Data/transcripts/4RFEkGKKhdE_20241225194907.txt

welcome to the huberman Lab podcast
where we discuss science and
science-based tools for everyday
[Music]
life I'm Andrew huberman and I'm a
professor of neurobiology and
Opthalmology at Stanford School of
Medicine my guest today is Dr Victor
Kion Dr Victor kerion is a professor and
the vice chair of Psychiatry and
Behavioral Sciences at Stanford
University School of Medicine he is one
of the world's foremost experts on
post-traumatic stress disorder in
particular the treatment of
post-traumatic stress disorder in
children and adolescen although his
knowledge and today's discussion
certainly extends to adult PTSD as well
Dr Karen is also the director of the
Stanford early life stress and
resilience program and today's
discussion focuses on the psychological
and the neurobiological underpinnings of
PTSD and which treatments are most
effective for PTSD we focus heavily on a
particular therapy called Q centered
therapy that was developed by Dr kerion
and colleagues that has been shown to
offset the triggering by words or events
or memories that often are the
precursors to PTSD episodes and this has
been shown to be effective in both
children and adults today's discussion
explores the difference between anxiety
stress and Trauma we talk about how
those things of course are related but
how they can be separated out to better
understand if indeed somebody has trauma
and how to best approach the treatment
of that trauma as you'll soon see what
makes Dr kion's work so unique is that
it combines the psychological the
neurobiological but also practical tools
such as mindfulness it relates
mindfulness and cognitive behavioral
therapy to the underlying biology and
what's known about the Psychiatry and
psychology of PTSD at its different
stages depending on the trauma the age
of the person Etc today Dr Kon clearly
explains all of that so that by the end
of today's conversation you'll really
understand what PTSD is and is not and
of course the best ways to treat it
before you begin I'd like to emphasize
that this podcast is separate from my
teaching and research roles at Stanford
it is however part of my desire and
effort to bring zero cost to Consumer
information about science and science
related tools to the general public in
keeping with that theme I'd like to
thank the sponsors of today's podcast
our first sponsor is eight sleep eight
sleep makes Smart mattress covers with
cooling Heating and sleep tracking
capacity I've spoken many times before
on this podcast about the critical need
for us to get adequate amounts of
quality sleep each night that's truly
the foundation of all mental health
physical health and performance and one
of the best ways to ensure that you get
a great night's sleep is to control the
temperature of your sleeping environment
and that's because in order to fall and
stay deeply asleep your body temperature
actually has to drop by about 1 to 3°
and in order to wake up feeling
refreshed and energized your body
temperature actually has to increase
about 1 to 3° eight sleep makes it
incredibly easy to control the
temperature of your sleeping environment
by allowing you to control the
temperature of your mattress cover at
the beginning middle and end of the
night and it turns out the ability to do
so allows you to get the maximum amount
of Deep Sleep slow wave sleep and rapid
eye movement sleep at the different
stages of the night I've been sleeping
on an eight Sleep mattress cover for
nearly 4 years now and it has completely
transformed and improve the quality of
my sleep eight sleep has now launched
their newest generation of the Pod cover
the Pod 4 ultra the Pod 4 ultra has
improved cooling and heating capacity
higher Fidelity sleep tracking
technology and even has snoring
detection that will automatically lift
your head a few degrees to improve your
air flow and stop your snoring if you'd
like to try an eights Sleep mattress
cover go to 8sleep.com Huber
to save up to $350 off their pod 4 ultra
eight sleep currently ships in the USA
Canada UK select countries in the EU and
Australia again that's 8sleep.com
huberman today's episode is also brought
To Us by betterhelp betterhelp offers
Professional Therapy with a licensed
therapist carried out entirely online
I've been doing weekly therapy for well
over 30 years initially I didn't have a
choice it was a condition of being
allowed to stay in school but pretty
soon I realized that doing regular
quality therapy is an extreme important
component to overall health in fact I
consider doing regular therapy just as
important as getting regular physical
exercise including cardiovascular
exercise and resistance training which
of course I also do every single week
there are essentially three components
to excellent therapy first of all
excellent therapy should provide good
rapport with somebody that you can trust
and talk to about all issues in your
life second of all it should provide
support in the form of emotional support
or directed guidance or both and thirdly
expert therapy should provide useful
insights insights that can allow you to
do better not just in your emotional
life and relationship life but of course
also your relationship to yourself your
professional life and all of your career
and life goals with better help they
make it very easy to find an expert
therapist with whom you can build all
three of these effective components of
therapy if you'd like to try betterhelp
you can go to betterhelp.com huberman to
get 10% off your first month again
that's betterhelp.com
huberman today's episode is also brought
To Us by waking up waking up is a
meditation app that offers hundreds of
guided meditation programs mindfulness
trainings yoga needra sessions and more
I started practicing meditation when I
was about 15 years old and it made a
profound impact on my life and by now
there are thousands of quality peer
reviewed studies that emphasize how
useful mindfulness meditation can be for
improving our Focus managing stress and
anxiety improving our mood and much more
in recent years I started using the
waking up app for my meditations because
I find it to be a terrific resource for
allowing me to really be consistent with
my meditation practice many people start
a meditation practice and experience
some benefits but many people also have
challenges keeping up with that practice
what I and so many other people love
about the waking up app is that it has a
lot of different meditations to choose
from and those meditations are of
different durations so it makes it very
easy to keep up with your meditation
practice both from the perspective of
novelty you never get tired of those
meditations there's always something new
to explore and to learn about yourself
and about the effectiveness of
meditation and you can always fit
meditation into your schedule even if
you only have two or three minutes per
day in which to meditate if you'd like
to try the waking up app please go to
waking up.com huberman where you can
access a free 30-day trial again that's
waking up.com huberman to access a free
30-day trial and now for my discussion
with Dr Victor Kion Dr Victor Kion
welcome thank you thank you so much for
having me I'd like to talk today about
PTSD post-traumatic stress disorder in
particular in young people but also in
adults but before we do that can you
educate us on the definition of stress
and maybe distinguish between short-term
stress and long-term stress and then
perhaps we can segue into PTSD that's a
very good way of starting because in
reality my main interest was the role of
stress and the role of stressors and how
stressors really would
activate the gene makeup and make us
vulnerable to things that we might be
vulnerable um but at the time when I was
training everything Psychiatry as a
field was very diagnosis based so you
needed an anchor and hence I use BTSD to
communicate what I was really referring
to but the reality is that the
experience of stress as we now know is a
spectrum from beneficial to not
beneficial to traumatic so it really
stress operates in our lives as an
inverted ushaped curve The more stress
we have the better we perform the better
we do if we don't care about that exam
that we're going to have tomorrow we'll
probably fail so it's good to be so
muchat stress right vaccines are a
stress in the system so
um we'll talk about this uh I hope but
I'm very concerned also about the
overprotection of kids to to protect
them from any type of stress because it
is through this experience of early
stress that of us develop our problem
solving abilities and we become aware of
our coping mechanisms we become aware of
our support system how can I manage that
stress and we can we can manage stress
because in the same way that through the
process of homeostasis
we process um we have a range of
temperatures right in which we can live
the same thing with stress we can
actually cope up to a certain point
after a certain point it's not
homeostasis anymore and it turns into
what we call allostasis when when it
really starts having a physiological
cost to the body so in that inverted
U-shaped curve there's that optimal
point where your health your happiness
your performance everything is better
because of the stress you've been having
but after that optimal Point all of
those outcomes Health performance start
to decline happiness starts to decline
and it is in that second part of the
curve where we find traumatic stress
traumatic stress being a type of stress
that is not only something you have to
cope with but it actually puts your
physical Integrity in gibberty is a
threat and and you have to manage that
and when you experience traumatic stress
many outcomes are possible one is that
you're resilient and we'll talk a little
bit about that as well I hope um but
another one is that you may develop
symptoms of post-traumatic stress
disorder and the reason that I didn't
anchor on the diagnosis right away from
the outset and I was interest
in uh studying stressors is because many
kids we were seeing many kids that that
had symptoms of PTSD without having the
diagnosis that were demonstrating
functional impairment so they were not
doing well in school they were not doing
well with their relationships they were
experiencing distress right so their
function was affected yet they didn't
have have the diagnosis so the diagnosis
is is good and that is there and and it
it is a behavioral definition that we
can anchor in but but there's more
Nuance to that so then that that chose
the whole the whole spectrum and of
course we can come out of PTSD and we
can go back to that optimal point so we
don't want to get rid of stress but we
just want to return to that optimal
point
and treatment is is available and and
people can recover from PTSD and
especially kids can recover from PTSD
but there's one thing that really gets
in the way and that's something that in
my team we call uh we have a phrase that
we say PTSD feeds on avoidance if we
pretend that something didn't happen if
we pretend that it will go away if we
pretend that treatment is not necessary
then and that that's when it gets
complicated and he gets complicated with
uh substance abuse he gets complicated
with self-injurious behaviors and then
at that point it becomes harder to treat
is it also possible that PTSD gets worse
if we tend to look at it um over and
over again ruminate on it in the absence
of any structured clinical support
meaning if people perseverate on their
traumas can the uh negative impact of
those traumas actually uh root deeper
into us it's interesting that you use
the word perseverate because one of the
characteristics of trauma when it
affects children is that it robs them
from play play is something that's
essential in development is how we grow
socially emotionally
physically but when play becomes
traumatic play it becomes non- joyful
but it becomes pers
and repetitive this is the attempt of
the individual to try to make sense of
what happened and the reason why it's
not good to be alone with it and kind of
perseverate on it by oneself is that
we're probably not looking at the right
insult so in our
experience uh usually PTSD doesn't
result from that one traumatic event
we all carry a backpack and we can all
carry all the stressors that have come
our way like we were saying before but
if you're five six seven years old and
that backpack gets really heavy you can
fall
backwards and when you fall backwards
that's because you don't have the tools
really to carry that but what I'm saying
is that that it is the
accumulation of stressors some of which
may be trauma atic that cuss the
symptoms of PTSD so for
example um some of us went to Haiti
after an earthquake right and I was
starting my program at that time I was
very young already to talk about
earthquakes and know everything about
earthquakes it was the last thing they
wanted to talk about they saw the
earthquake as an opportunity to talk
about the violence that had been
experiencing the poverty the lack of
education so they were talking to me
about everything they were carrying that
led some of them to develop symptoms of
PTSD I see as you describe these other
aspects of one's life that can have
negative impact poverty violence Etc um
I get the impression that PTSD can be
caused by a single event or trauma but
that there's a cumulative aspect to it
so is it the case that in children
because their brain is far more plastic
we know this I mean brain circuits are
modified even by passive experience in
childhood whereas in adulthood it
requires focused attention in order to
learn unless it's a negative event for
better or worse um that in kids it takes
uh far fewer or less intense negative
experiences in order to create PTSD
because the brain is so plastic or is
there a similarity between Youth and
adult PTSD epidemiological study
confirm what your assertion children we
think we we usually you know one line
that I really don't like is children are
resilient because children are really
not they're more vulnerable they have
the opportunity to become resilient if
we help them and we tell them what tools
to use and how to develop and and all of
that but they are more vulnerable to
PTSD and part of it might be that
neuroplasticity and and this is why we
care for them right this is why we
protect them and give them safety
because they are
vulnerable um by the same token that
neuroplasticity can work both ways
because if PTSD is teaching us that the
environment can have an impact on
biology that's the only lesson right
environment can have an impact in
biology in PTSD is a negative impact
because of a negative stressor or
accumulation of stressors
but that also means that if the impact
is positive as in a good supportive
system or as in Psychotherapy that
recovery can actually happen in an
easier
way before we talk about therapeutic
interventions I'm curious about genetic
predisposition and a topic that comes up
a lot anytime the the letters PTSD are
stated in that order um is transgener
ational trauma I can imagine at least
two forms of transgenerational trauma
one
is a generation of what are now
grandparents or great-grandparents or
parents are impacted by some trauma
either in the family or maybe in culture
or you know even broader
scale and then discussions about that
pass through generations impact the uh
children and therefore their adult life
I could also Imagine and I think this is
normally what people are referring to
when they talk about transgenerational
trauma this idea that somehow The genome
is modified by the trauma such that even
if kids are raised by um parents that
adopted them or they have no contact
with the grandparents or
great-grandparents that experiened the
trauma that somehow they are more
vulnerable to or in some cases the idea
has been put forward carry that trauma
put in air quotes such that their life
is more difficult even though they never
had a direct experience of that trauma
what are your thoughts about
transgenerational passage of trauma both
forms both the narrative passage as well
as the um potential for epigenomic or
genomic passage of transgenerational no
this is a very interesting uh subject
