum

00:07:26.700 | from beneficial to not beneficial to traumatic.

00:07:31.700 | So it really, stress operates in our lives

00:07:35.020 | as an inverted U-shaped curve.

00:07:39.020 | The more stress we have, the better we perform,

00:07:42.340 | the better we do.

00:07:43.180 | If we don't care about that exam

00:07:44.380 | that we're gonna have tomorrow, we'll probably fail.

00:07:47.720 | So it's good to be somewhat stressed, right?

00:07:50.180 | Vaccines are a stress in the system.

00:07:53.420 | So we'll talk about this, I hope,

00:07:58.420 | but I'm very concerned also about the overprotection of kids

00:08:03.420 | to protect them from any type of stress

00:08:06.180 | because it is through this experience of early stress

00:08:09.980 | that of us develop our problem-solving abilities.

00:08:14.540 | And we become aware of our coping mechanisms.

00:08:18.100 | We become aware of our support system.

00:08:20.360 | How can I manage that stress?

00:08:22.780 | And we can, we can manage stress

00:08:25.080 | because in the same way that through the process

00:08:28.160 | of homeostasis, we process,

00:08:32.220 | we have a range of temperatures, right,

00:08:34.420 | in which we can live, the same thing with stress.

00:08:37.980 | We can actually cope up to a certain point.

00:08:42.820 | After a certain point, it's not homeostasis anymore,

00:08:46.180 | and it turns into what we call allostasis,

00:08:49.480 | when it really starts having

00:08:52.420 | a physiological cost to the body.

00:08:56.040 | So in that inverted U-shaped curve,

00:08:58.920 | there's that optimal point where your health,

00:09:01.660 | your happiness, your performance, everything is better

00:09:04.260 | because of the stress you've been having.

00:09:06.460 | But after that optimal point, all of those outcomes,

00:09:10.020 | health, performance, start to decline.

00:09:13.180 | Happiness starts to decline.

00:09:15.260 | And it is in that second part of the curve

00:09:18.520 | where we find traumatic stress.

00:09:21.140 | Traumatic stress being a type of stress

00:09:24.380 | that is not only something you have to cope with,

00:09:27.200 | but it actually puts your physical integrity in jeopardy.

00:09:32.820 | It's a threat, and you have to manage that.

00:09:37.500 | And when you experience traumatic stress,

00:09:41.060 | many outcomes are possible.

00:09:42.660 | One is that you're resilient,

00:09:44.500 | and we'll talk a little bit about that as well, I hope.

00:09:47.780 | But another one is that you may develop symptoms

00:09:51.940 | of post-traumatic stress disorder.

00:09:54.300 | And the reason that I didn't anchor on the diagnosis

00:09:56.940 | right away from the outset,

00:09:58.460 | and I was interested in studying stressors,

00:10:03.300 | is because many kids, we were seeing many kids

00:10:07.740 | that had symptoms of PTSD without having the diagnosis

00:10:12.740 | that were demonstrating functional impairment.

00:10:18.020 | So they were not doing well in school,

00:10:20.200 | they were not doing well with their relationships,

00:10:23.180 | they were experiencing distress, right?

00:10:26.500 | So their function was affected,

00:10:28.500 | yet they didn't have the diagnosis.

00:10:31.120 | So the diagnosis is good in that it's there,

00:10:34.540 | and it is a behavioral definition that we can anchor in,

00:10:39.540 | but there's more nuance to that.

00:10:43.640 | So then that shows the whole spectrum.

00:10:46.900 | And of course, we can come out of PTSD,

00:10:50.020 | and we can go back to that optimal point.

00:10:52.860 | So we don't want to get rid of stress,

00:10:56.140 | but we just want to return to that optimal point.

00:10:59.580 | And treatment is available,

00:11:03.620 | and people can recover from PTSD,

00:11:06.340 | and especially kids can recover from PTSD.

00:11:09.460 | But there's one thing that really gets in the way,

00:11:13.260 | and that's something that in my team we call,

00:11:16.780 | we have a phrase that we say, "PTSD feeds on avoidance."

00:11:21.020 | If we pretend that something didn't happen,

00:11:23.380 | if we pretend that it will go away,

00:11:25.820 | if we pretend that treatment is not necessary,

00:11:28.940 | then that's when it gets complicated.

00:11:31.880 | And it gets complicated with substance abuse,

00:11:35.180 | it gets complicated with self-injurious behaviors,

00:11:38.060 | and then at that point, it becomes harder to treat.

00:11:41.620 | - Is it also possible that PTSD gets worse

00:11:44.340 | if we tend to look at it over and over again,

00:11:47.900 | ruminate on it in the absence

00:11:49.900 | of any structured clinical support?

00:11:52.580 | Meaning if people perseverate on their traumas,

00:11:57.540 | can the negative impact of those traumas

00:12:00.460 | actually root deeper into us?

00:12:03.620 | - It's interesting that you use the word perseverate,

00:12:06.160 | because one of the characteristics of trauma

00:12:09.500 | when it affects children is that it robs them from play.

00:12:14.500 | Play is something that's essential in development,

00:12:17.960 | it's how we grow socially, emotionally, physically.

00:12:22.960 | But when play becomes traumatic play,

00:12:26.040 | it becomes non-joyful,

00:12:27.920 | but it becomes perseverant and repetitive.

00:12:31.360 | This is the attempt of the individual

00:12:33.660 | to try to make sense of what happened.

00:12:36.960 | And the reason why it's not good to be alone with it

00:12:41.960 | and kind of perseverate on it by oneself

00:12:47.320 | is that we're probably not looking at the right insult.

00:12:51.720 | So in our experience,

00:12:54.320 | usually PTSD doesn't result from that one traumatic event.

00:12:59.320 | We all carry a backpack,

00:13:01.840 | and we can all carry all the stressors

00:13:04.760 | that have come our way, like we were saying before.

00:13:08.340 | But if you're five, six, seven years old,

00:13:11.280 | and that backpack gets really heavy,

00:13:14.240 | you can fall backwards.

00:13:16.560 | And when you fall backwards,

00:13:18.440 | that's because you don't have the tools, really,

00:13:20.680 | to carry that.

00:13:22.080 | But what I'm saying is that it is the accumulation

00:13:26.280 | of stressors, some of which may be traumatic,

00:13:30.320 | that cause the symptoms of PTSD.

00:13:33.480 | So for example, some of us went to Haiti

00:13:37.780 | after an earthquake, right?

00:13:39.120 | And I was starting my program at that time,

00:13:42.020 | I was very young, all ready to talk about earthquakes

00:13:44.520 | and know everything about earthquakes.

00:13:46.320 | It was the last thing they wanted to talk about.

00:13:48.720 | They saw the earthquake as an opportunity

00:13:51.120 | to talk about the violence they had been experiencing,

00:13:54.080 | the poverty, the lack of education.

00:13:56.820 | So they were talking to me about everything

00:13:59.200 | they were carrying that led some of them

00:14:02.140 | to develop symptoms of PTSD.

00:14:04.760 | - I see.

00:14:05.680 | As you describe these other aspects of one's life

00:14:10.120 | that can have negative impact, poverty, violence, et cetera,

00:14:14.960 | I get the impression that PTSD can be caused

00:14:18.480 | by a single event or trauma,

00:14:21.360 | but that there's a cumulative aspect to it.

00:14:25.040 | So is it the case that in children,

00:14:27.800 | because their brain is far more plastic, we know this,

00:14:31.160 | I mean, brain circuits are modified

00:14:32.840 | even by passive experience in childhood,

00:14:34.800 | whereas in adulthood it requires focused attention

00:14:37.240 | in order to learn, unless it's a negative event,

00:14:39.800 | for better or worse,

00:14:42.480 | that in kids it takes far fewer

00:14:46.160 | or less intense negative experiences

00:14:48.960 | in order to create PTSD because the brain is so plastic?

00:14:52.920 | Or is there a similarity between youth and adult PTSD?

00:14:57.720 | - Epidemiological studies confirm your assertion.

00:15:02.640 | Children, we think, we usually,

00:15:05.360 | you know, one line that I really don't like

00:15:07.280 | is children are resilient,

00:15:09.720 | because children are really not.

00:15:11.480 | They're more vulnerable.

00:15:13.400 | They have the opportunity to become resilient

00:15:15.600 | if we help them and we tell them what tools to use

00:15:18.640 | and how to develop and all of that,

00:15:21.560 | but they are more vulnerable to PTSD,

00:15:24.600 | and part of it might be that neuroplasticity,

00:15:27.400 | and this is why we care for them, right?

00:15:29.960 | This is why we protect them and give them safety,

00:15:32.800 | because they are vulnerable.

00:15:34.240 | By the same token, that neuroplasticity can work both ways,

00:15:39.880 | because if PTSD is teaching us

00:15:42.840 | that the environment can have an impact on biology,

00:15:47.360 | that's the only lesson, right?

00:15:49.880 | Environment can have an impact on biology.

00:15:52.000 | In PTSD, it's a negative impact

00:15:55.280 | because of a negative stress or accumulation of stressors,

00:15:59.560 | but that also means that if the impact is positive,

00:16:03.400 | as in a good supportive system or as in psychotherapy,

00:16:07.120 | that recovery can actually happen in an easier way.

00:16:12.120 | - Before we talk about therapeutic interventions,

00:16:16.280 | I'm curious about genetic predisposition,

00:16:19.240 | and a topic that comes up a lot

00:16:21.280 | anytime the letters PTSD are stated in that order

00:16:26.280 | is transgenerational trauma.

00:16:30.560 | I can imagine at least two forms

00:16:32.440 | of transgenerational trauma.

00:16:34.200 | One is a generation of what are now grandparents

00:16:39.200 | or great-grandparents or parents

00:16:41.720 | are impacted by some trauma,

00:16:43.240 | either in the family or maybe in culture

00:16:45.800 | or even broader scale.

00:16:47.720 | And then discussions about that pass through generations,

00:16:53.360 | impact the children, and therefore their adult life.

00:16:58.360 | I could also imagine,

00:16:59.640 | and I think this is normally what people are referring to

00:17:01.720 | when they talk about transgenerational trauma,

00:17:03.640 | this idea that somehow the genome is modified by the trauma

00:17:08.200 | such that even if kids are raised by parents

00:17:11.520 | that adopted them or they have no contact

00:17:13.960 | with the grandparents or great-grandparents

00:17:15.920 | that experienced the trauma,

00:17:17.720 | that somehow they are more vulnerable to,

00:17:19.760 | or in some cases, the idea has been put forward,

00:17:22.520 | carry that trauma, put in air quotes,

00:17:25.360 | such that their life is more difficult,

00:17:27.840 | even though they never had a direct experience

00:17:30.280 | of that trauma.

00:17:31.440 | What are your thoughts

00:17:32.280 | about transgenerational passage of trauma, both forms,

00:17:35.640 | both the narrative passage,

00:17:38.520 | as well as the potential for epigenomic

00:17:42.720 | or genomic passage of transgenerational trauma?

00:17:45.480 | - No, this is a very interesting subject.

00:17:48.720 | The jury is still out if genomic changes

00:17:51.840 | that result as a consequence of stress

00:17:55.200 | can be passed from one generation to the other.

00:17:58.400 | But certainly the genes that made one generation vulnerable

00:18:02.480 | are being passed to the next generation as well,

00:18:05.920 | that we know.

00:18:06.960 | So it can be passed that way.

00:18:09.220 | But what happens is that there's also

00:18:13.400 | this impact of learning.

00:18:15.920 | And I have treated kids that come to me

00:18:18.720 | with all of the symptoms of PTSD,

00:18:21.720 | and there's no trauma.

00:18:24.360 | I cannot find the trauma,

00:18:25.920 | and the parent cannot find the trauma,

00:18:27.560 | and the kid doesn't report a trauma.

00:18:30.160 | But when I'm talking with the parent,

00:18:32.560 | the trauma becomes evident in the history of the parent.

00:18:36.320 | So the parent has developed PTSD

00:18:38.840 | and behaves in a way that has been learned

00:18:42.360 | by the new generation,

00:18:44.160 | ways like avoidance, or re-experience,

00:18:49.160 | or hyper-vigilance, or lack of trust, things like that.

00:18:55.000 | So certainly, there are pathways

00:18:57.400 | in which it can go from one generation to the other.

00:19:01.040 | And we know that the battle between nature and nurture

00:19:05.400 | is pretty much over, right?

00:19:06.880 | We know that they both influence vulnerability

00:19:11.320 | and that they both interact.

00:19:13.600 | And I imagine that's what's happening

00:19:16.280 | in some of these situations.

00:19:18.480 | - In terms of stress,

00:19:21.720 | I always think of stress as both a response within the brain

00:19:26.440 | and a response within the body.

00:19:28.200 | And I'm not alone in that belief, I think.

00:19:31.440 | We know that adrenaline, epinephrine,

00:19:33.360 | is released from the adrenals,

00:19:34.880 | but also from areas of the brain like locus coeruleus,

00:19:37.960 | so that there's this parallel effect

00:19:40.120 | of elevated states of mind, more alert,

00:19:43.280 | more focused on narrow locations in space and time.

00:19:47.160 | And the body is also prepared for action.

00:19:49.760 | I think this is what underlies the increased heart rate,

00:19:52.000 | the, you know, shaking in some cases, sweating.

00:19:54.840 | It's essentially a preparation for action.

00:19:58.380 | With PTSD, I often hear that some of the symptoms

00:20:03.800 | are more of the opposite end of the spectrum

00:20:06.560 | in terms of autonomic arousal, right?

00:20:08.680 | Things like dissociation, fatigue,

00:20:12.720 | kind of checking out, which I realize is dissociation.

00:20:16.640 | But things that are more akin

00:20:19.360 | to kind of parasympathetic, right?

00:20:21.280 | For those that don't know,

00:20:22.120 | the sympathetic/parasympathetic

00:20:23.400 | represents the continuum of autonomic interaction.

00:20:25.600 | Sympathetic having nothing to do with emotional sympathy.

00:20:27.680 | It's all about fight or flight type responses.

00:20:30.700 | Although at lower levels,

00:20:31.960 | it's what's responsible for us being alert here,

00:20:35.320 | but not in fight or flight.

00:20:36.840 | And parasympathetic being more of the rest and digest,

00:20:40.060 | even leading into sleep type responses.

00:20:42.820 | - So, you know, if somebody experiences a big stressor,

00:20:47.820 | a trauma, or chronic stress to the point

00:20:51.980 | where it becomes PTSD,

00:20:54.300 | is there a tendency for them to be more hypervigilant

00:20:57.420 | and have a, you know, a startle response,

00:20:59.480 | to have their head on a swivel all the time,

00:21:03.380 | looking for danger, or to be more dissociative,

00:21:06.900 | or can both sets of phenotypes exist in the same person?

00:21:11.380 | - Yeah.

00:21:12.620 | No, this is very interesting.

00:21:13.460 | While we're talking about the letters,

00:21:14.860 | let me say that a lot of people

00:21:16.900 | call post-traumatic stress disorder

00:21:18.580 | post-traumatic stress injury.

00:21:20.860 | Not considering it a disorder,

00:21:23.060 | but considering it something

00:21:25.360 | that where our fight or flight mechanism,

00:21:28.700 | the autonomic nervous system,

00:21:30.580 | has been desensitized,

00:21:33.140 | and we need to regulate it again.

00:21:35.440 | And it's gonna hurt.

00:21:37.700 | It's gonna be painful.

00:21:38.580 | It's just like when you break your arm

00:21:40.540 | and go to the emergency room,

00:21:41.980 | and it hurts to be placed back in place,

00:21:45.300 | but it's the cure, is what cures it.

00:21:47.340 | So a lot of people visualize,

00:21:48.620 | and sometimes I do, as an injury,

00:21:50.820 | rather than a disorder.

00:21:52.420 | - Post-traumatic stress injury.

00:21:54.180 | - Injury.

00:21:55.000 | - Interesting.

00:21:55.840 | - And so what happens?

00:21:57.260 | So this autonomic system gets activated.

00:22:00.060 | We have our fight or flight reaction.

00:22:02.620 | But what happens to a young kid?

00:22:04.380 | Because they're very little, and they cannot fight.

00:22:07.380 | They're also very dependent, and they cannot flight.

00:22:11.700 | So they're stuck.

00:22:13.060 | They're stuck there.

00:22:14.500 | So they freeze.

00:22:16.340 | They freeze, and that's dissociation.

00:22:18.540 | It's actually, during development,

00:22:20.500 | a healthy defense mechanism.

00:22:24.580 | But very much like a white blood cell,

00:22:27.180 | that's very helpful,

00:22:28.500 | if you have too much of it,

00:22:30.620 | you develop a leukemia.

00:22:32.360 | You can develop dissociative disorders

00:22:35.660 | if that's the only thing you have.

00:22:38.160 | But it does help children cope

00:22:41.660 | with some of these situations,

00:22:43.620 | pretending this is not real,

00:22:46.220 | or this is not happening to me.

00:22:48.040 | It's the only thing they have left.

00:22:50.120 | And because this arousal system is so key

00:22:56.540 | in the development of these children,

00:23:00.300 | I thought that we should look at the hormone cortisol

00:23:03.980 | in the kids.

00:23:05.480 | And when I started, when I was a fellow

00:23:08.660 | doing my child psychiatry fellowship,

00:23:11.180 | I was seeing all types of kids

00:23:13.940 | with all kinds of issues.

00:23:16.400 | Some had ADHD, some had OCD,

00:23:20.100 | some had PTSD symptoms.

00:23:22.360 | But I was getting a lot of kids with notes

00:23:26.780 | from school saying, "This kid has ADHD.

00:23:30.140 | "Please place on Ritalin," right?

00:23:32.900 | A stimulant medication.

00:23:35.100 | And I'm like, "Wow, the diagnosis has been made.

00:23:37.500 | "There's already a treatment plan.

00:23:39.120 | "What am I training here for?" (laughs)

00:23:41.980 | But in some instances, they were right.

00:23:45.620 | The kids had ADHD.

00:23:46.820 | But in most cases, what happened is that

00:23:49.860 | that hypervigilance that you're talking about

00:23:52.900 | was being misinterpreted as hyperactivity.

00:23:56.780 | And the dissociation was being misinterpreted

00:24:01.140 | as inattentiveness.

00:24:03.460 | So the kids were getting a diagnosis

00:24:05.540 | that was not correct.

00:24:06.700 | Of course, there are other very complex cases

00:24:09.700 | where you have both ADHD and PTSD.

00:24:12.440 | Also, ADHD can put you at risk to develop PTSD

00:24:15.960 | 'cause you're not as attentive

00:24:17.440 | as to what's happening in your environment.

00:24:20.840 | But there are definitely two different conditions.

00:24:23.600 | And it was that clinical observation

00:24:27.080 | that made me think, well,

00:24:28.640 | people don't know enough about PTSD.

00:24:32.440 | And certainly they don't know enough

00:24:33.680 | about PTSD in children.

00:24:35.880 | And we were having some research in adults

00:24:38.680 | around that time in terms of cortisol levels.

00:24:42.360 | David Spiegel, who you've had here,

00:24:44.040 | Rachel Yehuda at the Bronx VA,

00:24:46.360 | looking at PTSD in adults.

00:24:49.020 | But I said, "But how does PTSD look early on?

00:24:52.080 | "What's happening in the hypothalamic

00:24:54.240 | "pituitary adrenal axis that is responsible

00:24:57.180 | "for secreting cortisol and regulate cortisol

00:25:00.480 | "when these children are young?"

00:25:03.200 | Because this is a new axis.

00:25:05.520 | Is it already not working or is it working right?

00:25:10.120 | And so we did a number of studies

00:25:12.800 | that demonstrated that the normal circadian

00:25:15.600 | rhythmicity of cortisol was there.

