back to indexErasing Fears & Traumas Based on the Modern Neuroscience of Fear | Huberman Lab Podcast #49
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Welcome to the Huberman Lab Podcast,
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where we discuss science and science-based tools
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for everyday life.
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I'm Andrew Huberman, and I'm a professor of neurobiology
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and ophthalmology at Stanford School of Medicine.
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Today, we're going to talk about the neuroscience of fear.
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We are also going to talk about trauma
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and post-traumatic stress disorders.
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The neuroscience of fear has a long history in biology
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and in the field of psychology.
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However, I think it's fair to say that in the last 10 years,
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the field of neuroscience has shed light
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on not just the neural circuits,
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meaning the areas of the brain
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that control the fear response and the ways that it does it,
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but some important ways to extinguish fears
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using behavioral therapies, drug therapies,
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and what we call brain-machine interfaces.
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Today, we are going to talk about all of those,
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and you are going to come away
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with both an understanding of the biology of fear
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and trauma, as well as many practical tools
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to confront fear and trauma.
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In fact, we are going to discuss
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one very recently published study
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in which five minutes a day of deliberate exposure to stress
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was shown to alleviate longstanding depressive
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and fear-related symptoms.
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We will get into the details of that study
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and the protocol that emerges from that study
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a little later in the podcast,
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but it stands as a really important,
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somewhat counterintuitive example
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of how stress itself can be used to combat fear.
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To give you a sense of where we are going,
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I'll just lay out the framework for today's podcast.
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First, I'm going to teach you
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about the biology of fear and trauma,
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literally the cells and circuits and connections in the body
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and chemicals in the body
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that give rise to the so-called fear response,
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and why sometimes, but not always,
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fear can turn into trauma.
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I will also describe the biology of how fear is unlearned,
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or what we call extinguished,
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and there too, you're going to get some serious surprises.
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You're going to learn, for instance,
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that we can't just eliminate fears,
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we actually have to replace fears with a new positive event.
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And again, there are tools with which to do that,
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and I will teach you those tools today.
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Before we begin, I'd like to emphasize that this podcast
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is separate from my teaching and research roles at Stanford.
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It is, however, part of my desire and effort
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to bring zero cost to consumer information about science
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and science-related tools to the general public.
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In keeping with that theme,
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I'd like to thank the sponsors of today's podcast.
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Our first sponsor is Athletic Greens.
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Athletic Greens is an all-in-one
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vitamin mineral probiotic drink.
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I've been taking Athletic Greens every day since 2012,
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so I'm delighted that they're sponsoring the podcast.
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The reason I started taking Athletic Greens,
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and the reason I still take Athletic Greens,
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Nowadays, there's a lot of data out there
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literally little microbes that live in our gut
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and it has a number of other things
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If you'd like to try Athletic Greens,
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you can go to athleticgreens.com slash Huberman
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Today's podcast is also brought to us by Inside Tracker.
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Well, fear falls into a category of nervous system phenomenon
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that we can reliably call an emotion,
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and it is hotly debated nowadays,
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and it's been hotly debated really for centuries
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what an emotion is and what an emotion isn't.
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Now, that's not a debate that I want to get into today.
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I think it's fair to say that emotions include responses
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within our body, quickening of heart rate,
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changes in blood flow,
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things that we experience as a warming
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or a cooling of our skin,
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but that there's also a cognitive component.
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There are thoughts, there are memories.
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There's all sorts of stuff that goes on in our mind
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and in our body that together we call an emotion,
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and there's a vast amount of interest
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and literature devoted to trying to understand
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how many different emotions there are,
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how different people experience emotions,
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and that's certainly a topic that we will embrace
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in a future podcast episode.
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But today, I just want to talk about fear as a response,
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because when we talk about fear as a physiological response
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and as a cognitive response,
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then we can get down to some very concrete mechanisms
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and some very concrete and practical tools
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that can be used to deal with fear when fear is not wanted.
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So let's talk first about what fear isn't.
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Most people are familiar with stress,
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both as a concept and as an experience.
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Stress is a physiological response.
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It involves quickening of the heart rate,
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typically quickening of breathing,
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blood flow getting shuttled to certain areas
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of the brain and body and not to others.
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It can create a hypervigilance or an awareness.
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Typically, that awareness is narrower,
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literally narrower in space,
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like a soda straw view of the world,
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than when we are relaxed.
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And it is fair to say that we cannot have fear
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without having several, if not all of the elements
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of the stress response.
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However, we can have stress without having fear.
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Likewise, people are familiar with the phrase,
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or the word, rather, anxiety.
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Anxiety tends to be stress about some future event,
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although it can mean other things as well.
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We can't really have fear without seeing or observing
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or experiencing some of the elements of anxiety,
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but we can have anxiety without having fear.
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So what you're starting to realize is that fear is built up
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from certain basic elements that include stress and anxiety.
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And then there is trauma.
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And trauma also requires a specific,
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what we will call operational definition.
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An operational definition is just a definition
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that allows us to have a conversation
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because we both agree on, or mostly agree on,
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what the meaning of a given word is.
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It makes conversations much easier.
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In fact, I would argue,
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if we all had operational definitions
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for more things in the world,
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that there would be fewer misunderstandings and arguments,
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and we'd all move a lot further as a species.
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But that's another topic entirely.
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The operational definition of trauma
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is that some fear took place,
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which of course includes stress and anxiety,
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and that fear somehow gets embedded
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or activated in our nervous system
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such that it shows up at times when it's maladaptive,
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meaning that fear doesn't serve us well,
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and it gets reactivated at various times.
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Like when you first wake up in the morning,
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if you're not in the presence of something that scared you,
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but you suddenly have what feels like a panic attack
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and you're in deep fear,
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well, that's post-traumatic stress.
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That's post-traumatic fear.
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So I don't want to get bogged down
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too much in the nomenclature,
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but what I'm doing here is building up
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a sort of a series of layers
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where stress and anxiety form the foundation
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of what we're calling fear and trauma.
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And then there are other phrases out there
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that we would be remiss if we didn't mention
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things like phobias and panic attacks.
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Panic attacks are the experience of extreme fear,
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but without any fear-inducing stimulus.
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So it's kind of like trauma.
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And a phobia tends to be extreme fear
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of something specific, fear of spiders,
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fear of heights, fear of flying, fear of dying,
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these kinds of things, okay?
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The reason for laying all that out there
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is not to create a word soup to confuse us.
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Rather, it is to simplify the issue
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because now that we acknowledge
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that there are many different phrases
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to describe this thing that we call fear
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and then related phenomenon,
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we can start to just focus on two of these issues,
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fear and trauma, as it relates
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to specific biological processes,
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specific cognitive processes,
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and we can start to dissect how fears are formed,
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how fears are unformed,
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and how new memories can come
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to replace previously fearful experiences.
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So in this effort to establish a common language
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around fear and trauma,
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I want to point out autonomic arousal.
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Autonomic arousal relates to this aspect
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of our nervous system
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that we call the autonomic nervous system.
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Autonomic means automatic.
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That's somewhat of a misnomer
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because there are aspects of your autonomic nervous system
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that you can control,
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but your autonomic nervous system
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controls things like digestion,
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urination, sexual behavior, stress.
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When you want to be awake,
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when you want to be asleep,
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it basically has two branches to it,
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two branches meaning two different systems.
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One is the so-called sympathetic autonomic nervous system.
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It has nothing to do with sympathy.
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It has everything to do with increasing alertness.
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Think of the sympathetic nervous system
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as the alertness nervous system.
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It's what ramps up your levels of alertness,
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ramps up your levels of vigilance.
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Think about it as the accelerator
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on your alertness and attention.
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The other branch of the autonomic nervous system
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is the so-called parasympathetic branch
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of the autonomic nervous system.
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I know that's a mouthful.
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The parasympathetic branch of the autonomic nervous system
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are the cells and neurons and chemicals
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and other aspects of your brain and body
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that are involved in the calming nervous system.
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So sympathetic is alerting, parasympathetic is calming,
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and it acts as sort of a seesaw
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to adjust your overall level of alertness.
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So for instance, right now I'm alert,
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but I feel pretty calm.
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I'm not ready to go to sleep or anything like that.
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I don't feel like I need a nap.
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I'm alert, but I'm calm.
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I'm not in a state of stress or panic.
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So that seesaw we could imagine is more or less level.
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Maybe it's tilted up a little bit
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to the side of increased sympathetic or alertness
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rather than parasympathetic because I feel wide awake.
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If I were sleepy, the opposite would be true.
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The parasympathetic side would be increased
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relative to the sympathetic side.
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There are many different aspects
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to the autonomic nervous system,
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but one of the main aspects is an aspect
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that's going to come up again and again and again today.
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It's very important that you understand what it is.
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It's called the HPA axis.
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The HPA axis stands
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for hypothalamic pituitary adrenal axis.
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The hypothalamus is a collection of neurons.
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It's an area of your brain, real estate,
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that's deep in the brain, at the base of the brain,
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that contains many, many different areas
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that control things like temperature and desire to have sex,
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desire to eat, thirst.
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It also controls the desire to not mate, have sex,
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not eat, not drink more water or any other type of fluid.
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So it has accelerators and breaks in there as well.
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The hypothalamus connects to the so-called pituitary.
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The pituitary lives close to the roof of your mouth.
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It releases hormones into your bloodstream.
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And so the hypothalamus has this ability
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to trigger the release or prevent the release
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of particular hormones like cortisol
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or the hormones that go stimulate ovaries
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to produce estrogen or testes to produce testosterone
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or adrenals to produce adrenaline.
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And speaking of the adrenals,
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that A in the HPA are the adrenals.
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You have two glands that sit above your kidneys
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in your lower back.
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They receive signals by way of nerve cells, neurons,
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and by way of hormones and other things released
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from the brain and elsewhere in the body.
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And they release different hormones
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and other types of chemicals into the body.
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And the two main ones that you need to know
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about today are adrenaline,
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also called epinephrine, and cortisol.
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Both of those are so-called stress hormones,
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but they're not always involved in stress.
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They're also involved in waking up in the morning
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when you, excuse me, when you rise from sleep.
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And so this HPA axis should be thought of
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in the following way.
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The HPA axis includes a piece of the brain,
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the hypothalamus, the pituitary, and the adrenal.
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So it's a beautiful three-part system
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that can use your brain to alert or wake up your body
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and prepare it for action.
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And it can do that in the short term
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by triggering the release of hormones and chemicals
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that make you alert and ready to go right away.
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And by triggering the release of neurotransmitters
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and hormones and other chemicals
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that give that alertness a very long tail,
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a very long latency before it shuts off.
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And that's important because one of the hallmarks of fear
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and one of the hallmarks of trauma
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is that they involve fear responses that are long lasting.
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Even if those fearful events,
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the events in the world that trigger the HPA axis
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can be very brief,
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like a car that almost hits you as you step off the curb
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or something, a gunshot that goes off suddenly,
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and it's just a very quick, like 500 millisecond
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or one second event,
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the fear response can reverberate through your system
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because the chemicals that are involved in this HPA axis
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have a fast component and a longer lasting component.
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And the longer lasting component can actually change
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not just the connections of different areas of the brain
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and the way that our organs work,
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like our heart and the way that we breathe,
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it actually can feed back to the brain
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and literally control gene expression,
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which can take many days and build out new circuits
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and new chemicals that can embed fear in our brain and body.
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And that might sound very depressing,
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but there's a reason and there's an adaptive reason
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why there's this slow and fast phase of the HPA axis
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and the fear response.
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And fortunately, that gene expression
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and the long arc of the fear response,
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the way it kind of lives in our system,
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kind of like a phantom in some ways,
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can also be leveraged to undo the fear response,
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to extinguish the fear response and replace it
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with non-fearful associations.
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So let's dig a little deeper into the neural circuits
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and biology of fear, because in doing that,
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we can start to reveal the logic of how to attack fear
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if that's the goal.
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We can't really have a discussion about fear
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without discussing the famous amygdala.
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Famous because I think most people by now
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have heard of the amygdala.
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Amygdala means almond, it's an almond-shaped structure
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on both sides of the brain.
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So you have one on the right side of your brain
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and one on the left side of your brain.
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The amygdala is part of what we can call the threat reflex.
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And this is very important to conceptualize fear
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as including a reflex.