the jury is still out if genomic changes
that result as a consequence of stress
can be passed from one generation to the
other but certain certainly the genes
that made one generation vulnerable are
being passed to the Next Generation as
well that we know so it can be passed
that way um but what happens is that
there's also this impact of learning and
I have treated kids that come to me with
all of the symptoms of
PTSD and there's no trauma I cannot find
the trauma and the parent cannot find
the trauma and the kid doesn't reported
trauma but when I'm talking with the
parent the trauma becomes evident in the
history of the parent so the parent has
developed PTSD and behaves in a way that
has been learned by the new generation
ways like avoidance or
re-experience or hyper vigilance or lack
of trust you know things like that so
certainly there are Pathways in which it
can go from one generation to the other
and and we know that the battle between
nature and nurture is pretty much over
right we know that that they both
influence uh vulnerability and that they
both interact and I imagine that's
what's happening in in some of these
situations in terms of stress you know I
always think of stress as both a
response within the brain and a response
within the body and I'm not alone in
that belief I I think uh we know that
adrenaline epinephrine is released from
the adrenals but also from areas of the
brain like Locus culus so that there's
this parallel effect of elevated states
of mind more alert more focused on
narrow locations in space and time and
the body is also prepared for Action I
think this is what underlies the
increased heart rate the you know
shaking in some cases sweating it's
essentially a preparation for action
with PTSD I often hear that some of the
symptoms are more of the opposite end of
the Spectrum in terms of autonomic
arousal right things like
dissociation fatigue um kind of checking
out which I realize this dissociation
but things that uh are more akin to kind
of parasympathetic right for those that
don't know the sympathetic
parasympathetic represents the Continuum
of autonomic interaction sympathetic
having nothing to do with emotional
sympathy it's all about um fight ORF
flight type responses although at lower
levels it's what's responsible for us
being alert here but not in fight ORF
flight and parasympathetic being more of
the rest and digest even leading into
sleep type responses so you know if
somebody experiences a big stressor a
trauma or chronic stress to the point
where it becomes
PTSD is there a tendency for them to be
more hypervigilant and you know a start
response um to uh have their head on a
swivel all the time looking for danger
or to be more dissociative or can the
both sets of phenotypes exist in the
same person yeah no this is very
interesting well we're talking about the
letters let me say that a lot of people
call post-traumatic stress disorder
post-traumatic stress injury not
considering it a disorder but
considering it something that where our
fight or flight mechanism the autonomic
nervous system has been
desensitized and we need to regulate it
again uh and it's going to hurt it's
going to be painful it's just like when
you break your arm and go to the
emergency room and it hurts to be placed
back in place but is the cure is what
cures it so a lot of people visualize it
I do as an injury rather than a disorder
traumatic stress injury injury
interesting and so what happens so these
autonomic system gets activated we have
our fight ORF flight reaction but what
happens to a young kid because they're
very little and they cannot fight
they're also very dependent and they
cannot
flight so they're stuck they're stuck
there so they freeze they freeze and
that's dissociation it's actually during
development a
healthy um defense mechanism but very
much like a white blood cell that's very
helpful if you have too much of it you
develop a leukemia you can develop
dissociative disorders if that's the
only thing you have but it does help
children cope with some of the
situations pretending this is not real
or this is not happening to me is the
only thing they have
left um and because this arousal system
is so key in the development of of this
children um I thought that we should
look at the hormone cortisol in in in
the kids and and when I started when I
was a fellow doing my shell Psychiatry
Fellowship I was seeing all types of
kids with all kinds of issues uh some
had ADHD some had OCD some had PTSD
symptoms but I was getting a lot of kids
with notes uh from school saying this
kid has ADHD please place on rolin right
a stimulant
medication and I'm like wow the
diagnosis has been made there's already
a treatment plan what am I training here
for um but in some instances they were
right you know the kids had ADHD but in
most cases what happened is that that
hypervigilance that you're talking about
was being misinterpreted as
hyperactivity and the dissociation was
being
misinterpreted as
inattentiveness so the kids were getting
a diagnosis that was not correct of
course there are other very complex
cases where you have both ADHD and pthd
also ADHD can put you at risk to develop
PTSD because you're not as attentive as
to what's happening in your
environment but there's definitely two
different conditions and and it was that
clinical observation that made me think
well
people don't know enough about PTSD and
certainly they don't know enough about
PTSD in children and we were having some
research in adult around that time in
terms of cortisol levels David Spiegel
who you've had here raciel Yehuda the
Bronx VA looking at PTSD in adults but I
said but what how does PTSD look early
on what's happening in the hypothalamic
pituitary adrenal AIS that is
responsible for secreting cortis
and regulate cortisol uh when these
children are young because this is a new
access you know is is is it already not
working or is it working right and so we
did a number of studies that
demonstrated that the normal circadian
rhythmicity of cortisol was there it was
higher uh early in the morning which we
need to jump out of bed and as the day
progresses it
decreases uh very helpful it goes up
when we are stressed like when we have
lunch after we have lunch cortisol goes
up right so that we can help manage the
insult of digestion or or whatever uh
and this kids were having those levels
but something was happening uh in a
number of studies and we noted that the
pre-bedtime level was higher we were
measuring it at different times uh in
the morning pre- breakfast pre- lunch
pre- dinner pre- bedtime but it was the
bedtime level that wouldn't come as low
as the healthy controls it would remain
high and this was also important
clinically because many of the symptoms
these kids were having were happening at
night anyes right bed wedding nightmares
not sleeping deep enough not sleeping
long enough um
fears at that point I felt
uh well we don't know anything other
than the cortisol pret time is elevated
right maybe they needed to be who knows
uh but I was concerned about the work by
sapolsky right and Bruce mchu and his
mentor demonstrating the neurotoxicity
that glucocorticoids can have in key
areas of the brain areas in the lyic
system and the cortical system where uh
which interestingly enough have a lot of
gluc coroy
receptors so then uh we decided to look
at brain structure and brain function in
youth with PTSD symptoms and see how
this cortisol would relate to that or
not uh and we did that through MRI
magnetic resonance imaging let's talk
about cortisol for a moment it's a topic
that has not received enough attention
uh in previous episodes of the podcast
I'm just going to summarize a little bit
of what you said and you'll tell me
where I'm wrong cortisol starts to rise
just before we wake up in the morning
assuming a good night's sleep and Peaks
a maybe I don't know 30 to 90 minutes
after
waking for you slow risers like me uh
probably a little delayed by the way the
height of that Peak and the acceler the
uh I would say the steepness of the
curve can be uh increased uh by viewing
morning sunlight we know this bright
light increases that cortisol Peak it'll
make you a better early riser but in any
typically the pattern then is that it
rises um through mid morning and into
the early afternoon and then starts to
taper off to lower levels and as you
mentioned we'll see bumps in cortisol
post meal if there's a stressor we get a
disturbing text we get a bump in
cortisol but these aren't huge Peaks
unless it's a big stressor correct and
then by evening cortisol levels in
healthy individuals are typically low
and that allows for transition into
sleep among other things allow for
transition into sleep but you said in
these kids with
PTSD cortisol doesn't come down to low
levels as much as it does in healthy
individuals um in the evening and
nighttime and that I imagine would lead
to perseverating on stressors from the
day this kid was mean I have a test
tomorrow maybe any stressor becomes more
um intense in our mind and body as it
were um and that perhaps could lead to
issues with
quality or duration of sleep which then
could perpetuate this cycle do I have
that correct correct okay so um has the
direct intervention of just trying to
suppress evening cortisol ever been done
I mean certainly there are drugs that
will do this um has that approach ever
been taken I thought about that when I
had those high levels but I I felt that
we needed to understand better I I think
I think yes that there were some
attempts with some medications and I I
don't think that led to anything uh in
terms of of helping those kids um or
just helping individuals in general that
had high levels of cortisol because of
of uh traumatic stress um but nighttime
you're right it is a time when basically
we fall asleep because we let it go and
and this kid's hyper arousability does
not allow them to Let It
Go um so if these levels are high why as
I was Finding you know what impact are
they having in brain development and and
usually the younger you are the more
universally distributed receptors are so
glucocorticoid receptors could be
anywhere at that point but as as we age
uh they become more localized and The
glucocorticoid receptors and cortisol is
a type of
glucocorticoid um are more common in
areas like the hypoc campus and the
prefrontal cortex which I also found
interesting because these areas relate
to the symptoms right that that many
individuals with PTSD have memory
anticipation of the future problem
solving context dependent problem
solving so on and even those attention
issues that make them overlap with kids
that have ADHD as well um so this
frontal limbic pathway the prefrontal
cortex community ating with these
emotional areas of the brain including
the amydala which is very close to the
hypoc campus um needed to be
investigated in in in a pediatric PTSD
and what I sometimes call Pediatric ptss
because post-traumatic stress symptoms
uh because as I mentioned there's a
group of kids that have post-traumatic
symptoms do not fulfill criteria for
dsm5 PTSD
but their function continues to be inair
sometimes that's because um of
comorbidity there's a high incidence of
comorbidity with anxiety and depression
so most of our studies that have look at
PTSD symptoms also look at the impact of
the interventions that we're doing in
anxiety and depression as well I'd like
to take a quick break and acknowledge
our sponsor ag1 ag1 is a vitamin mineral
probiotic drink that also includes
prebiotics and adaptogens ag1 is
designed to cover all of your
foundational nutritional needs and it
tastes great now I've been drinking ag1
since 2012 and I started doing that at a
time when my budget for supplements was
really Limited in fact I only had enough
money back then to purchase one
supplement and I'm so glad that I made
that supplement ag1 the reason for that
is even though I strive to eat most of
my foods from Whole Foods and minimally
processed foods it's very difficult for
me to get enough fruits vegetables
vitamins and minerals micronutrients and
adaptogens from food alone and I need to
do that in order to ensure that I have
enough energy throughout the day I sleep
well at night and keep my immune system
strong but when I take ag1 daily I find
that all aspects of my health my
physical health my mental health and my
performance both cognitive and physical
are better I know that because I've had
lapses when I didn't take ag1 and I
certainly felt the difference I also
notice and this makes perfect sense
given the relationship between the gut
microbiome and the brain that when I
regularly take ag1 which for me means a
serving in the morning or midm morning
and again late later in the afternoon or
evening that I have more mental Clarity
and more mental energy if you'd like to
try ag1 you can go to drink a1.com
huberman to claim a special offer right
now they're giving away five free travel
packs and a year supply of vitamin D3 K2
again that's drink a1.com huberman to
claim that special offer I definitely
want to get into some of those
interventions including some of the ones
that you've developed that are very
novel and are um being used to great
success um I want to just circle back
for a moment on this relationship
between PTSD and in some cases
inappropriate diagnosis of ADHD as you
mentioned these two things can coexist
in the same person um so we don't want
anyone who has been told that they have
ADHD um and PTSD or even just ADHD to
immediately assume that that diagnosis
is wrong based on what we're going to
talk about but it is possible um that
the a DHD that a child is told they have
is reflective of PTSD and I imagine that
if that PTSD arises through something in
the family structure or dynamic it would
be even harder to unmask because the
parent perhaps would be less motivated
to try and understand that if they
played some sort of role in it so I
realize this is a complex problem with a
lot of layers but um if you were to just
throw out a number based on your
experience what percent percentage of
pure ADHD
diagnosis would you like to see explored
for the possibility of a
PTSD influence let's just keep it kind
of uh diplomatic that way as opposed to
saying what percentage of ADHD do you
think is actually PTSD I firmly believe
that ADHD does exist um I'm I'm going to
say two facts that we know in the field
one are kids getting over medicated it
the answer is a clear yes they're
getting more medications that they need
for ADHD for for anything in general
kids now in ADHD they're getting
undermedicated so that's the second fact
so the first one is that if we look at
kids overall in the field of mental
health those that manage to receive
treatment which access is something else
we should talk about because like 50% of
them do not get access to Mental Health
Services um those that manag to get it
may end up uh
with the appropriate treatment right a
medication or a psychotherapy but
there's another subset of them that will
be medicated no matter what they present
with because they need to be seen fast
or is a fast solution so there's many
reasons for that but are kids getting
overmedicated yes but within those kids
those the those that truly have
attention deficit hyperactivity disorder
are getting undermedicated and that's
because of that access issue because
most of them we're not identifying and
that's a Pity because the first line of
intervention for ADHD is stimulant
treatment it does work and it works very
well uh for children that have the
correct diagnosis but the first line of
intervention for children that have a
history of PTSD be acute or chronic is
psychosocial it's a psychosocial
intervention so if you give a kid that
has PTSD and know ADHD a stimulant
medication not only is not taking care
of ADHD because they don't have it but
it adds to that hyper arousability you
know that is manifested there from
before by the way there are clinical
ways of separating
hyperactivity from this hyper oability
and hyper vigilance hyperactivity if you
see a kid that is not medicated and has
ADHD and they have the hyperactive
symptoms and the hyperactive type
they're going to be hyperactive for most