00:25:19.040 | It was higher early in the morning,

00:25:22.720 | which we need to jump out of bed.

00:25:24.680 | And as the day progresses, it decreases.

00:25:27.340 | Very helpful, it goes up when we are stressed,

00:25:31.360 | like when we have lunch.

00:25:32.320 | After we have lunch, cortisol goes up, right?

00:25:34.200 | So that we can help manage

00:25:35.800 | the insult of digestion or whatever.

00:25:38.460 | And these kids were having those levels.

00:25:42.240 | But something was happening in a number of studies.

00:25:46.100 | And we noted that the pre-bedtime level was higher.

00:25:50.340 | We were measuring it at different times.

00:25:53.040 | In the morning, pre-breakfast, pre-lunch,

00:25:55.240 | pre-dinner, pre-bedtime.

00:25:57.640 | But it was the pre-bedtime level

00:26:00.040 | that wouldn't come as low as the healthy controls.

00:26:03.680 | It would remain high.

00:26:05.880 | And this was also important clinically

00:26:08.680 | because many of the symptoms these kids were having

00:26:12.360 | were happening at night.

00:26:14.440 | Aneurysis, right?

00:26:15.680 | Bedwetting, nightmares, not sleeping deep enough,

00:26:20.120 | not sleeping long enough, fears.

00:26:24.280 | At that point, I felt, well, we don't know anything

00:26:31.160 | other than the cortisol pre-bedtime is elevated, right?

00:26:33.760 | Maybe they need it to be.

00:26:35.480 | Who knows?

00:26:36.320 | But I was concerned about the work by Sapolsky, right?

00:26:42.160 | And Bruce McEwen, his mentor,

00:26:44.480 | demonstrating the neurotoxicity

00:26:47.640 | that glucocorticoids can have in key areas of the brain.

00:26:51.760 | Areas in the limbic system and the cortical system.

00:26:54.960 | Which, interestingly enough,

00:26:57.480 | have a lot of glucocorticoid receptors.

00:27:00.680 | So then we decided to look at brain structure

00:27:04.720 | and brain function in youth with PTSD symptoms

00:27:08.920 | and see how this cortisol would relate to that or not.

00:27:13.280 | And we did that through MRI, magnetic resonance imaging.

00:27:17.080 | - Let's talk about cortisol for a moment.

00:27:18.720 | It's a topic that has not received enough attention

00:27:21.520 | in previous episodes of the podcast.

00:27:24.960 | I'm just going to summarize a little bit of what you said

00:27:26.880 | and you'll tell me where I'm wrong.

00:27:28.640 | Cortisol starts to rise

00:27:30.560 | just before we wake up in the morning,

00:27:33.200 | assuming a good night's sleep.

00:27:34.960 | And peaks maybe, I don't know,

00:27:37.400 | 30 to 90 minutes after waking.

00:27:39.260 | For you slow risers like me, probably a little delayed.

00:27:44.600 | By the way, the height of that peak

00:27:47.240 | and I would say the steepness of the curve

00:27:50.640 | can be increased by viewing morning sunlight.

00:27:53.940 | We know this.

00:27:54.780 | Bright light increases that cortisol peak.

00:27:56.080 | It'll make you a better early riser.

00:27:57.660 | But in any case, typically the pattern then

00:27:59.820 | is that it rises through mid morning

00:28:02.560 | and into the early afternoon

00:28:03.740 | and then starts to taper off to lower levels.

00:28:06.120 | And as you mentioned,

00:28:07.200 | we'll see bumps in cortisol post meal.

00:28:09.720 | If there's a stressor, we get a disturbing text,

00:28:12.200 | we get a bump in cortisol,

00:28:13.720 | but these aren't huge peaks

00:28:15.360 | unless it's a big stressor, correct?

00:28:17.520 | And then by evening cortisol levels

00:28:19.920 | in healthy individuals are typically low

00:28:23.640 | and that allows for transition into sleep,

00:28:25.600 | among other things allow for transition into sleep.

00:28:28.020 | But you said in these kids with PTSD,

00:28:32.180 | cortisol doesn't come down to low levels

00:28:37.020 | as much as it does in healthy individuals

00:28:39.820 | in the evening and nighttime.

00:28:41.340 | And that I imagine would lead to perseverating

00:28:45.340 | on stressors from the day.

00:28:47.020 | This kid was mean, I have a test tomorrow.

00:28:50.300 | Maybe any stressor becomes more intense in our mind

00:28:53.860 | and body, as it were,

00:28:56.180 | and that perhaps could lead to issues

00:28:57.960 | with quality or duration of sleep,

00:29:00.280 | which then could perpetuate the cycle.

00:29:02.740 | Do I have that correct?

00:29:03.740 | - Correct.

00:29:04.580 | - Okay, so has the direct intervention

00:29:08.020 | of just trying to suppress evening cortisol ever been done?

00:29:11.740 | I mean, certainly there are drugs that will do this.

00:29:14.180 | Has that approach ever been taken?

00:29:15.900 | - I thought about that when I had those high levels,

00:29:18.540 | but I felt that we needed to understand better.

00:29:21.780 | I think yes, that there were some attempts

00:29:25.500 | with some medications, and I don't think that led

00:29:28.660 | to anything in terms of helping those kids,

00:29:32.800 | or just helping individuals in general

00:29:35.820 | that had high levels of cortisol

00:29:37.380 | because of traumatic stress.

00:29:40.340 | But nighttime, you're right.

00:29:43.080 | It is a time when basically we fall asleep

00:29:46.820 | because we let it go.

00:29:48.900 | And this kid's hyperarousability does not allow them

00:29:53.540 | to let it go.

00:29:54.520 | So if these levels are high, as I was finding,

00:30:00.620 | what impact are they having in brain development?

00:30:05.020 | And usually the younger you are,

00:30:08.480 | the more universally distributed receptors are.

00:30:12.100 | So glucocorticoid receptors could be anywhere at that point,

00:30:14.620 | but as we age, they become more localized.

00:30:18.260 | And the glucocorticoid receptors,

00:30:20.300 | and cortisol is a type of glucocorticoid,

00:30:23.260 | are more common in areas like the hippocampus

00:30:28.060 | and the prefrontal cortex,

00:30:29.980 | which I also found interesting

00:30:31.500 | because these areas relate to the symptoms, right,

00:30:34.580 | that many individuals with PTSD have.

00:30:38.460 | - Memory, anticipation of the future, problem-solving,

00:30:42.900 | context-dependent problem-solving, so on.

00:30:46.020 | - And even those attention issues that make them overlap

00:30:49.780 | with kids that have ADHD as well.

00:30:52.360 | So this frontal limbic pathway,

00:30:56.420 | the prefrontal cortex communicating

00:30:58.780 | with these emotional areas of the brain,

00:31:00.500 | including the amygdala,

00:31:01.920 | which is very close to the hippocampus,

00:31:04.140 | needed to be investigated in pediatric PTSD.

00:31:10.740 | And what I sometimes call pediatric PTSS

00:31:14.660 | because post-traumatic stress symptoms.

00:31:17.860 | Because, as I mentioned, there's a group of kids

00:31:21.460 | that have post-traumatic symptoms,

00:31:23.780 | do not fulfill criteria for DSM-5 PTSD,

00:31:28.620 | but their function continues to be impaired.

00:31:31.460 | Sometimes that's because of comorbidity.

00:31:35.060 | There's a high incidence of comorbidity

00:31:37.000 | with anxiety and depression.

00:31:38.820 | So most of our studies that have looked at PTSD symptoms

00:31:42.180 | also look at the impact of the interventions

00:31:45.580 | that we're doing in anxiety and depression as well.

00:31:48.560 | - I'd like to take a quick break

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00:33:18.700 | - I definitely wanna get into some of those interventions,

00:33:20.940 | including some of the ones that you've developed

00:33:22.820 | that are very novel and are being used to great success.

00:33:27.820 | I want to just circle back for a moment

00:33:30.520 | on this relationship between PTSD and, in some cases,

00:33:35.740 | inappropriate diagnosis of ADHD.

00:33:38.660 | As you mentioned, these two things can coexist

00:33:40.660 | in the same person.

00:33:42.340 | So we don't want anyone who has been told

00:33:45.180 | that they have ADHD and PTSD, or even just ADHD,

00:33:49.900 | to immediately assume that that diagnosis is wrong

00:33:52.160 | based on what we're gonna talk about.

00:33:53.460 | But it is possible that the ADHD

00:33:58.420 | that a child is told they have is reflective of PTSD.

00:34:03.060 | And I imagine that if that PTSD arises

00:34:05.280 | through something in the family structure or dynamic,

00:34:08.100 | it would be even harder to unmask

00:34:10.220 | because the parent perhaps would be less motivated

00:34:14.660 | to try and understand that

00:34:16.020 | if they played some sort of role in it.

00:34:17.860 | So I realize this is a complex problem with a lot of layers.

00:34:21.780 | But if you were to just throw out a number

00:34:24.500 | based on your experience,

00:34:25.980 | what percentage of pure ADHD diagnosis

00:34:31.820 | would you like to see explored

00:34:35.160 | for the possibility of a PTSD influence?

00:34:38.600 | Let's just keep it kind of diplomatic that way.

00:34:40.960 | As opposed to saying what percentage of ADHD

00:34:42.960 | do you think is actually PTSD?

00:34:44.880 | - I firmly believe that ADHD does exist.

00:34:49.880 | I'm gonna say two facts that we know in the field.

00:34:53.820 | One, are kids getting over-medicated?

00:34:58.480 | The answer is a clear yes.

00:35:00.640 | They're getting more medications that they need.

00:35:02.960 | - For ADHD.

00:35:04.200 | - For anything in general, kids.

00:35:07.680 | Now, in ADHD, they're getting under-medicated.

00:35:12.680 | So that's the second fact.

00:35:14.400 | So the first one is that if we look at kids overall

00:35:16.760 | in the field of mental health,

00:35:19.360 | those that manage to receive treatment,

00:35:21.360 | which access is something else we should talk about

00:35:23.960 | 'cause like 50% of them do not get access

00:35:27.480 | to mental health services.

00:35:30.040 | Those that manage to get it

00:35:31.920 | may end up with the appropriate treatment, right?

00:35:36.920 | A medication or a psychotherapy.

00:35:40.480 | But there's another subset of them

00:35:42.620 | that will be medicated no matter what they present with

00:35:47.320 | because they need to be seen fast or it's a fast solution.

00:35:51.400 | So there's many reasons for that.

00:35:52.860 | But are kids getting over-medicated?

00:35:54.680 | Yes.

00:35:55.880 | But within those kids,

00:35:57.760 | those that truly have attention deficit hyperactivity

00:36:01.400 | disorder are getting under-medicated.

00:36:03.960 | And that's because of that access issue

00:36:06.200 | because most of them were not identifying.

00:36:09.520 | And that's a pity because the first line of intervention

00:36:12.740 | for ADHD is stimulant treatment.

00:36:16.000 | It does work.

00:36:17.240 | And it works very well for children

00:36:20.920 | that have the correct diagnosis.

00:36:23.540 | But the first line of intervention for children

00:36:25.800 | that have a history of PTSD, be it acute or chronic,

00:36:29.800 | is psychosocial.

00:36:31.320 | It's a psychosocial intervention.

00:36:33.460 | So if you give a kid that has PTSD and no ADHD

00:36:38.460 | a stimulant medication,

00:36:40.840 | not only is not taking care of ADHD 'cause they don't have it

00:36:44.120 | but it adds to that hyperarousability

00:36:47.560 | that is manifested there from before.

00:36:50.240 | By the way, there are clinical ways

00:36:51.720 | of separating hyperactivity from this hyperarousability

00:36:56.720 | and hypervigilance.

00:36:58.640 | Hyperactivity, if you see a kid that is not medicated

00:37:01.440 | and has ADHD and they have the hyperactive symptoms

00:37:05.360 | and the hyperactive type,

00:37:06.880 | they're gonna be hyperactive for most of the time

00:37:09.220 | that you're with them.

00:37:10.700 | The kid that has hyperarousability,

00:37:13.280 | it will be more of an on and off phenomenon.

00:37:16.200 | The hypervigilance and hyperarousability comes more

00:37:20.960 | when they're presented with a cue

00:37:23.280 | that consciously or unconsciously reminds their body

00:37:27.520 | of the traumatic event or the traumatic experiences.

00:37:30.660 | What happens though is that usually we don't know

00:37:34.640 | what those cues are, right?

00:37:37.000 | So we just see a kid that sporadically becomes

00:37:39.960 | hypervigilant or hyperaroused.

00:37:44.200 | And then the other thing is,

00:37:45.880 | is hypervigilance something that needs to be treated?

00:37:49.960 | You know, I learned this from a mother early in my career.

00:37:53.600 | She's like, I was giving some talk in the community

00:37:56.420 | and she came to me afterwards and she said,

00:37:58.440 | "Listen, we live in a street that's very dark

00:38:03.120 | "and it's very dangerous.

00:38:04.700 | "And my kid has to pass through that every day.

00:38:08.780 | "I want him to be hypervigilant.

00:38:11.080 | "And if he has developed this trait of hypervigilance,

00:38:14.420 | "this is something that could be helpful to him."

00:38:17.480 | And I said, "You're right."

00:38:19.040 | I said, "You're right, it's not only to him,

00:38:20.760 | "to a lot of people, it could become very helpful

00:38:23.700 | "to be hypervigilant to assess the environment

00:38:26.440 | "in which they are in."

00:38:27.880 | So the problem is not the hypervigilance.

00:38:30.600 | The problem is knowing when to turn it on

00:38:34.320 | and when to turn it off.

00:38:36.280 | Having the cognitive flexibility, right?

00:38:39.800 | To be able to say, yes, this is a dangerous situation

00:38:44.040 | and I better respond this way.

00:38:46.360 | If I can give you an example of a kid, right?

00:38:50.040 | A kid that experiences domestic violence

00:38:53.000 | and has associated that with noise in the house,

00:38:58.000 | learns that running and getting into the room

00:39:00.920 | is a safe thing for them

00:39:02.520 | because they're out of the picture, right?

00:39:04.220 | And they protect themselves in the room.

00:39:06.840 | But a year later, they're in the classroom

00:39:09.880 | and for some reason the classroom gets this level of noise.

00:39:13.540 | The body, without him knowing, right?

00:39:16.880 | The body reacts by the response that was helpful.

00:39:21.600 | This is classical conditioning, right?

00:39:23.440 | So he runs out of the classroom.

00:39:26.040 | But he's missing the context.

00:39:27.600 | The teacher is missing the context.

00:39:29.440 | When the teacher sends him to the principal's office,

00:39:32.520 | the principal doesn't have the context, right?

00:39:35.640 | That this response was actually adaptive

00:39:38.480 | at one point and helpful at one point

00:39:40.880 | and the body has had a hard time letting it go.

00:39:44.180 | To ask that kid to give us the only response that he has

00:39:48.960 | is not the way to help him.

00:39:51.880 | We need to help him develop new competitive responses

00:39:56.200 | so that the experience of the other responses

00:39:58.800 | then extinguishes that response

00:40:02.200 | that was adaptive at one point but now is maladaptive.

00:40:06.080 | By the way, if they are in a traumatic situation,

00:40:07.880 | again, we still want them to use it, right?

00:40:09.920 | We still want them to run and get out of there.

00:40:12.400 | It's part of that hypervigilance

00:40:14.160 | that's protecting them in a way.

00:40:17.000 | - It's so interesting.

00:40:18.280 | You said, if I understood correctly,

00:40:19.960 | that in kids with genuine ADHD,

00:40:23.880 | the hyperactivity is fairly persistent across environments

00:40:27.960 | and with different people, et cetera.

00:40:30.520 | - I'm sorry to interrupt, but if I could add,

00:40:32.320 | the inattention comes and goes

00:40:35.000 | because we all know kids that have ADHD

00:40:36.640 | that if you give them the right video game,

00:40:39.040 | all of a sudden they become attentive, right?

00:40:41.040 | - This is a very important point.

00:40:42.760 | When I did the solo episode on ADHD,

00:40:44.920 | I was frankly shocked to learn,

00:40:48.200 | but it was validated by the literature

00:40:50.280 | and certainly by the responses from the audience

00:40:52.320 | that kids with ADHD and adults with ADHD, for that matter,

00:40:57.160 | absolutely have the ability to sharply attend to something

00:41:00.520 | if it's something that's very engaging to them,

00:41:02.880 | really exciting, something that they typically enjoy.

00:41:06.160 | But their ability to direct and maintain attention

00:41:08.960 | in other environments that are required

00:41:10.760 | for normal life progression,

00:41:12.240 | school, work, relationships, et cetera,

00:41:14.960 | is very diminished compared to those without ADHD.

00:41:19.480 | So what I have in my mind is a step function,

00:41:21.460 | meaning an increase in a steady state of hyperactivity

00:41:26.120 | in a kid with ADHD,

00:41:27.360 | but then a jagged line beneath that of attention.

00:41:30.040 | This is, I believe, the picture we're painting here,

00:41:32.880 | but that in PTSD, the hyperactivity is a jagged line

00:41:38.880 | and it really needs a cue, as you said, a loud noise,

00:41:43.120 | or maybe it's the presence of a particular voice.

00:41:46.440 | I once attended a trauma,

00:41:49.160 | it wasn't trauma release as much as it was genuine

00:41:52.160 | trauma treatment center out in Florida.

00:41:55.000 | A friend of mine runs the center

00:41:56.160 | and I was out there learning about the practices they use

00:41:59.200 | in order to inform potential experiments

00:42:03.280 | for intervention in my lab back at Stanford.

00:42:05.920 | And he said something really interesting.

00:42:09.000 | He said, you know, when you bring people in

00:42:12.280 | to this sort of environment and they've all had trauma,

00:42:14.800 | you see a pretty rich array of responses

00:42:19.200 | to even just the same conversation.

00:42:21.920 | And then at one point, perhaps because he said that,

00:42:25.240 | I noted that a woman raised her hand

00:42:27.960 | and she said that particular timbres of voices in the room

00:42:32.200 | were really activating her.

00:42:34.200 | You know, this was important.

00:42:35.160 | It wasn't just what was being said.

00:42:37.000 | It wasn't that people were yelling at each other

00:42:38.680 | or even the volume of the voices,

00:42:40.840 | but that even just the frequency,

00:42:43.200 | the lowness or the highness of the voice, as it were,

00:42:46.040 | was triggering something in her brain

00:42:47.800 | that was giving her these bodily sensations.

00:42:49.720 | And it was a very important insight for her

00:42:52.760 | to be able to then start to direct interventions.

00:42:55.880 | So I guess we all hear the kind of now stereotypical example

00:43:00.200 | of, you know, the veteran who experiences combat comes back

00:43:03.960 | and hears a car backfire and then they hide.

00:43:05.840 | That's kind of, we read about this and hear about this,

00:43:08.300 | but it seems like it's much more subtle than that,

00:43:10.440 | that sometimes the cues for this hyperactivity,

00:43:13.600 | this hypervigilance is very much linked to something

00:43:18.600 | that sometimes even the person with PTSD doesn't recognize

00:43:22.100 | until they start to be put into that environment

00:43:24.640 | again and again, and then they can pinpoint it.

00:43:26.720 | My question now is if they can pinpoint what the cue is,

00:43:30.040 | do they stand a better chance of recovery

00:43:33.560 | as opposed to somebody that just like,

00:43:35.840 | feels like I'm hyperactive, then I'm exhausted,

00:43:37.800 | I'm wired and tired.

00:43:38.940 | And now I also imagine that in kids,

00:43:41.120 | they don't have necessarily the verbal proficiency

00:43:43.480 | to be able to express what's going on for them.