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So much as you have reflexes that cause you
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to lift your foot up if you are to step on something sharp,
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you literally have a reflex within your spinal cord
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that causes you to lift up one foot
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and extend the other one toward the ground,
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believe it or not.
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You always think that you step on something sharp,
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you pull your foot up,
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but you actually step on something sharp,
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you pull your foot up and in pulling it up,
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there's another reflex that's activated
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that as you extend your other leg
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so that you don't fall over.
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Similarly, in the process of experiencing fear,
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you have a reflex for particular events
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in your brain and body.
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And that reflex involves things like
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quickening of your heart rate, hypervigilance,
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your attentional systems pop on,
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increased ability to access energy stores
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for movement and thought and so forth.
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But just like that step on the tack reflex example,
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all of the neural circuits that are associated
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with being calm, with being able to go to sleep,
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with being able to visualize the full picture
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of your environment, literally,
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to see your entire environment
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or to hear other things around you,
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all of those get shut down
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when the so-called threat reflex gets activated.
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And the amygdala is part of the threat reflex,
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so much so that we can really say
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that it's the final common pathway
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through which the threat reflex flows.
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In other words, the amygdala is essential
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for the threat response.
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But the threat reflex and the threat response
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is kind of a dumb response.
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It's not a sophisticated thing.
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It's very generic.
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And this is also a very important point.
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One of the beauties of the fear system
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is that it's very generalizable.
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It's not designed for you to be afraid of any one thing.
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Sure, there are some debates
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and probably some good data out there
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that support the fact that human babies are innately,
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meaning it requires no learning,
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innately afraid of certain things
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like heights or snakes or spiders.
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There's debate about this,
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and it depends on the quality of the experiment, et cetera.
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But the real capacity of the fear system
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is that we can become afraid of anything
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provided that this threat system is activated
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in conjunction with some external experience.
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So the way I'd like you to think about the amygdala
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is not as a fear center,
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but that it's a critical component of the threat reflex.
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I'd like you to also internalize the idea
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that the threat reflex involves
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this activation of certain systems
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and suppression of all the systems for calming,
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the parasympathetic system.
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And now I'm going to describe the way
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that information flows into
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and through this threat reflex.
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And in doing that, it will reveal how specific things,
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like a spider, like a snake, like a physical trauma,
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like a car accident, like a fear of public speaking,
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whatever happens to scare you or scare somebody,
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how that gets attached to this reflex.
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Because this reflex is very generic.
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It doesn't really know what to be afraid of.
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It only knows how to create the sensation,
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this internal landscape that we think of as fear.
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So while the amygdala might look like an almond,
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it's actually part of a much bigger complex
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or collection of neurons called the amygdaloid complex.
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That complex has anywhere from 12 to 14 areas,
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depending on which neuroanatomist is naming things
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and carving it up.
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In neuroscience and in much of biology,
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we like to joke that there are lumpers
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and there are splitters.
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So some people like to draw boundaries
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between every little distinct difference
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and say, oh, that's a separate area
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and other people are lumpers.
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And they say, well, listen, why complicate things?
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Let's lump those together.
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I'm neither a lumper nor a splitter.
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I'm somewhere in between.
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I think the number 12 is a good number
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in terms of the number of different areas of the amygdala.
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Why is that important to us?
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Well, it turns out that the amygdala
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is not just a area for threat.
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It's an area for generating threat reflexes
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that integrates lots of different types of information.
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So for those of you that want to know,
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I'm going to give you some names, some nomenclature.
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For those of you that don't,
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you can tune out for this,
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but basically information from our memory systems,
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like the hippocampus and from our sensory systems,
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our eyes, our ears, our nose, our mouth, et cetera.
link |
So taste information, vision, auditory information,
link |
touch, et cetera, flow into the so-called lateral portion
link |
of the amygdala or the amygdala complex.
link |
It flows into the lateral portion
link |
and then there are multiple outputs from the amygdala.
link |
And this is where things get particularly interesting
link |
because the outputs of the amygdala
link |
have a lot of different areas,
link |
but there are two main pathways.
link |
One involves the hypothalamus,
link |
which you heard about before,
link |
this collection of neurons that control
link |
a lot of our primitive drives for sex,
link |
for food, for thirst, and for warmth, et cetera.
link |
And it also feeds out to our adrenals,
link |
those glands that you learned about a few minutes ago
link |
to create a sense of alertness and action.
link |
It also feeds out.
link |
What I mean by feeds out, by the way,
link |
is there are neurons that send wires,
link |
we call those wires axons connections,
link |
where they can release chemicals
link |
and trigger the activation of different brain areas.
link |
So it feeds out to other brain areas such as the PAG.
link |
PAG is very interesting for our discussion today.
link |
It's the periaqueductal gray.
link |
The periaqueductal gray contains neurons
link |
that can trigger freezing, can trigger the,
link |
some people talk about the fawning response,
link |
which is kind of an appeasing response to traumatic events,
link |
but some people outright freeze in response to fear, right?
link |
We've heard of fight or flight,
link |
and indeed the pathway that I'm describing
link |
can create a sense of fight and cause people
link |
to want to lean in in an aggressive way
link |
to combat things that they're afraid of,
link |
or flight to run away, essentially to avoid by mobilizing
link |
the thing that they feel they're threatened by.
link |
Now, even in the absence of some threat,
link |
somebody that has, say, a fear of public speaking
link |
might hesitate or move away from a podium
link |
or hesitate or move away from raising their hand,
link |
if raising their hand meant that they might be called on
link |
and would be public speaking.
link |
So there's fight and flight,
link |
but there's also the freeze response.
link |
And the freeze response is controlled
link |
by a number of brain centers,
link |
but the periaqueductal gray, the PAG,
link |
is central for this freeze response.
link |
And neurons there also create
link |
what are called endogenous opioids.
link |
Many of you have heard of the opioid crisis,
link |
which is a crisis of prescription medication
link |
given out too broadly for people that don't need it,
link |
who become addicted to opioids.
link |
Those are exogenous opioids,
link |
but endogenous opioids are chemicals released from neurons
link |
in the PAG and from elsewhere in the body
link |
that give us a sense of numbing.
link |
They actually numb us against pain.
link |
And you can imagine why biology
link |
would be organized this way.
link |
A threat occurs or something that we perceive as a threat,
link |
we're afraid of it, and a natural analgesic
link |
is released into our body
link |
because there's likely to be an interaction
link |
that's very uncomfortable, that's physically uncomfortable.
link |
So it's like we have our own endogenous release
link |
of these opioids and that's occurring in the PAG.
link |
The other area, and again,
link |
sorry to litter the conversation
link |
with these names of structures,
link |
but some people seem to enjoy knowing these structures.
link |
You're fine if you just understand what the structures do.
link |
If you want to know the names, that's fine.
link |
But the other structure is the locus coeruleus.
link |
The locus coeruleus creates a sense of arousal
link |
by releasing adrenaline, epinephrine,
link |
and norepinephrine, a related chemical, into the brain.
link |
So basically the activation of the amygdaloid complex
link |
could be from any number of different things,
link |
a memory of something fearful,
link |
an actual sensory experience of something that's fearful.
link |
But then the fear response itself is taking part
link |
because of the threat reflex gets activated.
link |
And that threat reflex then sends a whole set
link |
of other functions into action,
link |
freezing, activation of the adrenals,
link |
activation of locus coeruleus for arousal and alertness,
link |
activation of this endogenous pain system
link |
or anti-pain system in the PAG.
link |
That's one pathway out of the amygdala.
link |
The other pathway out of the amygdala
link |
is to a very interesting area
link |
that typically is associated with reward and even addiction.
link |
So this might come as a surprise to many of you.
link |
In fact, it came as a surprise to me.
link |
I remember when these data were published,
link |
but the amygdaloid complex actually projects to areas
link |
of the dopamine system, the so-called nucleus accumbens,
link |
the mesolimbic reward pathway.
link |
For those of you that want to look that up
link |
or that remember from the dopamine episodes,
link |
we have pathways in our brain
link |
that are associated with pursuit, motivation and reward.
link |
And the neuromodulator dopamine is largely responsible
link |
for that feeling of craving, pursuit and reward.
link |
And this threat center is actually able to communicate with
link |
and activate the dopamine system.
link |
And later you will realize why that is very important
link |
and why you can leverage the dopamine system
link |
in order to wire in new memories to replace fearful ones.
link |
So I've been hitting you with a lot of names of things,
link |
but for the moment,
link |
even if you're interested in all the neuroscience names
link |
and structures and so forth,
link |
I'd like you to just conceptualize
link |
that you have a circuit in your brain,
link |
meaning a set of cells and connections
link |
that are arranged in the following way.
link |
You have a threat reflex
link |
that can be activated at any time, very easily,
link |
but what activates that threat reflex
link |
can depend on two things.
link |
One are prior memories coming from brain areas
link |
that are involved in storage of memories,
link |
or it can be immediate experiences.
link |
Things are happening in the now, okay?
link |
So where's something fearful to happen right now?
link |
Your threat reflex could be activated.
link |
Were you to remember something very scary
link |
that happened to you in the past?
link |
Your threat reflex could be activated.
link |
And that threat reflex circuit has two major outputs.
link |
One of the major outputs is to areas
link |
that are involved in the threat response,
link |
freezing, pain management, and alertness.
link |
And the other major output is to areas involved
link |
in reward, motivation, and reinforcement, okay?
link |
There's a fourth component,
link |
and I promise this is the last component
link |
that we need to put into this picture
link |
of the neural circuits for fear.
link |
And this is a circuit that involves an area of the brain
link |
called the prefrontal cortex and some of its subdivisions,
link |
so literally in the front.
link |
And it's involved in what we call top-down processing.
link |
Top-down processing is the way that your prefrontal cortex
link |
and other areas of the brain can control
link |
or suppress a reflex, okay?
link |
A good example of this would be the step on the tack example
link |
that I gave before.
link |
So when you step on a tack,
link |
you immediately pull up your foot
link |
and you extend the other leg.
link |
That's the reflex that prevents you from injuring yourself
link |
and from falling over.
link |
However, if you wanted, not that you would want to,
link |
but if you wanted, you could, for instance,
link |
place your foot onto a tack
link |
and decide not to pull your foot away.
link |
It would be difficult.
link |
And again, I don't recommend that you do that,
link |
but you could override that reflex, okay?
link |
There are other examples of reflexes,
link |
like, for instance, getting into cold water.
link |
Most people will start to huddle their body.
link |
Most people won't want to get into the cold water.
link |
Many people will jump out.
link |
But all of that is reflexive.
link |
And should you want to,
link |
you could override that reflex through top-down processing.
link |
You could tell yourself,
link |
oh, I heard on a previous Huberman Lab podcast
link |
or on an Instagram post that cold water exposure
link |
can be beneficial for metabolism and resilience, et cetera,
link |
and indeed it can.
link |
And you can decide to get into the water
link |
and to stretch out your body, not to huddle,
link |
and you can fight those reflexes, okay?
link |
The fighting of reflex is carried out
link |
through top-down processing,
link |
largely through the prefrontal cortex.
link |
You provide a narrative.
link |
You tell yourself, I want to do this, or I should do this,
link |
or even though I don't want to, I'm going to do it anyway.
link |
So top-down processing is not just
link |
for getting into cold water.
link |
And it certainly isn't for overriding reflexes
link |
that can damage us like stepping on the tack example.
link |
It is the way in which we can override
link |
any number of internal reflexes,
link |
including the threat reflex.
link |
And the way that we do that is by giving a new story
link |
or a new narrative to this experience that we call threat.
link |
And you know the threat response.
link |
The threat response is quickening of the heart rate,
link |
quickening of the breathing.
link |
We don't generally like the feeling of adrenaline
link |
A lot of people are so-called adrenaline junkies,
link |
and they get a mixture of dopamine and adrenaline
link |
from certain high-intensity events.
link |
I confess in previous aspects of my life,
link |
I've tended to like adrenaline.
link |
I don't think I was at the extreme of thrill-seeking,
link |
but I'm somebody that, for instance, I tend to like.
link |
I like roller coasters.
link |
I've done various things where I'm familiar with
link |
and I enjoy the sensation of adrenaline in my body,
link |
but I enjoy it because of the alertness that it brings
link |
and the hyperacuity that it brings.
link |
Many people don't feel that way.
link |
In fact, most people don't like the sensation
link |
of a lot of adrenaline in their system.