of the time that you're with them the
kid that has hyper arousability it will
be more of an on and off phenomenon the
the hypervigilance and Hyper arability
comes more when they're presented with a
cue that consciously or unconsciously
reminds their body of the traumatic
event or the traumatic
experiences um what happens though is
that usually we don't know what those
cues are right so we just see a kid that
sporadically becomes um hyper Vigilant
or
hyperaroused and then the other thing is
is hypervigilance something that needs
to be treated you know I I learned this
from a mother early in my career she's
like I was giving some talk in the
community and she came to me afterwards
and she said listen uh we live in a
street that's very dark and it's very
dangerous and my kid has to pass through
that every day I want him to be
hypervigilant and if he has developed
this trait of hypervigilance this is
something that could be helpful to him
and I said you're right I said you're
right it's not only to him to a lot of
people it could become very helpful to
be hypervigilant to assess the
environment in which they are in so the
problem is not the hypervigilance the
problem is knowing when to turn it on
and when to turn it off having the
cognitive flexibility right to be able
to say yes this is a dangerous situation
and I better respond this way if if I
can give you an example of of of a kid
right a kid that experiences domestic
violence and has Associated that with
noise in the in the house house learns
that running and getting into the room
is is a safe thing for them because
they're out of the picture right and
they protect themselves in the room but
a year later they're in the classroom
and for some reason the classroom gets
this level of noise the body without him
knowing right uh the body reacts by the
response that was helpful this is
classical conditioning right so he runs
out of the classroom but he's missing
the context the teacher is missing the
context when the teacher sends him to
the principal's office the principal
doesn't have the context right that this
response was actually adaptive at one
point and helpful at one point and the
body has had a hard time letting it go
to ask that kid to give us the only
response that he has is not the way to
help him we need to help him develop new
competitive responses so that the
experience of the other responses then
extinguishes that response that was
adaptive at one point but now it's
maladaptive by the way if they are in a
traumatic situation again we still want
them to use it right we still want them
to run and get out of there it's part of
that hyper vigilance that that's
protecting them in a way it's so
interesting uh you said if I understood
correctly that in kids with genuine ADHD
the hyperactivity is fairly persistent
across environments and with different
people Etc I'm sorry to interrupt but if
I could add the in attention comes and
goes because we all know kids that have
ADHD that you if you give them the right
video game all of a sudden they become
attentive right right this is a very
important Point uh when I did the solo
episode on ADHD I was um frankly shocked
to learn but it was validated by the
literature and certainly by the
responses from the audience that kids
with ADHD and adults with ADHD for that
matter absolutely have the ability to
sharply attend to something if it's
something that's very engaging to them
really exciting something that they
typically
enjoy but their ability to direct and
maintain attention in other environments
that are required for normal life
progression school work relationships
Etc is very diminished compared to those
without ADHD so what I have in my mind
is a step function meaning a you know an
increase in a steady state of
hyperactivity in a kid with ADHD but
then a jagged line beneath that of
attention this is I believe the picture
we're I'm painting here but that in
PTSD the hyperactivity is a jagged line
it really needs a Quee as you said um a
loud noise or um maybe it's the presence
of a particular voice I once attended a
um a trauma um it wasn't trauma release
as much as it was genuine uh trauma
Treatment Center out in Florida a friend
of mine runs this Center and I was out
there learning about the practices they
use in order to inform uh potential uh
experiments for intervention in my lab
back at Stanford and um and he said
something really interesting he said you
know when you bring people into this
sort of environment and they they've all
had trauma you see a pretty rich array
of of responses um to even just the same
conversation and then at one point
perhaps because he said that I I noted
that a woman raised her hand and she
said that particular tambers of voices
in the room were really activating her
you know this was important it wasn't
just what was being said it wasn't that
people were yelling at each other or
even the volume of the voices but that
even just the the the frequency the the
lowness or the highness of the voice as
it were was triggering something in her
brain that was giving her these bodily
Sensations and it was a very um
important insight for her to be able to
then start to direct interventions so I
guess we all hear that kind of now um
stereotypical example of you know the
the veteran who experiences combat comes
back and he's a car backfire and then
they hide that's kind we we read about
this and hear about this but it seems
like it's much more subtle than that
that sometimes the cues for this uh
hyperactivity this
hypervigilance is um very much linked to
something that sometimes even the person
with PTSD doesn't recognize until they
start to be put into that environment
again and again and then they can
pinpoint it my question now is if they
can pinpoint what the queue is do they
stand a better chance of recovery um as
opposed to somebody that just like feels
like I'm hyperactive then I'm exhausted
I'm wired and tired and and now I also
Imagine That in kids they don't have
necessarily the verbal proficiency to be
able to express what's going on for them
and in fact many adults don't really
know because we don't have a great
language for expressing this body mind
thing in any event a lot of questions
there but um what are your thoughts
about the requirement for being able to
understand what the cues what the
triggers are in order for a child Andor
adult to be able to start to make
inroads into their PTSD uh first a word
on the Vietnam veteran because there's a
very important study that was published
years ago that
demonstrated that those veterans that
had a history of child Mal treatment and
went to war had PTSD at higher
prevalence than the ones that did not
have a history of child Mal treatment so
child maltreatment I see so they were
traumatized before they went to combat
and and maybe they did not develop PTSD
but once again that point of the
accumulation right of of the stressors
at different times and I'm just
mentioning that because you may have a
veteran and you're waiting to look at
the classical cues where in fact it
might be more like a voice like the
example that you were giving that
triggers them what triggers an
individual is very personal so cues are
usually neutral and they're usually
related to our senses and I know you
like senses a lot so what we see what we
hear you know all of these things the
senses are really the the window to the
central nervous system right this is how
we get information the first time so in
this state of hyper arousability when
something traumatizing is happening our
senses are really acutely aware of
what's going on and they are making
sense of the insult but they also are
registering everything that's related to
that so these cues usually are neutral
so they're they're not like a gun for
example because a gun is not a queue
it's a threatening it's a threat right
but it's usually a color so there was a
red car part near where they were so the
color red made may be a que maybe a
trigger it was raining the day that that
happened so rain may be a queue maybe a
trigger and to answer your question
identifying those cues are important
because they let you know when your
symptoms are coming they let you know
that they're not coming out of nowhere
they let you know that you're not a
problem or that you're crazy or that
you're bad which is sometimes the
messages that kids get when they go to
that principal's office okay but they
let you know that they learned
themselves this is a normal response
right I've learned through my
psychosocial intervention I've learned
that this is a Quee that triggers a
response from me triggers a response
that was helpful at one time and through
classical conditioning and we do teach
classical conditioning to the kids those
respon has then
become uh present become conditioned
right uh when the queue is there when
the triggers there so yes to answer your
question it is important to know the
cues now what happens are we going to
know all the cues to everything to all
of our behaviors and this shift in mood
that sometimes we have during the day
and we don't know why right no the
answer is no we're not going to we're
not going to know all the cues but the
beauty of this is that if we can just
learn about one or two or three cues
what our response is there's more of a
forgiveness to ourselves in that when we
respond inappropriately we can think
well maybe I was exposed to a queue
right because I've learned all of this
about cues and classical conditioning
maybe that's what What's Happening Here
Yeah I'm thinking again about
post-traumatic stress injury the reason
I like that term even though I realize
I'm using it
non-clinically
is that if we understand that the
autonomic nervous system the seawing
back and forth or this Push Pull between
the sympathetic fight ORF flight and
parasympathetic rest and digest Loosely
speaking systems are always at play in
us when we sleep more parasympathetic
when we're alert and calm more
sympathetic and when we're stressed or
having a panic attack extremely
sympathetic
if we understand that as a biological
system which it is that deploys hormones
and shapes our patterns of thinking and
what's available to us in our memory and
Etc
then ptsi post-traumatic stress
injury I I feel like it liberates us a
bit to understand that yeah this
autonomic system has been disrupted in a
way and if I think about the autonomic
system as a seesaw which I often do and
I think about
the Seesaw having a pivot point with a
with a hinge it's almost like the
post-traumatic stress injury is to
create the tendency for that hinge to be
too
tight and sometimes that makes it more
like dissociative and we're exhausted
and kind checked out and maybe it
creates the hinge to be too tight such
that we're more on the sympathetic
excuse me sympathetic the way I uh for
those listening I'm using my hands but
you don't have to to see it to
understand that the the the alertness
system is locked in place it's hard to
get out of that and I almost feel like
the the injury that is post-traumatic
stress injury is a tightening down of
the hinge with the Seesaw tilted too
much to one or the other side and I I as
a biologist I I just wish that we
understood what that
disregulation uh was or is um chances
are it's not one location in the brain
or body it's going to be a network
phenomenon but um I feel like the word
disorder the D in PTSD is so critical
because it highlights the importance and
the pervasiveness of this thing but that
the eye in post-traumatic stress injury
hopefully will give people it certainly
is giving me some some sense of um uh
relief or Liberty and understanding that
like these are nervous system injuries
that um need treatment and that there
isn't something wrong or crazy with us
because of because of the fact that we
you know suddenly feel like we're having
a panic attack you know I've had people
I know close to me in my life say I'm
having a panic attack like what do you
mean what what happened like nothing
happened that's the point well how do
you sleep well it's okay you know and
you start doing the the curbside
diagnosis that neither of us is
qualified to do right but this is what
we do as as caretakers for each other in
our lives and it very well could be that
their autonomic system just got that
hinge is just locked in place for
whatever reason reason maybe it's one
sip too much of coffee maybe it's one
sip too little it's probably something
or a bunch of things does am I am I I
realize I'm getting outside my expertise
here because I'm not a clinician but I
feel like this ptsi thing is is is
sticky and important for for people to
hear about it certainly changing the way
that I think about
PTSD yes no and I like the
visualization of your seesaw and the
example of the hinge because it it it
reminds me of that cognitive flexibility
right it's not there it's kind of stuck
it's kind of tight too tight and and in
some individuals they just experience
the dissociation they're like stuck on
on the bottom right sitting on the
bottom on the seiso whereas for the
other individuals they hyper arous all
the time then you have everything in
between but but no I that's a very good
representation of it and I feel like a
good night's
sleep allows some recalibration of the
tightness of that hinge put differently
anytime we don't sleep well or long
enough we're not good psychologically a
good night's sleep is good for
everything we're finally at the point in
history where we where everyone seems to
accept that I really have to tip my hat
to uh Dr Matthew Walker from UC Berkeley
for writing the book why we sleep you
know it was only a few years ago that
book came out and um he deserves such a
token of praise for that
because prior to that there was this oh
I'll sleep when I'm dead mentality I I
think people knew sleep was important
but they didn't really understand and he
had to come out as kind of the um kind
of the downer message like listen you
know this is serious stuff you better
sleep you better sleep but I think we're
there now I think in in in 2024 we're
there I think people understand and I
think people have their own experiences
with sleep right we we've all felt that
c
that's coming and and if we really sleep
those eight hours we may be able to
fight it because we've strengthened our
immune system if we don't we will get
sick yeah
absolutely well let's talk about some of
the treatments that you use and have
developed for PTSD in young people and
maybe we should Define young people are
we talking about you know the 18 and
under just because that's typically what
we think about so in pediatric uh
Psychiatry we have three different
populations we have the preschoolers we
have the school age and we have the
teenagers and they are all very
different they all uh have responses and
defenses that are very different the
projects that I'm describing happen
mostly with the school age uh school age
children so preschoolers are going to be
essentially I think of kindergarten
starting at 5 so you're talking about
zero more to to more or less five or six
years old as the preschoolers
kindergartener and then transition Point
correct um and then for the kids we're
about to talk about we're really talking
about what six years old until about end
of adolescence yeah 15 and and and then
yeah then their teenagers later on okay
so I work mostly with the school age the
school age kids and like I said when
when we started doing magnetic resonance
imaging to look at the impact of
cortisol we have a number of studies
really demonstrating that those kids
with higher levels of cortisol had um
less volume of the hypoc campus uh the
first study that we did in that was
cross-sectional and there was no
difference and it gave me a lot of hope
that there would be a window of
opportunity there where we could
intervene uh because what we were seeing
in chronic PTSD in adults was that there
was smaller volumes of the hypoc campus
which help us process memories and have
strong connections with the emotion
center of the brain the amydala and also
with the prefrontal cortex and um and
what what we found was that
cross-sectionally there was not this
difference but we also follow a small