00:43:45.640 | And in fact, many adults don't really know

00:43:47.660 | because we don't have a great language

00:43:49.200 | for expressing this body-mind thing.

00:43:51.360 | In any event, a lot of questions there,

00:43:53.160 | but what are your thoughts about the requirement

00:43:56.160 | for being able to understand what the cues,

00:43:58.080 | what the triggers are in order for a child and or adult

00:44:02.080 | to be able to start to make inroads into their PTSD?

00:44:06.080 | - First, a word on the Vietnam veteran,

00:44:08.160 | because there's a very important study

00:44:10.480 | that was published years ago that demonstrated

00:44:13.420 | that those veterans that had a history of child maltreatment

00:44:18.160 | and went to war had PTSD at higher prevalence

00:44:22.920 | than the ones that did not have a history

00:44:25.440 | of child maltreatment.

00:44:26.840 | So-- - Child maltreatment.

00:44:28.600 | - Yeah. - I see.

00:44:29.440 | So they were traumatized before they went to combat.

00:44:31.800 | And maybe they did not develop PTSD,

00:44:34.440 | but once again, that point of the accumulation, right,

00:44:37.480 | of the stressors at different times.

00:44:39.880 | And I'm just mentioning that because you may have a veteran

00:44:44.280 | and you're waiting to look at the classical cues,

00:44:48.460 | where in fact, it might be more like a voice,

00:44:51.120 | like the example that you were giving that triggers them.

00:44:54.360 | What triggers an individual is very personal.

00:44:57.120 | So cues are usually neutral.

00:45:00.600 | And they're usually related to our senses.

00:45:03.040 | And I know you like senses a lot.

00:45:04.400 | So what we see, what we hear, all of these things.

00:45:08.000 | The senses are really the window

00:45:11.600 | to the central nervous system, right?

00:45:13.640 | This is how we get information the first time.

00:45:17.040 | So in this state of hyperarousability,

00:45:20.720 | when something traumatizing is happening,

00:45:23.000 | our senses are really acutely aware of what's going on.

00:45:29.360 | And they are making sense of the insult,

00:45:34.160 | but they also are registering everything

00:45:37.220 | that's related to that.

00:45:39.440 | So these cues usually are neutral.

00:45:43.240 | So they're not like a gun, for example,

00:45:46.200 | because a gun is not a cue, it's a threat, right?

00:45:50.280 | But it's usually a color.

00:45:52.480 | So there was a red car parked near where they were,

00:45:55.200 | so the color red may be a cue, may be a trigger.

00:45:59.120 | It was raining the day that that happened,

00:46:01.400 | so rain may be a cue, may be a trigger.

00:46:05.400 | And to answer your question,

00:46:06.960 | identifying those cues are important

00:46:10.720 | because they let you know when your symptoms are coming.

00:46:15.720 | They let you know that they're not coming out of nowhere.

00:46:20.240 | They let you know that you're not a problem

00:46:22.240 | or that you're crazy or that you're bad,

00:46:25.160 | which is sometimes the messages that kids get

00:46:27.480 | when they go to that principal's office, okay?

00:46:30.840 | But they let you know that they learn themselves,

00:46:34.960 | this is a normal response, right?

00:46:37.440 | I've learned through my psychosocial intervention,

00:46:40.960 | I've learned that this is a cue

00:46:44.080 | that triggers a response from me,

00:46:46.920 | triggers a response that was helpful at one time.

00:46:51.320 | And through classical conditioning,

00:46:53.040 | and we do teach classical conditioning to the kids,

00:46:56.240 | those responses then become present,

00:47:00.400 | become conditioned, right?

00:47:02.760 | When the cue is there, when the trigger is there.

00:47:05.400 | So yes, to answer your question,

00:47:07.000 | it is important to know the cues.

00:47:08.720 | Now, what happens?

00:47:09.560 | Are we gonna know all the cues to everything,

00:47:12.000 | to all of our behaviors and this shift in mood

00:47:15.880 | that sometimes we have during the day

00:47:18.040 | and we don't know why, right?

00:47:20.160 | No, the answer is no, we're not gonna know all the cues.

00:47:24.720 | But the beauty of this is that if we can just learn

00:47:29.160 | about one or two or three cues, what our response is,

00:47:34.160 | there's more of a forgiveness to ourselves

00:47:37.120 | in that when we respond inappropriately,

00:47:39.480 | we can think, well, maybe I was exposed to a cue, right?

00:47:43.360 | Because I've learned all of this

00:47:44.520 | about cues and classical conditioning,

00:47:46.400 | maybe that's what's happening here.

00:47:49.640 | - Yeah, I'm thinking again

00:47:51.040 | about post-traumatic stress injury.

00:47:53.320 | The reason I like that term,

00:47:55.760 | even though I realize I'm using it non-clinically,

00:47:59.480 | is that if we understand that the autonomic nervous system,

00:48:03.960 | this seesawing back and forth,

00:48:05.680 | or this push-pull between the sympathetic, fight or flight,

00:48:09.040 | and parasympathetic, rest and digest, loosely speaking,

00:48:13.480 | systems are always at play in us.

00:48:17.040 | When we sleep, more parasympathetic.

00:48:18.800 | When we're alert and calm, more sympathetic.

00:48:21.340 | And when we're stressed or having a panic attack,

00:48:23.840 | extremely sympathetic.

00:48:25.360 | If we understand that as a biological system,

00:48:29.800 | which it is, that deploys hormones

00:48:32.060 | and shapes our patterns of thinking

00:48:34.480 | and what's available to us in our memory, et cetera,

00:48:38.160 | then PTSI, post-traumatic stress injury,

00:48:43.160 | I feel like it liberates us a bit to understand that,

00:48:47.200 | yeah, this autonomic system has been disrupted in a way.

00:48:51.540 | And if I think about the autonomic system as a seesaw,

00:48:54.420 | which I often do,

00:48:56.040 | I think about the seesaw having a pivot point with a hinge.

00:49:01.040 | It's almost like the post-traumatic stress injury

00:49:03.980 | is to create the tendency for that hinge to be too tight.

00:49:08.980 | And sometimes that makes it more dissociative

00:49:13.340 | and we're exhausted and kind of checked out.

00:49:15.940 | And maybe it creates the hinge to be too tight

00:49:20.100 | such that we're more on the sympathetic, excuse me,

00:49:23.060 | sympathetic the way I, for those listening,

00:49:25.320 | I'm using my hands,

00:49:26.180 | but you don't have to see it to understand

00:49:27.900 | that the alertness system is locked in place.

00:49:31.260 | It's hard to get out of that.

00:49:32.780 | And I almost feel like the injury

00:49:34.660 | that is post-traumatic stress injury

00:49:37.140 | is a tightening down of the hinge

00:49:39.480 | with the seesaw tilted too much to one or the other side.

00:49:43.700 | And I, as a biologist,

00:49:45.580 | I just wish that we understood

00:49:47.500 | what that dysregulation was or is.

00:49:51.380 | Chances are it's not one location in the brain or body,

00:49:53.740 | it's gonna be a network phenomenon.

00:49:55.680 | But I feel like the word disorder,

00:49:58.340 | the D in PTSD is so critical

00:50:00.240 | because it highlights the importance

00:50:02.280 | and the pervasiveness of this thing,

00:50:05.260 | but that the I in post-traumatic stress injury

00:50:09.540 | hopefully will give people,

00:50:10.820 | it certainly is giving me some sense of relief

00:50:15.820 | or liberty and understanding

00:50:17.180 | that these are nervous system injuries

00:50:19.540 | that need treatment

00:50:22.180 | and that there isn't something wrong or crazy with us

00:50:25.220 | because of the fact that we, you know,

00:50:28.860 | suddenly feel like we're having a panic attack.

00:50:30.940 | You know, I've had people I know close to me in my life say,

00:50:33.700 | "I'm having a panic attack."

00:50:35.380 | I'm like, "What do you mean?

00:50:36.200 | What happened?"

00:50:37.040 | They're like, "Nothing happened.

00:50:37.940 | That's the point."

00:50:38.780 | "Well, how'd you sleep?"

00:50:39.620 | "Well, it's okay."

00:50:40.900 | You know, and you start doing the curbside diagnosis

00:50:44.100 | that neither of us is qualified to do, right?

00:50:47.260 | But this is what we do as caretakers

00:50:49.100 | for each other in our lives.

00:50:50.620 | And it very well could be that their autonomic system

00:50:53.100 | just got, that hinge is just locked in place

00:50:56.100 | for whatever reason.

00:50:57.140 | Maybe it's one sip too much of coffee.

00:50:59.140 | Maybe it's one sip too little.

00:51:00.780 | It's probably something or a bunch of things.

00:51:03.800 | I realize I'm getting outside my expertise here

00:51:07.500 | because I'm not a clinician,

00:51:08.800 | but I feel like this PTSI thing is sticky and important

00:51:13.520 | for people to hear about it.

00:51:14.740 | Certainly changing the way that I think about PTSD.

00:51:17.940 | - Yes, no, and I like the visualization of your seesaw

00:51:22.300 | and the example of the hinge

00:51:23.820 | because it reminds me of that cognitive flexibility, right?

00:51:28.380 | It's not there.

00:51:29.220 | It's kind of stuck.

00:51:30.420 | It's kind of tight, too tight.

00:51:32.700 | And in some individuals,

00:51:35.100 | they just experience the dissociation.

00:51:37.180 | They're like stuck on the bottom, right?

00:51:39.780 | Sitting on the bottom on the seesaw.

00:51:41.700 | Whereas for the other individuals,

00:51:43.140 | they're hyperaroused all the time.

00:51:44.700 | Then you have everything in between.

00:51:46.540 | But no, that's a very good representation of it.

00:51:51.180 | - And I feel like a good night's sleep

00:51:53.260 | allows some recalibration of the tightness of that hinge.

00:51:59.540 | Put differently, anytime we don't sleep well or long enough,

00:52:03.380 | we're not good psychologically.

00:52:06.060 | A good night's sleep is good for everything.

00:52:08.360 | - We're finally at the point in history

00:52:10.980 | where everyone seems to accept that.

00:52:13.020 | I really have to tip my hat to Dr. Matthew Walker

00:52:16.580 | from UC Berkeley for writing the book, "Why We Sleep."

00:52:18.980 | You know, it was only a few years ago that book came out

00:52:21.740 | and he deserves such a token of praise for that

00:52:26.740 | because prior to that, there was this,

00:52:31.260 | oh, I'll sleep when I'm dead mentality.

00:52:33.060 | I think people knew sleep was important,

00:52:34.860 | but they didn't really understand.

00:52:36.420 | And he had to come out as kind of the downer message,

00:52:41.420 | like, listen, this is serious stuff.

00:52:44.700 | - You better sleep. - You better sleep.

00:52:46.420 | But I think we're there now.

00:52:47.460 | I think in 2024, we're there.

00:52:50.620 | I think people understand.

00:52:52.060 | - And I think people have their own experiences

00:52:53.860 | with sleep, right?

00:52:54.700 | We've all felt that cold that's coming.

00:52:58.460 | And if we really sleep those eight hours,

00:53:01.720 | we may be able to fight it

00:53:03.220 | 'cause we've strengthened our immune system.

00:53:05.700 | If we don't, we will get sick.

00:53:08.700 | - Yeah, absolutely.

00:53:09.840 | Let's talk about some of the treatments that you use

00:53:13.580 | and have developed for PTSD in young people.

00:53:17.540 | And maybe we should define young people.

00:53:19.100 | Are we talking about the 18 and under

00:53:22.300 | just because that's typically what we think about?

00:53:24.380 | - So in pediatric psychiatry,

00:53:27.180 | we have three different populations.

00:53:28.920 | We have the preschoolers, we have the school age,

00:53:32.860 | and we have the teenagers.

00:53:35.180 | And they're all very different.

00:53:37.100 | They all have responses and defenses

00:53:40.260 | that are very different.

00:53:41.380 | The projects that I'm describing

00:53:43.580 | happen mostly with the school age children.

00:53:47.580 | - So preschoolers are gonna be essentially,

00:53:49.820 | I think of kindergarten starting at five.

00:53:52.280 | So you're talking about zero more to more or less

00:53:54.580 | five or six years old as the preschoolers,

00:53:56.460 | kindergartners, and then transition point.

00:53:58.420 | - Correct.

00:53:59.620 | - And then for the kids we're about to talk about,

00:54:02.500 | we're really talking about what, six years old

00:54:05.300 | until about end of adolescence?

00:54:07.740 | - Yeah, 15 and then, yeah, then the teenagers later on.

00:54:12.580 | - Okay, great.

00:54:13.540 | - So I work mostly with the school age kids.

00:54:16.800 | And like I said, when we started doing

00:54:19.340 | magnetic resonance imaging to look at the impact

00:54:22.320 | of cortisol, we have a number of studies

00:54:26.060 | really demonstrating that those kids

00:54:28.060 | with higher levels of cortisol

00:54:30.060 | had less volume of the hippocampus.

00:54:35.060 | The first study that we did in that was cross-sectional

00:54:37.780 | and there was no difference.

00:54:39.060 | And it gave me a lot of hope that there would be

00:54:41.140 | a window of opportunity there where we could intervene.

00:54:44.580 | Because what we were seeing in chronic PTSD in adults

00:54:47.180 | was that there was smaller volumes of the hippocampus

00:54:51.180 | which help us process memories

00:54:53.500 | and have strong connections with the emotional center

00:54:57.100 | of the brain, the amygdala,

00:54:58.460 | and also with the prefrontal cortex.

00:55:01.000 | And what we found was that cross-sectionally

00:55:06.000 | there was not this difference,

00:55:09.180 | but we also follow a small sample longitudinally.

00:55:12.420 | And there we saw a correlation

00:55:14.580 | between that higher pre-bedtime cortisol

00:55:17.420 | and the smaller hippocampal volume.

00:55:19.600 | More impactful was a functional imaging study,

00:55:24.540 | as many of your audience members know,

00:55:26.620 | with magnetic resonance imaging

00:55:28.340 | we not only can look at the structure,

00:55:30.480 | but we can also give tasks of memory, for example,

00:55:34.420 | or of executive function and different tasks

00:55:37.840 | that tap at the areas that we are interested in looking.

00:55:42.280 | So when we look, when we give a memory task

00:55:45.340 | and we looked at how children

00:55:48.100 | with post-traumatic stress symptoms were behaving

00:55:51.360 | compared to kids that do not have symptoms

00:55:54.700 | or other psychiatry diagnosis,

00:55:56.940 | we were seeing that the healthy kids

00:55:59.620 | were activating a lot of more voxels

00:56:02.900 | or units of the imaging of the hippocampus.

00:56:07.740 | So there was concern here that yes,

00:56:10.700 | that plasticity that you talked at the beginning

00:56:13.340 | was really affecting the development

00:56:16.060 | of the brain of the kids.

00:56:17.700 | And then with the prefrontal cortex

00:56:19.720 | we saw something similar in the ventromedial area

00:56:24.720 | of the prefrontal cortex.

00:56:27.740 | So, but with other tasks, right?

00:56:30.080 | With tasks of executive function or tasks of emotion,

00:56:35.080 | looking at faces, for example, emotional faces.

00:56:41.560 | All of this to say that they probably have

00:56:46.120 | a malfunctioning frontostriatal pathway and frontolimbic.

00:56:51.120 | So, frontolimbic, I'm sorry.

00:56:54.280 | So if we think of the amygdala, for example,

00:56:59.280 | in close proximity to the hippocampus,

00:57:04.960 | being involved in this hypervigilance

00:57:07.080 | and we have some data to show

00:57:08.960 | that the amygdala becomes active very quickly

00:57:11.440 | when you present emotional faces to young kids.

00:57:16.140 | And that that hyperactive amygdala

00:57:19.620 | needs a break of some sort.

00:57:22.500 | That break comes from the prefrontal cortex.

00:57:24.860 | But if you have a prefrontal cortex

00:57:26.980 | that's not working that well either,

00:57:29.420 | then your break is not working, right?

00:57:32.940 | So then the issue came here.

00:57:35.440 | Well, this is important information

00:57:37.940 | to know what we need to target with treatment.

00:57:40.920 | And can we target this with psychosocial interventions

00:57:44.340 | and the way that we provide treatment?

00:57:47.820 | And we decided to begin with what we discussed earlier,

00:57:51.380 | with the cues, right?

00:57:53.860 | And teaching and having kids understand what cues are,

00:57:58.860 | what classical conditioning is,

00:58:01.820 | talking to them about the impact of trauma,

00:58:07.540 | talking to them about the impact of treatment

00:58:11.420 | and how recovery is possible, right?

00:58:14.940 | So an educational piece.

00:58:18.740 | And something that I never thought I would end up doing

00:58:22.780 | was developing a treatment, right?

00:58:24.400 | I felt I'm here to investigate

00:58:26.620 | and use the treatments that we have.

00:58:29.060 | But it became very clear to me

00:58:31.260 | that there were a population of kids

00:58:33.860 | that still needed a form of treatment

00:58:35.780 | that was not out there.

00:58:37.700 | So most treatments out there for trauma

00:58:40.520 | were targeting one traumatic event

00:58:43.620 | and not targeting that backpack, that allostatic load.

00:58:47.500 | Also, and rightfully so, most treatments

00:58:50.780 | were requiring that the parents

00:58:55.780 | were involved in treatment as well.

00:58:59.820 | - I could see where that might be problematic

00:59:01.640 | when the parents perhaps were the source of the trauma.

00:59:04.900 | - And also when there's avoidance, right?

00:59:07.500 | And also when there's practicalities

00:59:09.480 | that if they lose one day from work

00:59:11.460 | they're gonna get fired.

00:59:12.740 | So sometimes the parents are just not available

00:59:15.620 | and the kids are totally ready to begin and do the work.

00:59:18.740 | So I wanted them to be able to do so.

00:59:21.260 | So how can we devise a treatment that is hybrid,

00:59:25.620 | and by that I mean multi-modal,

00:59:27.940 | that is not only cognitive behavioral therapy

00:59:30.900 | but that it brings other elements that are important

00:59:34.620 | like self-efficacy, empowerment, insight-oriented work,

00:59:39.620 | and give it a structure that can be tested.

00:59:45.760 | And that's how we created Q-Center, Q being C-U-E,

00:59:51.800 | Q-Center Therapy for kids that have PTSD.

00:59:56.720 | And we've had a number of trials with them

00:59:58.480 | and it helps decrease symptoms of anxiety,

01:00:02.760 | symptoms of depression, and symptoms of PTSD.

01:00:07.120 | And not only as scored by the student

01:00:12.120 | but also scored by observers, by the parents.

01:00:16.040 | And in one of the trials where we measure actually

01:00:18.440 | how the parents were doing,

01:00:19.720 | parents that were not participating in treatment,

01:00:22.380 | their own anxiety was decreasing as well.

01:00:25.320 | And that's easy to understand, right?

01:00:26.800 | If your kid is doing better,

01:00:27.960 | you're gonna do better as well.

01:00:31.200 | So that was very, very good to see.

01:00:34.320 | But then we wanted to see that plasticity too.

01:00:36.920 | Is this doing something to the activation of the brain?

01:00:40.880 | And that's when we brought functional

01:00:43.040 | near-infrared spectroscopy into the picture

01:00:46.920 | because it's cheaper than MRI

01:00:48.760 | and it's more portable and it's easier to do.

01:00:51.640 | It only gives you cortical information.

01:00:53.440 | It doesn't get into those interesting limbic structures.