link |
It makes them feel very uncomfortable and out of control.
link |
We will do an entire episode about adrenaline
link |
and adrenaline junkies and adrenaline aversives
link |
in the future, but the threat reflex
link |
inevitably involves the release of adrenaline
link |
And then it becomes a question of whether or not
link |
you remain still, move forward, or retreat
link |
from that adrenaline experience.
link |
And when I say the adrenaline experience,
link |
I mean the threat reflex.
link |
So this fourth component of fear is really our ability
link |
to attach narrative, to attach meaning,
link |
and to attach purpose to what is,
link |
by all accounts and purposes, a generic response.
link |
There's no negotiating what fear feels like.
link |
There's only negotiating what it means.
link |
There's only negotiating whether or not you persist,
link |
whether or not you pause, or whether or not you retreat.
link |
So this is usually the point in the podcast
link |
where I think people start asking,
link |
okay, well, there's the biology, there's the mechanism,
link |
there's the logic, how do I eliminate fear?
link |
Well, it's not quite that simple,
link |
although by understanding the logic and the mechanisms
link |
by which these circuits are built,
link |
we can eventually get to that place.
link |
I do want to plant a flag around a particular type of tool
link |
or a logical framework around a particular set of tools,
link |
rather, that we are going to build out through this episode.
link |
And based on what you now know,
link |
that the threat reflex gets input and it has outputs,
link |
and it's subject to these top-down processing events,
link |
these narratives, you should be asking yourself,
link |
what sort of narrative should I apply to eliminate fear?
link |
Well, first let's take a step back
link |
and it just acknowledged the reality,
link |
which is that fear is, in some cases, an adaptive response.
link |
We don't want people eliminating fears
link |
that can get them injured or killed, right?
link |
The reason that the fear threat response
link |
and reflex exists at all is to help us from dying,
link |
to help us from making really bad decisions.
link |
It just so happens that a number of things happen to us
link |
that are not lethal, that don't harm us,
link |
but that harm us from the inside.
link |
And I think that, and here I'm borrowing language
link |
from an excellent researcher
link |
who's done important work in this area at Harvard.
link |
His name is Dr. Kerry Ressler.
link |
He's both a medical doctor and a PhD, so an MD PhD.
link |
He's the chief scientific officer at McLean Hospital.
link |
He's a professor of psychiatry at Harvard Medical School,
link |
and he's done extensive and important work on fear.
link |
I'm going to refer back to Dr. Ressler's work
link |
several times during this podcast,
link |
including important and super interesting work
link |
on transgenerational passage of trauma.
link |
He's a absolutely world-class biologist,
link |
absolutely world-class clinician.
link |
And Dr. Ressler has described fear before
link |
as containing a historical component.
link |
So it's not just about a readiness for things
link |
that might injure us or kill us in the immediate circumstance
link |
but also protecting us for the future
link |
because of our important need and ability to anticipate.
link |
And what he describes are memories as protective
link |
or memories as dangerous.
link |
Some memories, even if they evoke a sense of fear in us
link |
They protect us from making bad mistakes
link |
that could get us injured or killed
link |
or put us into really horrible circumstances.
link |
Other memories are dangerous
link |
because they create a sense in us of discomfort
link |
and they tend to limit our behavior
link |
in ways that are maladaptive,
link |
that prevent us from having healthy relationships to others,
link |
healthy job relationships,
link |
healthy relationship to ourselves, frankly.
link |
So this language of memories as protective
link |
or memories as dangerous in the context of fear
link |
is not something that I said,
link |
it's really something that I lifted from Dr. Ressler
link |
in one of his many impressive lectures.
link |
And it's an important aspect of fear
link |
because much of the fear system is a memory system.
link |
It's designed to embed a memory
link |
of certain previous experiences in us
link |
such that the threat reflex is activated
link |
in the anticipation of what might happen, okay?
link |
So let's talk for a second about how certain memories
link |
get attached to this fear system.
link |
And this brings us to a beautiful
link |
and indeed Nobel prize-winning aspect
link |
of biology and physiology,
link |
which is Pavlovian conditioning.
link |
Many of you are probably familiar with Pavlov's dogs
link |
and the famous Pavlovian conditioning experiments.
link |
They go something like this.
link |
You know, if you and Pavlov did these experiments
link |
and ring a bell, a dog doesn't do much
link |
in response to a bell, it might attend to it,
link |
but it doesn't salivate typically in response to the bell.
link |
However, if you pair the ringing of a bell
link |
with a presentation of food enough times,
link |
the dog will salivate in response to the food.
link |
Eventually you take away the food,
link |
you just ring the bell and the dog will salivate
link |
in response to the bell, okay?
link |
So in the context of so-called Pavlovian conditioning,
link |
these things have names like conditioned stimulus
link |
and unconditioned stimulus and responses.
link |
People often get these mixed up
link |
and it can be a little confusing,
link |
but I'm just going to make it really simple for you.
link |
The unconditioned stimulus is the thing
link |
that evokes a response unconditionally.
link |
So food is the unconditioned stimulus
link |
in the example I just gave.
link |
A foot shock or a loud bang
link |
would be the unconditioned stimulus in,
link |
for instance, an experiment geared toward exploring fear.
link |
That unconditioned stimulus is unconditional.
link |
It unconditionally evokes a startle
link |
or in the case of food, salivating.
link |
The bell in the previous example
link |
is what we call the conditioned stimulus
link |
or the conditioning stimulus.
link |
Sometimes people mix these up.
link |
The conditioned stimulus is paired with the thing
link |
that naturally creates a response.
link |
And then eventually the conditioned stimulus
link |
creates the response itself.
link |
You might think, well,
link |
that just seems endlessly boring and simple,
link |
but this is actually the way that our fear systems work.
link |
Except unlike Pavlov's dogs,
link |
you don't need many, many pairings
link |
of a bell with some unconditioned stimulus
link |
in order to get a response.
link |
You can get what's called one trial learning.
link |
And in this circuit that involves the amygdala,
link |
the threat reflex, and all this other stuff
link |
that I was talking about earlier,
link |
the system is set up for learning.
link |
It's set up to create memories and to anticipate problems.
link |
It's a very good system
link |
because it was designed to keep us safe.
link |
And so the way to think about this is that for many people,
link |
one intense experience, one burn, one bad breakup,
link |
one bad experience public speaking,
link |
one bad experience with somebody's pet snake
link |
or whatever it happens to be
link |
can cause intense fear in the moment,
link |
a long reverberatory experience of fear,
link |
like trouble sleeping that night and the following night,
link |
memories of the experience that are troubling,
link |
physiological responses that are troubling.
link |
Essentially, it gets wired in as a fear with one trial,
link |
which is quite different
link |
than the other forms of neuroplasticity.
link |
Neuroplasticity, of course,
link |
just being the nervous system's ability to change
link |
in response to experience.
link |
Other forms of neuroplasticity like learning a language,
link |
learning music, learning math, those take a while.
link |
We don't generally get one trial learning
link |
to positive or neutral experiences.
link |
We get one trial learning to negative experiences.
link |
So there's this asymmetry in how we're wired.
link |
So now you should understand how classical conditioning,
link |
as it's called, occurs.
link |
You go to give a piano recital as a kid,
link |
you sit down and you freeze up
link |
and it's horribly embarrassing.
link |
And even if you just freeze up for a few seconds,
link |
the heart rate increase and the perspiring, the sweating,
link |
and the shame that you feel
link |
leads you to want to avoid playing instruments
link |
or public displays of performances
link |
for a long period of time
link |
unless you do something to overcome it.
link |
That's one trial learning.
link |
Some people, it tends to be more
link |
an accumulation of experiences.
link |
They have a bad relationship that lasts an entire summer,
link |
an entire year, or God forbid, a decade.
link |
And then they have what they feel
link |
is kind of a general sense of fear
link |
about closeness to others and attachment.
link |
These are common fears that people experience.
link |
Fears can be in the short term,
link |
fears can be in the long term,
link |
they can be in the medium term.
link |
Again, the fear system is very generic.
link |
It's wired to include memories that are very acute,
link |
that happen within a moment,
link |
or that include many, many events and long periods of time
link |
that kind of funnel into a general sense
link |
of relationships are bad,
link |
or this particular city or location is bad.
link |
So there's a key, what we call temporal component.
link |
There's a component of the fear system
link |
being able to batch many events in time
link |
and create one specific fear,
link |
or take one very specific isolated incident
link |
that happened very briefly
link |
and create one very large general sense of fears.
link |
And I'll give an example of the latter
link |
just to kind of flesh this out a little bit.
link |
I had a friend come visit me in San Francisco some years ago
link |
and their car got broken into,
link |
unfortunately, a frequent occurrence in San Francisco
link |
and in the middle of the day,
link |
never leave anything in your car in San Francisco.
link |
They'll break in in the middle of the day, doesn't matter.
link |
Police can be having coffee right there in front of them.
link |
They'll still do it for reasons we could discuss.
link |
This is a problem.
link |
They got their belongings taken
link |
and they decided they were never coming back
link |
This was an isolated incident that forever colored
link |
their view of the city, which I, you know, frankly,
link |
understanding the fear system, I can understand.
link |
We can have isolated incidents that wick out
link |
to broad decisions about entire places,
link |
or we can have many experiences
link |
that funnel into very specific isolated fears
link |
about particular circumstances, places, and things.
link |
So I like to think that by now
link |
you have a pretty good understanding
link |
of the circuits that underlie the threat reflex,
link |
the fear response, and how we have top-down control,
link |
meaning we can attach a narrative to the fear response,
link |
and that the fear response can be learned
link |
in association with particular events, okay?
link |
I haven't really talked about how the learning occurs,
link |
and so I just want to take a moment and describe that
link |
because it leads right into our discussion
link |
about how to eliminate fears,
link |
and indeed how to replace fears
link |
with more positive experiences.
link |
There's a process in our nervous system
link |
that we call neuroplasticity.
link |
Neuroplasticity broadly defined
link |
is the nervous system's ability
link |
to change in response to experience,
link |
but at a cellular level,
link |
that occurs through a couple of different mechanisms.
link |
One of the main mechanisms
link |
is something called long-term potentiation.
link |
Long-term potentiation involves the strengthening
link |
of particular connections between neurons,
link |
the connection sites between neurons we call synapses.
link |
Actually, technically synapses are the gaps
link |
between those connections,
link |
but nonetheless, synapses are the point of communication
link |
between neurons, and those can be strengthened
link |
so that certain neurons can talk to other neurons
link |
more robustly than they happened to before.
link |
And anytime we talk about a particular event,
link |
the car, the snake, the public speaking,
link |
the trauma, the horrible experience
link |
wiring into the fear system,
link |
what we're talking about is a change in synaptic strengths.
link |
We're talking about neurons that previously
link |
did not communicate well, communicating very well.
link |
It's like going from a old school dial-up connection
link |
or even an old school telephone connection
link |
or Morse code connection of communication
link |
to high-speed ethernet, okay, to a 5G connection.
link |
It gets faster, it gets more robust,
link |
and it's very, very clear.
link |
That's what happens when you get long-term potentiation.
link |
And long-term potentiation
link |
involves a couple of cellular mechanisms
link |
that are going to be relevant to our discussion
link |
about treatments to undo fear.
link |
And I'll just throw out a couple of the names
link |
of some of those cellular elements right now.
link |
The main one is the so-called NMDA receptor,
link |
N-methyl-D-aspartate receptor.
link |
And what this is is this is a little docking site,
link |
like a little parking slot on a neuron.
link |
And when a neuron gets activated very strongly,
link |
like from an intense event, in the example of my friend,
link |
the intense event almost certainly activated NMDA receptors
link |
related to their concept of protecting their property
link |
in their cars, the break into their car
link |
caused the NMDA receptor to be activated.
link |
Normally that NMDA receptor is not easily activated.
link |
And when it is activated, it sets off a cascade,
link |
a series of signals within those neurons
link |
that change those neurons.
link |
It changes the genes they express.
link |
It shuttles more parking spots to the surface of those cells
link |
so that the communication to those cells becomes easier.
link |
It becomes faster.
link |
And so the way to think about the NMDA receptor
link |
is it's used sometimes for normal things
link |
that we do every day, making cups of coffee
link |
and things like that, but it's often used for learning.
link |
It's used for creating new associations
link |
in our nervous system.