sample longitudinally and there we saw a
correlation between that higher preet
time cortisol and the smaller hipocampal
volume uh more impactful was a
functional Imaging study uh as as many
of your audience members now with
magnetic resonance imaging we not only
can look at the structure but we can
also give tasks uh of memory for example
or of executive function and different
tasks that tap at the at the areas that
we are interested in looking uh so when
we look uh when we give a memory task
and we looked at how children with
post-traumatic stress symptoms were
behaving compared to kids that do not
have symptoms or other Psychiatry
diagnosis
we were seeing that the healthy kids
were activating a lot of more voxels or
units of the Imaging of the of the haboc
campus so so there was concern here that
yes that plasticity that you talked at
the beginning was really affecting the
development of the brain of the kids and
then with the prefrontal cortex we saw
something uh similar in the uh ventral
medial area of the prefrontal Al cortex
so but with other tasks right with tasks
of executive function or or tasks of
emotion
um looking at faces for example
emotional faces all of this to say that
they probably have a malfunctioning
frontal
striatal pathway and front olymic so
front olymic I'm sorry so um
if we think of the amydala for
example in close proximity to the hypoc
campus being involved in this
hypervigilance and we have some data to
show that the amydala becomes active
very quickly when you present emotional
faces uh to young kids um and that that
hyperactive amydala needs a a break of
some sort that break comes from the
prefrontal cortex but if you have a
prefrontal c cortex that's not working
that well either then your break is not
working right so so then the issue came
here well this is important information
to know what we need to Target with
treatment and can we target this with
psychosocial interventions and the way
that we provide
treatment and we decided to begin with
what we discussed earlier with the cues
right and uh teaching and having kids
understand what cues are what classical
conditioning is
um talking to them about the impact of
trauma talking to them about the impact
of treatment and how recovery is
possible right so an educational an
educational piece and something that I
never thought I would end up doing was
developing a treatment right I I felt
I'm here to invest investigate and use
the treatments that we have but it
became very clear to me that there were
a population of kids that still needed a
form of treatment that was not out there
so most treatments out there for trauma
were targeting one traumatic event and
not TR targeting that backpack that
allostatic load also and rightfully so
most treatments
were
um requiring that the parents were
involved in treatment as well I can see
where that might be problematic when the
parents perhaps were the source of the
trauma and also when there's avoidance
right and also when there's
practicalities that if they lose one day
from work they're going to get fired so
so sometimes the parents are just not
available and the kids are totally ready
to begin and do the work so I I wanted
them to be able to do so so how can we
devise a treatment that is hybrid and by
that I mean multimodal that is not only
cognitive behavioral therapy but that it
brings other elements that are important
like
self-efficacy
empowerment Insight oriented work and
give it a structure that uh can be
tested and that's how we created Q
Center Q being cue Q centered therapy
for kids that have PT D SD and we've had
a number of trials with them and it it
helps uh decrease symptoms of anxiety
symptoms of depression and symptoms of
PTSD and not
only as uh scored by the student but
also scored by observers by the parents
and in one of the trials where we
measure actually how the parents were
doing parents that were not
participating in treatment their own
anxiety was decreasing as well and
that's is it to understand right if your
kid is doing better you're going to do
better as well um so so that was very
very good to see but then we wanted to
see that plasticity too is this some
doing something to the activation of the
brain and that's when we brought
functional near infrared spectroscopy
into the picture because it's cheaper
than MRI and it's more portable and it's
easier to do it only gives you cortical
information it doesn't get into those
interesting lyic structure
so it's um just to uh just highlight for
a second the fmri fun functional
magnetic resonance imaging is wonderful
because it allows a lot of um uh Imaging
both on the superficial outer parts of
the brain but also deep into the brain
my understanding is that and perhaps
this has changed in in recent years that
the um spatial resolution can be very
good you can pinpoint very small areas
if you have a powerful enough machine
magnet um the temporal resolution the
ability to see changes in the neural uh
circuit activation and deactivation over
time at one point was somewhat limited
but now some of those limitations have
been overcome but then what you're
talking about near infrared
spectroscopy is excellent because it can
be taken to a school right you don't
have to you couldn't bring an fmri
machine to a school unless it's a
medical school where there's the machine
um it's much less expensive the downside
is oh excuse me and my understanding is
that the spatial resolution isn't quite
as high as MRI but the temporal but the
temporal resolution is very high which
is a huge advantage and then there's
this one disadvantage that you can only
really image the outer portions of the
brain but nonetheless there's a lot of
information there right so a little
technical lesson for people and these
outside areas of the brain the cortical
areas in the prefrontal area were
helping predict which kids would do
better only for those kids that were
having Q Center therapy and another gold
standard treatment called trauma Focus
cognitive behavioral therapy when they
were both compare to treatment as usual
I'd like to take a quick break and thank
one of our sponsors function I recently
became a function member after searching
for the most comprehensive approach to
lab testing while I've long been a fan
of blood testing I really wanted to find
a more in-depth program for analyzing
blood urine and saliva to get a full
picture of my heart health my hormone
status my immune system regulation my
metabolic function my vitamin and
mineral status and other critical areas
of my overall health and vitality
function not only provides testing of
over 100 biomarkers key to physical and
mental health but it also analyzes these
results and provides insights from to
doctors on your results for example in
one of my first tests with function I
learned that I had two high levels of
mercury in my blood this was totally
surprising to me I had no idea prior to
taking the test function not only helped
me detect this but offered medical
doctor informed insights on how to best
reduce those mercury levels which
included limiting my tuna consumption
because I'd been eating a lot of tuna
while also making an effort to eat more
leafy greens and supplementing with
Knack and acetylcysteine both of which
can support glutathione production and
detoxification and worked to reduce my
mercury levels comprehensive lab testing
like this is so important for health and
while I've been doing it for years I've
always found it to be overly complicated
and expensive I've been so impressed by
function both at the level of ease of
use that is getting the tests done as
well as how comprehensive and how
actionable the tests are that I recently
joined their Advisory Board and I'm
thrilled that they're sponsoring the
podcast if you'd like to try function go
to function health.com huberman function
currently has a weight list of over
250,000 people but they're offering
Early Access to hubman lab listeners
again that's function health.com
huberman to get early access to function
I want to get into the Q centered
therapy versus cognitive behavioral uh
versus the uh no therapy um conditions
you just described but before we do that
I just want to have a brief uh
discussion about some of the
Neuroscience you mentioned because I
think people will find this very
interesting and um certainly not just a
listing off of names of
structures you said that the
frontolimbic pathway is important here
the limic pathway including the amydala
but other structures as well and my
understanding and I think the generally
accepted understanding about these lyic
Pathways is that they create a response
State a state of alertness a state of
relaxation that they um translate
certain information that impinges on
them into uh a level of reactivity
either low medium or very high when I
say reactivity a tendency to move toward
or away from something or stay still for
it put in uh broadly speaking now the
fronto piece the feed the feeding in of
information from the frontal cortex
where context dependent decision-making
and as you said executive function takes
place is so critical for all of us as we
mature even as a I would say if you look
at a puppy everything's a stimulus and
then over time they're not going to pick
up everything in the room that's without
question largely due to the development
of these fronto limic Pathways and in
children and in um in humans that is
it's the same I can imagine that the
signals coming from the frontal Pathway
to the lyic system are going to be
somewhat cryptic to people that aren't
familiar with um Psych patry and
Neuroscience so maybe we could just um
throw a few of those out there here's an
example tell me if I'm wrong um but the
way I think about this is okay uh a kid
is in a room and they're
hyperactive and um or maybe something
set them off and they're particularly uh
Vigilant and stressed they're in the
stress response the frontal cortex is
the pathway by which an internal
dialogue could be de delivered to quiet
that lyic pathway the message that would
perhaps trigger that would be the kid
recognizing because they learned uh this
is okay I've had this happen
before it passes or I'm supported
there's Dr Kion there's my mom there's
my dad there's my teacher there's my
friend I'm supported because we know
social support is important or it's
normal to feel stress every once in a
while so these kinds of thoughts are
these internal dialogues that we're told
that we should do for ourselves when
we're
stressed I think we can be pretty
certain that that's the kind of
information that would trigger this
front to Olympic suppression and can I
comment on that dialogue because all of
those are examples of positive thoughts
right positive thoughts that are good uh
but they're not automatic thoughts they
are thoughts that need to be practiced
right negative thoughts unfortunately
that reside in our reptile brain are
automatic so that hyper response I mean
danger type of
situation when we evolved right is
responsible for our survival so we learn
the negative thoughts very well I'm in
danger I have to run I have to get on
top of this tree the lion might come
whatever so only 50 million years ago
when we developed the frontal cortex
more uh positive thoughts came into the
picture and they're very helpful for all
the reasons you're mentioning but
they're not
automatic like the negative ones are
hopefully they will become so what I
tell the kids is if I if they don't play
guitar if I give you a guitar right now
would you be able to play me a song
absolutely not I have absolutely zero
minus one musical ability but I love
music but if you if I gave you a guitar
with guitar lessons and you practice you
probably will be able to play a song a
year from now well me with some degree
of proficiency but not but everybody
else yes a support system a support
system that's right and with enough
practice hours and enough deter focus
and determination I'm I'm convinced I
could um become at least proficient um
even at 49 years of age so we have a
slogan in in my team which is practice
positive thoughts all the thoughts you
were mentioning are good ones and we
have to practice them right this is what
I'm learning no I'm I'm not bad this is
happening because of the que even when
the lyic system is not active should do
you encourage uh your patients to
practice positive thinking even when
they're not in the stress response all
the time interesting it's like it's
learning a tool so in this Q Center
therapy one of the lessons is that they
have an empty toolbox and and this
toolbox gets filled with tools that they
learn and practicing positive thoughts
deep breathing mindfulness all of this
muscle relaxations are tools that we
teach them but they decide and here's
where the empowerment comes in they
decide what the cues are they decide
what tools they're going to put into
their toolbox or they're not going to
put in the toolbox and by far whatever
tools they develop that have not been
taught by me or anybody
else work better when they develop it
themselves interesting and you know I I
I had this case once and and it got
Illustrated really well when I I was in
in one of the sessions you teach them
breathing exercises muscle relaxation
things that we know help and I'll talk a
little bit more about how we know that
they help and um and then they have like
a week to practice and then they come
the next week and we see where they are
and what's in the toolbox and things
like that
and the next week when when she came she
was much much better you know and I said
I was very proud I'm like oh you've been
practicing the tools right that we
discussed last week and she's like no I
actually don't remember anything you
said last time but I I came up with this
thing that when I feel bad I'm I'm
drinking a glass of orange juice every
time and at that moment I knew I could
go both ways I could go no no you must
practice is my tools or I could say how
wonderful you've identified a tool that
helps you to drink a glass of orange
juice which obviously is what I did and
then she was able to have that in her in
her toolbox and and we have multiple
examples like this so she would drink a
glass of orange juice in order to quell
her anxiety yeah if she felt bad and is
this something that she would do even
when she wasn't feeling stressed I mean
it's kind of interesting it suggests and
it completely squares with everything I
understand about prefrontal cortical
limic Pathways which is that they're
highly subject to contextual learning
right if any the frontal cortex is this
incredible feat of evolution that um
allows us to link essentially any
stimulus with any um non uh learned
response in the body right I mean this
is what allows you know soldiers to
learn to overcome their fear of Bomb
Blast and run toward them if if
necessary I mean I mean it it can cut
both ways of course um but for me and
this still needs to be tested is is
nothing necessarily about the glass or
even the orange or the vitamin C or
anything like that it's about the fact
that she has this message she has sent a
message to herself I can take care of
myself because the best tool that I have
is me it's my own body whatever these
kids go in the future there's something
that's always going to be there with
them which is themselves so they as
themselves is the best tool they can
have you know their body the the way
they think all of these things do you
think this is why we hear the uh kind of
classic anecdote about the patient who
has anxiety attacks whose psychiatrist
gives them a a couple of pills of
medication that can help reduce anxiety
and they decide to keep those pills in
their pocket should they have an anxiety
attack and knowing they have those pills
in their pocket allows them to control
their
anxiety yes because it it gives them a
sense of control right and and they have
control over this and some people may
choose to leave them in the fridge and
some people may choose to put them
elsewhere but is what they decide is
that decision they're making that gives
them uh a sense of control that's
important it's so interesting the sense
of agency and control over the um