01:00:56.480 | - So it's, just to highlight for a second,

01:00:59.680 | the fMRI, functional magnetic resonance imaging

01:01:03.200 | is wonderful because it allows a lot of

01:01:05.200 | imaging both on the superficial outer parts of the brain

01:01:10.160 | but also deep into the brain.

01:01:12.080 | My understanding is that,

01:01:13.960 | and perhaps this has changed in recent years,

01:01:16.200 | that the spatial resolution can be very good.

01:01:19.280 | You can pinpoint very small areas

01:01:21.800 | if you have a powerful enough machine, magnet.

01:01:24.940 | The temporal resolution, the ability to see changes

01:01:28.560 | in the neural circuit activation and deactivation over time

01:01:32.840 | at one point was somewhat limited,

01:01:34.240 | but now some of those limitations have been overcome.

01:01:36.840 | But then what you're talking about,

01:01:38.240 | near-infrared spectroscopy is excellent

01:01:42.560 | because it can be taken to a school, right?

01:01:45.760 | You don't have to,

01:01:46.840 | you couldn't bring an fMRI machine to a school

01:01:49.300 | unless it's a medical school where there's the machine.

01:01:52.360 | It's much less expensive.

01:01:54.240 | The downside is, oh, excuse me.

01:01:56.440 | And my understanding is that the spatial resolution

01:01:58.720 | isn't quite as high as MRI,

01:02:00.660 | but the temporal resolution is very high,

01:02:03.160 | which is a huge advantage.

01:02:05.120 | And then there's this one disadvantage

01:02:07.940 | that you can only really image

01:02:09.900 | the outer portions of the brain,

01:02:11.240 | but nonetheless, there's a lot of information there, right?

01:02:13.600 | So a little technical lesson.

01:02:15.000 | - And these outside areas of the brain,

01:02:16.840 | the cortical area and the prefrontal area,

01:02:19.460 | we're helping predict which kids would do better,

01:02:24.280 | only for those kids that were having Q-center therapy

01:02:27.460 | and another gold standard treatment called trauma-focused

01:02:31.060 | cognitive behavioral therapy,

01:02:33.020 | when they were both compared to treatment as usual.

01:02:37.860 | - I'd like to take a quick break

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01:04:25.100 | I want to get into the Q-centered therapy

01:04:27.460 | versus cognitive behavioral,

01:04:29.580 | versus the no therapy conditions you just described.

01:04:33.440 | But before we do that,

01:04:34.540 | I just want to have a brief discussion

01:04:36.980 | about some of the neuroscience you mentioned,

01:04:38.460 | because I think people will find this very interesting

01:04:41.140 | and certainly not just a listing off of names of structures.

01:04:45.300 | You said that the frontolimbic pathway is important here,

01:04:49.380 | the limbic pathway, including the amygdala,

01:04:51.220 | but other structures as well.

01:04:52.660 | And my understanding,

01:04:54.220 | and I think the generally accepted understanding

01:04:56.020 | about these limbic pathways,

01:04:57.180 | is that they create a response state,

01:05:00.700 | a state of alertness, a state of relaxation,

01:05:03.440 | that they translate certain information

01:05:06.780 | that impinges on them into a level of reactivity,

01:05:10.900 | either low, medium, or very high.

01:05:13.020 | When I say reactivity,

01:05:14.100 | a tendency to move toward or away from something

01:05:17.020 | or stay still, put in broadly speaking.

01:05:20.620 | Now, the fronto piece,

01:05:21.820 | the feeding in of information from the frontal cortex,

01:05:25.380 | where context-dependent decision-making,

01:05:27.860 | and as you said, executive function takes place,

01:05:30.700 | is so critical for all of us as we mature.

01:05:33.280 | Even as a, I would say, if you look at a puppy,

01:05:35.260 | everything's a stimulus.

01:05:36.540 | And then over time,

01:05:38.320 | they're not going to pick up everything in the room.

01:05:39.860 | That's without question,

01:05:41.380 | largely due to the development

01:05:42.740 | of these frontolimbic pathways.

01:05:45.100 | And in children and in humans, that is, it's the same.

01:05:48.860 | I can imagine that the signals coming

01:05:50.260 | from the frontal pathway to the limbic system

01:05:52.000 | are going to be somewhat cryptic to people

01:05:53.540 | that aren't familiar with psychiatry and neuroscience.

01:05:56.620 | So maybe we could just throw a few of those out there.

01:05:59.460 | Here's an example, tell me if I'm wrong.

01:06:01.460 | But the way I think about this is,

01:06:04.140 | okay, a kid is in a room and they're hyperactive.

01:06:09.140 | And, or maybe something set them off

01:06:11.900 | and they're particularly vigilant and stressed.

01:06:14.780 | They're in the stress response.

01:06:17.060 | The frontal cortex is the pathway

01:06:20.100 | by which an internal dialogue could be delivered

01:06:25.100 | to quiet that limbic pathway.

01:06:28.060 | The message that would perhaps trigger that

01:06:30.640 | would be the kid recognizing because they learned,

01:06:33.400 | this is okay, I've had this happen before, it passes.

01:06:39.860 | Or I'm supported, there's Dr. Carrion,

01:06:44.580 | there's my mom, there's my dad, there's my teacher,

01:06:46.580 | there's my friend, I'm supported

01:06:48.420 | because we know social support is important.

01:06:50.380 | Or it's normal to feel stress every once in a while.

01:06:54.220 | So these kinds of thoughts or these internal dialogues

01:06:57.020 | that we're told that we should do for ourselves

01:06:59.220 | when we're stressed, I think we can be pretty certain

01:07:02.420 | that that's the kind of information

01:07:03.940 | that would trigger this frontal to limbic suppression.

01:07:06.380 | - And can I comment on that dialogue

01:07:07.940 | because all of those are examples

01:07:10.020 | of positive thoughts, right?

01:07:12.380 | Positive thoughts that are good,

01:07:14.340 | but they're not automatic thoughts.

01:07:18.860 | They are thoughts that need to be practiced, right?

01:07:23.300 | Negative thoughts, unfortunately,

01:07:25.660 | that reside in our reptile brain are automatic.

01:07:29.860 | So that hyper response, I'm in danger type of situation,

01:07:34.860 | when we evolved, right, is responsible for our survival.

01:07:40.500 | So we learn the negative thoughts very well.

01:07:43.300 | I'm in danger, I have to run,

01:07:44.820 | I have to get on top of this tree,

01:07:46.620 | the lion might come, whatever.

01:07:48.460 | So only 50 million years ago,

01:07:52.420 | when we developed the frontal cortex more,

01:07:54.940 | positive thoughts came into the picture.

01:07:58.140 | And they're very helpful

01:08:00.580 | for all the reasons you're mentioning,

01:08:03.300 | but they're not automatic like the negative ones are.

01:08:06.540 | Hopefully they will become.

01:08:08.220 | So what I tell the kids is if they don't play guitar,

01:08:10.900 | if I give you a guitar right now,

01:08:12.860 | would you be able to play me a song?

01:08:14.380 | - Absolutely not.

01:08:15.220 | I have absolutely zero minus one musical ability,

01:08:19.140 | but I love music.

01:08:20.580 | - But if I gave you a guitar with guitar lessons

01:08:25.340 | and you practice,

01:08:27.020 | you probably will be able to play a song a year from now.

01:08:30.380 | - Well, me with some degree of proficiency,

01:08:32.820 | but not much. - With a lot of help.

01:08:33.660 | - But everybody else, yes.

01:08:35.380 | - A support system.

01:08:36.380 | - A support system, that's right.

01:08:37.980 | And with enough practice hours

01:08:39.500 | and enough focus and determination,

01:08:41.540 | I'm convinced I could become at least proficient

01:08:45.300 | even at 49 years of age.

01:08:48.660 | - So we have a slogan in my team,

01:08:50.220 | which is practice positive thoughts.

01:08:52.660 | All the thoughts you were mentioning are good ones

01:08:55.500 | and we have to practice them, right?

01:08:57.820 | This is what I'm learning.

01:08:59.220 | No, I'm not bad.

01:09:00.780 | This is happening because of the cue.

01:09:03.420 | - Even when the limbic system is not active,

01:09:05.860 | do you encourage your patients

01:09:07.660 | to practice positive thinking?

01:09:08.860 | - All the time.

01:09:09.700 | - Even when they're not in the stress response?

01:09:11.460 | - All the time.

01:09:12.300 | - Interesting.

01:09:13.140 | - It's like, it's learning a tool.

01:09:14.900 | So in this Q-Center therapy,

01:09:16.900 | one of the lessons is that they have an empty toolbox

01:09:20.380 | and this toolbox gets filled with tools that they learn.

01:09:25.380 | I'm practicing positive thoughts,

01:09:27.940 | deep breathing, mindfulness,

01:09:30.780 | all of this muscle relaxations are tools that we teach them,

01:09:34.940 | but they decide and here's where the empowerment comes in.

01:09:38.540 | They decide what the cues are.

01:09:41.460 | They decide what tools

01:09:43.060 | they're gonna put into their toolbox

01:09:45.340 | or they're not going to put in the toolbox.

01:09:48.180 | And by far, whatever tools they develop

01:09:51.940 | that have not been taught by me or anybody else

01:09:54.300 | work better when they develop it themselves.

01:09:59.060 | - Interesting.

01:10:00.100 | - And you know, I had this case once

01:10:04.140 | and it got illustrated really well.

01:10:06.060 | When I was in one of the sessions,

01:10:08.940 | you teach them breathing exercises, muscle relaxation,

01:10:13.140 | things that we know help

01:10:14.340 | and I'll talk a little bit more

01:10:15.540 | about how we know that they help.

01:10:17.460 | And then they have like a week to practice

01:10:21.140 | and then they come the next week

01:10:22.340 | and we see where they are

01:10:23.380 | and what's in the toolbox and things like that.

01:10:25.740 | And the next week when she came,

01:10:29.380 | she was much, much better, you know?

01:10:32.380 | And I said, I was very proud.

01:10:34.180 | I'm like, oh, you've been practicing the tools, right?

01:10:36.500 | That we discussed last week.

01:10:37.740 | And she's like, no,

01:10:39.020 | I actually don't remember anything you said last time.

01:10:42.980 | But I came up with this thing that when I feel bad,

01:10:45.860 | I'm drinking a glass of orange juice every time.

01:10:49.700 | And at that moment, I knew I could go both ways.

01:10:53.460 | I could go, no, no, you must practice my tools.

01:10:56.620 | Or I could say, how wonderful.

01:10:59.220 | You've identified a tool that helps you

01:11:01.940 | to drink a glass of orange juice,

01:11:04.020 | which obviously is what I did.

01:11:05.700 | And then she was able to have that in her toolbox.

01:11:09.340 | And we have multiple examples like this.

01:11:11.460 | - So she would drink a glass of orange juice

01:11:13.620 | in order to quell her anxiety?

01:11:15.420 | - Yeah, if she felt bad.

01:11:17.180 | - And is this something that she would do

01:11:19.300 | even when she wasn't feeling stressed?

01:11:21.580 | I mean, it's kind of interesting,

01:11:22.660 | but it suggests and it completely squares

01:11:25.300 | with everything I understand

01:11:26.380 | about prefrontal cortical limbic pathways,

01:11:29.740 | which is that they're highly subject

01:11:31.740 | to contextual learning, right?

01:11:33.660 | If anything, the frontal cortex

01:11:35.740 | is this incredible feat of evolution

01:11:38.260 | that allows us to link essentially any stimulus

01:11:42.420 | with any non-learned response in the body, right?

01:11:47.420 | I mean, this is what allows soldiers

01:11:50.420 | to learn to overcome their fear of bomb blasts

01:11:52.620 | and run toward them if necessary.

01:11:55.100 | I mean, it can come both ways, of course.

01:11:57.580 | - But for me, and this still needs to be tested,

01:12:01.260 | is nothing necessarily about the glass

01:12:03.300 | or even the orange or the vitamin C or anything like that.

01:12:05.980 | It's about the fact that she has this message.

01:12:10.020 | She has sent a message to herself.

01:12:13.140 | I can take care of myself

01:12:15.380 | because the best tool that I have is me, is my own body.

01:12:20.380 | Whatever these kids go in the future,

01:12:22.860 | there's something that's always gonna be there with them,

01:12:25.300 | which is themselves.

01:12:26.560 | So they, as themselves, is the best tool they can have.

01:12:30.260 | You know, their body, the way they think,

01:12:32.420 | all of these things.

01:12:33.900 | - Do you think this is why we hear

01:12:35.860 | the kind of classic anecdote

01:12:37.740 | about the patient who has anxiety attacks

01:12:40.740 | whose psychiatrist gives them a couple of pills

01:12:44.740 | of medication that can help reduce anxiety,

01:12:47.020 | and they decide to keep those pills in their pocket

01:12:49.800 | should they have an anxiety attack.

01:12:51.500 | And knowing they have those pills in their pocket

01:12:54.140 | allows them to control their anxiety.

01:12:57.620 | - Yes, because it gives them a sense of control, right?

01:13:01.460 | And they have control over this.

01:13:03.860 | And some people may choose to leave them in the fridge,

01:13:06.580 | and some people may choose to put them elsewhere,

01:13:08.980 | but it's what they decide.

01:13:10.420 | It's that decision they're making

01:13:12.900 | that gives them a sense of control.

01:13:16.320 | That's important.

01:13:17.420 | - It's so interesting, the sense of agency and control

01:13:19.840 | over the non-negotiable stress response.

01:13:23.700 | You know, I sometimes, unfortunately, get, in my opinion,

01:13:28.700 | incorrectly attached to ice baths.

01:13:34.020 | We've talked about cold water exposure on this podcast.

01:13:36.380 | Our colleague Craig Heller

01:13:37.460 | at Stanford Department of Biology,

01:13:39.340 | phenomenal scientist, was on this podcast.

01:13:41.020 | We talked about some of the beneficial uses

01:13:43.940 | of deliberate cold exposure.

01:13:46.140 | There are a lot of arguments.

01:13:47.180 | Does it increase metabolism?

01:13:48.580 | Doesn't seem like it does very much.

01:13:50.160 | Is it useful for inflammation?

01:13:52.360 | Perhaps, but the one thing that everyone agrees

01:13:55.280 | is that being in uncomfortably cold water

01:13:57.720 | makes you breathe faster, excuse me, and stress a bit.

01:14:01.760 | In other words, it kind of sucks.

01:14:03.600 | It's uncomfortable.

01:14:05.080 | And I think one non-negotiable fact

01:14:09.300 | about deliberate cold exposure

01:14:11.380 | is that it gives people an opportunity

01:14:13.520 | to explore their own stress response

01:14:16.140 | if they're going to do it safely, right?

01:14:17.740 | You take a cold shower, you have some control.

01:14:19.600 | You can get out immediately, obviously.

01:14:21.680 | You don't want it so cold

01:14:22.600 | that you give yourself cardiac arrest.

01:14:24.480 | You know, you have to be careful

01:14:25.320 | with deliberate cold exposure.

01:14:26.460 | But the adrenaline response to uncomfortable cold

01:14:30.320 | is non-negotiable.

01:14:31.720 | And I believe that whether or not somebody decides

01:14:34.960 | to recite the alphabet or think about how cold it is

01:14:38.000 | or whatever it is, what they're doing

01:14:40.200 | is they are practicing this frontal control

01:14:42.880 | over the limbic pathways.

01:14:44.640 | It's just sort of a general exercise

01:14:47.420 | for controlling the limbic system through thought.

01:14:51.020 | But as our colleague David Spiegel has said to me many times,

01:14:54.980 | he says, you know, it's not just the state that you're in.

01:14:59.300 | Here, we're talking about stress as the state.

01:15:01.500 | It's how you got there.

01:15:03.940 | And in particular, did you have any control

01:15:07.160 | over how you got there and whether or not you can get out?

01:15:10.460 | And I think that the kind of stress

01:15:11.800 | that you're talking about in post-traumatic stress disorder

01:15:14.580 | or in post-traumatic stress injury

01:15:17.080 | is typically of the sort that people didn't have a choice.

01:15:20.620 | Certainly, these kids didn't have a choice

01:15:22.340 | about the initial exposure to the trauma or stressors,

01:15:26.080 | but that also the stress is showing up

01:15:29.160 | when they would least want it to appear

01:15:31.060 | or when it's very inconvenient to appear.

01:15:33.360 | - So this narrative is an important part of recovery,

01:15:38.360 | but we feel that it needs to come after the education piece

01:15:44.060 | and after learning a toolbox, having defenses,

01:15:49.060 | because sometimes it can get very charged

01:15:52.440 | when you go through the narrative

01:15:53.860 | and you want to assess many things during the narrative.

01:15:57.100 | You want to assess gaps of memory.

01:15:59.140 | You want to assess potential cues.

01:16:01.680 | You want to assess the emotions that are present.

01:16:05.060 | So, and the narrative should be one

01:16:08.340 | that covers not only negative events,

01:16:11.100 | but also neutral ones and also positive events.

01:16:15.060 | And it sounds like a lot, right?

01:16:16.740 | But when you're talking about kids

01:16:18.040 | that have 10, 11, 12 years, it is doable.

01:16:20.920 | You know, you can really manage it.

01:16:23.520 | By the way, with the cold showers,

01:16:24.860 | I think you're getting to the hinge of that see-saw.

01:16:28.140 | I think the cold shower probably does,

01:16:31.340 | not the cold shower, what do you call it?

01:16:32.980 | - Deliberate cold.

01:16:33.800 | It could be from a cold shower.

01:16:35.180 | I always say that because oftentimes people think,

01:16:37.660 | oh, you know, they're just trying to sell cold plunges.

01:16:40.140 | And the truth is you don't need that.

01:16:41.660 | I mean, the fact of the matter is

01:16:43.420 | it's independent of income.

01:16:45.140 | Actually, a cold shower will save you money

01:16:46.920 | on your heating bill.

01:16:47.900 | I'm not saying everyone should take a cold shower.

01:16:49.660 | I love a nice warm or hot shower.

01:16:52.260 | I sometimes use the cold shower as a stimulus

01:16:54.260 | and I hate it every time,

01:16:55.980 | but I always learn something each time.

01:16:59.460 | By the way, it feels great when you get out.

01:17:01.480 | So that's nice.

01:17:02.340 | And it does for many hours,

01:17:03.740 | especially if you end it with some warm water.

01:17:05.900 | But the learning I believe is in recognizing

01:17:10.860 | just how destabilized our patterns of thinking get

01:17:14.080 | when we have adrenaline in our body,

01:17:15.580 | which is what uncomfortable cold does.

01:17:18.060 | And it deploys that adrenaline in the brain and body.

01:17:21.000 | And it also is a great learning

01:17:22.920 | in seeing the return to a baseline,

01:17:25.140 | just seeing how that affects our psychology.

01:17:27.460 | And to my mind, I can think of no other zero cost

01:17:32.340 | or even negative cost, meaning saves money,

01:17:35.780 | approach that works the first time in every time,

01:17:39.200 | that is safe enough, right?

01:17:42.420 | I mean, I'm not interested in anything

01:17:43.860 | that has to do with snakes, for instance.

01:17:45.620 | I don't mind spiders.

01:17:46.620 | I'll pick them up with my hands

01:17:47.580 | as long as it's not a black widow

01:17:49.180 | or a particularly large spider and I'll put it outside.

01:17:51.500 | But I don't like snakes.

01:17:53.020 | I don't like thinking about them.

01:17:53.900 | I don't like being near them.

01:17:55.020 | So, you know, there are other stressors that one could use,

01:17:57.820 | but it's so individual.

01:17:59.420 | Whereas cold water seems to be

01:18:01.420 | pretty uncomfortable for everybody.

01:18:02.940 | - I think you need some exposure of snakes

01:18:04.740 | when you're cold.