link |
And so the activation of the NMDA receptor and LTP,
link |
and it involves some other things that you may have heard of
link |
like brain-derived nootropic factors and calcium entry,
link |
things that we can leave for a discussion for a future time,
link |
but basically a whole cascade of events happen within cells
link |
that then make just even the mere thought of something
link |
or somebody or some event that happened
link |
able to activate that threat reflex, okay?
link |
So long-term potentiation is one of the main mechanisms
link |
by which we take formally innocuous or irrelevant events
link |
and we make them scary.
link |
We make them traumatic.
link |
Our neurons have mechanisms to do this.
link |
Now, fortunately, the NMDA receptor
link |
and long-term potentiation
link |
can also run the whole system in reverse.
link |
You can get what's called long-term depression,
link |
and that doesn't have anything to do
link |
with the depression associated with low mood.
link |
What we're talking about is a weakening of connections.
link |
You can go from having a very high-speed ethernet connection
link |
between neurons, so to speak,
link |
to a connection that's more like Morse code
link |
or is like a poor dial-up connection, a really weak signal.
link |
And that's what's happening when you extinguish a fear,
link |
when you unlearn a fear.
link |
So now I'd like to talk about therapies
link |
that are carried out in humans
link |
that allow fears to be undone,
link |
that allow traumas to be reversed
link |
such that people no longer feel bad
link |
about a particular person, place, or thing,
link |
either real interactions with that person, place, or thing,
link |
or imagined interactions with that person, place, or thing.
link |
That process, as I just mentioned,
link |
also involves things like the NMDA receptor,
link |
but rather than strengthening the connections,
link |
the first thing that has to happen
link |
is there needs to be a weakening of connections
link |
that associate the person, place, or thing
link |
with that threat reflex.
link |
Subsequent to that, we will see,
link |
there needs to be a strengthening of some new experience
link |
that's positive, okay?
link |
This is a key element of where we are headed.
link |
Contrary to popular belief, it is not going to work
link |
to simply extinguish a fear.
link |
One needs to extinguish a fear and or trauma
link |
and replace that fearful or traumatic memory or idea
link |
or response with a positive response.
link |
And this is something that's rarely discussed
link |
both in the scientific literature,
link |
but certainly in the general discussion
link |
around fear and trauma.
link |
There's this idea that we can extinguish fears,
link |
we can rewire ourselves, we can eliminate our traumas,
link |
and indeed we can, but that process has to involve
link |
not just becoming comfortable
link |
with a particular fearful event or trauma,
link |
but also attaching a new positive experience
link |
to that previously fearful or traumatic event.
link |
There are a lot of different approaches out there
link |
that are in clinical use to try and alleviate
link |
fear and trauma and indeed PTSD,
link |
post-traumatic stress disorder.
link |
It might be surprising to learn that many
link |
of those treatments, such as SSRIs,
link |
the selective serotonin reuptake inhibitors,
link |
things like Prozac and Zoloft and similar
link |
and other antidepressants, or things like benzodiazepines,
link |
which are essentially like painkillers.
link |
They create a elevation in certain transmitters
link |
in the brain, like GABA among others.
link |
They can have a pain relieving effect.
link |
They are generally, however, considered anxiolytics.
link |
They reduce anxiety.
link |
And even antipsychotic drugs or beta blockers,
link |
sometimes called adrenergic blockers,
link |
drugs that are designed to prevent the heart
link |
from beating too fast or to reduce blood pressure,
link |
to reduce some elements of that
link |
hypothalamic pituitary axis response
link |
that we talked about earlier.
link |
Many people experience some degree of relief
link |
from the symptoms of anxiety and fear and PTSD
link |
in taking these various compounds.
link |
Indeed, that's why they're prescribed so broadly.
link |
But you may find it interesting to note
link |
that none of those current treatments
link |
are based on the neurobiology of fear,
link |
at least not directly, right?
link |
People that take SSRIs oftentimes will experience
link |
a reduction in anxiety.
link |
It depends on the dosage and the individual, of course,
link |
right, and you have to work with a doctor,
link |
a psychiatrist to determine whether or not
link |
they're right for you in the correct dosage
link |
if they are right for you.
link |
But that modulation of anxiety can indirectly
link |
reduce the likelihood that one will have a panic attack
link |
or experience a fear, an intense experience of fear,
link |
a reliving of a trauma.
link |
But the SSRIs themselves are not plugging
link |
into some specific mechanism related
link |
to how fear comes about in the system.
link |
It's an indirect support.
link |
That's important because if the goal of modern psychiatry
link |
and the goal of modern biology
link |
is to provide mechanistic understanding
link |
that leads to treatments,
link |
we need to think about what are the sorts of treatments
link |
that tap into the very fear circuits
link |
that we described before?
link |
The fact that there are memories attached
link |
to a generic threat reflex and response,
link |
and the threat reflex response can be linked up
link |
with the dopamine system and can be linked up
link |
with other systems that are involved in pain relief
link |
and anxiety and so forth.
link |
And so that brings us to which treatments
link |
are directly related to the fear circuitry
link |
and the circuitry related to trauma.
link |
And the primary one to begin with
link |
is the so-called behavioral therapies.
link |
Now, oftentimes we all wish, I think, from time to time,
link |
that there's some specific pill that we can take,
link |
or there's some machine or device
link |
that we can plug our finger into,
link |
or that we can put on a headset and all of a sudden
link |
we just rewire our nervous system,
link |
fear is gone, trauma is gone, but it doesn't work that way.
link |
And when we think of language and narrative
link |
as a tool to rewire our nervous system
link |
in comparison to those kinds of ideas
link |
about pills and machines and potions,
link |
it starts to seem a little bit weak, right?
link |
If we just think, oh, well,
link |
how could talking actually change the way
link |
that we respond to something?
link |
But actually there are three forms of therapy
link |
that purely through the use of language
link |
have been shown to have very strong positive impact,
link |
meaning reduced fears and traumas.
link |
And those three are prolonged exposure therapy,
link |
cognitive processing, or CPT,
link |
and cognitive behavioral therapy.
link |
And I'm not going to go into the entire literature
link |
around prolonged exposure, cognitive processing,
link |
and cognitive behavioral therapy,
link |
but I will just illustrate the central theme
link |
that allows them to work.
link |
Now, remember that the circuit for fear,
link |
the circuit for trauma involves this generic reflex,
link |
and then there are those top-down elements
link |
coming from the forebrain.
link |
It's very clear because it's been measured
link |
that if you look at the amount of anxiety,
link |
the pure physiological anxiety response
link |
of quickening of heart rate, blushing of the skin,
link |
sometimes quaking of the hands, the experience of fear,
link |
over time, when people recount or retell their trauma,
link |
that the first time they do that,
link |
especially when it's recounted in a lot of detail,
link |
there's a tremendous anxiety response,
link |
sometimes even as great or greater than the actual exposure
link |
to the fearful event or trauma.
link |
And obviously this is something that is done
link |
with a clinician present
link |
because it is very traumatic to the person.
link |
They're literally reliving the trauma in full rich detail,
link |
and they are encouraged to provide full rich detail.
link |
They're often encouraged to speak in complete sentences,
link |
to flesh out details about how they felt inside,
link |
to flesh out details about their memories
link |
going into this traumatic or fearful event,
link |
going through it, and after,
link |
really digging into all the nuance and contours
link |
of these horrible experiences.
link |
But what's remarkable is that in the second and the third
link |
and the fourth retelling of these traumatic
link |
or fearful events, that anxiety response
link |
and the amount of the physiological response,
link |
I should say that the amplitude
link |
of the physiological response
link |
becomes progressively diminished with each retelling.
link |
Now, some of you might be saying, well, duh,
link |
you tell a story enough times
link |
that eventually it wears off.
link |
Just like if you watch a movie enough times
link |
and you hear the same joke enough times,
link |
eventually it doesn't have the same impact.
link |
But that needn't be the case, right?
link |
You could imagine that this high amplitude anxiety response,
link |
this high amplitude activation
link |
of the sympathetic nervous system in retelling
link |
would actually create a even deeper
link |
routed fear response and trauma,
link |
but that's not what happens.
link |
And every clinician I spoke to in anticipation
link |
of this episode, which include clinical psychologists,
link |
psychiatrists, and people who actually work
link |
on the fear system at a biological level,
link |
said the exact same thing,
link |
which is that a detailed recounting
link |
of the traumatic and fearful events is absolutely essential
link |
in order to get the positive effects of prolonged exposure,
link |
cognitive processing, and cognitive behavioral therapy.
link |
Again, this has to be done with the appropriate support.
link |
This isn't something that should be taken lightly
link |
because as we've mentioned before,
link |
the fear response can have a very long lasting
link |
People can sometimes have trouble sleeping for days and days
link |
and afterwards we'll talk about sleep in a little bit,
link |
but the point is that the retelling is important.
link |
And the idea here is to take what was a terrible
link |
and extremely troubling,
link |
meaning physiologically troubling,
link |
psychologically troubling story,
link |
and turn it into what is essentially a boring bad story.
link |
It never really becomes a good story at this point
link |
in the treatment process that we're describing.
link |
So a terrible event is a terrible event, period,
link |
but there's a way in which the retelling of that event
link |
starts to uncouple the threat reflex from the narrative.
link |
And with each successive retelling in detail
link |
of these traumatic events, of these fearful events,
link |
the threat reflex is activated at a progressively
link |
lower and lower amplitude such that eventually
link |
it just becomes a really bad, really boring story.
link |
Now that's one part of the process of getting over a fear.
link |
It's what we call fear extinction.
link |
And we can bring ourselves back to our earlier example
link |
of Pavlovian conditioning because many studies
link |
have been done both in animals and in humans
link |
showing that, for instance, if you pair a tone,
link |
you know, a bell or a buzzer with a foot shock
link |
that an animal or a person will brace themselves
link |
for the foot shock,
link |
eventually you can just give the bell or tone
link |
and the person will experience that same freezing up
link |
or the same fight or flight or freeze response.
link |
So you condition that.
link |
But if you give the tone or the bell over and over
link |
and there's no foot shock, there's no pain,
link |
and in humans, this is sometimes done with foot shock,
link |
sometimes believe it or not with mild burn,
link |
there are even some studies, there's older studies,
link |
you couldn't do those now, nor would you want to,
link |
but eventually what happens is the tone,
link |
the bell no longer evokes that response, okay?
link |
So you see this as a reversal of the classical conditioning
link |
and we call that reversal extinction.
link |
So the retelling of this traumatic or fearful narrative,
link |
excuse me, fearful narrative is essentially
link |
an extinction process.
link |
Now, how is this done?
link |
One can do this in a therapist's office face-to-face,
link |
that's sometimes done,
link |
it's sometimes done in group type settings
link |
where people actually stand up
link |
or sit in front of a group, small or large,
link |
and recount in detail their traumatic experience.
link |
It's sometimes done by people writing out
link |
the experience in detail.
link |
And which one of these is most effective
link |
isn't really clear, the literature points to the fact
link |
that a feeling of trust, obviously,
link |
between the patient and the clinician
link |
or the person and the group is essential,
link |
some people don't have access to because of finances
link |
or other limitations to therapy of that sort,
link |
in that case, journaling in detail
link |
has been shown to be effective,
link |
although, again, I want to caution people
link |
about reactivating traumas without consideration
link |
for the kinds of social support they might need
link |
around that reactivation,
link |
and we will talk a little bit later
link |
about some of the chemicals involved in social support
link |
and why those help extinguish fears.
link |
So the thing to embed in your mind is that recognition
link |
of the early traumatic or fearful event in detail
link |
over and over is key to forming a new
link |
non-traumatic association with that event or person.
link |
So that's part one.
link |
You need to diminish the old experience.
link |
And when I say diminish,
link |
I mean reduce the amplitude of the physiological response.
link |
Now, this is just but one approach.
link |
I'm going to talk about other approaches
link |
to eliminating fear and trauma as we go forward.
link |
But I want to emphasize that diminishing the amplitude
link |
of the physiological response is the first step.
link |
So it's like a clearing away of the association
link |
between the person, place, or thing and that threat reflex.
link |
But even after that's occurred,
link |
there's an essential need to relearn a new narrative.
link |
Why is there essential need to relearn a new narrative
link |
or create a new association?
link |
Well, that has to do with that fear reflex circuitry.