non-negotiable stress response you know
I sometimes
unfortunately get um in my opinion uh
incorrectly attached
to ice baths uh we've talked about cold
water exposure on this podcast our
colleague Craig heler at Stanford
Department of biology phenomenal
scientist was on this podcast we talked
about some of the beneficial uses of
deliberate cold exposure there are a lot
of arguments does it increase metabolism
doesn't seem like it does very much is
it useful for inflammation perhaps um
but the one thing that everyone agrees
is that being in uncomfortably cold
water makes you breathe F faster excuse
me and stress a bit in other words it
kind of sucks it's
uncomfortable and I think one
non-negotiable fact about deliberate
cold exposure is that it gives people an
opportunity to explore their own stress
response if they're going to do it
safely right you take a cold shower you
have some control you can get out
immediately obviously you don't want it
so cold that you give yourself cardiac
arrest you know you have to be care care
f with deliberate cold exposure but the
adrenaline response to uncomfortable
cold is non-negotiable and I believe
that whether or not somebody decides to
you know recite the alphabet or think
about how cold it is or whatever it is
what they're doing is they are
practicing this frontal control over the
lyic pathways it's just sort of a
general exercise for controlling the
lyic system through thought but as our
colleague David Spiegel has said to me
many times says um you know it's not
just the state that you're in here we're
talking about stress as the state it's
how you got there and in particular did
you have any control over how you got
there and whether or not you can get out
and I think that the kind of stress that
you're talking about in post-traumatic
stress disorder or in post-traumatic
stress injury is typically of the sort
that people didn't have a choice
certainly these kids didn't have a
choice about the initial exposure to the
trauma or stress
but that also the stress is showing up
when they would least want it to appear
or when it's very inconvenient to appear
so this this narrative is important is
an important part of of recovery um but
we feel that it needs to come after the
education piece and after learning uh a
toolbox having defenses because
sometimes it can get very charged when
you go through the narrative and you
want to assess
many things during the narrative you
want to assess gaps of memory you want
to assess potential cues you want to
assess the emotions that are present so
and and the narrative should be one that
covers not only negative events but also
neutral ones and also positive events
and and it sounds like a lot right but
when you're talking about kids that have
10 11 12 years it is doable you know you
can really manage it by the way with the
cold showers I I think you're getting to
the hinge of that seao I I think the
cold shower probably does not the cold
shower what do you call deliberate cold
it could be from cold shower I always
say that because oftentimes people think
oh you know they're just trying to sell
cold plunges and the truth is you don't
need that I mean the fact of the matter
is uh it's uh independent of income
actually a cold shower will save you
money on your heating bill I'm not
saying everyone should take a cold
shower I I love a nice warm or hot
shower I sometimes use the cold shower
as a stimulus and I hate it every time
but I always learn something each time
um by the way it feels great when you
get out so that's nice and it does for
many hours um especially if you end it
with some warm water but the uh the
learning I believe is in recognizing
just how destabilized our patterns of
thinking get when we have adrenaline in
our body which is what uncomfortable
cold does and it deploys that adrenaline
in the brain and body and it also is a
great learning in seeing the return to a
BAS line just seeing how that affects
our psychology and I I to my mind I can
think of no other zero cost or even
negative cost um meaning saves money
approach that works the first time and
every time you know that is safe enough
right I mean I'm not interested in
anything that has to do with snakes for
instance I don't mind spiders I'll pick
them up with my hands as long as it's
not a black widow or a particularly
large spider and I'll put it outside but
I don't like snakes I don't like
thinking about them I don't like being
near them so you know there are other
stressors that one could use but it's so
individual whereas cold water seems to
be uh pretty uncomfortable for everybody
I think you need some exposure of snakes
and you're
cold no interest it's so interesting you
know these things get so firmly rooted
but I'd love to talk about this toolbox
um because first of all it's according
to your work and um this has been done
repeatedly It's very effective and and I
I love the idea that it can be
customized so the words that come to
mind is a customized toolbox for
combating stress and
PTSD and the fact that it can be
customized and maybe even covert like we
can have these tools inside us we don't
need to share them with anybody if we
don't want to but that they are very
effective I think that those are very
compelling reasons for exploring the uh
the toolbox approach a bit more here so
you mentioned one way to go about this
is to think about or to have in mind
some negative some neutral and some
positive experiences and then to think
about the different tools that one would
deploy under those different conditions
correct so so the exercise of the events
is a Lifeline that we do separate from
the toolbox we actually work on the
toolbox first to
identify um coping mechanisms and coping
tools that help so what would that look
like let's say I'm a a nine-year-old I
come into your clinic and I meet the
criteria for ptsi or
PTSD um
what sorts of questions would you ask
yes so I the first thing I would say
when you're
feeling a certain way whatever way we're
talking about right agitated anxious
nervous uh is there anything that makes
you feel better because the experience
of having something and they bringing
something is important too and sometimes
they do they say I listen to music or
you know I play the guitar or I go to
play or my friends or my friends are my
teammates mostly actually they say
teammates teammates is pretty popular I
love that yes there's something about
sports and and and sports is something
that comes up a lot when we do the
toolbox people put in their Sports
they're doing or talking to their coach
or talking to their teammates or
learning a new sport uh sports are big
so that's an example that they give uh
talking to
friends um uh planning a
sleepover uh listening to
music uh different things like this are
there any particular tools for um when
kids are stuck in a stress response yes
so because I I myself am familiar with
um you know the toolkit that I use um
certainly teammates is is one of them
and I have others including long exhale
breathing physiological size these
things will be familiar to some of the
listeners but certainly there are times
when we're stressed about something and
we don't want to be and we have a hard
time pulling our thoughts and our
emotions and the stress response you
know out so the ones I just mentioned
are are some ideas that the kids bring
with them what we always try to do is we
teach them uh exercises of relaxation we
have to be very careful with this
because like like you say it's good to
be personalized right it's good that
it's adapted to the kid and that's why
we don't tell them put this in your
toolbox we tell them learn it and if it
helps you you decide if you put it in
the toolbox or not so when I talk about
the treatment being not so much about
the what because there's many components
here like education
narrative uh that are common right
exposure we we can talk about uh it's
it's not so much about the what but it's
about the how it's about empowering kids
to identify those cues to say if a tool
works or doesn't work to develop their
own tools so but sometimes they are very
stuck right and and they need a little
bit of help so we teach them breathing
exercises and we have a script for that
we te Teach them muscle relaxation and
we have uh something for that we teach
them the positive thinking for example
so that's a cognitive uh type of tool um
and we teach them mindfulness because of
our other work in prevention that we can
talk about uh later in in which um
mindfulness has been helpful and and and
also yoga very simple yoga exercises so
so nothing too complicated things like
the mountain pose for example uh can be
quite helpful for some kids if anything
it helps them uh reassess the moment
and and stop and if we're going to think
about it in cognitive behavioral terms
kind of break break that chain of
negative thoughts that happen one after
the other which can lead to a panic
attack right that's many times how a
panic attack can start well what's so
interesting to me about the stress
response is that while it's quick to
start it's slow to shut off for logical
reasons related to our evolutionary
trajectory right um wouldn't it be one
wonderful if you could stress when
needed and then it would turn off when
needed but what we're really talking
about here is intervening in the stress
response either before or as it's
happening but then also making sure that
the tail of that stress response isn't
too long we're also talking about
eradicating stress that causes
discomfort right and is this causes this
stress uh not necessarily to live a life
without stress or to get rid completely
of stress because that's would be
impossible
in certain cultures there are um
accepted practices that adults use to
deal with stress things like worry beads
um and a few years back there were those
what were those F what were the little
spinner things that kids had um uh when
those were popular maybe they're still
popular Did You observe any reductions
in stress um you know kids have a lot of
energy like sometimes I think we confuse
energy and stress um wouldn't we all
love to have the kind of energy that we
had in childhood um
I was observing this the other day you
know you'll see a kid sitting
cross-legged listening in class and then
all of a sudden it's time to move across
the room and they'll just pop up and
move across the room like when was the
last time any of us like popped up out
of our chairs unless we were
particularly excited or scared as adults
um just that immediacy to action um
implies that there's a lot of energy in
the system so I could imagine that
having some ways to siphon off some of
that energy through as far as I can tell
you know um things like worry beads or
or fidgets or whatever those are called
I mean they might irritate some adults
around but really they're pretty
innocuous when you think about it I like
that you're not calling it nervous
energy because it is just what you said
it's Just Energy it's extra energy uh
that needs to be placed somewhere and
they're trying to find out where to
place it I mean we have colleagues that
not all of them this is not a
requirement for being a professor at
Stanford but I've got colleagues that
work 80 hours a
week you could argue that's healthy or
unhealthy depending on the context and
their agreements with others but you
know that requires a lot of energy and I
know they are not particularly happy
working less so you know I think
sometimes we are dismissive or kind of
um pejorative about you know uh physical
energy and and shaking and moving but
you know I I see I know someone in my
life who bounces her knee while she
works and it it's it kind of makes me a
little bit nervous but boy does she have
a lot of focus and energy you know so I
mean I think it's wonderful in other
words yeah yeah and and some of us you
know choose to have meetings while
walking rather than being in an office
that's certainly my preference you know
I go for a walk sometimes uh when I have
a meeting so yes so there there is
increased energy but there's increased
energy that of of I feel like I need to
do something and there's increased
energy that causes a lot of discomfort
so for this kid that kids that
experience discomfort then they can look
at their tool point and say which one
I'm going to use and and that gives them
also a choice which goes back to that
sense of control again earlier meaning
off microphone we were talking about the
fact that some people indeed some kids
have a different tendency to Anchor
towards thinking or feeling or action
when under stress and um you were
describing the four quadrant system uh
could you share with us this four
quadrant system because I think it's
both extremely valuable to children and
to adults it's certainly something that
I plan to incorporate into my life yes
so we have to be careful with uh
structured uh interventions because
sometimes a structured interventions can
break a little bit the
fluidity uh of the relationship that a
therapist and a child may have or a
therapist on on a patient so it's it's
better to be semi structure and to
really be attentive to the temperament
that the kid brings into that
relationship or into that session and
certainly with the toolbox as you
mentioned we see an example of
that we also add that in Q Center
therapy by dissecting and examining a
response so for example a child that
breaks windows or child that screams or
a child that lives the classroom running
we try to understand what's happening at
that moment and the way that we do that
is by looking at a square and a square
is composed of four corners and the Four
Corners are what you're thinking so it's
a cognitive side to it uh what you're
feeling
emotionally what you're feeling
physically and what your are uh actually
doing what the action is and and this is
your classical triangle of cognitive
behavioral therapy in terms of what
you're thinking what you're doing and
how you're feeling but but we felt it
was important to add that somatic
physiological component because for many
children they don't have the vocabulary
to talk about all of this they just tell
you I have a headache or I have a
stomach ache and and there's no other
Medical reason that explains it right so
depending on the kid that comes you're
going to start examining their response
through one of those Corners so if the
kid is really brainy and likes to think
about the things they think or don't
don't think you start in the cognitive
corner you know other kids are very
attentive to their body and they say I
feel my heart racing when when I engage
in this Behavior or in this response and
you start with that corner the beauty of
this is that most of the time you don't
have to work in all of the corners by
just working in one corner all the other
Corners change and a new response
develops okay so if I'm thinking that
I'm not in danger maybe I don't need to
leave running maybe I can just tell the
teacher I'm distressed by the amount of
noise all of a sudden the kid has
created a new Square that's another
Square so hopefully we take that one
response as a square and build a cube
right of many potential
responses so that when the Quee happens
now there's an armentarium of responses
and if I'm too distress to think what
response to do I can bring myself there
by using my
toolbox so it it all kinds of starts
tying together and then as I have more
responses as I understand cues I can
begin talking about this narrative that
I have where I will fix some cognitive
distortions hopefully like it was my
fault I made it happen to things
like no it wasn't my fault somebody else
was responsible and I'm just a Survivor
right I'm not a victim I'm a Survivor
that's another cognitive distortion that
can be fixed so so all of that we we've
included all of this in a manual for
therapist right so we have a manual for
therapist that is called Q Center
therapy for youth with post-traumatic
symptoms published by
Oxford but I believe that adults that
want to reexamine their childhood or
their history or want to think about
their kids or are interested in trauma
can get a lot from actually examining
this manual and studying this manual and
in fact I believe in so so strongly that