01:18:05.900 | (laughing)

01:18:07.220 | - No interest.

01:18:08.100 | It's so interesting.

01:18:08.940 | You know, these things get so firmly rooted,

01:18:10.580 | but I'd love to talk about this toolbox

01:18:13.500 | because first of all, it's according to your work,

01:18:18.660 | and this has been done repeatedly, it's very effective.

01:18:21.980 | And I love the idea that it can be customized.

01:18:24.940 | So the words that come to mind is a customized toolbox

01:18:28.540 | for combating stress and PTSD.

01:18:31.460 | And the fact that it can be customized

01:18:34.660 | and maybe even covert,

01:18:35.860 | like we can have these tools inside us.

01:18:37.580 | We don't need to share them with anybody

01:18:39.060 | if we don't want to, but that they are very effective.

01:18:42.020 | I think that those are very compelling reasons

01:18:44.260 | for exploring the toolbox approach a bit more here.

01:18:48.140 | So you mentioned one way to go about this

01:18:50.940 | is to think about or to have in mind some negative,

01:18:54.500 | some neutral and some positive experiences.

01:18:57.780 | And then to think about the different tools

01:18:59.500 | that one would deploy under those different conditions.

01:19:02.180 | - Correct.

01:19:03.020 | So the exercise of the events is a lifeline

01:19:06.340 | that we do separate from the toolbox.

01:19:08.180 | We actually work on the toolbox first

01:19:10.820 | to identify coping mechanisms and coping tools that help.

01:19:15.820 | - So what would that look like?

01:19:17.940 | Let's say I'm a nine-year-old, I come into your clinic

01:19:20.540 | and I meet the criteria for PTSI or PTSD.

01:19:23.540 | What sorts of questions would you ask?

01:19:28.420 | - Yes, so the first thing I would say,

01:19:30.660 | when you're feeling a certain way,

01:19:34.220 | whatever way we're talking about, right?

01:19:36.180 | - Anxious. - Agitated, anxious.

01:19:38.380 | - Nervous.

01:19:39.220 | - Is there anything that makes you feel better?

01:19:40.980 | Because the experience of having something

01:19:43.660 | and they bringing something is important too.

01:19:46.440 | And sometimes they do, they say, I listen to music

01:19:49.220 | or I play the guitar or I go to play or--

01:19:53.060 | - My friends.

01:19:53.900 | - Or my friends or my teammates mostly, actually.

01:19:58.020 | - They say teammates?

01:19:58.940 | - Teammates is pretty popular.

01:20:00.420 | - I love that.

01:20:01.260 | - Yeah, there's something about sports.

01:20:03.300 | And sports is something that comes up a lot

01:20:06.380 | when we do the toolbox.

01:20:07.780 | People put in their sports they're doing

01:20:10.740 | or talking to their coach or talking to their teammates

01:20:14.100 | or learning a new sport.

01:20:16.800 | Sports are big, so that's an example that they give.

01:20:20.500 | Talking to friends,

01:20:23.100 | planning a sleepover,

01:20:28.240 | listening to music,

01:20:30.220 | different things like this.

01:20:33.860 | - Are there any particular tools

01:20:35.340 | for when kids are stuck in a stress response?

01:20:40.340 | - Yes.

01:20:41.260 | - Because I, myself, am familiar with the toolkits

01:20:45.860 | that I use, certainly teammates is one of them.

01:20:48.900 | And I have others, including long exhale breathing,

01:20:51.240 | physiological size, these things will be familiar

01:20:53.380 | to some of the listeners.

01:20:55.460 | But certainly there are times when we're stressed

01:20:59.260 | about something and we don't want to be

01:21:01.840 | and we have a hard time pulling our thoughts

01:21:05.260 | and our emotions and the stress response out.

01:21:09.300 | - So the ones I just mentioned are some ideas

01:21:11.500 | that the kids bring with them.

01:21:12.900 | What we always try to do is we teach them

01:21:17.460 | exercises of relaxation.

01:21:19.600 | We have to be very careful with this

01:21:21.620 | because, like you say, it's good to be personalized, right?

01:21:25.540 | It's good that it's adapted to the kid.

01:21:29.220 | And that's why we don't tell them put this in your toolbox.

01:21:32.700 | We tell them learn it and if it helps you,

01:21:35.740 | you decide if you put it in the toolbox or not.

01:21:38.940 | So when I talk about the treatment being not so much

01:21:41.340 | about the what, because there's many components here

01:21:44.060 | like education, narrative, that are common, right?

01:21:48.820 | Exposure, we can talk about.

01:21:51.500 | It's not so much about the what, but it's about the how.

01:21:54.100 | It's about empowering kids to identify those cues,

01:21:57.820 | to say if a tool works or doesn't work,

01:22:00.620 | to develop their own tools.

01:22:02.740 | So, but sometimes they're very stuck, right?

01:22:05.600 | And they need a little bit of help.

01:22:07.340 | So we teach them breathing exercises

01:22:10.020 | and we have a script for that.

01:22:11.360 | We teach them muscle relaxation

01:22:14.620 | and we have something for that.

01:22:17.120 | We teach them the positive thinking, for example.

01:22:20.240 | So that's a cognitive type of tool.

01:22:23.080 | And we teach them mindfulness because of our other work

01:22:29.540 | in prevention that we can talk about later

01:22:32.820 | in which mindfulness has been helpful.

01:22:37.820 | And also yoga, very simple yoga exercises.

01:22:42.620 | So nothing too complicated.

01:22:44.820 | Things like the mountain pose, for example,

01:22:47.940 | can be quite helpful for some kids.

01:22:50.560 | If anything, it helps them reassess the moment and stop.

01:22:55.560 | And if we're gonna think about it

01:22:58.760 | in cognitive behavioral terms,

01:23:01.000 | kind of break that chain of negative thoughts

01:23:05.240 | that happen one after the other,

01:23:06.600 | which can lead to a panic attack, right?

01:23:08.760 | That's many times how a panic attack can start.

01:23:12.320 | - Well, what's so interesting to me

01:23:13.520 | about the stress response is that while it's quick to start,

01:23:16.720 | it's slow to shut off for logical reasons

01:23:19.620 | related to our evolutionary trajectory, right?

01:23:23.800 | Wouldn't it be wonderful if you could stress when needed

01:23:26.420 | and then it would turn off when needed?

01:23:27.820 | But what we're really talking about here

01:23:29.500 | is intervening in the stress response

01:23:31.860 | either before or as it's happening,

01:23:33.680 | but then also making sure that the tail

01:23:35.420 | of that stress response isn't too long.

01:23:37.340 | - We're also talking about eradicating stress

01:23:40.300 | that causes discomfort, right?

01:23:42.320 | And this causes distress,

01:23:45.840 | not necessarily to live a life without stress

01:23:49.200 | or to get rid completely of stress

01:23:51.920 | 'cause that would be impossible.

01:23:53.960 | - In certain cultures, there are accepted practices

01:23:58.600 | that adults use to deal with stress,

01:24:01.880 | things like worry beads.

01:24:03.680 | And a few years back, there were those,

01:24:05.680 | what are those, what were the little spinner things

01:24:07.920 | that kids had?

01:24:09.900 | When those were popular, maybe they're still popular,

01:24:12.580 | did you observe any reductions in stress?

01:24:16.020 | You know, kids have a lot of energy.

01:24:17.300 | Like sometimes I think we confuse energy and stress.

01:24:20.860 | Wouldn't we all love to have the kind of energy

01:24:22.540 | that we had in childhood?

01:24:23.860 | I was observing this the other day.

01:24:27.260 | You'll see a kid sitting cross-legged, listening in class,

01:24:29.820 | and then all of a sudden it's time to move across the room

01:24:32.180 | and they'll just pop up and move across the room.

01:24:34.020 | Like when was the last time any of us

01:24:35.540 | like popped up out of our chairs

01:24:36.740 | unless we were particularly excited or scared as adults?

01:24:39.980 | Just that immediacy to action

01:24:42.060 | implies that there's a lot of energy in the system.

01:24:45.880 | So I could imagine that having some ways

01:24:47.940 | to siphon off some of that energy through,

01:24:51.300 | as far as I can tell, you know,

01:24:53.340 | things like worry beads or fidgets

01:24:55.380 | or whatever those are called.

01:24:56.580 | I mean, they might irritate some adults around,

01:24:58.580 | but really they're pretty innocuous

01:24:59.940 | when you think about it.

01:25:00.780 | - I like that you're not calling it nervous energy

01:25:04.020 | because it is just what you said, it's just energy.

01:25:06.380 | It's extra energy that needs to be placed somewhere

01:25:09.740 | and they're trying to find out where to place it.

01:25:11.540 | - I mean, we have colleagues that, not all of them,

01:25:13.660 | this is not a requirement for being a professor at Stanford,

01:25:15.980 | but I've got colleagues that work 80 hours a week.

01:25:19.660 | You could argue that's healthy or unhealthy

01:25:23.140 | depending on the context and their agreements with others,

01:25:25.940 | but, you know, that requires a lot of energy

01:25:28.760 | and I know they are not particularly happy working less.

01:25:33.060 | So, you know, I think sometimes we are dismissive

01:25:35.760 | or kind of pejorative about physical energy

01:25:40.300 | and shaking and moving.

01:25:41.640 | But, you know, I see, I know someone in my life

01:25:44.040 | who bounces her knee while she works

01:25:46.060 | and it kind of makes me a little bit nervous,

01:25:48.880 | but boy, does she have a lot of focus and energy.

01:25:52.060 | You know, so, I mean, I think it's wonderful,

01:25:54.220 | in other words.

01:25:55.060 | - Yeah, and some of us, you know,

01:25:56.900 | choose to have meetings while walking

01:25:59.900 | rather than being in an office.

01:26:01.420 | - That's certainly my preference.

01:26:02.540 | - You know, I go for a walk sometimes

01:26:04.700 | when I have a meeting.

01:26:06.140 | So, yes, so there is increased energy,

01:26:09.060 | but there's increased energy that of,

01:26:13.020 | I feel like I need to do something

01:26:14.540 | and there's increased energy

01:26:16.060 | that causes a lot of discomfort.

01:26:18.000 | So, for this kid, kids that experience discomfort,

01:26:22.060 | then they can look at their toolbox and say,

01:26:25.820 | "Which one I'm gonna use?"

01:26:27.860 | And that gives them also a choice,

01:26:29.780 | which goes back to that sense of control again.

01:26:32.940 | - Earlier, meaning off microphone,

01:26:35.460 | we were talking about the fact that some people,

01:26:39.100 | indeed some kids, have a different tendency

01:26:41.940 | to anchor towards thinking or feeling or action

01:26:45.380 | when under stress.

01:26:46.220 | And you were describing the four quadrant system.

01:26:49.860 | Could you share with us this four quadrant system?

01:26:51.820 | Because I think it's both extremely valuable

01:26:54.520 | to children and to adults.

01:26:57.780 | It's certainly something that I plan

01:26:59.100 | to incorporate into my life.

01:27:01.460 | - Yes, so we have to be careful

01:27:04.460 | with structured interventions

01:27:07.500 | because sometimes structured interventions

01:27:10.740 | can break a little bit the fluidity

01:27:14.220 | of the relationship that a therapist and a child may have

01:27:18.980 | or a therapist and a patient.

01:27:21.420 | So, it's better to be semi-structured

01:27:24.300 | and to really be attentive to the temperament

01:27:28.860 | that the kid brings into that relationship

01:27:32.100 | or into that session.

01:27:33.620 | And certainly, with the toolbox, as you mentioned,

01:27:36.620 | we see an example of that.

01:27:38.500 | We also add that in Q-Center therapy

01:27:43.340 | by dissecting and examining a response.

01:27:48.260 | So, for example, a child that breaks windows

01:27:53.260 | or a child that screams

01:27:55.840 | or a child that leaves the classroom running,

01:27:59.460 | we try to understand what's happening at that moment.

01:28:02.500 | And the way that we do that is by looking at a square.

01:28:05.620 | And a square is composed of four corners.

01:28:09.300 | And the four corners are what you're thinking,

01:28:13.060 | so it's a cognitive side to it,

01:28:15.120 | what you're feeling emotionally,

01:28:19.660 | what you're feeling physically,

01:28:23.300 | and what you're actually doing, what the action is.

01:28:28.300 | And this is your classical triangle

01:28:32.620 | of cognitive behavioral therapy

01:28:34.200 | in terms of what you're thinking,

01:28:36.220 | what you're doing, and how you're feeling.

01:28:38.460 | But we felt it was important to add

01:28:41.380 | that somatic physiological component

01:28:44.460 | because for many children,

01:28:46.820 | they don't have the vocabulary to talk about all of this.

01:28:49.460 | They just tell you, "I have a headache,"

01:28:51.060 | or, "I have a stomachache,"

01:28:52.580 | and there's no other medical reason that explains it, right?

01:28:56.480 | So, depending on the kid that comes,

01:29:00.300 | you're gonna start examining their response

01:29:03.220 | through one of those corners.

01:29:05.300 | So, if the kid is really brainy

01:29:06.980 | and likes to think about the things they think

01:29:09.020 | or don't think, you start in the cognitive corner.

01:29:12.980 | Other kids are very attentive to their body

01:29:15.460 | and they say, "I feel my heart racing

01:29:17.820 | when I engage in this behavior or in this response,"

01:29:21.820 | and you start with that corner.

01:29:23.500 | The beauty of this is that most of the time,

01:29:26.020 | you don't have to work in all of the corners.

01:29:27.900 | By just working in one corner,

01:29:30.100 | all the other corners change and a new response develops.

01:29:34.460 | Okay, so if I'm thinking that I'm not in danger,

01:29:38.080 | maybe I don't need to leave running.

01:29:39.740 | Maybe I can just tell the teacher

01:29:42.380 | I'm distressed by the amount of noise.

01:29:45.460 | All of a sudden, the kid has created a new square.

01:29:47.940 | That's another square.

01:29:48.860 | So, hopefully we take that one response as a square

01:29:52.020 | and build a cube, right, of many potential responses

01:29:56.660 | so that when the cube happens,

01:29:59.140 | now there's an armamentarium of responses

01:30:03.580 | and if I'm too distressed to think what response to do,

01:30:08.420 | I can bring myself there by using my toolbox.

01:30:12.060 | So, it all kinds of starts tying together

01:30:15.300 | and then as I have more responses, as I understand cues,

01:30:19.580 | I can begin talking about this narrative that I have

01:30:24.580 | where I will fix some cognitive distortions, hopefully,

01:30:29.660 | like it was my fault I made it happen to things like,

01:30:34.660 | no, it wasn't my fault.

01:30:37.140 | Somebody else was responsible and I'm just a survivor,

01:30:40.660 | right, I'm not a victim.

01:30:41.660 | I'm a survivor.

01:30:42.500 | That's another cognitive distortion that can be fixed.

01:30:44.980 | So, all of that, we've included all of this

01:30:49.100 | in a manual for therapists, right?

01:30:51.540 | So, we have a manual for therapists

01:30:53.220 | that is called Cue Center Therapy for Youth

01:30:56.620 | with Post-Traumatic Symptoms published by Oxford.

01:31:00.620 | But I believe that adults that want to re-examine

01:31:05.620 | their childhood or their history

01:31:08.380 | or want to think about their kids

01:31:10.620 | or are interested in trauma can get a lot

01:31:13.500 | from actually examining this manual and studying this manual

01:31:17.180 | and in fact, I believe in so, so strongly

01:31:19.820 | that we are beginning the first steps of adapting it

01:31:24.820 | not only for youth, but also for adults.

01:31:29.340 | - In this four-corner system, and forgive me

01:31:33.060 | because I called it a four-quadrant system,

01:31:34.840 | but in this four corners of the square system,

01:31:37.540 | you said there's thinking, which is cognitive,

01:31:39.380 | there are emotions, then there's feelings,

01:31:43.280 | which are somatic, physical, and then actions.

01:31:45.900 | So, actions are straightforward.

01:31:47.340 | Thinking would be, for instance,

01:31:50.500 | if I understand correctly, I'm in danger.

01:31:52.740 | Emotions would be, I'm scared.

01:31:56.300 | So, it's a verbal label.

01:32:00.740 | I'm depressed, I'm scared, I'm sad, I'm--

01:32:04.660 | - Yeah, in a way, it's cognitive too, right?

01:32:06.420 | But it carries an emotion with it.

01:32:09.020 | And then, in terms of the physical feeling,

01:32:10.660 | it's of the body, but it could include of the head too.

01:32:13.820 | Like, I have a headache, or my heart is racing,

01:32:17.060 | or I'm, you know, or something of that sort.

01:32:20.940 | And then, actions, of course, is the action that they--

01:32:22.980 | - And action is a really fun one

01:32:24.660 | because you can imagine there are some kids

01:32:27.060 | that are not psychologically minded at all,

01:32:29.340 | and they don't even want to engage in this with me.

01:32:32.020 | And they are like, okay, what is it that I'm doing?

01:32:33.980 | I'll do something different.

01:32:35.300 | So, they'll immediately develop the next square.

01:32:38.300 | So, they cannot talk too much about their emotions

01:32:41.700 | or how they're feeling physically

01:32:43.780 | or look at the negative thought.

01:32:46.020 | But they say, oh, is the problem

01:32:47.940 | that I'm running out of the classroom?

01:32:49.820 | Well, what if I don't?

01:32:51.540 | And they give you another action.

01:32:53.380 | And so, some kids start with that corner.

01:32:56.540 | So, you can really start with any of the corners.

01:32:59.260 | - Yeah, I love that earlier,

01:33:01.020 | you were talking about practicing positive thinking

01:33:04.140 | even when, perhaps especially when,

01:33:06.500 | one is not in the stress response or trauma response,

01:33:09.040 | but also, of course, when one is in the trauma response.

01:33:11.220 | I think that's just so vitally important

01:33:13.720 | for people to hear, certainly for me to hear.

01:33:16.980 | I'm not claiming to have PTSD,

01:33:18.820 | but as a novel concept that I've not heard raised before

01:33:23.100 | around these topics.

01:33:26.300 | The other is this four-corner system,

01:33:29.300 | which immediately occurs to me as so powerful

01:33:33.780 | because it breaks down the kind of reflex arc

01:33:37.860 | of the stress response into its component parts, right?

01:33:40.700 | What's of the body, what's of the thinking,

01:33:42.580 | what's of the thinking that's emotional,

01:33:44.200 | and then what's the action?

01:33:45.420 | And you said as soon as one identifies one of these corners

01:33:50.420 | and starts to kind of look at it differently

01:33:53.580 | and consider some of the optionality that exists,

01:33:56.020 | an alternative, that all these other options

01:33:58.700 | cascade from that.

01:33:59.740 | And I believe that in doing that,

01:34:01.260 | you've described what for thousands of years, really,

01:34:05.980 | but recently we've heard a lot about

01:34:08.340 | in the kind of mindfulness arena as creating space, right?

01:34:12.940 | Like this notion of creating space, not outer space,

01:34:15.540 | but creating space within us to choose better options

01:34:19.960 | is something that I think until right now,

01:34:21.960 | as you've described this,

01:34:23.020 | has remained unfortunately very mysterious.

01:34:25.660 | You know, people talk about, okay, you know,

01:34:28.860 | you want to be reactive, excuse me,

01:34:32.120 | you want to be responsive, not reactive.

01:34:34.940 | Responsive implies some optionality to your responses.

01:34:37.700 | Reactive implies kind of a reflex arc

01:34:39.620 | of just whatever the default was.

01:34:42.120 | But this notion of space is like too squishy for me

01:34:44.680 | as a biologist to really be able to latch onto.

01:34:48.940 | And I would argue, given the prevalence of PTSD and stress,

01:34:52.340 | it's probably too squishy for most people.