link |
As you recall, there are outputs to areas of the brain
link |
that are associated with dopamine release and reinforcement.
link |
And that we now know offers the capacity
link |
for these fear circuits and these circuits
link |
that underlie trauma to be mapped onto new experiences
link |
that are of positive association.
link |
So I'm going to give a kind of basic example.
link |
It's a kind of a silly example,
link |
but I'm giving it as a template
link |
for what could be any number of other different examples.
link |
Example I'll give is let's say a kid is biking
link |
to play soccer, soccer practice,
link |
and they get into a bad car accident, okay?
link |
Terrible thing to happen, but they survive, they recover.
link |
And somehow, and we really don't know why
link |
certain fear memories get wired in more broadly
link |
Somehow this kid just doesn't even want to bicycle anymore.
link |
And they actually don't even want to play sports.
link |
And they actually just don't want to go anywhere.
link |
They're kind of isolating
link |
and not interacting with friends very much at all.
link |
It's a pretty broad response.
link |
It didn't have to be that way.
link |
Some kids would just decide they don't want to cycle anymore
link |
down that particular street.
link |
Well, the process of retelling the narrative
link |
to a clinician would allow an extinction
link |
of the fear response, right?
link |
So a reduction in the heart rate,
link |
a reduction in the narrowing of focus,
link |
a reduction in all the things that we consider fear.
link |
But a really good cognitive behavioral therapist
link |
or somebody that understands the neuroscience
link |
of fear and trauma would understand
link |
that that's not sufficient.
link |
That's what's really important is that this child,
link |
this hypothetical child relearn a new narrative
link |
that they don't just manage to bike to soccer practice
link |
or manage to spend time with friends,
link |
but that they actually start wiring
link |
in new positive associations with biking to practice,
link |
with playing soccer, with social events.
link |
And this is the somewhat surprising feature of this
link |
and that they link that back
link |
to that early traumatic experience.
link |
That it's not just that they're replacing
link |
a bad experience and memory
link |
with a good experience and memory,
link |
but they're actually holding in mind
link |
in these top-down narrative circuits, if you will,
link |
they're holding in mind,
link |
ah, I'm not just biking to soccer practice.
link |
I'm actually biking to soccer practice
link |
and I'm enjoying it despite the fact
link |
that I was in a bad car accident,
link |
despite the fact that two months ago or two years ago
link |
or maybe even 10 years ago, I couldn't even leave my room
link |
or I didn't want to associate with anybody.
link |
So the building up of the positive associations are key.
link |
And the linking of those positive associations
link |
with the earlier traumatic event is key
link |
for the following reason.
link |
The top-down circuitry from the prefrontal cortex
link |
to this threat reflex circuit
link |
is not like the other connections in that circuit.
link |
The other connections in that circuit
link |
are what we call glutamatergic and excitatory.
link |
They are all about activating other neurons,
link |
like a chain reaction, one neuron activates,
link |
the next activates, the next dominoes falling.
link |
These top-down circuits that feed into the threat reflex
link |
and all its parts is what we call inhibitory.
link |
It tends to prevent activation of those given circuitries.
link |
It tends to prevent activation of the threat reflex.
link |
So it's acting as a break.
link |
And so when we think of positive experiences
link |
being associated with what was previously
link |
a negative experience,
link |
we're not talking about forgetting
link |
that the car accident was horrible
link |
or forgetting that the assault was absolutely dreadful.
link |
We're talking about attaching a new positive memory
link |
to the circuitry so that the previous fear response
link |
is far less likely to occur and that it remains extinguished.
link |
So just to make sure this is absolutely clear,
link |
there's a first step which involves retelling
link |
and reliving in order to extinguish the fear and the trauma,
link |
to reduce the amplitude of the response.
link |
Then there's a need to replace or attach positive experiences
link |
to the earlier what would be traumatic response.
link |
The extinction has to go first.
link |
You can't simply say, oh, you know,
link |
the car accident was actually a good thing
link |
because I stayed home a lot that year and I got to study.
link |
You can tell yourself that, and that could also be true,
link |
but that won't necessarily and probably won't
link |
eliminate the fear or the traumatic association
link |
of the car accident.
link |
And again, I'm using car accident as a general example
link |
or generic example here.
link |
Okay, so there's a three-part process.
link |
One, diminish the old experience
link |
through repetitive narrative.
link |
And almost inevitably, the initial repetition of that
link |
is going to be very high amplitude and quite troubling,
link |
but over time it will reduce, right?
link |
You're turning the terrible, really upsetting story
link |
into a terrible, boring story.
link |
That's the extinction process.
link |
Then there's a relearning of a new narrative
link |
that includes some sort of sense of reward,
link |
and that sense of reward has to be tacked back
link |
onto the traumatic event
link |
or what was previously a traumatic event.
link |
And that is all through narrative.
link |
It's all through cognition.
link |
And I think this is a very important point.
link |
Oftentimes I think we tend to undervalue
link |
the importance of rationalization
link |
and of story and of narrative.
link |
But the prefrontal cortex is this amazing capacity
link |
of our brain real estate to create meaning,
link |
to attach meaning and purpose to things
link |
that otherwise are just reflexive.
link |
And in the example of an ice bath,
link |
it might be a little trivial.
link |
In the example of the kid with the car accident,
link |
it becomes a little more relevant.
link |
And in the example of things like people surviving genocide
link |
or attaching stories of great victory
link |
to what were previously thought of as stories of great loss
link |
of time, of people, of any number of things,
link |
that process of narrative is one of the major ways
link |
that the human brain rewires itself.
link |
Narrative should not be undervalued
link |
as a tool for relieving fear and trauma.
link |
In fact, narrative is one of the best and most potent ways
link |
that we can rewire our fear circuitry
link |
and that indeed we can form completely new relationships
link |
to things over time.
link |
So basically narrative should not be undervalued
link |
as a tool to rewire our nervous system,
link |
but it has to be engaged in the correct sequence.
link |
And that correct sequence is first extinction,
link |
then relearning a new narrative with positive associations
link |
and attaching those positive associations
link |
to the formerly traumatic or fearful event.
link |
Now I mentioned prolonged exposure therapy,
link |
cognitive processing and cognitive behavioral therapy.
link |
For those of you that are seeking relief
link |
from fear and traumatic events,
link |
you can look up licensed clinicians that can carry out
link |
those one or several of those types of therapies.
link |
I get a lot of questions about other forms of therapy.
link |
One of the ones that comes up a lot is so-called EMDR,
link |
eye movement desensitization reprocessing
link |
developed by Francine Shapiro in the 80s.
link |
Eye movement desensitization reprocessing
link |
involves moving the eyes side to side
link |
while recounting a traumatic or fearful narrative,
link |
typically with a clinician present.
link |
Why would that work?
link |
Well, basically when I first heard about EMDR
link |
from my stance as a vision scientist,
link |
I thought the whole thing was kind of crazy
link |
and half-baked frankly.
link |
I heard these theories that,
link |
oh, it recreates the eye movements
link |
in rapid eye movement sleep or REM sleep.
link |
And that's completely false.
link |
I heard the argument EMDR activates
link |
both sides of the brain,
link |
which I guess hypothetically
link |
was thought to be important somehow.
link |
And frankly, there's no evidence whatsoever
link |
that EMDR activates both sides of the brain
link |
in a way that's beneficial.
link |
I mean, by looking from side to side,
link |
just because of the way that binocular visual circuits
link |
are organized, it will do that.
link |
But it never made any sense to me why EMDR would work
link |
until several years ago when I saw,
link |
because I reviewed no fewer than five papers,
link |
some in animal models, others in humans,
link |
looking at lateral eye movements,
link |
meaning eye movements from side to side with eyes open,
link |
not eyes up or down.
link |
And what was observed in these experiments,
link |
in all of them actually,
link |
all five of those papers was a dramatic reduction
link |
in the activation and actually an inhibition,
link |
a suppression of the fear or threat reflex circuitry,
link |
which was a jaw dropper for me.
link |
I thought, wow, actually it was a jaw dropper,
link |
eye widener for me.
link |
I thought, oh my goodness,
link |
maybe this EMDR stuff works according to some mechanism
link |
and maybe this is the mechanism.
link |
And indeed many laboratories, not mine,
link |
but many laboratories are now pursuing that idea
link |
and it's looking very likely.
link |
Why would that happen?
link |
Well, just very briefly,
link |
a lateralized eye movements of the sort that I'm describing
link |
and I'm moving my hand like this,
link |
but I'll just do it with my eyes,
link |
even though it's a little embarrassing to do that
link |
because I know it looks strange,
link |
I don't mind because I'm doing EMDR
link |
and EMDR reduces activation of the amygdala
link |
and related circuitries, which reduces anxiety
link |
and reduces the amplitude of the threat reflex,
link |
reduces sympathetic autonomic arousal.
link |
In other words, we feel calmer or we feel less alert,
link |
less stressed when moving our eyes from side to side.
link |
And the just so story about this
link |
is that these are the sorts of eye movements that we do
link |
when we are ambulating, moving through space,
link |
through some sort of self-generated motion.
link |
And one can make up a pretty reasonable story
link |
in the evolutionary context or ethological context
link |
that forward movement and fear
link |
are generally incompatible with one another.
link |
That generally a fear response
link |
involves a freezing or a retreating.
link |
Some people will advance,
link |
but that's usually a trained advance in response to fear.
link |
So first responders and so forth.
link |
Most people freeze or retreat when they're afraid.
link |
Forward movement generates these eye movements.
link |
It does seem to suppress activation of this threat reflex
link |
and the amygdala in particular.
link |
So for the many EMDR practitioners out there,
link |
these papers, I think are a great celebration.
link |
And I think there is now increasing excitement about EMDR
link |
in the psychiatric and psychological community
link |
for its utility for treating fear, trauma, and PTSD.
link |
However, I should point out that in discussing EMDR
link |
with various colleagues of mine at Stanford and elsewhere,
link |
I was told that EMDR has been shown to be beneficial
link |
in particular for single event type traumas
link |
or fearful experiences,
link |
not so much for relieving the trauma
link |
or feelings of fear associated, for instance,
link |
with an entire bad marriage or an entire childhood,
link |
but more for single, more acute events
link |
that can be described within a very kind of brief narrative.
link |
Brief, not necessarily in time, but that the car accident,
link |
the bad interaction with another individual,
link |
the assault, God forbid, these sorts of things.
link |
And I realize we're down in the weeds of topics
link |
that are unpleasant.
link |
And so I have great sensitivity to that,
link |
but I think it's also important that we be realistic
link |
about the kinds of things that traumatize people.
link |
So is EMDR useful?
link |
Well, it seems like it works for these single event
link |
or kind of constrained event type traumas
link |
that people can describe while moving their eyes
link |
from side to side, generally in the presence of a clinician.
link |
However, if we think back to the model of how you extinguish
link |
and then replace a trauma or fear,
link |
remember you have to diminish the old experience,
link |
the amplitude of that, that's the extinguish portion.
link |
Then you need to relearn a new narrative
link |
and attach reward to the old traumatic event.
link |
EMDR only really taps into the extinction
link |
of the physiological response to the old experience.
link |
I'm sure that there are EMDR practitioners out there
link |
that are thinking about the attaching
link |
of the new narrative and reward,
link |
but there I've heard less
link |
and I've seen fewer peer-reviewed papers on that.
link |
So let's think about this logically.
link |
Let's say, and indeed it's the case,
link |
that sitting down in a chair,
link |
moving eyes side to side deliberately
link |
for some period of time reduces activation
link |
of the threat reflex.
link |
I, or the patient in this case,
link |
recites or repeats over and over the traumatic event
link |
or the fearful event.
link |
I'm doing that in the presence
link |
of a lower amplitude response.
link |
Remember back to where we talked about
link |
how the retelling works best
link |
if the first time it's done,
link |
there's a huge amplitude response.
link |
And then with each successive repeat,
link |
that response, the threat response gets lower and lower.
link |
With EMDR, you're sort of short circuiting.
link |
You're kind of sneaking around the corner
link |
of that high amplitude response.
link |
And so it's taking a somewhat different approach
link |
of trying to extinguish the bad feelings
link |
in body and mind associated with an experience
link |
by reducing the physiological response.
link |
So it's somewhat different.