we are um beginning the first first
steps of adapting it not only for youth
but also for
adults in this four corner system and
forgive me because I called it a four
quadrant system but in this four uh
corners of the square system you said
there's thinking which is cognitive
there are
emotions then there's feelings which are
somatic physical and then actions so
actions are straightforward thinking uh
would be for instance uh if I understand
correctly I'm in danger um emotions
would be I'm scared so it's a it's a a a
a verbal label I'm depressed I'm scared
I'm sad I'm yeah and it way is cognitive
too right but it carries an emotion with
it and then in terms of the physical
feeling it's you know of the body but it
could include of the head too like I
have a headache or my heart is racing or
I'm I um or something of that sort and
then actions of course is the action
that they an action is really fun one
because you can imagine there are some
kids that are not psychologically minded
at all and they don't even want to
engage in this with me and they're like
okay what is it that I'm doing I'll do
something different so they'll they'll
immediately develop the next Square so
they cannot things talk too much about
their emotions or how they're feeling
physically or look at the negative
thought but they say oh is the problem
that I'm running out of the classroom
well what if I don't and they give you
another action and and so some kids
start with that corner so you can really
start with any of the corners yeah I
love that earlier you were talking about
practicing positive thinking even when
perhaps especially when one is not in
the stress response or trauma response
but also of course when one is in the
trauma response I think that's just so
vitally important for people to hear
certainly for for me to hear um I'm not
claiming to have PTSD it just but as a
as a novel concept that I've not heard
raised before you um around these topics
the other is this four corner system um
which
immediately occurs to me is so powerful
because it breaks down um the kind of
reflex arc of the stress response into
its component parts right what's of the
body what's of the thinking what's of
the thinking that's emotional and then
what's the action and you said as soon
as one um identifies one of these
corners and starts to kind of look at it
differently and consider some of the
optionality that exists an alternative
that all these other options Cascade
from that and I believe that in doing
that you've described what um for
thousands of years really um but
recently we've heard a lot about in the
kind of mindfulness Arena as creating
space right like like this notion of
creating space not outer space but
creating space within us to to uh choose
better options is something that I think
until right now as you've described this
has remained unfortunately very
mysterious you know people talk about
okay you um you know you want to be uh
reactive excuse me you want to be um
responsive not reactive responsive
implies some optionality to your
responses reactive implies kind of a
reflex arc of just whatever the default
was but this notion of space is like too
squishy for me as a biologist to really
um to really be able to latch on to and
I I would argue given the prevalence of
PTSD and stress it's probably too
squishy for me most people it hasn't
really LED anywhere specific but I think
what you're describing is the ability to
become responsive as opposed to reactive
um assuming that the word responsive
includes like some options within it and
so this four corner system to me is
genius because it gives us an anchor
point to start from so could you say
that if a child or adult is um
uncomfortably stressed maybe about a
trauma but just as like caught in the
stress response that actually pulling
out a pen or pencil or crayon as it were
and and write and drawing a square and
and just really like what am I thinking
like maybe it's just like this is
terrible I don't like it writing down um
I'm embarrassed like I'm not with my
friends like I'm like not you know I'm
flush you know my cheeks are flushing
whatever um I'm feeling like just
weighed down or something and then think
well what what are the actions I want to
remove myself from the situation at that
point is the suggestion that one find
what is the the point of entry that
feels most accessible and to start there
yes with one
caveat we usually use um
Wagner's um emotional thermometer to
measure where the kid is at and it goes
from like 0er to 10 or 1 to 10 uh with
different levels of stress and and it's
good to use something concrete because
sometimes we think they are a 10 and
they're at five or vice versa yeah we're
very poor at assessing others internal
states are as our colleague Carl dth
who's also been a guest on this podcast
I heard him once say this in a very
large lecture he said you know we're
terrible absolutely Dreadful at
assessing other people's emotions in
fact most of the time we don't even know
how we feel yeah he he always says that
and it's true it's true but I would say
if the kid is at 10 at that moment the
best thing is to use a tool from the
toolbox and not to engage on the Square
at that moment until they come down a
little bit and they can pick pay
attention and they can listen to you
because then that they will be letting
the information come in they're so
emotionally charged right at the moment
that that may not be the right
time um which also by the way is the
same thing as as when you need to talk
to kids about traumas that are happening
in our society right sometimes you just
want to let them know that the door is
open for communication you may want to
talk about it at the moment with the kid
K may not be ready but you can let them
know Well when you're ready we can talk
about it here the same when you're ready
let's go over the square exercise or the
example if the Kitt is already familiar
with it or I have something to show you
right and pick his C curiosity that way
um but I would say use the thermometer
to see if that's a good time right if if
it's 10 98 probably not wait till it's
like 543
and then engage in that so the toolbox
should be used essentially under any
conditions um and the kid should
generate their own tools to add to the
toolbox customize the tools and then the
square can be used when they are at a
slightly lower level of stress because
it requires a certain level of cognitive
intervention they need to be able to
think about and and express their own
State correct okay and is this something
that you suggest kids only do with their
therapist or is this something that they
can do on their own as well assuming
that they're old enough to to write and
to think about it yeah well our our hope
is that after a kid goes through Q
Center therapy that they can internalize
a lot of these activities and exercises
and like I said become their own tool
like like take those for life and
continue to use them yeah I'm certain
that many many adults not just children
can benefit from these tools I mean I
mean I would argue that most most of the
bad things that happen in the world are
the consequence of disregulated
autonomic
function put kind of bluntly Yeah by
directional right kind of making things
worse once they happen they impact the
system even further yeah I mean I think
most homicides are homicides of of
jealous rage from what I have read I
don't know if that's still true but and
of course then that it's probably also
true for all the things that are not as
severe as homicide but still dreadfully
bad like assault and things like that
yeah um and and it's interesting that
you bring that up because I often think
about we we've been talking about how we
experience trauma as individuals right
but we experience trauma in our
civilization we experience trauma in our
history we experience trauma in our
nation and how those in nation heal how
does a system heal well the steps are
not that different perhaps this is the
appropriate time to um give you the
opportunity to editorialize a little bit
about um social media and online
behavior um setting aside really
aggressive online Behavior bullying and
things like that which of course exists
and is really serious
um do you see the behavior of kids and
adults online the sort of um just maybe
even the the addiction to online um
commenting and reading of comments and
the kind of battling of issues back and
forth it clearly isn't going anywhere
some of it goes someplace functional but
most of it I would argue especially
among the adults is going nowhere it's
just very circular it's my side versus
your side my side versus your side and
emotions get really stirred on there
yeah um do you think that is reflective
of um a lack of tools for
self-regulation um do you think like
what we're seeing is the manifestation
of of just a lot of challenges in the
world um and or an outlet for people to
just vent without the need to address
their own internal State and what's
underlying the venting I I know many
very very intelligent adults who
eventually just had to quit social media
in order to have any level of
functionality in their life it comes
down to that space you were talking
about and building that space and
creating that mindfulness time that you
need which is also going to be
personalized it's going to be different
for different people uh this spring I
was in Morocco and I visited the Medina
was staying at the Medina and I was
overstimulated as you can be and
enjoying it but I imagine this is the
state that teenagers are in all the time
when they are with social media bringing
them information and different tid bits
and different things that are happening
all over the place and very much like I
found it restful to go to my hotel for a
couple of hours before dinner uh people
need to build that space people need to
create that space what I tell parents is
that it's important to
remember that this was also a very
helpful tool for us when we were in the
pandemic right the kids were interacting
socially Academic School was happening
uh through
technology so how can something so good
be at times so harmful and I remind them
about when they brought hammers to their
house right and they had little kids
they had to teach them how to use them
this is a very important tool when you
need to nail something or when you need
to take a nail out this can be dangerous
right you don't run with scissors you
you have all these rules around other
tools we have to have these rules around
social media as well and and I and I
think that's what the Surgeon General is
getting at when when he talks about we
need some regulations around it um but
at the family level at the family level
I think parents need to say there are
certain boundaries that we are going to
have for so a dinner time for example in
this baskets all the phones go into the
basket and that's what we're going to do
from now on but it is very difficult
because when you establish rules like
that kids watch you like a hawk so you
have to model the behavior you are
expecting right the moment that you as a
parent decide oh no I need to go to the
basket during dinner because I need to
check this thing out then it
breaks so that's what I think I I think
it can be quite helpful and and I think
that it can be dangerous we've seen
examples of that and and it is a tool
like any other like a knife that we need
to learn how to use it I think what
you're describing to my mind uh is a
situation where the tool has become the
terrain it's like social media has
become the landscape in which many
people live as opposed to the real
world I mean my original understanding
of social media is that one would
experience and do things in the real
world and then bring those to social
media that's certainly what I do I teach
on social media and um I do the learning
for that teaching the drawing in some
cases the preparation in the quote
unquote real world and then bring it to
social media but I feel like the it's
almost like the the hammer has become
the um has become the landscape the
house or yeah or something like that the
hammer has become the house yes that's
much more eloquent and and and
appropriate um yeah I feel like with
social media the tool of social media
has become the terrain in which people
are living in so that just feels like a
um a closed loop is sort of an
engineering uh example just like it
doesn't go anywhere like you C you can
never actually get the relief that
you're seeking and I think we default to
descriptions about dopamine and dop
dopamine hits and there's some truth to
that but the more I look at the
literature on brain activation during
social media use it it doesn't really
speak to dopamine and reward prediction
error as much as it does just sort of a
Mindless compulsion and um kind of just
P passive overuse as opposed to like
rewards like oh this is so cool and that
so cool I mean it can be I mean I've
been watching some of the track and
field races of the Olympics and there's
a I mean I was cheering out loud for a
few of them
but it's it's usually something quite
different yeah I I think if if you live
in a virtual
world all the time then you're not
living right you're not in the real
world so it's like how can you use the
virt are there ways that the virtual
world can help you
live the current world in a better way
yes so that's that's why I think it's
helpful um but if you replace your life
with a virtual life then that's a Pity
that's very sad I see that in a lot of
adults as well as kids let's talk about
risk you know up until now we've been
envisioning a a treatment situation or a
study that you're running where a kid
and perhaps parents as well are brought
into the laboratory or clinic at
Stanford and you're talking to them
assessing them they're developing a
custom toolbox and that's a wonderful
opportunity for um kids who sadly have
PTSD or ptsi um to be assessed and to
develop tools that can really help them
that's been proven by the work you've
and others have done but what about the
many many millions of kids and adults
who are at risk either because of lack
of
access it could be due to finances
geography poverty any number of
different things or they simply don't
even know what PTSD and ptsi are uh
their parents don't know um what are
some of the tools and interventions that
you think could be implemented at the
level of schools families or even
individuals that might help them so here
we were in my program we had created Q
Center therapy right we develop a
training program for it we have a Q
Center therapy training
program and I became increasingly
concerned about my own staff and my own
team because this is a team as you can
imagine that are seeing trauma every day
and are seeing trauma in
kids I was worried about vicarious
trauma and the impact that this would
have in their health so I remember that
when I was doing my residency I took a
course in hypnosis and I was really
struck by how much control one has
during hypnosis so it's nothing like
anyone is doing to anybody else is is is
really kind of having the control to
relax yourself self-directed hypnosis
self-directed uh type of hypnosis and
and I said I would like to bring
something like that and I met a PhD John
redger that was a yoga instructor and
also a mindfulness instructor and I
brought him to the team and and he had
other things to do but one of the main
goals was to take care of the team and
we started regularly practicing yoga and
practicing mindfulness as we were seeing
all these cases and working with trauma
and so forth and I was able to see
firsthand how helpful it was for me
personally and for my team at the time
we were doing some work in East paloalto
in some of the schools we're doing some
prono counseling because this another
problem many of the schools have no
counselors right so um and this but this
was a while back this like 10 years ago
yeah the East Palo School District for
those that don't know
paloalto I guess it could be called West
paloalto is a separate city and county
from East paloalto pal Alto is not
exclusively but is known for at least
nowadays let's just be frank fairly
tremendous affluence relative to most