01:34:54.220 | It hasn't really led anywhere specific.

01:34:57.060 | But I think what you're describing is

01:34:58.700 | the ability to become responsive as opposed to reactive,

01:35:01.580 | assuming that the word responsive

01:35:03.860 | includes like some options within it.

01:35:06.740 | And so this four corner system to me is genius

01:35:09.740 | because it gives us an anchor point to start from.

01:35:12.700 | So could you say that if a child or adult

01:35:14.660 | is uncomfortably stressed, maybe about a trauma,

01:35:17.620 | but just is caught in the stress response,

01:35:20.480 | that actually pulling out a pen or pencil

01:35:22.500 | or crayon as it were, and drawing a square,

01:35:25.500 | and just really like, what am I thinking?

01:35:27.540 | Like, maybe it's just like, this is terrible.

01:35:31.140 | I don't like it.

01:35:32.700 | Writing down, I'm embarrassed.

01:35:35.700 | Like, I'm not with my friends.

01:35:38.060 | Like, I'm like not, you know, I'm flush.

01:35:40.300 | You know, my cheeks are flushing, whatever.

01:35:42.740 | I'm feeling like just weighed down or something.

01:35:47.460 | And then thinking, well, what are the actions?

01:35:49.080 | I wanna remove myself from the situation.

01:35:51.780 | At that point is the suggestion that one find,

01:35:54.100 | what is the point of entry that feels most accessible?

01:35:57.940 | And to start there?

01:35:59.180 | - Yes, with one caveat.

01:36:01.460 | We usually use Wagner's emotional thermometer

01:36:06.460 | to measure where the kid is at.

01:36:10.140 | And it goes from like zero to 10 or one to 10

01:36:13.460 | with different levels of stress.

01:36:16.220 | And it's good to use something concrete

01:36:19.000 | because sometimes we think they're at 10

01:36:21.140 | and they're at five or vice versa.

01:36:23.300 | - Yeah, we're very poor at assessing others' internal states.

01:36:26.180 | - We are.

01:36:27.020 | - As our colleague, Karl Deisseroth,

01:36:27.900 | who's also been a guest on this podcast,

01:36:29.980 | I heard him once say this in a very large lecture.

01:36:31.860 | He said, you know, we're terrible,

01:36:33.580 | absolutely dreadful at assessing other people's emotions.

01:36:36.720 | In fact, most of the time, we don't even know how we feel.

01:36:38.820 | - Yeah, he always says that.

01:36:40.340 | And it's true.

01:36:41.180 | - It's so true. - And it's true.

01:36:42.500 | But I would say if the kid is at 10 at that moment,

01:36:46.160 | the best thing is to use a tool from the toolbox

01:36:48.860 | and not to engage on the square at that moment

01:36:51.380 | until they come down a little bit

01:36:53.060 | and they can pay attention and they can listen to you.

01:36:55.920 | Because then they will be letting the information come in.

01:36:59.700 | They're so emotionally charged right at the moment

01:37:02.700 | that that may not be the right time.

01:37:04.860 | Which also, by the way, is the same thing

01:37:09.620 | as when you need to talk to kids

01:37:11.580 | about traumas that are happening in our society, right?

01:37:16.580 | Sometimes you just wanna let them know

01:37:18.820 | that the door is open for communication.

01:37:21.780 | You may wanna talk about it at the moment

01:37:23.340 | where the kid may not be ready.

01:37:25.080 | But you can let them know, well, when you're ready,

01:37:28.260 | we can talk about it.

01:37:29.900 | Here, the same.

01:37:30.940 | When you're ready, let's go over the square exercise

01:37:35.580 | or the example if the kid is already familiar with it.

01:37:38.180 | Or I have something to show you, right?

01:37:40.820 | And pick his curiosity that way.

01:37:43.380 | But I would say use the thermometer

01:37:46.620 | to see if that's a good time, right?

01:37:48.500 | If it's 10, nine, eight, probably not.

01:37:51.140 | Wait 'til it's like five, four, three.

01:37:53.740 | And then engage in that.

01:37:55.660 | - So the toolbox should be used

01:37:59.380 | essentially under any conditions.

01:38:01.020 | And the kid should generate their own tools

01:38:05.200 | to add to the toolbox, customize the tools.

01:38:09.060 | And then the square can be used

01:38:11.600 | when they are at a slightly lower level of stress

01:38:14.300 | because it requires a certain level

01:38:15.660 | of cognitive intervention.

01:38:16.900 | They need to be able to think about

01:38:18.340 | and express their own state.

01:38:21.020 | - Correct.

01:38:22.260 | - And is this something that you suggest kids

01:38:24.900 | only do with their therapist

01:38:26.260 | or is this something that they can do on their own as well,

01:38:28.660 | assuming that they're old enough to write

01:38:30.900 | and to think about it?

01:38:31.780 | - Yeah, well, our hope is that after a kid

01:38:34.820 | goes through Q-Center therapy,

01:38:36.500 | that they can internalize a lot of these activities

01:38:39.500 | and exercises and, like I said, become their own tool.

01:38:43.420 | Take those for life and continue to use them.

01:38:47.020 | - Yeah, I'm certain that many, many adults,

01:38:49.340 | not just children, can benefit from these tools.

01:38:51.820 | I mean, I would argue that most of the bad things

01:38:55.820 | that happen in the world are the consequence

01:38:59.100 | of dysregulated autonomic function, put kind of bluntly.

01:39:04.100 | - Yeah, by directional, right?

01:39:06.460 | Kind of making things worse.

01:39:07.740 | Once they happen, they impact the system even further.

01:39:11.140 | - Yeah, I mean, I think most homicides

01:39:12.740 | are homicides of jealous rage.

01:39:15.620 | From what I have read, I don't know if that's still true.

01:39:18.920 | And, of course, then that is probably also true

01:39:21.660 | for all the things that are not as severe as homicide,

01:39:23.940 | but still dreadfully bad, like assault and things like that.

01:39:27.180 | - And it's interesting that you bring that up

01:39:29.940 | because I often think about,

01:39:32.600 | we've been talking about how we experience trauma

01:39:35.580 | as individuals, right?

01:39:37.420 | But we experience trauma in our civilization.

01:39:41.740 | We experience trauma in our history.

01:39:43.820 | We experience trauma in our nation

01:39:46.100 | and how does a nation heal?

01:39:48.540 | How does a system heal?

01:39:50.480 | Well, the steps are not that different.

01:39:53.080 | - Perhaps this is the appropriate time

01:39:54.860 | to give you the opportunity to editorialize

01:39:58.000 | a little bit about social media and online behavior,

01:40:02.300 | setting aside really aggressive online behavior,

01:40:05.020 | bullying and things like that,

01:40:06.240 | which of course exists and is really serious.

01:40:08.540 | Do you see the behavior of kids and adults online,

01:40:15.680 | this sort of just maybe even the addiction to online,

01:40:20.540 | commenting and reading of comments

01:40:22.160 | and the kind of battling of issues back and forth,

01:40:24.200 | that clearly isn't going anywhere.

01:40:25.740 | Some of it goes someplace functional,

01:40:27.480 | but most of it, I would argue,

01:40:29.320 | especially among the adults, is going nowhere.

01:40:31.320 | It's just very circular.

01:40:32.480 | It's my side versus your side, my side versus your side.

01:40:35.080 | And emotions get really stirred on there.

01:40:37.700 | Do you think that is reflective

01:40:40.400 | of a lack of tools for self-regulation?

01:40:45.000 | Do you think like what we're seeing

01:40:46.240 | is the manifestation of just a lot of challenges

01:40:50.320 | in the world and/or an outlet for people

01:40:54.040 | to just vent without the need

01:40:55.720 | to address their own internal state

01:40:57.560 | and what's underlying the venting?

01:40:59.160 | I know many very, very intelligent adults

01:41:03.160 | who eventually just had to quit social media

01:41:05.520 | in order to have any level of functionality in their life.

01:41:08.200 | - It comes down to that space you were talking about

01:41:10.500 | and building that space and creating that mindfulness,

01:41:14.200 | time that you need, which is also gonna be personalized.

01:41:16.520 | It's gonna be different for different people.

01:41:19.600 | This spring, I was in Morocco and I visited the Medina.

01:41:23.200 | I was staying at the Medina.

01:41:25.100 | And I was overstimulated, as you can be, and enjoying it.

01:41:30.100 | But I imagine this is the state

01:41:32.560 | that teenagers are in all the time

01:41:35.000 | when they are with social media,

01:41:36.780 | bringing them information and different tidbits

01:41:39.760 | and different things that are happening all over the place.

01:41:43.440 | And very much like I found it restful

01:41:46.400 | to go to my hotel for a couple of hours before dinner,

01:41:49.420 | people need to build that space.

01:41:52.560 | People need to create that space.

01:41:55.300 | What I tell parents is that it's important to remember

01:42:00.300 | that this was also a very helpful tool for us

01:42:05.040 | when we were in the pandemic, right?

01:42:07.560 | The kids were interacting socially,

01:42:10.520 | academics, school was happening through technology.

01:42:15.140 | So how can something so good be at times so harmful?

01:42:20.140 | And I remind them about when they brought hammers

01:42:26.520 | to their house, right?

01:42:29.120 | And they had little kids.

01:42:30.480 | They had to teach them how to use them.

01:42:32.820 | This is a very important tool

01:42:34.680 | when you need to nail something

01:42:36.680 | or when you need to take a nail out.

01:42:39.000 | This can be dangerous, right?

01:42:40.200 | You don't run with scissors.

01:42:41.360 | You have all these rules around other tools.

01:42:44.800 | We have to have these rules around social media as well.

01:42:48.960 | And I think that's what the Surgeon General is getting at

01:42:53.080 | when he talks about we need some regulations around it.

01:42:56.960 | But at the family level,

01:43:01.120 | I think parents need to say there are certain boundaries

01:43:05.800 | that we are going to have.

01:43:08.760 | So at dinner time, for example,

01:43:11.240 | in this baskets, all the phones go into the basket.

01:43:15.400 | And that's what we're gonna do from now on.

01:43:17.800 | But it is very difficult

01:43:19.360 | because when you establish rules like that,

01:43:22.200 | kids watch you like a hawk.

01:43:24.820 | So you have to model the behavior you are expecting, right?

01:43:29.820 | The moment that you as a parent decide,

01:43:32.320 | oh no, I need to go to the basket during dinner

01:43:34.200 | 'cause I need to check this thing out, then it breaks.

01:43:39.000 | So that's what I think.

01:43:39.840 | I think it can be quite helpful.

01:43:41.920 | And I think that it can be dangerous.

01:43:44.860 | We've seen examples of that.

01:43:46.960 | And it is a tool like any other, like a knife,

01:43:51.020 | that we need to learn how to use it.

01:43:53.160 | - I think what you're describing to my mind

01:43:55.360 | is a situation where the tool has become the terrain.

01:43:58.720 | It's like social media has become the landscape

01:44:01.120 | in which many people live as opposed to the real world.

01:44:06.000 | I mean, my original understanding of social media

01:44:08.400 | is that one would experience and do things in the real world

01:44:11.260 | and then bring those to social media.

01:44:12.840 | That's certainly what I do.

01:44:13.700 | I teach on social media

01:44:14.920 | and I do the learning for that teaching,

01:44:18.200 | the drawing in some cases,

01:44:19.840 | the preparation in the quote-unquote real world,

01:44:22.880 | and then bring it to social media.

01:44:24.040 | But I feel like it's almost like the hammer

01:44:27.560 | has become the landscape.

01:44:31.040 | - The house.

01:44:31.880 | - Yeah, or something like that.

01:44:33.040 | The hammer has become the house.

01:44:34.100 | Yes, that's a much more eloquent and appropriate.

01:44:38.180 | Yeah, I feel like with social media,

01:44:40.020 | the tool of social media has become the terrain

01:44:42.200 | in which people are living in.

01:44:43.620 | So that just feels like a closed loop.

01:44:47.320 | Use sort of an engineering example.

01:44:51.660 | So it's like, it doesn't go anywhere.

01:44:53.100 | Like you can never actually get the relief

01:44:55.140 | that you're seeking.

01:44:55.980 | And I think we default to descriptions about dopamine

01:44:58.780 | and dopamine hits.

01:45:00.180 | And there's some truth to that.

01:45:01.780 | But the more I look at the literature on brain activation

01:45:04.660 | during social media use,

01:45:06.740 | it doesn't really speak to dopamine

01:45:08.540 | and reward prediction error as much as it does,

01:45:10.540 | just sort of a mindless compulsion

01:45:13.500 | and kind of just passive overuse

01:45:17.140 | as opposed to like rewards,

01:45:18.340 | like, oh, this is so cool and that's so cool.

01:45:19.900 | I mean, it can be.

01:45:21.020 | I mean, I've been watching some of the track

01:45:22.340 | and field races of the Olympics and there's a,

01:45:24.500 | I mean, I was cheering out loud for a few of them,

01:45:26.900 | but it's usually something quite different.

01:45:31.780 | - Yeah, I think if you live in a virtual world all the time,

01:45:36.780 | then you're not living, right?

01:45:40.620 | You're not in the real world.

01:45:42.100 | So it's like, how can you use the virtual?

01:45:44.340 | Are there ways that the virtual world

01:45:46.500 | can help you live the current world in a better way?

01:45:51.460 | Yes, so that's why I think it's helpful.

01:45:55.420 | But if you replace your life with a virtual life,

01:46:00.420 | then that's a pity.

01:46:01.620 | That's very sad.

01:46:03.100 | - I see that in a lot of adults as well as kids.

01:46:06.740 | Let's talk about risk.

01:46:08.180 | You know, up until now we've been envisioning

01:46:10.020 | a treatment situation or a study that you're running

01:46:12.720 | where a kid and perhaps parents as well

01:46:15.660 | are brought into the laboratory or clinic at Stanford

01:46:19.020 | and you're talking to them, assessing them.

01:46:20.400 | They're developing a custom toolbox

01:46:22.100 | and that's a wonderful opportunity

01:46:25.500 | for kids who sadly have PTSD or PTSI to be assessed

01:46:30.500 | and to develop tools that can really help them.

01:46:34.140 | That's been proven by the work you and others have done.

01:46:37.420 | But what about the many, many millions of kids and adults

01:46:41.560 | who are at risk either because of lack of access,

01:46:45.140 | it could be due to finances, geography, poverty,

01:46:49.460 | any number of different things,

01:46:51.380 | or they simply don't even know what PTSD and PTSI are.

01:46:55.700 | Their parents don't know.

01:46:57.740 | What are some of the tools and interventions

01:46:59.740 | that you think could be implemented

01:47:01.540 | at the level of schools, families,

01:47:03.180 | or even individuals that might help them?

01:47:05.940 | - So here we were in my program,

01:47:08.460 | we had created Q-Center Therapy, right?

01:47:11.340 | We developed a training program for it.

01:47:14.120 | We have a Q-Center Therapy training program.

01:47:18.220 | And I became increasingly concerned

01:47:21.180 | about my own staff and my own team

01:47:24.340 | because this is a team, as you can imagine,

01:47:26.340 | that are seeing trauma every day

01:47:28.180 | and are seeing trauma in kids.

01:47:30.780 | I was worried about vicarious trauma

01:47:33.980 | and the impact that this would have in their health.

01:47:37.080 | So I remember that when I was doing my residency,

01:47:41.660 | I took a course in hypnosis

01:47:43.700 | and I was really struck by how much control

01:47:47.860 | one has during hypnosis.

01:47:49.660 | So it's nothing like anyone is doing to anybody else.

01:47:52.220 | It's really kind of having the control to relax yourself.

01:47:57.220 | - Self-directed hypnosis.

01:47:59.140 | - Self-directed type of hypnosis.

01:48:02.300 | And I said, "I would like to bring something like that."

01:48:05.500 | And I met a PhD, John Rutger, that was a yoga instructor

01:48:10.500 | and also a mindfulness instructor,

01:48:12.980 | and I brought him to the team.

01:48:14.680 | And he had other things to do,

01:48:16.860 | but one of the main goals was to take care of the team.

01:48:19.460 | And we started regularly practicing yoga

01:48:22.500 | and practicing mindfulness,

01:48:24.280 | as we were seeing all these cases

01:48:25.780 | and working with trauma and so forth.

01:48:28.100 | And I was able to see firsthand

01:48:30.980 | how helpful it was for me personally and for my team.

01:48:35.460 | At the time, we were doing some work in Ispalo Alto

01:48:39.340 | in some of the schools.

01:48:40.860 | We were doing some pro bono counseling

01:48:42.480 | because this is another problem.

01:48:44.140 | Many of the schools have no counselors, right?

01:48:46.800 | So, but this was a while back, it's like 10 years ago.

01:48:51.520 | - Yeah, the Ispalo Alto School District,

01:48:52.980 | for those that don't know, Palo Alto,

01:48:56.060 | I guess it could be called West Palo Alto,

01:48:57.740 | is a separate city and county from Ispalo Alto.

01:49:00.580 | Palo Alto is not exclusively, but is known for,

01:49:04.700 | at least nowadays, let's just be frank,

01:49:07.260 | fairly tremendous affluence

01:49:08.640 | relative to most places in the world, put bluntly.

01:49:12.580 | Ispalo Alto, a separate county,

01:49:15.000 | different school district, police system,

01:49:17.260 | has for as long as I can remember,

01:49:19.940 | having grown up in Palo Alto,

01:49:23.660 | has always been stricken with far fewer resources.

01:49:27.740 | And while there've been tremendous efforts

01:49:30.880 | to improve the situation there,

01:49:34.380 | it is still at a steep disadvantage financially.

01:49:38.000 | But of course, many amazing people working there

01:49:43.060 | and living there, and growing up,

01:49:46.540 | there was some exchange across that Ispalo Alto,

01:49:51.540 | West Palo Alto border, as it were, in the school district,

01:49:55.420 | but they're pretty separate domains

01:49:57.540 | when it comes to resources.

01:49:58.940 | - And it is not now, but many years ago,

01:50:02.500 | it was the number one murder capital in the US.

01:50:06.440 | It's also the place where Facebook is now.

01:50:11.300 | So, and IKEA, and there's people

01:50:14.780 | that bring some employment to the area,

01:50:17.700 | but also bring some other problems.

01:50:20.700 | - Yeah, that area where IKEA is used to be called,

01:50:23.700 | do you remember it was called Whiskey Gulch?

01:50:25.820 | - Didn't know that.

01:50:26.660 | - For years, kind of terrible name, right?

01:50:28.900 | But it was a stark contrast,

01:50:30.600 | right as you literally crossed the train tracks

01:50:32.620 | heading towards Highway 101.

01:50:34.760 | In that case, that portion of Palo Alto, Crescent Park,

01:50:38.180 | an extreme of wealth to an extreme of poverty.

01:50:41.940 | - Yes.

01:50:42.780 | - In literally a distance of 10 meters.

01:50:46.340 | - And of course, there are wonderful families there.

01:50:51.340 | - Of course.

01:50:52.980 | - That support the kids.

01:50:55.420 | There's a Ravenswood, which is also the other name

01:50:59.020 | for Ispalo Alto Family Health Center,

01:51:01.600 | that really provides a lot of good resources to the area.

01:51:07.340 | And there's a good school district,

01:51:09.460 | but at this time, it was missing counselors.

01:51:11.660 | So we had some presence there.

01:51:13.900 | We decided to bring some of the things

01:51:16.780 | that we were learning in terms of yoga

01:51:19.260 | and in terms of mindfulness to two of the classrooms.

01:51:23.780 | At the end of about three months,

01:51:25.820 | I get called to the principal's office.