link |
And at least to my knowledge,
link |
and EMDR practitioners, please correct me,
link |
but at least to my knowledge,
link |
there isn't an active component to EMDR
link |
of relearning a new narrative and attaching reward.
link |
Now, reward and attaching reward
link |
requires a somewhat high amplitude sympathetic arousal.
link |
It requires a feeling of a victory, which is arousal.
link |
Okay, it's positive arousal, not negative arousal,
link |
but it is arousal.
link |
So I'm not focusing on this
link |
to try and diminish the potential impact of EMDR.
link |
I know many people have achieved great relief from EMDR,
link |
but it doesn't tap into all the aspects
link |
of the extinction and relearning
link |
that we talked about previously.
link |
And therefore, I think on its own,
link |
at least in many cases,
link |
is unlikely to be a complete therapy for fear and trauma.
link |
If there are people out there
link |
who've had terrific results with EMDR,
link |
please let us know in the comments section.
link |
On YouTube would be the ideal place.
link |
If you've had bad experiences with EMDR
link |
or it didn't work for you, also let us know.
link |
I think that EMDR practitioners,
link |
like most practitioners
link |
in the psychiatric and psychological space,
link |
are eager to expand their practices
link |
in order to make them more effective
link |
rather than clinging ardently to something
link |
that perhaps is incomplete
link |
or that doesn't work for certain individuals.
link |
So I think they would appreciate that feedback, as would I.
link |
So as I mentioned before,
link |
most of these therapies are done in conjunction
link |
with a skilled, often one would hope, credentialed clinician.
link |
There are many people, however,
link |
that don't have access to that
link |
or who are working through stuff.
link |
They have things in their past
link |
that are very uncomfortable to them.
link |
And I'm aware that many people
link |
are working through those things through journaling,
link |
through talking to a friend,
link |
through any number of different
link |
sort of non-traditional approaches.
link |
One thing that really pertains to everybody
link |
who's working through fear and trauma of any kind
link |
is the importance of social connection
link |
as it relates to the chemical systems
link |
and the neural circuits associated with fear and trauma.
link |
And this is a emerging literature in neuroscience
link |
that is really a beautiful one
link |
because it's a very conserved biology.
link |
We see it, believe it or not, in flies, in fruit flies,
link |
a commonly used model system,
link |
in mice and indeed in humans as well.
link |
And this is the work of David Anderson's group at Caltech,
link |
of again, of Dr. Ressler's group at Harvard Medical
link |
and elsewhere, of course.
link |
And this is the work as it relates to tachykinin.
link |
Tachykinin is a very interesting molecule in our brain.
link |
And it turns out that tachykinin is activated in neurons
link |
of what's called the central amygdala
link |
and some nearby structures.
link |
So really smack dab within the middle of this threat reflex
link |
very soon after some traumatic or fear inducing event occurs
link |
and it actually sets in motion a number of other things,
link |
including changes in gene expression and potentiation,
link |
meaning long-term potentiation,
link |
activation of NMDA receptors and so on in the circuits
link |
that reinforce that fearful or traumatic experience.
link |
Now, what's interesting about tachykinin
link |
is also that it's been shown to lead to
link |
low to moderate levels of anxiety
link |
and even kind of aggression, irritability.
link |
Tachykinin levels are further increased
link |
by social isolation.
link |
And that social isolation is oftentimes
link |
what can exacerbate preexisting traumas or fearful events.
link |
And in a kind of beautiful symmetry
link |
to that kind of dark and depressing story,
link |
social connection with people that we trust,
link |
and it doesn't have to be direct physical contact,
link |
but just social connection,
link |
conversing with, sharing a meal with,
link |
it could be physical touch if that's appropriate,
link |
those sorts of connections actually serve to reduce
link |
the effectiveness or even the levels of tachykinin.
link |
So the important point here is that
link |
trauma is traumatic in and of itself.
link |
Fearful events are hard in and of themselves.
link |
And if people are working through them,
link |
either through clinical work or through individual work,
link |
And ideally one would still be trying to access
link |
social connection outside of that specific work
link |
related to the trauma.
link |
Now, it doesn't necessarily have to be outside of that.
link |
For instance, if you are,
link |
you have a good relationship with a clinician or therapist
link |
to the point where there's real trust
link |
and you feel a social connection with them, wonderful.
link |
But for many people,
link |
they have a more transactional relationship
link |
to the EMDR practitioner or to their therapist,
link |
or they're working through things on their own.
link |
And it's really important to understand
link |
that regular social connection,
link |
trusting social connection of any kind
link |
is going to be very beneficial for that process.
link |
And so this is not kind of just hand wavy,
link |
new agey stuff like, oh, you need social connection.
link |
There's a actual neurochemical basis for social isolation
link |
that has an amplifying effect on fear and trauma.
link |
And there is a neurochemical basis for the relief
link |
from fear and trauma and isolation.
link |
And in the ideal circumstance,
link |
one is working through these traumas and fears
link |
very intensely in a very dedicated way,
link |
but then is also engaging in the sorts of social interactions
link |
that are going to diminish the amount of tachykinin
link |
and going to suppress those very circuits
link |
that would otherwise be amplified.
link |
So next I'd like to talk about some really interesting
link |
and almost kind of eerie scientific findings.
link |
And that's the transgenerational passage of trauma
link |
or predisposition to fear and trauma.
link |
This is a scientific literature that's been debated
link |
many times over the last really 50 plus years,
link |
but in more recent studies have really proven
link |
that we as humans have the capacity to inherit
link |
a predisposition to trauma or fear.
link |
Now that doesn't necessarily mean
link |
that we will become traumatized or experience extreme fear
link |
just because our parents or grandparents experienced that.
link |
It's a predisposition, it's a bias.
link |
Let me explain the papers that focus on this
link |
for a little bit, and then we'll talk about
link |
what this means for each of us.
link |
One of the most important papers in this area
link |
comes to us from someone I mentioned earlier,
link |
Dr. Kerry Ressler at Harvard.
link |
And the title of the paper is
link |
Association of FKB5 Polymorphisms and Childhood Abuse
link |
with Risk of Post-Traumatic Stress Disorder Symptoms
link |
And there are other papers as well.
link |
Another one from the Ressler Lab,
link |
first author Brian Dias, D-I-A-S,
link |
Parental Olfactory Experience Influences Behavior
link |
and Neural Structure in Subsequent Generations.
link |
I'm going to summarize these papers
link |
and their general contour and papers related to them,
link |
although feel free to look up the papers I just described.
link |
We will provide a link to them in the caption
link |
if you'd like to go further.
link |
But basically these explorations involve
link |
looking at the histories of human individuals
link |
who had trauma or abuse of some kind in their childhood,
link |
and then looking at the likelihood of fear
link |
and PTSD type symptomology in their offspring.
link |
And essentially what they identified is that indeed,
link |
if you had a parent,
link |
and there does seem to be a kind of a bias toward an effect
link |
where if the father had abuse
link |
and it's severe abuse or moderate abuse,
link |
that abuse causes a change in his genetics, in his sperm,
link |
that can be passed on to offspring,
link |
such that the offspring have a lower threshold
link |
to develop trauma or extreme fear
link |
to certain types of events.
link |
Now, what's important to point out is that predisposition
link |
or bias is not necessarily to the same sorts of events.
link |
It's not that the abuse itself gets passed
link |
from one generation to the next.
link |
It's a predisposition.
link |
And the title of that paper mentioned FKB5,
link |
excuse me, FKBP5 polymorphisms.
link |
And the FKBP5 polymorphism maps
link |
to a location in the genome that's associated
link |
with the so-called glucocorticoid system
link |
with cortisol release.
link |
So the predisposition that one might inherit
link |
from having a parent, father or mother,
link |
but stronger tendency to inherit it from the father,
link |
who experienced abuse,
link |
is one in which the glucocorticoid system,
link |
the cortisol system and that HPA axis
link |
that we talked about before,
link |
the hypothalamic-pituitary-adrenal axis,
link |
is sensitized or reactive in a way
link |
that sets a lower threshold to become traumatized
link |
or very afraid of certain types of events.
link |
But it's not unique to the specific type of abuse
link |
that the parent experienced.
link |
Now, this is really, really important
link |
because a lot of times out there,
link |
I will hear that there's passage
link |
or transgenerational passage of actual trauma,
link |
the specific trauma.
link |
Now, that could be through narrative telling.
link |
If somebody is exposed to a lot of narrative
link |
about their parents' trauma in one form or another,
link |
it may be that they start to internalize
link |
some of that trauma.
link |
And there could be,
link |
because we obviously can't rule it out,
link |
there could be some other signatures
link |
of prior specific traumas they get passed on to offspring.
link |
But more likely, and certainly what these data
link |
about these polymorphisms point to,
link |
is that what gets passed on is a propensity
link |
for the threat reflex to get activated
link |
and attached to a wider variety
link |
or to less intense types of inputs and experiences.
link |
And the important point to take away from this
link |
is that it's not some magical, mysterious,
link |
and mystical thing that's being transplanted
link |
from parent to child.
link |
It's a gene or it's a modification in a set of genes
link |
that gives a heightened level of responsivity
link |
to fearful type events,
link |
or even a heightened level of responsivity
link |
such that things that wouldn't be fear-inducing
link |
or trauma-inducing to certain individuals
link |
can trigger fear and trauma in these children
link |
that inherit this particular gene.
link |
Now, that doesn't necessarily mean that they are fated
link |
to forever be traumatized or live in fear.
link |
That's simply not the case.
link |
It's just a genetic predisposition.
link |
Regardless of whether or not you had a parent or parents
link |
that were traumatized or not,
link |
there's no evidence, at least as far as I'm aware,
link |
that the treatments for trauma should be any different.
link |
As far as I know, there aren't gene therapies
link |
currently aimed at these particular variants
link |
like FKBP5 and so forth
link |
that could reverse those particular genetic underpinnings
link |
of the trauma predisposition.
link |
So this transgenerational passage of trauma,
link |
I think is extremely interesting in large part
link |
because it brings us back to this idea
link |
that the threat reflex is part of a larger sensory system.
link |
Normally we think of seeing as a sensory system
link |
or hearing as a sensory system,
link |
but the threat detection and threat learning system,
link |
the fear learning system is in many ways a sensory system.
link |
It's just a sensory system that is very generic
link |
That generic response again is good
link |
because it allows for flexibility,
link |
but it's bad because it reduces specificity, right?
link |
We can essentially become fearful or traumatized by anything
link |
if the circuit gets activated
link |
and these particular children inherit a predisposition
link |
for more things and less intense things to traumatize them.
link |
In a few minutes, we are going to discuss
link |
some of the behavioral treatments,
link |
including some really new exciting protocols
link |
for dealing with fear and trauma.
link |
But for a few minutes,
link |
I'd like to discuss some of the drug treatments
link |
that are starting to emerge as potential therapeutics,
link |
in particular for PTSD.
link |
The two drug treatments I'd like to focus on
link |
are ketamine assisted psychotherapy
link |
and MDMA assisted psychotherapy.
link |
Currently ketamine assisted psychotherapy is legal.
link |
It is approved provided it is prescribed
link |
by a board certified physician in the United States.
link |
I'm not certain about other areas of the world.
link |
MDMA, also sometimes called ecstasy therapy
link |
is in clinical trials in the US,
link |
it is still an illegal drug to possess or to sell.
link |
So I want to be very clear about that.
link |
However, MDMA is being explored as a potential therapeutic
link |
for PTSD and other forms of trauma.
link |
And of course, ketamine and MDMA
link |
are also both being explored for chronic depression,
link |
eating disorders and a number of other psychiatric disorders.
link |
But for the moment, I would just like to touch on
link |
ketamine and MDMA as they relate to the fear circuitry
link |
and trauma circuitry that we've described
link |
in the early part of the episode and throughout the episode,
link |
because I think that in viewing them through that lens,
link |
we can gain some additional insight
link |
into how they might be providing the sorts of relief
link |
that some of the early clinical studies
link |
are starting to point to.
link |
Ketamine is a dissociative anesthetic.
link |
That's right, it's a dissociative anesthetic.
link |
Its main function is to create a state of dissociation.
link |
And I've never taken ketamine personally,
link |
so I can't describe the experience of it.
link |
But a colleague of mine in psychiatry
link |
shared their experience with a patient's experience of it
link |
as making that patient feel as if quote,
link |
they were getting out of the cockpit of a plane,
link |
but that they were observing themselves doing it.