places in the world put bluntly um East
paloalto a separate County different
School District police system has for as
long as I can remember having grown up
um in pal Alto
um has always been stricken with far
fewer resources and U while there have
been tremendous efforts to improve the
um the situation there it is still at a
um steep disadvantage financially um but
of course um many uh amazing people
working there and living there and um
you know and growing up um there was
some exchange across uh that um east
palto west palalo uh border as it were
uh in the school district but they're
pretty separate domains when it comes to
resources and it is not now but many
years ago it was the number one murder
capital in the
US um it's also the place where Facebook
is now so so in Ikea and there there's
people that bring some employment to the
area but also bring some other problems
yeah that area where Ikea is used to be
called do you remember it was called
whiskey Gulch they didn't know for years
a kind of terrible name right but it was
a stark contrast to right as you
literally cross the train tracks heading
towards Highway 101 um in that case that
portion of palalo Crescent Park an
extreme of wealth to an extreme of
poverty yes in in literally a distance
of 10
meters and of course there are uh
wonderful families there of course uh uh
that support the kids there's a
Ravenswood which is also the other name
for is paloalto Family Health Center uh
that that really provides a lot of good
resources to the area and there's a good
school district but at this time it was
missing counselors so we had some
presence there we decided to to bring
some of the things that that we were
learning in terms of yoga and in terms
of mindfulness to two of the class rooms
at the end of about 3 months I get
called to the principal's office I have
to go to the principal's office to
because the principal was interested in
finding out what was going on in there
because none of those kids in those
classrooms had gone to her office in all
that time they hadn't gotten in trouble
they had not gotten in trouble so I
explained what it was and we decided to
do you know a bigger scale uh study and
and eventually we partner with a group
called Pure power uh pure power inc.org
uh developing a yoga and mindfulness
curriculum for students at
schools at that time we started bringing
yoga instructors into the classroom but
we we very quickly learn that the best
approach to this would be to teach the
teachers and have the teachers teach the
students because the yoga instructors
had no training on how to control a
classroom and the teachers did and some
of these poses were so Elemental that
you know it was okay if they were not a
yoga
instructor so anyway we tested this
curriculum and and there was a piece
about it in the newsour I think it might
still be there and I get this uh
wonderful phone call by uh this family
in New York that wants to see how they
can help me spread this further into not
only the classrooms that I was working
but uh into the whole school or the
school
district and I knew at that point that
two things were important not only that
they wanted and I wanted but that the
school district should want it and also
that at this time we would need to do a
very in-depth study to see what our
intervention was and what the curriculum
was because mindfulness can be the name
that you give to many different things
so we wanted to make sure that our
intervation of yoga and mindfulness
exercises that now pure power carries um
is really what we're being tested so
they were very very helpful in helping
sponsor not only the dissemination of
this curriculum through the school
district but a randomized control trial
where we actually had a whole other
District that would also be trained but
only after the study was over it was a
demographically comparison School in in
San Jose in in the city of San Jose uh
near enough for us to conduct a study
but far enough that were there wouldn't
be uh too much um dissemination from one
District to the other and it was good
that we did a a
districtwide control because if we would
have done
done it by classroom or by school it
wouldn't have worked because there was
so much diffusion of what the kids were
learning into the their friends and
their family and the other classes and
the other people in the community that
was beautiful to see but it would have
ruined a control study so you needed
literally physical and demographic
separation so you went with uh what used
to be called the peninsula the South Bay
East pal Alto and then San Jose far
enough apart that the kids weren't
talking enough to uh blur the the
treatment groups exactly so we
demonstrated feasibility you know we
were able to do it we demonstrated
acceptability the kids liked it the kids
would do it some schools actually had a
a room specifically for them to to go
and do it even if if the teachers were
not doing it in the in the classroom and
it ranged it was like uh twice to three
times a week for 15 or 50 minutes of
this curriculum in the in the classrooms
can I sorry to interrupt but can I ask
you a little bit more about the
curriculum um you said five uh you you
said or 15 to 50 5 Z minutes um two to
three times per week and did the kids
have to like change over to their yoga
clothes the reason I ask is that um I
could think of a number of real world
barriers to getting something like this
implemented I feel like going jogging
usually you get a little sweaty you need
running shoes you know there are other
forms of exercise that require that less
but um these days there as far as I know
not every school requires physical
education when I was growing up and
through High School you had to literally
suit up you had to go in the locker room
put on your your PE clothes as it as it
were and then you'd run or play
volleyball whatever the PE teacher told
you to do had to do if you wanted to get
a good a decent grade um is the yoga
being done you said it could be in the
classroom or at a separate location but
are the kids basically getting up out of
their chairs and just right in their
school clothes doing this for 15 to 50
minutes so they they stay with the same
clothes um but we had mats they had mats
every student had a mat and it's
interesting that you mentioned PE
because the first suggestion was let's
do it during PE class and I'm like no
that that's you know rowing from Paul to
to Peter
um until I learned that PE like you said
was not happening so sad which I
couldn't believe and if anything I think
the study has helped for them to bring
PE back and the classes which are these
lessons and yoga movements and
mindfulness were really taking place in
the classroom that whatever teacher
learned it so if it was the math teacher
she was taking 10 minutes aside to do it
if it was the p and B was not happening
there they may dedicate the 50 minutes
uh to do the yoga and the
mindfulness so
um we we have a a number of uh
assessments that we did and like I
mentioned yes it was acceptable and and
it improved mood and and all of that but
I think the biggest finding that we
published from that study was that it
increased 73 minutes of
sleep uh 73 73 minutes of sleep that's
EX extraordinarily high on average for
for the students and it increased the
depth of sleep so something that we did
in the study was that we also did
portable
polysomnography and it was not in a
Sleep Center it was in their own house
so collaborating with Ruth oara from
from the Department we were able to
assess their sleep and and deep sleep is
very important that's where you process
the events of the day so these kids were
increasing RM
total sleep deep sleep doing much better
and then another thing because of our
previous studies that we've talked about
in terms of brain function uh this
hasn't been published but we have some
preliminary data demonstrating that
those kids that went through the
intervention before and after the
intervention uh were able to decrease
the activity of their amydala which was
very powerful and also very helpful so
many of these kids adapted this into
their daily practices after this study
was over we went to our control group
and and we taught those lessons there
and um and now it has served to
identified even more tools that we can
put in the toolbox of CCT so so we
utilize some of the things there in here
so pure power and our program have been
collaborating a lot because it covers
the risk group and the treatment group
so sometimes when we go to schools and
we do trainings we um partner with them
so that we have the yoga and the
mindfulness and the Q Center therapy and
and and I by no means mean these are the
two things that everybody should be
using I'm saying these are two more
Tools in fact I think we need more
development more development of
interventions both for treatment and for
intervention and how do we identify who
needs what and and how is where we're
moving next wow what spectacular results
I mean 73 minutes more of sleep is like
I mean talk about effective medicine you
know I mean we agreed at the outset that
sleep is the foundation of mental health
and physical health and all forms of
cognitive and physical performance I
mean it's just me we know this the study
done at Stanford albe it a small one of
having athletes just get a bit more
sleep or even just stay in bed a bit
longer and know not on their phones but
just lying quietly with eyes closed and
resting or sleeping more improved shot
accuracy in basketball players this has
been shown in so many domains of
cognitive and physical it's like not
even worth spooling off all the examples
but that is spectacular it also makes me
think I should start doing some yoga um
because I I do get enough sleep but
that's
significant what do you think are the
barriers to having this sort of thing
implemented at national scale and I
always think about this you know okay so
the results are in maybe it's one study
maybe it's two but you're talking about
a basically um harmless intervention and
actually it's a very therapeutic
intervention sure there are some people
that won't be able to do all the poses
Etc but there's always something that
somebody can do um even people that are
immobilized there are certain forms of
uh believe it or not um uh cognitive
yoga and and that friend of mine who
works with people who are uh
quadriplegic they can do certain things
to keep nervous system function online
but you
know essentially anyone can do this um
what are the barriers from taking it
from this East pal Alto school to a
study to another study okay San Jose
school now let's say you get all of
Santa Clara or um you know neighboring
counties um you know what does it take
to get something implemented at National
scale so that the work can really Ripple
out and benefit all these kids who of
course are going to become adults well
we need to prioritize it right we need
to prioritize
education to to for starters right we
were talking about classes not even
having physical education or arts for
example uh and we need to prioritize
mental health and it needs to start
early and I think when we work our
national budget it needs to be
uh there needs to be ear marks for these
two areas and that should go to the
Department of Education the Department
of Education should make this a a
priority um teachers are really really
overwork uh they they are under
resource and like pediatricians many
times are responsible for doing somebody
else's work right everybody tells them
oh this will only take a minute or this
will only take two minutes or if you
make this assessment you know you can do
that but but it the time is finite right
and the space is finite so they need
more space they need more time they need
more support
teachers
uh and then this needs to be a priority
from districts to really Implement
programs like this so parents and and
even non-parents um talk to the teachers
in the school talk to the principles in
the school and I've been learning about
the power of the
telephone um for lobbying this has been
around some uh things I've been involved
with with the veterans community I mean
the ability to look up and call your
Congressman or congresswoman and tell
them that you are really concerned about
or excited about a particular program
does have impact I mean I I at first I
didn't think this was true but I
realized that when they start getting
100 a thousand messages about a
particular topic that people are
passionate about they pay attention um
maybe it's because they just want to get
reelected maybe it's because they are
genuinely um concerned about helping
people I I like to think it's the latter
but regardless of which they run those
messages up the flag pole uh when they
bring issues so so let me tell you what
we just started doing in Puerto Rico I'm
from Puerto Rico uh but Puerto Rico and
Puerto Rico
Puerto Rican students have gone through
a number of natural disasters that
started with hurricane Maria and
continue with other
hurricanes and and also with earthquakes
and and this has led to violence and
there's interpersonal violence so some
of the cases in Puerto Rico have gone
through a lot uh but also the whole
island of Puerto Rico is one of the
largest school districts in the US uh
the whole island is one District meaning
that if you do something like a program
like the one we're talking about you can
implement it
islandwide um currently we are launching
a project in Puerto Rico where all the
teachers will be train in the yoga and
mindfulness curriculum and all of the
counselors will be trained in Q Center
therapy the kids are being assessed at
Baseline then they go through their yoga
and curriculum and at time too when they
get assessed to see how they're doing
after that um we also screen those that
have uh ptss postraumatic stress
symptoms that cause impairment and then
those go through the trained counselors
and then they get assess again at the in
the latter part so the the goal is for
us to although we've talked about the
two treatments we've never really uh
have both of them happen
simultaneously and we want to do it in a
large scale like this because if if this
works if if it's sustainable if it's
feasible we can actually then bring it
to other large school districts like New
York like La for example and and start
disseminating this I'd love your
thoughts on something you know I'm so
impressed that you were able to bring
this from a study or set of studies to a
much larger scale in Puerto
Rico I could be wrong here but I feel
like uh in the United States we have
such a culture of Fame and popularity
and reward around people who are extreme
performers you know we hear about you
know these NBA stars and right now we're
seeing a lot about these incredible
track stars and we're um or we have
these Tech innovators that found huge
companies they used to be called unicorn
companies but all these incredible um
successes and um I wonder sometimes if
the hyper emphasis on these extreme
performers has led to the conclusion in
young people that unless you're going to
be Michael
Jordan or Lebron James or Mark
Zuckerberg or uh Elon Musk or win an
Olympic gold medal that the practices
that feed up to becoming those sorts of
people like mindfulness meditation or
becoming a yogi for that matter you know
I feel like the there's been a push
towards hyp specialization and
performance to the point where people
are writing off the The Incredible
utility of physical activity mindfulness
um you know learning math science
literature and the Arts you know talk
about the Arts studies music right even
for people like me you know I mean sure
they always gave me the triangle cuz I
could manage that one and I don't want
to insult the triangle players I'm sure
it's much more complicated than uh I'm
giving the impression is but the point
is that I feel like um there's been a uh
not so gradual uh disintegration of the
idea that there is utility indeed
there's great benefit to doing things
not with the intention of becoming a
high performer but just doing them for
sake of how it enriches us in a number
of different ways including our mental
health and I wonder whether or not the