01:51:28.040 | I have to go to the principal's office,

01:51:30.180 | because the principal was interested in finding out

01:51:32.500 | what was going on in there,

01:51:34.220 | because none of those kids in those classrooms

01:51:37.300 | had gone to her office in all that time.

01:51:40.080 | - They hadn't gotten in trouble.

01:51:40.920 | - They had not gotten in trouble.

01:51:42.820 | So I explained what it was,

01:51:44.260 | and we decided to do a bigger scale study.

01:51:49.260 | And eventually, we partner with a group called Pure Power,

01:51:54.500 | purepowerinc.org, developing a yoga

01:52:01.020 | and mindfulness curriculum for students at schools.

01:52:06.900 | At that time, we started bringing yoga instructors

01:52:11.340 | into the classroom, but we very quickly learned

01:52:15.140 | that the best approach to this

01:52:16.780 | would be to teach the teachers

01:52:18.740 | and have the teachers teach the students,

01:52:21.180 | because the yoga instructors had no training

01:52:23.660 | on how to control a classroom, and the teachers did.

01:52:28.120 | And some of these poses were so elemental

01:52:30.260 | that it was okay if they were not a yoga instructor.

01:52:34.960 | So anyway, we tested this curriculum,

01:52:38.540 | and there was a piece about it in the "NewsHour."

01:52:42.860 | I think it might still be there.

01:52:45.220 | And I get this wonderful phone call

01:52:50.220 | by this family in New York

01:52:55.080 | that wants to see how they can help me spread this further

01:53:00.080 | into not only the classrooms that I was working,

01:53:02.740 | but into the whole school or the school district.

01:53:07.700 | And I knew at that point that two things were important,

01:53:11.960 | not only that they wanted and I wanted,

01:53:14.160 | but that the school district should want it,

01:53:16.980 | and also that at this time,

01:53:19.860 | we would need to do a very in-depth study

01:53:22.620 | to see what our intervention was

01:53:24.740 | and what the curriculum was,

01:53:26.480 | because mindfulness can be the name

01:53:29.160 | that you give to many different things.

01:53:30.560 | So we wanted to make sure that our intervention

01:53:33.500 | of yoga and mindfulness exercises

01:53:35.960 | that now Pure Power carries

01:53:37.980 | is really what we're being tested.

01:53:40.980 | So they were very, very helpful in helping sponsor

01:53:45.980 | not only the dissemination of this curriculum

01:53:49.000 | through the school district,

01:53:50.600 | but a randomized controlled trial

01:53:52.640 | where we actually had a whole other district

01:53:55.200 | that would also be trained,

01:53:56.380 | but only after the study was over.

01:53:58.320 | It was a demographically comparison school in San Jose,

01:54:02.900 | in the city of San Jose.

01:54:04.540 | Near enough for us to conduct the study,

01:54:08.260 | but far enough that where there wouldn't be

01:54:12.020 | too much dissemination from one district to the other.

01:54:15.900 | And it was good that we did a district-wide control,

01:54:20.900 | because if we would have done it by classroom or by school,

01:54:25.020 | it wouldn't have worked,

01:54:26.780 | because there was so much diffusion

01:54:29.800 | of what the kids were learning

01:54:32.220 | into their friends and their family

01:54:35.140 | and the other classes and the other people

01:54:37.980 | in the community that was beautiful to see,

01:54:40.500 | but it would have ruined a control study.

01:54:43.140 | - So you needed literally physical

01:54:45.460 | and demographic separation.

01:54:47.660 | So you went with what used to be called the peninsula,

01:54:50.260 | the South Bay, East Palo Alto, and then San Jose,

01:54:53.700 | far enough apart that the kids weren't talking enough

01:54:56.560 | to blur the treatment groups.

01:55:00.220 | - Exactly.

01:55:01.060 | So we demonstrated feasibility.

01:55:02.660 | You know, we were able to do it.

01:55:03.820 | We demonstrated acceptability.

01:55:05.780 | The kids liked it.

01:55:07.400 | The kids would do it.

01:55:08.660 | Some schools actually had a room specifically

01:55:12.260 | for them to go and do it,

01:55:14.480 | even if the teachers were not doing it in the classroom.

01:55:18.340 | And it ranged.

01:55:19.340 | It was like twice to three times a week

01:55:24.140 | for 15 or 50 minutes of this curriculum in the classrooms.

01:55:29.140 | - Can I, sorry to interrupt,

01:55:31.640 | but could I ask you a little bit more about the curriculum?

01:55:34.300 | You said five, you said, or 15 to 50,

01:55:38.900 | five zero minutes, two to three times per week.

01:55:42.860 | And did the kids have to like change over

01:55:47.260 | to their yoga clothes?

01:55:49.100 | The reason I ask is that I could think of a number

01:55:52.900 | of real world barriers to getting something

01:55:55.100 | like this implemented.

01:55:56.380 | I feel like going jogging, usually you get a little sweaty,

01:55:58.940 | you need running shoes, you know,

01:56:00.740 | there are other forms of exercise that require that less.

01:56:03.740 | But these days they're, as far as I know,

01:56:07.060 | not every school requires physical education.

01:56:09.280 | When I was growing up and through high school,

01:56:11.700 | you had to literally suit up.

01:56:13.380 | You had to go in the locker room and put on your PE clothes

01:56:16.700 | as it were, and then you'd run or play volleyball,

01:56:19.980 | whatever the PE teacher told you to do, you had to do,

01:56:23.460 | if you wanted to get a decent grade.

01:56:25.440 | Is the yoga being done, I mean, you said it could be

01:56:29.300 | in the classroom or at a separate location,

01:56:31.300 | but are the kids basically getting up out of their chairs

01:56:33.260 | and just right in their school clothes,

01:56:34.940 | doing this for 15 to 50 minutes?

01:56:37.100 | - So they stay with the same clothes, but we had mats.

01:56:41.940 | They had mats, every student had a mat.

01:56:44.220 | Then it's interesting that you mentioned PE

01:56:45.660 | because the first suggestion was let's do it

01:56:47.780 | during PE class.

01:56:48.780 | And I'm like, no, that's, you know,

01:56:50.900 | rowing from Paul to get to Peter.

01:56:52.580 | Until I learned that PE, like you said, was not happening.

01:56:57.460 | - So sad. - Which I couldn't believe.

01:56:59.260 | And if anything, I think the study has helped

01:57:01.420 | for them to bring PE back.

01:57:03.020 | And the classes, which are these lessons

01:57:05.940 | and yoga movements and mindfulness,

01:57:07.900 | were really taking place in the classroom

01:57:11.140 | that whatever teacher learned it.

01:57:13.100 | So if it was the math teacher,

01:57:14.440 | she was taking 10 minutes aside to do it.

01:57:16.680 | If it was the PE and PE was not happening there,

01:57:19.100 | they may dedicate the 50 minutes

01:57:21.580 | to do the yoga and the mindfulness.

01:57:24.460 | So we have a number of assessments that we did.

01:57:29.460 | And like I mentioned, yes, it was acceptable

01:57:36.540 | and it improved mood and all of that.

01:57:39.740 | But I think the biggest finding

01:57:41.620 | that we published from that study

01:57:43.780 | was that it increased 73 minutes of sleep.

01:57:47.700 | - 73? - 73 minutes of sleep.

01:57:51.720 | - That's extraordinarily high.

01:57:53.480 | - On average for the students.

01:57:56.520 | And it increased the depth of sleep.

01:57:58.560 | So something that we did in this study

01:58:00.880 | was that we also did portable polysomnography.

01:58:03.800 | And it was not in a sleep center, it was in their own house.

01:58:07.960 | So collaborating with Ruth O'Hara from the department,

01:58:11.640 | we were able to assess their sleep.

01:58:14.700 | And deep sleep is very important.

01:58:16.900 | That's where you process the events of the day.

01:58:19.980 | So these kids were increasing REM, total sleep,

01:58:24.540 | deep sleep, doing much better.

01:58:27.420 | And then another thing because of our previous studies

01:58:30.940 | that we've talked about in terms of brain function,

01:58:34.020 | this hasn't been published,

01:58:35.140 | but we have some preliminary data demonstrating

01:58:37.700 | that those kids that went through the intervention

01:58:41.060 | before and after the intervention

01:58:44.340 | were able to decrease the activity of their amygdala,

01:58:48.100 | which was very powerful and also very helpful.

01:58:51.460 | So many of these kids adapted this

01:58:54.460 | into their daily practices.

01:58:56.940 | After this study was over, we went to our control group

01:59:00.300 | and we taught those lessons there.

01:59:03.140 | And now it has served to identify even more tools

01:59:10.620 | that we can put in the toolbox of CCT.

01:59:13.620 | So we utilize some of the things there and here.

01:59:17.180 | So Pure Power and our program have been collaborating a lot

01:59:20.700 | because it covers the risk group and the treatment group.

01:59:25.220 | So sometimes when we go to schools and we do trainings,

01:59:28.660 | we partner with them so that we have

01:59:31.900 | the yoga and the mindfulness and the cue center therapy.

01:59:35.940 | And I by no means mean these are the two things

01:59:40.140 | that everybody should be using.

01:59:41.740 | I'm saying these are two more tools.

01:59:43.580 | In fact, I think we need more development,

01:59:46.280 | more development of interventions,

01:59:47.980 | both for treatment and for intervention.

01:59:51.620 | And how do we identify who needs what and how

01:59:56.100 | is where we're moving next.

01:59:58.860 | - Wow, what spectacular results.

02:00:00.740 | I mean, 73 minutes more of sleep is like,

02:00:05.740 | I mean, talk about effective medicine.

02:00:09.060 | You know, I mean, we agreed at the outset

02:00:12.140 | that sleep is the foundation of mental health

02:00:14.300 | and physical health and all forms of cognitive

02:00:16.620 | and physical performance.

02:00:17.700 | I mean, when we know this, the study done at Stanford,

02:00:21.180 | albeit a small one of having athletes

02:00:22.900 | just get a bit more sleep or even just stay in bed

02:00:25.340 | a bit longer and no, not on their phones,

02:00:27.420 | but just lying quietly with eyes closed and resting

02:00:29.780 | or sleeping more improved shot accuracy

02:00:32.900 | in basketball players.

02:00:33.820 | This has been shown in so many domains

02:00:35.620 | of cognitive and physical.

02:00:36.820 | It's like not even worth spooling off all the examples,

02:00:40.120 | but that is spectacular.

02:00:41.940 | It also makes me think I should start doing some yoga

02:00:45.020 | because I do get enough sleep, but that's significant.

02:00:50.020 | What do you think are the barriers

02:00:53.000 | to having this sort of thing implemented at national scale?

02:00:56.180 | Now, I always think about this, you know,

02:00:57.780 | okay, so the results are in, maybe it's one study,

02:01:00.380 | maybe it's two, but you're talking about

02:01:02.540 | a basically harmless intervention

02:01:06.420 | and actually it's a very therapeutic intervention.

02:01:10.040 | Sure, there are some people that won't be able

02:01:11.420 | to do all the poses, et cetera,

02:01:12.940 | but there's always something that somebody can do.

02:01:16.080 | Even people that are immobilized,

02:01:17.420 | there are certain forms of, believe it or not,

02:01:19.960 | cognitive yoga and that friend of mine

02:01:23.860 | who works with people who are quadriplegic,

02:01:26.820 | they can do certain things to keep

02:01:28.180 | nervous system function online.

02:01:29.880 | But, you know, essentially anyone can do this.

02:01:35.240 | What are the barriers from taking it

02:01:37.200 | from this East Palo Alto school to a study,

02:01:40.320 | to another study, okay, San Jose school,

02:01:42.840 | now let's say you get all of Santa Clara

02:01:44.780 | or, you know, neighboring counties, you know,

02:01:49.480 | what does it take to get something implemented

02:01:51.360 | at national scale so that the work can really ripple out

02:01:55.360 | and benefit all these kids who are,

02:01:57.320 | of course, are going to become adults?

02:01:58.880 | - Well, we need to prioritize it, right?

02:02:01.000 | We need to prioritize education for starters, right?

02:02:05.880 | We were talking about classes not even having

02:02:08.320 | physical education or arts, for example.

02:02:12.760 | And we need to prioritize mental health

02:02:15.920 | and it needs to start early.

02:02:17.880 | And I think when we work our national budget,

02:02:21.000 | it needs to be, there needs to be earmarks

02:02:25.440 | for these two areas that should go

02:02:28.760 | to the Department of Education.

02:02:31.040 | The Department of Education should make this a priority.

02:02:34.280 | Teachers are really, really overworked.

02:02:39.080 | They are under-resourced and, like,

02:02:44.080 | pediatricians many times are responsible

02:02:48.920 | for doing somebody else's work, right?

02:02:50.780 | Everybody tells them, oh, this will only take a minute

02:02:53.120 | or this will only take two minutes

02:02:54.600 | or if you make this assessment, you know, you can do that.

02:02:57.840 | But the time is finite, right?

02:03:01.480 | And the space is finite.

02:03:02.720 | So they need more space, they need more time,

02:03:04.960 | they need more support, teachers.

02:03:07.280 | And then this needs to be a priority from districts

02:03:12.520 | to really implement programs like this.

02:03:15.240 | - So parents and even non-parents

02:03:18.720 | talk to the teachers in the school,

02:03:21.960 | talk to the principals in the school.

02:03:23.800 | And I've been learning about the power of the telephone

02:03:27.480 | for lobbying.

02:03:28.600 | This has been around some things I've been involved with

02:03:31.320 | with the veterans community.

02:03:32.940 | I mean, the ability to look up and call your congressman

02:03:36.920 | or congresswoman and tell them that you are

02:03:40.560 | really concerned about or excited about a particular program

02:03:44.360 | does have impact.

02:03:46.120 | I mean, at first I didn't think this was true,

02:03:48.960 | but I realized that when they start getting 50, 100,

02:03:52.960 | 1,000 messages about a particular topic

02:03:56.340 | that people are passionate about, they pay attention.

02:03:59.600 | Maybe it's because they just want to get reelected.

02:04:02.080 | Maybe it's because they are genuinely concerned

02:04:05.360 | about helping people.

02:04:06.300 | I like to think it's the latter.

02:04:07.820 | But regardless of which,

02:04:09.520 | they run those messages up the flagpole

02:04:12.920 | when they bring issues.

02:04:15.500 | - So let me tell you what we just started doing

02:04:17.400 | in Puerto Rico.

02:04:18.320 | I'm from Puerto Rico.

02:04:20.300 | But Puerto Rico and Puerto Rican students

02:04:23.720 | have gone through a number of natural disasters

02:04:27.300 | that started with Hurricane Maria

02:04:28.840 | and continue with other hurricanes

02:04:31.040 | and also with earthquakes

02:04:35.640 | and this has led to violence

02:04:38.480 | and there's interpersonal violence.

02:04:41.000 | So some of the kids in Puerto Rico have gone through a lot.

02:04:43.840 | But also, the whole island of Puerto Rico

02:04:47.560 | is one of the largest school districts in the U.S.

02:04:51.040 | The whole island is one district,

02:04:52.780 | meaning that if you do something,

02:04:54.480 | like a program like the one we're talking about,

02:04:56.440 | you can implement it island wide.

02:04:59.160 | Currently, we are launching a project in Puerto Rico

02:05:05.200 | where all the teachers will be trained

02:05:08.120 | in the yoga and mindfulness curriculum

02:05:10.860 | and all of the counselors will be trained

02:05:13.540 | in Q-Center therapy.

02:05:15.960 | The kids are being assessed at baseline.

02:05:19.280 | Then they go through their yoga and curriculum

02:05:21.880 | and at time two, when they get assessed

02:05:24.240 | to see how they're doing after that,

02:05:26.040 | we also screen those that have PTSS,

02:05:30.760 | post-traumatic stress symptoms that cause impairment.

02:05:33.600 | And then those go through the trained counselors

02:05:37.200 | and then they get assessed again in the latter part.

02:05:41.040 | So the goal is for us to,

02:05:44.320 | although we've talked about the two treatments,

02:05:46.000 | we've never really had both of them happen simultaneously

02:05:51.120 | and we want to do it in a large scale like this

02:05:53.800 | because if this works, if it's sustainable,

02:05:56.920 | if it's feasible, we can actually then bring it

02:06:00.080 | to other large school districts like New York,

02:06:03.040 | like LA, for example, and start disseminating this.

02:06:08.040 | - I'd love your thoughts on something.

02:06:10.220 | I'm so impressed that you were able to bring this

02:06:12.680 | from a study or set of studies

02:06:14.840 | to a much larger scale in Puerto Rico.

02:06:19.600 | I could be wrong here, but I feel like in the United States,

02:06:23.200 | we have such a culture of fame and popularity

02:06:26.880 | and reward around people who are extreme performers.

02:06:30.520 | You know, we hear about these NBA stars

02:06:33.120 | and right now we're seeing a lot

02:06:34.560 | about these incredible track stars

02:06:36.360 | and where we have these tech innovators

02:06:39.360 | that found huge companies.

02:06:41.180 | They used to be called unicorn companies,

02:06:42.720 | but all these incredible successes.

02:06:45.280 | And I wonder sometimes if the hyper-emphasis

02:06:50.280 | on these extreme performers has led to the conclusion

02:06:55.120 | in young people that unless you're going to be

02:06:57.920 | Michael Jordan or LeBron James or Mark Zuckerberg

02:07:02.920 | or Elon Musk or win an Olympic gold medal,

02:07:07.680 | that the practices that feed up

02:07:10.080 | to becoming those sorts of people,

02:07:11.820 | like mindfulness meditation or becoming a yogi

02:07:14.160 | for that matter, you know,

02:07:15.680 | I feel like there's been a push towards hyper-specialization

02:07:18.680 | and performance to the point where people are writing off

02:07:22.980 | the incredible utility of physical activity, mindfulness,

02:07:27.980 | you know, learning math, science, literature, and the arts.

02:07:32.660 | You know, you're talking about the arts.

02:07:33.500 | - Humanities studies.

02:07:34.320 | - Yeah, music, right?

02:07:35.160 | Even for people like me, you know, I mean, sure.

02:07:36.600 | They always gave me the triangle

02:07:37.920 | 'cause I could manage that one

02:07:39.120 | and I don't want to insult the triangle players.

02:07:40.640 | I'm sure it's much more complicated

02:07:42.740 | than I'm giving the impression it is.

02:07:44.480 | But the point is that I feel like there's been

02:07:47.680 | a not so gradual disintegration of the idea

02:07:52.240 | that there is utility.

02:07:53.860 | Indeed, there's great benefit to doing things,

02:07:56.440 | not with the intention of becoming a high performer,

02:07:59.280 | but just doing them for sake of how it enriches us

02:08:02.560 | in a number of different ways, including our mental health.

02:08:05.780 | And I wonder whether or not the lack of PE is sort of a,

02:08:09.200 | well, if you're not going to run track

02:08:11.560 | and try and medal or something, you know,

02:08:13.800 | or go to championship meets, then like, what's the point?

02:08:16.400 | But I don't, I certainly don't subscribe to that.

02:08:19.520 | I'm curious what your thoughts are.

02:08:21.280 | - Well, I think we need to redefine success

02:08:25.780 | and what it means to be successful.

02:08:27.760 | I think that we're currently describing it

02:08:31.480 | with the examples that you just gave,

02:08:33.420 | which probably was not the way that we were describing it

02:08:36.520 | in the '60s or the '70s.

02:08:40.280 | But it is harming individuals, which is most of us,

02:08:45.280 | that cannot attain that level of proficiency in an area.

02:08:51.760 | And in fact, the individuals that are choosing

02:08:55.640 | to have a broader belonging, in a way, are more protected.