link |
And this was of course,
link |
during a approved therapeutic session
link |
that they were doing this.
link |
And they were in some sort of intense visualization
link |
about a traumatic experience.
link |
They were describing some of their depressive symptoms
link |
as well as the trauma.
link |
And the narrative that they basically created
link |
or took away from this, and that was relayed to me,
link |
was one in which the patient felt like
link |
they were in their own body,
link |
but they were also viewing their own body from the outside.
link |
So dissociative, in other words.
link |
Again, I've never had this experience.
link |
Some of you may have with ketamine or through other means,
link |
but we might want to just take a moment
link |
and think about what ketamine actually does
link |
and what dissociation actually does
link |
at the level of neural circuits.
link |
And for that, we can look to this really beautiful paper
link |
that was published by my colleagues,
link |
Karl Deisseroth in psychiatry,
link |
Robert Malenka also in psychiatry,
link |
Legion Lowe also at Stanford.
link |
They paired up or teamed up rather
link |
to explore how systemic ketamine
link |
adjust circuitries in the brain.
link |
And what they discovered was that
link |
it changes the rhythm of cortical activity
link |
in certain layers of the cortex.
link |
The cortex is like a layered sandwich.
link |
The cortex of course, being the outside of the brain.
link |
And there was a particular rhythm,
link |
a one to three Hertz rhythm.
link |
One to three Hertz just means a particular frequency
link |
of electrical activity.
link |
In this case, in these layer five neurons
link |
of retrosplenial cortex.
link |
So you don't need to know much about retrosplenial cortex
link |
or one to three Hertz rhythms.
link |
I think the important thing to just take away from this
link |
is that there is now starting to be an understanding
link |
of how drugs like ketamine work
link |
to create this subjective experience
link |
that this patient and other patients describe
link |
You know, dissociation in its essence
link |
is really about not feeling what's happening.
link |
It's about viewing what's happening
link |
from a different perspective than what normally
link |
one would view that experience from.
link |
And so if we kind of plug that general notion
link |
of dissociation and ketamine induced dissociation
link |
into the circuit that we talked about before
link |
where we have this threat reflex involved in the amygdala,
link |
these outputs for freezing or for reward in the accumbens,
link |
and we've got this prefrontal narrative coming down
link |
as top-down processing,
link |
it brings us right to that prefrontal cortical input
link |
to the threat system and that narrative.
link |
What seems to be the case in my review
link |
of the paper I just described plus a review
link |
on how ketamine assisted trauma relief might work
link |
is that it somehow allows the patient, the individual,
link |
to recount their trauma while feeling either none
link |
or a very different set of emotional experiences
link |
that they experienced in the actual trauma
link |
or fearful experience.
link |
So it's a remapping of new onto old,
link |
new meaning new feelings onto old feelings
link |
while staying in the exact same narrative.
link |
So it's a little bit like EMDR
link |
of suppressing the threat reflex,
link |
but it seems to bring in a replacement of previous
link |
emotional experiences and sensations in the body
link |
And so in that way, we can sort of view,
link |
or we can try and view ketamine assisted psychotherapy
link |
for the treatment of trauma as bringing together
link |
the three elements that we talked about before.
link |
You want to diminish the intensity,
link |
the potency of the old original trauma experience
link |
or fear experience.
link |
So that seems to be accomplished through this dissociation
link |
and maybe through the kind of anesthetic component.
link |
So it's a reduction in pain in the body,
link |
a dissociation, a kind of observing of the self
link |
that leads to the extinction of the trauma and the fear.
link |
But then there also seems to be an automatic
link |
or kind of built in relearning of a new narrative
link |
and new set of experiences,
link |
which is the next step that we described earlier.
link |
So it's an intriguing therapy.
link |
It's one that's really catching on.
link |
And there are many, many clinics around the US
link |
that are now doing it.
link |
Whether or not it turns out to be the ultimate treatment
link |
for trauma and for fear isn't clear.
link |
My colleagues in psychiatry tell me that that's unlikely,
link |
although it does seem to be beneficial
link |
for a number of people,
link |
especially people that are experiencing trauma
link |
or have existing traumas and fear
link |
that are coupled with depressive symptoms
link |
because the data on ketamine and depression
link |
seems to be quite strong.
link |
So now let's talk about MDMA.
link |
MDMA, also sometimes called ecstasy or molly
link |
in its recreational form, is a powerful synthetic drug
link |
that at least as far as we know,
link |
creates a state in the brain and body
link |
that is unlike any other chemical state
link |
in the brain and body that's normally experienced.
link |
What do I mean by that?
link |
Well, we have several neuromodulator systems in our body.
link |
Neuromodulators are chemicals that change the likelihood
link |
that certain neural circuits will be active,
link |
meaning they can make it very likely
link |
that certain circuits will be active
link |
and make it very unlikely
link |
that other neural circuits will be active.
link |
Good examples of neuromodulators are dopamine,
link |
serotonin, acetylcholine, norepinephrine.
link |
These tend to work on different systems
link |
in the brain and body,
link |
but they tend to be activated more or less in parallel.
link |
You can have dopamine released in your brain
link |
and also norepinephrine.
link |
You can have serotonin released in your brain
link |
and also acetylcholine.
link |
So it's not an all or none kind of thing,
link |
but the degrees to which these things are activated
link |
And there is a little bit of a seesaw type phenomenon
link |
with dopamine and serotonin.
link |
Dopamine most commonly associated
link |
with activating neural circuits related to motivation,
link |
craving, and reward.
link |
And serotonin more typically activated
link |
in response to situations or conditions
link |
in which we are very happy and content with what we have.
link |
So dopamine is more about pursuing and seeking.
link |
Serotonin is more about kind of a pleasure and satisfaction
link |
with resources that we have in our immediate sphere.
link |
They don't tend to,
link |
serotonin doesn't tend to place the brain and body
link |
into a mode of action quite as much as dopamine does,
link |
MDMA is a unique compound
link |
in that it leads to very large increases
link |
in the amount of both dopamine and serotonin
link |
in the brain and body simultaneously.
link |
And that's a unique circumstance
link |
that is just simply not seen under normal conditions.
link |
From a subjective standpoint,
link |
people under the influence of MDMA
link |
in the therapeutic setting tend to report immense feelings
link |
of connection or resonance with people
link |
or even things with music, with objects.
link |
Certainly if it's being done in conjunction
link |
with a family member or a partner
link |
or with a therapist,
link |
they will feel extremely connected to that person.
link |
They'll feel a very close understanding and association
link |
oftentimes that goes beyond words.
link |
There is a chemical reason for that.
link |
It turns out that MDMA causes massive release of oxytocin,
link |
this neuropeptide that's associated with pair bonding
link |
and with bonding generally.
link |
The oxytocin system and the serotonin system
link |
are closely linked to one another in the brain and body.
link |
And they tend to be co-released often at the same times
link |
and by the same sorts of events.
link |
So MDMA is one mechanism by which oxytocin is released
link |
in these massive amounts.
link |
And I should just relay some of the levels of oxytocin
link |
because they're really quite striking
link |
gives a kind of a more vivid picture
link |
of why it is the MDMA would make people feel
link |
so associated in a positive way
link |
with the various things that are happening to them
link |
while they're under the influence of the drug.
link |
So the paper related to this that I'd like to highlight
link |
is in the journal, Psychoneuroendocrinology.
link |
The title of the paper is plasma oxytocin concentrations
link |
following MDMA or intranasal oxytocin in humans.
link |
And just remarkably,
link |
MDMA increased plasma oxytocin levels
link |
to 83.7, this is an average,
link |
83.7 picograms per milliliter,
link |
about 90 to 120 minutes into the MDMA session
link |
compared to a typical level of 18.6.
link |
So this is a massive increase in oxytocin.
link |
And I think that massive increase in oxytocin
link |
is part of the reason why people have these feelings
link |
of close resonance and association.
link |
Now, the dopamine increases
link |
are generally what lead to the feelings of euphoria
link |
inside of the MDMA session.
link |
And then the serotonin increases, it is thought,
link |
are what lead to the feelings of safety and comfort.
link |
So again, a very unusual chemical cocktail
link |
that would never be seen, at least not at this amplitude,
link |
under any normal conditions
link |
outside of an MDMA clinical psychotherapeutic session.
link |
Why would this state of mind and body
link |
be potentially useful for the treatment of trauma?
link |
Well, indeed it is revealing itself to be useful
link |
for the treatment of trauma.
link |
Again, these are legal clinical trials
link |
where people are doing this and discovering this.
link |
What it seems to allow is a very fast relearning
link |
or new associations to be tacked on
link |
to the previously traumatic experience.
link |
So again, it brings us back to the same model
link |
of how people extinguish fears and traumas
link |
and replace them with new experiences
link |
when there is no drug treatment involved.
link |
There needs to be a diminishing of the old experience,
link |
meaning an extinction,
link |
and then a relearning of a new narrative.
link |
What the chemical milieu of MDMA seems to be doing
link |
is creating an opportunity for all that to happen very fast
link |
without the need for many repetitions of the original trauma
link |
and reliving of the original trauma,
link |
probably because the reliving of it
link |
inside of one of these MDMA sessions is very acute,
link |
very intense, plus it seems to be offering the opportunity
link |
to extinguish and rewrite in or write in a new narrative
link |
associated with that trauma very quickly as well.
link |
So what this means is that treatments like MDMA
link |
that are under investigation in these clinical trials
link |
are unlikely to be magic potions, if you will,
link |
that allow access to a particular process
link |
that would otherwise not be accessible.
link |
It's more that the typical process of trauma
link |
and fear reduction that's carried out
link |
in things like prolonged exposure,
link |
cognitive processing, cognitive behavioral therapy
link |
seems to be compacted into a much shorter session,
link |
and that session is performed at a much higher intensity,
link |
higher intensity because the chemical milieu of the brain
link |
is completely different.
link |
I mean, the experience of MDMA is one in which
link |
people have a very heightened sense of euphoria,
link |
a very heightened sense of connection,
link |
so those positive experiences are essentially prime
link |
to be written in and over the traumatic experience,
link |
and because of the high levels of serotonin in the system
link |
and probably oxytocin as well,
link |
there's a safety that's written into the situation
link |
that allows people to lean into perhaps narratives
link |
or components of narratives
link |
that they would otherwise be holding back from.
link |
So these are powerful compounds,
link |
and I think the future of MDMA-assisted psychotherapy
link |
for trauma in particular is holding great promise.
link |
As of now, meaning at the time of the recording
link |
of this podcast, again, I want to reiterate
link |
that these are clinical trials that are being done legally.
link |
These drugs are still illegal to possess or sell
link |
outside of clinical trials.
link |
Doing this sort of thing is punishable,
link |
but it does seem that the FDA
link |
and some of the related bodies
link |
that control these sorts of things
link |
are eyes open to this stuff,
link |
and I think it's very likely in the next few years,
link |
things like MDMA and certainly ketamine is already
link |
in widespread use within the psychiatric community,
link |
and I think we're going to be seeing a lot more of that.
link |
One thing we have not touched on yet
link |
is how do you know if you're traumatized?
link |
How do you know if you have chronic fear
link |
or a debilitating fear?
link |
Much of the psychiatric community focuses
link |
on how many other problems people might have,
link |
trouble sleeping, trouble eating,
link |
trouble maintaining quality work or schoolwork and so forth,
link |
and all of those are certainly very valid criteria
link |
and necessary criteria for determining
link |
whether or not somebody meets clinical diagnosis or not,
link |
but there's a biological component
link |
that I think we can all assess for ourselves,
link |
and that's one of interoceptive versus exteroceptive balance
link |
and that sounds confusing,
link |
but it's actually really easy to understand.
link |
We can focus our perception on the external world,
link |
events going on around us beyond the confines of our skin
link |
or within the confines of our skin.
link |
A focus and a perception on the external world
link |
is what's called exteroception,
link |
and a focus on what's happening inside us
link |
and we have the capacity to build mental appraisal
link |
I can, for instance, stop for a moment
link |
and assess how my stomach feels, how hungry I feel,
link |
how quick my heart is beating.
link |
Some people, by the way, are much better at sensing
link |
whether or not their heart is beating at a particular rate
link |
and others not so much.
link |
Some people can actually count their heartbeats
link |
without having to take their pulse
link |
by placing pressure on their wrist or their neck.