lack of PE is sort of a well if you're
not going to run track and try and medal
or something and you know or go to
Championship meets then like what's the
point but I I don't um I certainly don't
subscribe to that I'm curious what your
thoughts are
um well I I think we need to redefine
success and what it means to be
successful uh I I think that we are
currently describing it with the
examples that you just gave which
probably was not the way that we were
describing it in the 60s or the
70s um
but it it is harming individuals that
which is most of us that cannot attain
that level of uh proficiency in an area
and in fact the individuals that are
choosing to have a broader belonging in
a way are more protected I I worry about
those other individuals too that have
that very
personalized um not personalized but
very very individualized unique
component in their life where they
dedicate everything to that one thing
they trust me they they often suffer in
one or more of their other domains of
life some don't but I would arue most do
but the the idea of belonging right is
that you have you belong to many
different facets of life um you are a
sports person you're a community person
you're a student you're a father you're
you know an ant you're you're different
things um when you're only one thing and
that fails your whole identity is gone
it doesn't even have to fail it has you
have to perceive that it has fail and
that's enough to throw you of course and
so with the current definition of
success we're not doing a service for
those that attain that definition and
those that do not attain that definition
I think it needs to be broader I think
belonging needs to be included I think
the way that we care not only for
ourselves but for the rest of our
citizens needs to be included uh
citizenship is
important um so
it is dynamic so far it has been Dynamic
how we define success and hopefully it
will change again I I agree
wholeheartedly let's talk about
resilience earlier you said you know
kids are not resilient but you also
implied maybe you even stated it
outright that they can become
resilient what is resilience and what
are some of the paths to resilience
resilience is a physical term right it
means you bounce the coil bounces back
to where it was I originally I I like to
think of the word
adaptation because it means not only you
bounce back but you bounce back to a
better place like I like to think that
we adapted during the experience of the
pandemic other than we were resilient of
it yes we were resilient because we
survived it some of us did not all right
some of us have to deal with the grief
of what happened during that
time um but adaptation means that not
only we go back to where we were before
the pandemic but that now we've learned
from that experience to be in a better
place now we know very little about
resilience and we definitely know very
little biology about resilience we know
that having a sense of humor is good we
know that persever perseverance is good
we know that the presence of an adult in
a child's life that was there to give
them opportunity or or to talk to them
about things they were going through
that's probably the the best known you
know resilient
Factor um but what if it's not the
presence of of that adult but there's
something in that child that makes them
seek and maintain that type of
relationship right so I feel that we
need to start looking at the biology of
resilience and one way that we've done
that in my program is through a
collaboration with Alex Urban from our
department and from genetics and
Caroline Perman who's in his lab and one
of his post dogs um they work with
organoids and I don't know if you've
mentioned organoids before to your
audience I have not but um uh one of my
good friends and uh uh colleagues at
Stanford Sergio pasca is one of the
world leaders in organoids and we hope
to host them on this podcast soon but uh
please um educate us on organoids they
are oh so cool and oh so science
fictiony but they are also real yes as
well so so we have stem cells that can
be converted to any type of cell under
the appropriate nutrients and
environments that we want to examine uh
so for a psychiatrist of course the
interest is to turn them into neurons
and not only they can grow in a Petri
dish but they grow suspended so is it's
almost like a 3D and and Sergio uses um
the term asem bloid for when he actually
assembles them further to create build
uh more organ specific mini brains mini
brains is the term that I like yes um so
these mini brains are this neurons that
are
growing uh in a in a circle like the
brain and they communicate with each
other and they are active with each
other and we can study so in
conversations with Alex and now that you
all know my previous work with cortisol
and all that I was telling him and
Carolyn well why would happen if we
expose some of organoids to
cortisol um and of course we needed to
come up with oh what would be the right
amount you know that would mimic trauma
so we also involve Robert saoli to help
us come up with a concentration that
would be trauma mimetic and so we expose
a number of organoids to different
levels of of cortisol for some of them
it was a trauma for others they were not
exposed then half of of that amount or
much less of that amount was a trigger
the Q right so some had the trauma on
the Q some had no exposure some only had
the queue and then we compare what was
Associated um with really um well the
first thing that they needed to do was
identified that these neurons actually
had these glucocorticoid receptors and
that they were active and they did have
them and they were
active so we looked through epigenetic
analysis I wi is the Royal Wii right is
more Alex and Carolyn they look at the
genes that were change that their
activity change because of this cortisol
exposure and through epigenetic analysis
which is the space you know uh between
DNA and RNA and there's like methylation
patterns and all that and some gen
activity
changes some turn on some turn off so
interestingly the majority of the genes
that we found there were genes that have
been addressed in the literature as
potentially being related to post
trumatic stress disorder things like the
glucocorticoid receptor genes and things
that you would think of but there was
another subset of genes that we identify
that were novel and I was very
interested in those because of my
interest in accelerated aging because of
stress and those were genes that are
related to collagen formation and we
know that atherosclerosis has been
related to stress for example and as and
we know that accelerated aging not only
in BTSD but in mental health conditions
overall individuals that suffer from
severe mental illness chronically in
their life end up dying 25 years Young
than the rest of the population that's
very
significant and um so stress and
accelerated aging interesting okay so
these are interesting findings in
organoids but but when you have those
what you do is you move on to a
population study so these kids in Puerto
Rico that are going through these
interventions besides me checking on
their PTSD their anxiety their
depression
they're giving me a vocal Swap and in
the vocal swap those epithelial cells we
can actually take them through
epigenetic analysis and see those kids a
time one that even though they've gone
through all this trauma may not be
fairing that much worse as as their
counterparts and compare them and not
only that we can actually also look at
response treatment response for the
intervention for the yoga and
mindfulness preventive intervention and
for the treatment for the Q Center
therapy so that's the plan that's the
plan in trying to bring more light into
what is the biology of resilience and
how can we understand resilience
better what a spectacular study goodness
and if any of you miss some of the
underlying mechanics I'll just quickly
recap these organoids are little brains
in dish that came to be by virtue of
taking fiber blasts or other cells so
skin cells essentially put into dishes
provided four what are called
transcription factors these are the four
transcription factors that uh yamanaka
won the Nobel Prize for identifying that
reverts those cells into stem cells and
then a few other goodies molecular
goodies that then allow them to become
neurons in particular then they grow
into little mini brains and then as Dr k
was explaining are exposed to cortisol
at appropriate concentrations to mimic
cortisol exposure in the whole person
and then from that the genomes of those
cells and the epigenomes are analyzed to
identify potential targets the results
are brought back to these kids in Puerto
Rico such that the genomes of all these
kids experiencing different levels of
stress and yoga mindfulness
interventions or not maybe they're in
the control
group the outcomes can be assessed and
then one can address hey what are the
genes that are protective against stress
AKA what are the genes that are
protective against high levels of
cortisol and a bunch of other surely to
be very transformative and important
facts about how stress impacts the young
brain to either give rise to PTSD or not
I must say as you described that study I
had three thoughts one wow how awesome
is this that you can Bridge across so
many different levels of analysis I mean
because you're talking about molecular
genetics all the way up to yoga in
school children in Puerto Rico and PTSD
you know it's just a complex disorder I
was also thinking to myself um wow what
an incredible Place Stamford is that
such a collaboration is possible Right
makes me Delight in the fact that
colleagues like you exist and Sergio and
forgive me the names of the other
colleagues I'm not familiar Urban and
Caroline Perman thank you and the third
thing is how important it is to bridge
across these different levels of
analysis I think this is the first time
on this podcast where somebody has
discussed an experiment that Bridges
across so many levels of analysis
literally from fiber blast skin cells in
a dish all the way to a complex
psychiatric condition and in an attempt
excuse me to create novel Therapeutics
so it's just truly spectacular so if
people are sensing a um even further
surge in my energy this is the kind of
thing that gets me so excited because in
the landscape of science we often see a
study or we hear about organoids or we
hear about a yoga intervention and these
things tend to exist in silos and
isolation but the ability to bridge
across these levels of analysis I
believe is uh critical and so um yeah
kudos to you for for being a part of
this incredible collaboration and
collaborations are key right because the
world is so complex now that there's no
way that a single lab could have all
this expertise so you're right a place
like Stanford allows for these
communications to happen for these
collaborations uh to happen uh in 28
years that I've been there I have never
heard no I'm not interested in that how
we say at at Stanford especially if two
scientists um meet for more than 30
minutes what comes out of that is a
collaboration as a final question I'm
going to ask you to limit it to one
answer but I'm sure that there are many
um the question is if you had a magic
wand and you could get any message out
to the whole world about PTSD and
ptsi in particular in kids and young
people but also in adults what is that
message what do you want people to know
about post-traumatic stress disorder
stress and post-traumatic stress injury
the first thing that comes to mind is
the importance of of listening and
listening to to what kids and adults
have to say about their
experiencing and really creating a space
for them where they or us don't feel
isolated uh that they feel supported and
that they feel that they can identify
their own uh
strengths and their own capabilities of
of making themselves better
um you know every everyone knows or has
heard about psychiatrist and everybody
thinks oh what would your Psychiatry say
and psychiatrist have these smart things
to say to people that help them with
their life but the best psychiatrist
that I know actually say very little
they listen uh so I would say that
listening to the experience that people
have is is Key Well thank you so much
for that and Dr car on vict thank you so
so much for the work you do thank you
for having me here yeah it's it's
spectacular work um at so many levels um
it's also very bold and brave work to
tackle such a big problem with such um
you know focus and to really give people
agency this notion of a custom toolbox I
think is profound to give kids and
adults as it were agency over their own
interventions in an effort to really
help themselves um I appreciate you
coming here today more than I can
express I know the listeners and viewers
of this podcast appreciate it as well um
you are involved with Stanford
clinically you're involved running uh
studies clinical studies of you know
great importance so for you to take time
to educate us with these tools is
absolutely spectacular and is really
appreciated um please keep us updated on
your progress and please come back and
tell us more about that progress uh when
the time is right thank you so much
thank you for joining me for today's
discussion about post-traumatic stress
disorder and its treatments with Dr
Victor Kion to learn more about Dr
kion's work please see the links in the
show note captions if you're learning
from and or enjoying this podcast please
subscribe to our YouTube channel that's
a terrific zeroc cost way to support us
in addition please subscribe to the
podcast on both Spotify and apple and on
both Spotify and apple you can leave us
up to a five-star review please check
out the sponsors mentioned at the
beginning and throughout today's episode
that's the best way to support this
podcast
if you have questions for me or comments
about the podcast or guests or topics
that you'd like me to consider for the
huberman Lab podcast please put those in
the comment section on YouTube I do read
all the comments for those of you that
haven't heard I have a new book coming
out it's my very first book it's
entitled protocols and operating manual
for the human body this is a book that
I've been working on for more than 5
years and that's based on more than 30
years of research and experience and it
covers protocols for everything from
sleep to exercise to Stress Control prot
protocols related to focus and
motivation and of course I provide the
scientific substantiation for the
protocols that are included the book is
now available by pre-sale at protocols
book.com there you can find links to
various vendors you can pick the one
that you like best again the book is
called protocols an operating manual for
the human body if you're not already
following me on social media I am
huberman lab on all social media
platforms so that's Instagram X formerly
known as Twitter threads Facebook and
Linkedin and on those platforms I
discuss science and science related
tools some of which overlaps with the
content of the hubman Lab podcast but
much of which is distinct from the
content on the hubman Lab podcast again
that's hubman lab on all social media
channels if you haven't already
subscribed to our neural network
newsletter our neural network newsletter
is a zeroc cost monthly newsletter that
includes podcast summaries as well as
protocols in the form of brief one to
three page PDFs those protocol PDFs are
on things like neuroplasticity and
learning optimizing dopamine improving
your sleep deliberate cold exposure
deliberate heat exposure we have a
foundational Fitness protocol that
describes a template routine that
includes cardiovascular training and
resistance training with sets and Reps
all backed by science and all of which
again is completely zero cost to
subscribe simply go to huberman lab.com
go to the menu tab up in the upper right
corner scroll down a newsletter and
provide your email and I should
emphasize that we do not share your
email with anybody thank you once again
for joining me for today's discussion
with Dr Victor Kion and last but
certainly not least thank you for your
interest in science
[Music]