02:09:00.640 | I worry about those other individuals, too,

02:09:03.120 | that have that very personalized, not personalized,

02:09:06.960 | but very individualized, unique component in their life

02:09:11.600 | where they dedicate everything to that one thing.

02:09:14.240 | - Trust me, they often suffer in one or more

02:09:18.120 | of their other domains of life.

02:09:19.520 | Some don't, but I would argue most do.

02:09:22.320 | - But the idea of belonging, right, is that you have,

02:09:25.760 | you belong to many different facets of life.

02:09:29.820 | You are a sports person, you're a community person,

02:09:34.560 | you're a student, you're a father,

02:09:37.360 | you're an aunt, you're different things.

02:09:40.560 | When you're only one thing and that fails,

02:09:46.000 | your whole identity is gone.

02:09:48.200 | It doesn't even have to fail.

02:09:49.840 | You have to perceive that it has failed,

02:09:52.000 | and that's enough to throw you off course.

02:09:55.080 | And so with the current definition of success,

02:09:59.000 | we're not doing a service for those

02:10:01.080 | that attain that definition

02:10:03.080 | and those that do not attain that definition.

02:10:05.440 | I think it needs to be broader.

02:10:06.880 | I think belonging needs to be included.

02:10:09.280 | I think the way that we care, not only for ourselves,

02:10:12.480 | but for the rest of our citizens needs to be included.

02:10:17.240 | Citizenship is important.

02:10:18.980 | So it is dynamic.

02:10:22.960 | So far it has been dynamic, how we define success,

02:10:26.360 | and hopefully it will change again.

02:10:29.040 | - All right, I agree wholeheartedly.

02:10:32.080 | Let's talk about resilience.

02:10:34.520 | Earlier you said, you know, kids are not resilient,

02:10:39.200 | but you also implied, maybe you even stated it outright,

02:10:42.920 | that they can become resilient.

02:10:46.160 | What is resilience

02:10:48.800 | and what are some of the paths to resilience?

02:10:51.560 | - Resilience is a physical term, right?

02:10:56.120 | It means you bounce, the coil bounces back

02:11:00.800 | to where it was originally.

02:11:04.880 | I like to think of the word adaptation

02:11:09.520 | because it means not only you bounce back,

02:11:12.160 | but you bounce back to a better place.

02:11:14.960 | Like I like to think that we adapted

02:11:17.680 | during the experience of the pandemic

02:11:20.280 | other than we were resilient of it.

02:11:23.080 | Yes, we were resilient because we survived it.

02:11:27.080 | Some of us did, not all, right?

02:11:29.640 | Some of us have to deal with the grief

02:11:31.400 | of what happened during that time.

02:11:33.260 | But adaptation means that not only we go back

02:11:38.480 | to where we were before the pandemic,

02:11:40.880 | but that now we've learned from that experience

02:11:43.720 | to be in a better place.

02:11:46.120 | Now, we know very little about resilience

02:11:50.680 | and we definitely know very little biology about resilience.

02:11:54.080 | We know that having a sense of humor is good.

02:11:57.920 | We know that perseverance is good.

02:12:01.440 | We know that the presence of an adult in a child's life

02:12:05.160 | that was there to give them opportunity

02:12:07.520 | or to talk to them about things they were going through,

02:12:11.160 | that's probably the best known resilient factor.

02:12:15.000 | But what if it's not the presence of that adult,

02:12:21.720 | but there's something in that child

02:12:24.400 | that makes them seek and maintain

02:12:27.360 | that type of relationship, right?

02:12:30.120 | So I feel that we need to start looking

02:12:33.640 | at the biology of resilience.

02:12:36.680 | And one way that we've done that in my program

02:12:41.100 | is through a collaboration with Alex Urban

02:12:45.040 | from our department and from genetics,

02:12:47.480 | and Caroling Pertman, who's in his lab

02:12:50.560 | and one of his postdocs.

02:12:53.400 | They work with organoids,

02:12:55.240 | and I don't know if you've mentioned organoids before

02:12:57.220 | to your audience.

02:12:58.060 | - I have not, but one of my good friends

02:13:02.480 | and colleagues at Stanford, Sergio Pasca,

02:13:06.120 | is one of the world leaders in organoids,

02:13:07.840 | and we hope to host him on this podcast soon.

02:13:09.520 | But please educate us on organoids.

02:13:13.000 | They are oh so cool and oh so science fictiony,

02:13:15.360 | but they are oh so real as well.

02:13:17.920 | - So we have stem cells that can be converted

02:13:21.840 | to any type of cell under the appropriate nutrients

02:13:25.520 | and environments that we want to examine.

02:13:29.800 | So for a psychiatrist, of course,

02:13:31.720 | the interest is to turn them into neurons.

02:13:34.520 | And not only they can grow in a Petri dish,

02:13:37.840 | but they grow suspended, so it's almost like a 3D.

02:13:41.880 | And Sergio uses the term asembloid

02:13:46.120 | for when he actually assembles them further

02:13:49.040 | to build more organ-specific--

02:13:51.880 | - Mini brains.

02:13:53.080 | - Mini brains is the term that I like, yes.

02:13:56.020 | So these mini brains are these neurons

02:13:59.600 | that are growing in a circle like the brain,

02:14:03.440 | and they communicate with each other,

02:14:05.560 | and they are active with each other, and we can study.

02:14:09.640 | So in conversations with Alex,

02:14:11.360 | and now that you all know my previous work

02:14:13.560 | with cortisol and all that,

02:14:15.280 | I was telling him and Carolyn,

02:14:17.960 | well, why would happen if we expose

02:14:20.720 | some of these organoids to cortisol?

02:14:23.880 | And of course, we needed to come up with,

02:14:27.880 | oh, what would be the right amount that would mimic trauma?

02:14:32.600 | So we also involved Robert Zabolsky

02:14:35.880 | to help us come up with a concentration

02:14:38.880 | that would be trauma mimetic.

02:14:41.120 | And so we exposed a number of organoids

02:14:44.400 | to different levels of cortisol.

02:14:47.160 | For some of them, it was a trauma.

02:14:48.640 | For others, they were not exposed.

02:14:50.400 | Then half of that amount, or much less of that amount,

02:14:53.000 | was a trigger, the cue, right?

02:14:55.960 | So some had the trauma and the cue.

02:14:58.120 | Some had no exposure.

02:15:00.600 | Some only had the cue.

02:15:01.840 | And then we compare what was associated

02:15:05.200 | with really, well, the first thing that they needed to do

02:15:11.320 | was identify that these neurons

02:15:14.040 | actually had these glucocorticoid receptors

02:15:18.440 | and that they were active.

02:15:19.800 | And they did have them, and they were active.

02:15:23.440 | So we looked through epigenetic analysis,

02:15:27.320 | I should say, we is the royal we, right?

02:15:29.080 | It's more Alex and Carolyn.

02:15:31.320 | They look at the genes that were changed,

02:15:35.960 | that their activity changed

02:15:37.600 | because of this cortisol exposure.

02:15:40.160 | And through epigenetic analysis,

02:15:41.880 | which is this space between DNA and RNA,

02:15:46.040 | and there's like methylation patterns and all that,

02:15:50.120 | and some genes activity changes.

02:15:53.560 | Some turn on, some turn off.

02:15:55.640 | So interestingly, the majority of the genes

02:15:59.800 | that we found there were genes that have been addressed

02:16:03.520 | in the literature as potentially being related

02:16:06.680 | to post-traumatic stress disorder.

02:16:08.600 | Things like the glucocorticoid receptor genes

02:16:11.760 | and things that you would think of.

02:16:14.000 | But there was another subset of genes

02:16:16.800 | that we identified that were novel.

02:16:19.280 | And I was very interested in those

02:16:21.440 | because of my interest in accelerated aging

02:16:24.680 | because of stress.

02:16:25.760 | And those were genes that are related to collagen formation.

02:16:30.760 | And we know that atherosclerosis

02:16:33.080 | has been related to stress, for example.

02:16:36.000 | And we know that accelerated aging, not only in PTSD,

02:16:40.560 | but in mental health conditions overall,

02:16:43.040 | individuals that suffer from severe mental illness

02:16:47.000 | chronically in their life end up dying 25 years younger

02:16:51.640 | than the rest of the population.

02:16:53.080 | That's very significant.

02:16:55.360 | And so stress and accelerated aging, interesting.

02:17:00.000 | Okay, so these are interesting findings in organoids.

02:17:03.280 | But when you have those,

02:17:05.240 | what you do is you move on to a population study.

02:17:09.880 | So these kids in Puerto Rico

02:17:12.600 | that are going through these interventions,

02:17:15.440 | besides me checking on their PTSD,

02:17:17.960 | their anxiety, their depression,

02:17:20.200 | they're giving me a vocal swap.

02:17:22.960 | And in the vocal swap, those epithelial cells,

02:17:26.320 | we can actually take them through epigenetic analysis

02:17:29.560 | and see those kids at time one

02:17:32.880 | that even though they've gone through all this trauma,

02:17:35.800 | may not be faring that much worse as their counterparts

02:17:40.800 | and compare them.

02:17:43.520 | And not only that, we can actually also look at response,

02:17:47.560 | treatment response for the intervention,

02:17:49.680 | for the yoga and mindfulness preventive intervention,

02:17:52.760 | and for the treatment, for the cue center therapy.

02:17:56.240 | So that's the plan.

02:17:57.360 | That's the plan in trying to bring more light

02:18:00.560 | into what is the biology of resilience

02:18:04.400 | and how can we understand resilience better.

02:18:08.200 | - What a spectacular study, goodness.

02:18:12.000 | And if any of you missed some of the underlying mechanics,

02:18:14.800 | I'll just quickly recap.

02:18:16.380 | These organoids are little brains in a dish

02:18:21.380 | that came to be by virtue of taking fibroblasts

02:18:25.880 | or other cells, so skin cells essentially,

02:18:28.240 | put into dishes,

02:18:29.960 | provided for what are called transcription factors.

02:18:33.480 | These are the four transcription factors

02:18:35.120 | that Yamanaka won the Nobel prize for identifying

02:18:38.120 | that reverts those cells into stem cells.

02:18:40.240 | And then a few other goodies, molecular goodies,

02:18:43.240 | that then allow them to become neurons in particular.

02:18:46.160 | Then they grow into little mini brains.

02:18:48.320 | And then as Dr. Carrion was explaining,

02:18:52.220 | are exposed to cortisol at appropriate concentrations

02:18:56.500 | to mimic cortisol exposure in the whole person.

02:19:00.280 | And then from that, the genomes of those cells

02:19:03.160 | and the epigenomes are analyzed

02:19:04.840 | to identify potential targets.

02:19:06.840 | The results are brought back to these kids in Puerto Rico,

02:19:09.400 | such that the genomes of all these kids

02:19:11.880 | experiencing different levels of stress

02:19:13.840 | and yoga, mindfulness interventions, or not,

02:19:16.960 | maybe they're in the control group.

02:19:18.720 | The outcomes can be assessed and then one can address,

02:19:22.280 | hey, what are the genes that are protective against stress?

02:19:26.040 | AKA, what are the genes that are protective

02:19:28.000 | against high levels of cortisol?

02:19:30.200 | And a bunch of other, surely to be very transformative

02:19:33.840 | and important facts about how stress impacts

02:19:36.240 | the young brain to either give rise to PTSD or not.

02:19:40.000 | I must say, as you described that study,

02:19:42.120 | I had three thoughts.

02:19:43.000 | One, wow, how awesome is this?

02:19:45.680 | That you can bridge across

02:19:46.920 | so many different levels of analysis.

02:19:48.680 | I mean, because you're talking about molecular genetics

02:19:51.600 | all the way up to yoga in school children in Puerto Rico.

02:19:56.520 | And PTSD, you know, it's just a complex disorder.

02:20:00.600 | I was also thinking to myself, wow,

02:20:03.320 | what an incredible place Stanford is

02:20:05.600 | that such a collaboration is possible, right?

02:20:07.920 | Makes me delight in the fact that colleagues like you exist

02:20:10.880 | and Sergio and forgive me the names of the other colleagues,

02:20:13.440 | I'm not familiar.

02:20:14.280 | - Alex Urban and Carolyn Perlman.

02:20:15.920 | - Thank you.

02:20:16.800 | And the third thing is how important it is to bridge

02:20:20.040 | across these different levels of analysis.

02:20:21.800 | I think this is the first time on this podcast

02:20:24.520 | where somebody has discussed an experiment

02:20:26.760 | that bridges across so many levels of analysis,

02:20:29.280 | literally from fibroblasts, skin cells in a dish,

02:20:32.000 | all the way to a complex psychiatric condition

02:20:35.840 | and in an attempt, excuse me, to create novel therapeutics.

02:20:39.840 | So it's just truly spectacular.

02:20:41.920 | So if people are sensing a even further surge in my energy,

02:20:45.600 | this is the kind of thing that gets me so excited

02:20:47.960 | because in the landscape of science, we often see a study

02:20:50.860 | or we hear about organoids

02:20:52.360 | or we hear about a yoga intervention.

02:20:53.800 | And these things tend to exist in silos, in isolation,

02:20:56.560 | but the ability to bridge across these levels of analysis,

02:20:59.440 | I believe is critical.

02:21:01.200 | And so, yeah, kudos to you

02:21:04.340 | for being a part of this incredible collaboration.

02:21:07.080 | - And collaborations are key, right?

02:21:09.480 | Because the world is so complex now

02:21:12.080 | that there's no way that a single lab

02:21:14.880 | could have all these expertise.

02:21:17.500 | So you're right, a place like Stanford allows

02:21:20.360 | for these communications to happen,

02:21:22.040 | for these collaborations to happen.

02:21:25.400 | In 28 years that I've been there, I have never heard,

02:21:29.400 | no, I'm not interested in that.

02:21:31.480 | - I always say it, at Stanford especially,

02:21:33.800 | if two scientists meet for more than 30 minutes,

02:21:37.160 | what comes out of that is a collaboration.

02:21:39.200 | [laughing]

02:21:41.200 | As a final question,

02:21:42.800 | I'm gonna ask you to limit it to one answer,

02:21:46.600 | but I'm sure that there are many.

02:21:48.640 | The question is, if you had a magic wand

02:21:52.480 | and you could get any message out to the whole world

02:21:57.480 | about PTSD and PTSI,

02:22:02.000 | in particular in kids, in young people, but also in adults,

02:22:06.880 | what is that message?

02:22:08.120 | What do you want people to know

02:22:09.520 | about post-traumatic stress disorder,

02:22:12.320 | stress and post-traumatic stress injury?

02:22:14.920 | - The first thing that comes to mind

02:22:16.280 | is the importance of listening

02:22:19.680 | and listening to what kids and adults have to say

02:22:23.320 | about their experiencing,

02:22:26.240 | and really creating a space for them

02:22:29.360 | where they or us don't feel isolated,

02:22:33.200 | that they feel supported,

02:22:36.440 | and that they feel that they can identify their own strengths

02:22:42.520 | and their own capabilities of making themselves better.

02:22:47.520 | Everyone knows or has heard about psychiatrists

02:22:54.400 | and everybody thinks, "Oh, what would your psychiatry say?"

02:22:57.880 | And psychiatrists have these smart things to say to people

02:23:01.640 | that help them with their life,

02:23:03.320 | but the best psychiatrists that I know

02:23:05.680 | actually say very little. [laughing]

02:23:08.000 | They listen.

02:23:09.920 | So I would say that listening to the experience

02:23:13.240 | that people have is key.

02:23:16.600 | - Well, thank you so much for that.

02:23:18.000 | And Dr. Karyon Victor, thank you so, so much

02:23:22.880 | for the work you do.

02:23:23.960 | - Thank you for having me here.

02:23:25.320 | - It's spectacular work at so many levels.

02:23:29.060 | It's also very bold and brave work

02:23:30.840 | to tackle such a big problem with such focus

02:23:34.720 | and to really give people agency,

02:23:37.920 | this notion of a custom toolbox, I think, is profound,

02:23:41.240 | to give kids and adults, as it were,

02:23:43.800 | agency over their own interventions

02:23:47.200 | in an effort to really help themselves.

02:23:49.440 | I appreciate you coming here today.

02:23:52.580 | More than I can express,

02:23:54.260 | I know the listeners and viewers of this podcast

02:23:56.180 | appreciate it as well.

02:23:58.260 | You are involved with Stanford Clinically,

02:24:00.880 | you're involved running studies,

02:24:02.960 | clinical studies that have great importance.

02:24:05.100 | So for you to take time to educate us with these tools

02:24:08.120 | is absolutely spectacular and is really appreciated.

02:24:11.720 | Please keep us updated on your progress

02:24:13.640 | and please come back and tell us more about that progress

02:24:17.160 | when the time is right.

02:24:18.400 | - Thank you so much.

02:24:19.400 | - Thank you for joining me for today's discussion

02:24:21.480 | about post-traumatic stress disorder

02:24:23.400 | and its treatments with Dr. Victor Karyon.

02:24:25.800 | To learn more about Dr. Karyon's work,

02:24:27.680 | please see the links in the show note captions.

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02:24:50.900 | If you have questions for me or comments about the podcast

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02:25:00.900 | For those of you that haven't heard,

02:25:02.040 | I have a new book coming out.

02:25:03.260 | It's my very first book.

02:25:04.860 | It's entitled "Protocols,

02:25:06.260 | An Operating Manual for the Human Body."

02:25:08.420 | This is a book that I've been working on

02:25:09.580 | for more than five years,

02:25:10.740 | and that's based on more than 30 years

02:25:13.060 | of research and experience.

02:25:14.620 | And it covers protocols for everything from sleep,

02:25:17.660 | to exercise, to stress control,

02:25:20.160 | protocols related to focus and motivation.

02:25:22.620 | And of course, I provide the scientific substantiation

02:25:25.980 | for the protocols that are included.

02:25:28.060 | The book is now available by presale at protocolsbook.com.

02:25:31.960 | There you can find links to various vendors.

02:25:34.340 | You can pick the one that you like best.

02:25:36.100 | Again, the book is called

02:25:37.060 | "Protocols, An Operating Manual for the Human Body."

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02:25:42.420 | I am Huberman Lab on all social media platforms.

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02:25:51.420 | I discuss science and science-related tools,

02:25:53.540 | some of which overlaps with the content

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02:25:56.500 | but much of which is distinct from the content

02:25:58.380 | on the Huberman Lab podcast.

02:25:59.580 | Again, that's Huberman Lab on all social media channels.

02:26:02.640 | If you haven't already subscribed

02:26:03.800 | to our Neural Network newsletter,

02:26:05.600 | our Neural Network newsletter

02:26:07.000 | is a zero-cost monthly newsletter

02:26:09.020 | that includes podcast summaries,

02:26:10.560 | as well as protocols in the form of brief

02:26:12.760 | one-to-three-page PDFs.

02:26:14.520 | Those protocol PDFs are on things

02:26:16.800 | like neuroplasticity and learning,

02:26:18.680 | optimizing dopamine, improving your sleep,

02:26:21.240 | deliberate cold exposure, deliberate heat exposure.

02:26:23.440 | We have a foundational fitness protocol

02:26:25.520 | that describes a template routine

02:26:27.680 | that includes cardiovascular training

02:26:29.180 | and resistance training with sets and reps,

02:26:31.140 | all backed by science,

02:26:32.580 | and all of which, again, is completely zero cost.

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02:26:45.540 | Thank you once again for joining me

02:26:46.900 | for today's discussion with Dr. Victor Karyan.

02:26:49.460 | And last, but certainly not least,

02:26:51.860 | thank you for your interest in science.

02:26:53.940 | [upbeat music]

02:26:56.520 | (upbeat music)

Dr. Victor Carrión: How to Heal From Post-Traumatic Stress Disorder (PTSD)

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