link |
Some people can't.
link |
In other words, some people have very high interoceptive
link |
awareness and other people less so.
link |
This whole business of fear and trauma
link |
relates to taking external experiences
link |
and funneling those experiences into this thing
link |
that I'm calling a threat reflex or the fear circuitry.
link |
A recent paper published in the journal Science,
link |
so absolutely spectacular journal, Science, Nature, and Cell
link |
being the apex journals of scientific publishing,
link |
gets at this issue of where in our mind
link |
and how do we assess
link |
whether or not what we are feeling internally
link |
is reasonable given what's going on externally.
link |
And it's a really fascinating study.
link |
I'm just going to highlight a little bit of it for you,
link |
and then I'll touch on some of the relevant aspects
link |
and how that can be adopted into a practice
link |
to assess and reduce fear and anxiety.
link |
The title of this paper,
link |
published just a few weeks ago in Science,
link |
is Fear Balance is Maintained by Bodily Feedback
link |
to the Insular Cortex in Mice.
link |
We've not talked too much about the insula,
link |
also called the insular cortex.
link |
This is a brain area that my lab has worked on
link |
and other labs have worked on.
link |
It's a brain area that has within it a map
link |
of our internal interoceptive landscape.
link |
It's a map of our internal bodily sensations.
link |
It's a really interesting structure.
link |
So the way this study was carried out
link |
is that subjects were taught or conditioned
link |
to a particular danger signal
link |
through repeated presentation of a sound with a foot shock.
link |
So there's a sound and there's a foot shock.
link |
And as you know from our earlier discussion
link |
about Pavlovian learning,
link |
conditioned stimuli and unconditioned stimuli,
link |
eventually the sound alone comes to evoke the fear response.
link |
And that's just classical conditioning.
link |
The insula is this brain area
link |
that's associated with determining
link |
whether or not one's internal sensations,
link |
gut, heart, lungs, et cetera,
link |
are reasonable or not given the external circumstances.
link |
It can even measure or is associated with our understanding
link |
of what are called atrial baroreceptors.
link |
These are blood pressure sensors.
link |
So believe it or not, when your pulse rate increases
link |
or you feel like you're stressed out,
link |
your atrial baroreceptors are sending a signal
link |
to your insular cortex and your insular cortex is saying,
link |
wow, I'm really stressed out.
link |
My blood pressure is up.
link |
You don't actually have to measure your blood pressure
link |
Your insula is doing it for you.
link |
It's not getting a quantitative readout,
link |
but it's getting a qualitative readout.
link |
The main effect of inhibiting
link |
or reducing the activity of the insula
link |
was that the intensity of an outside world experience
link |
led to a range of different internal effects.
link |
In other words, for most people,
link |
a mild shock would induce a mild increase in heart rate,
link |
a mild increase in blood pressure,
link |
whereas an intense shock to the skin
link |
would lead to a big increase in heart rate
link |
and a big increase in blood pressure.
link |
Turns out the insula is important
link |
for establishing that match of intensity.
link |
And when the insula is inhibited,
link |
what ends up happening is that a mild shock
link |
can create a big increase in blood pressure.
link |
And that can be maintained such that
link |
anything that's paired with that shock,
link |
like a bell or a tone,
link |
would lead to a big increase in blood pressure.
link |
You've probably seen examples of this in the real world.
link |
Maybe this is even you.
link |
Some people are very jumpy in response
link |
to just even small changes in their environment.
link |
So if somebody is working and you walk in and you say hello,
link |
and they'll go, and they're kind of, they're jumpy.
link |
They have a low threshold to a big anxiety
link |
or a fear response.
link |
Other people are really calm.
link |
I recall my bulldog, unfortunately, he passed away.
link |
But before he passed away,
link |
if you walked in the room and you said,
link |
hey Costello, he might turn his eyes in your direction.
link |
He had a very high threshold to respond.
link |
He was pretty low anxiety animal.
link |
A lot of people are like that.
link |
You come up behind someone and you say, hello,
link |
and they just turn around real slow,
link |
or they might just turn around at normal speed and say hello,
link |
whereas other people would jump out of their seat.
link |
The insula seems to be involved in calibrating how big
link |
or how high amplitude a given physiological response is.
link |
So it's pairing the internal landscape
link |
with the external world.
link |
And this might seem like just a mechanistic,
link |
but non-actionable point.
link |
But what you'll see from the next study
link |
that I'm going to describe is that recalibrating
link |
the relationship between outside events
link |
and internal responses, which is the job of the insula,
link |
is actually something that's under our control.
link |
And through a very simple, very short protocol,
link |
we can actually recalibrate that system so much so
link |
that we can potentially reduce the amount of fear
link |
and trauma that we experience in response to a memory
link |
or to a real event.
link |
And the entire process can occur very quickly.
link |
So I'm really excited to tell you about this next study
link |
for a number of reasons.
link |
First of all, it's extremely recent.
link |
Second of all, it's very well grounded
link |
in our current understanding of the mechanisms
link |
of stress, trauma, and PTSD,
link |
and unlearning of stress, trauma, and PTSD.
link |
And third, it points to a actionable protocol
link |
that while certainly is not the only approach
link |
that I think people could or should take
link |
for fear, trauma, and PTSD is one that I think
link |
we are going to see implemented
link |
into the clinical setting very soon
link |
if it's not happening already.
link |
Now, there's a fourth reason I'm very interested in it,
link |
which is that my lab works on stress, stress relief,
link |
and tools for managing sleep and improving focus, et cetera.
link |
And one of the hallmarks of the studies
link |
we've been doing lately is very brief
link |
five minute a day interventions of the sort
link |
that was used in this particular study,
link |
although I should emphasize I had nothing to do
link |
with this particular study.
link |
Now, this particular study was carried out
link |
in an animal model in mice.
link |
The work in my laboratory focuses on human subjects,
link |
but the similarities of the stress system,
link |
at least at the level that it was explored in this study,
link |
I think have great relevance,
link |
maybe even direct relevance to humans.
link |
So the title of this study is repeated exposure
link |
with short-term behavioral stress
link |
resolves preexisting stress-induced
link |
depressive-like behavior in mice.
link |
Again, this study was in mice.
link |
And basically what they did is they stressed out mice,
link |
got them depressed, and you actually can do that in a mouse
link |
using a restraint protocol.
link |
And that's a long lasting restraint protocol
link |
of 15 minutes or more.
link |
Mice don't like it.
link |
You do it often enough.
link |
They stop working so hard in their life,
link |
in their mouse life to gain food, to gain mates.
link |
They show depressive symptoms in a number of levels.
link |
They show elevated glucocorticoids.
link |
You see the same thing in humans.
link |
Chronic stress in humans lasting weeks or more
link |
does the same exact thing.
link |
So again, a very close match here
link |
in terms of mechanism overall.
link |
And then what they did was a very counterintuitive thing.
link |
Rather than give these animals stress relief
link |
at the level of reducing their anxiety
link |
with benzodiazepines
link |
or giving them a nice little mouse vacation
link |
or enhanced or enriched environment,
link |
things that have been done in a lot of previous studies,
link |
what they did is they subjected them to five minutes a day
link |
of intense stress, but only five minutes a day.
link |
And what they found was miraculously,
link |
but also very convincingly,
link |
daily short bouts of intense stress
link |
actually undid, reversed the effects of chronic stress.
link |
And it did this at the level of glucocorticoids,
link |
of hormones, of neurotransmitters,
link |
and a number of other different mechanisms.
link |
Now, I find this very exciting for a number of reasons,
link |
but in particular, because my laboratory
link |
in collaboration with David Spiegel's laboratory,
link |
our associate chair of psychiatry at Stanford,
link |
been exploring how five minute a day
link |
respiration protocols can alleviate stress.
link |
And while those data are not yet published,
link |
they are at the stage
link |
where I'm comfortable talking about them.
link |
And we are seeing some very impressive
link |
and significant effects on stress reduction,
link |
not just from respiration protocols
link |
that allow people to calm themselves,
link |
but also respiration protocols
link |
that bring people into a heightened state
link |
of autonomic sympathetic arousal, AKA stress.
link |
As my colleague, Dr. David Spiegel,
link |
he's an MD, psychiatrist, and PhD, likes to say,
link |
when it comes to trauma, anxiety, and PTSD,
link |
and the treatment of trauma, anxiety, and PTSD,
link |
it's not just the state that you are in or that you go into,
link |
it's how you got there
link |
and whether or not you had anything to do with it.
link |
And this brings us right back to those top-down mechanisms
link |
and the narrative around
link |
what we are experiencing internally.
link |
So let's zoom out and I'll explain how this works
link |
and what to do about it.
link |
We have this brain structure called the insula.
link |
We talked about the insula a few minutes ago.
link |
The insula is calibrating how we feel internally
link |
versus what's going on externally.
link |
It's involved in setting
link |
whether or not what we are feeling is appropriate
link |
given what's happening.
link |
We have a system that can generate threat responses.
link |
And in the case of trauma, PTSD, and extreme stress,
link |
chronic stress, that system gets ramped up
link |
so that it takes very little, maybe even just a memory
link |
or maybe even an association that we're not even aware of,
link |
you know, a location triggers something,
link |
we're not even aware of it,
link |
and we start experiencing that symptomology.
link |
How do we recalibrate the system?
link |
Well, most of the approaches that are out there
link |
involving drug treatments,
link |
typical drug treatments would involve
link |
suppressing the level of internal arousal,
link |
just trying to bring that down.
link |
Now, some of those drug treatments work,
link |
but oftentimes they don't.
link |
And if you think about it,
link |
it's probably not surprising that they don't
link |
because by taking a drug that just lowers your anxiety,
link |
overall, you're creating a different sort of
link |
miscalibration of the system.
link |
So what we've been doing in human subjects
link |
is having them do either breathing protocols that calm them,
link |
and I'll explain what that is in a moment,
link |
or doing breathing protocols
link |
that increase their level of autonomic arousal
link |
and seeing how that impacts their response to stress overall
link |
not just during that particular breathing protocol.
link |
So the calming protocol that we use
link |
involves these physiological sighs.
link |
I've talked about these previously
link |
on the podcast and elsewhere,
link |
but if you just need a reminder,
link |
if you haven't heard about it,
link |
there's a pattern of breathing that we all do in sleep
link |
when our carbon dioxide levels in our bloodstream
link |
get too high, and we do this when we get claustrophobic,
link |
meaning we do it reflexively,
link |
and that's a double inhale through the nose
link |
followed by a long exhale.
link |
and yes, the inhales should be through the nose,
link |
and yes, the exhales should be done
link |
through the mouth, ideally.
link |
So it's a big filling of the lungs
link |
through two breaths back to back inhales.
link |
Even if you can only sneak in a little air
link |
on that second one, no talking if you're going to do it right
link |
and then a long exhale, which allows you to offload
link |
a lot of carbon dioxide in the exhale.
link |
And we have people doing that in real time,
link |
anytime they experience stress,
link |
but the particular breathing protocol
link |
that we've been giving human subjects
link |
is for them to do the repeated, what we call cyclic sighing.
link |
So double inhale, exhale, double inhale, exhale,
link |
double inhale, exhale, repeatedly for five minutes,
link |
which is actually a pretty long time to repeat that,
link |
but you can do it pretty slowly.
link |
And people report and the data point to the fact
link |
that it's very calming.
link |
People feel more relaxed afterwards,
link |
and that relaxation wicks out
link |
into other aspects of their life.
link |
Now, we did not look at stress and trauma in that condition.
link |
We also have another condition
link |
where people do what's called cyclic hyperventilation,
link |
which is very different
link |
and creates a very different internal state
link |
and is somewhat stressful.
link |
It's five minutes a day of stress,
link |
much like the study that I just described,
link |
and it involves basically doing this,
link |
what I'll do in a moment,
link |
for five minutes, which is hyperventilating,
link |
which is, ah, ah, ah, ah,
link |
but not continuously for the five minutes,
link |
because many people would pass out
link |
or feel extremely uncomfortable.
link |
It involves inhale, exhale, inhale, exhale, very deep,
link |
inhale through the nose, exhale through the mouth,
link |
and then every 25 or 30 breaths or so,
link |
doing a full exhale and holding one's breath,
link |
lungs empty for about 25, maybe 30, maybe even 60 seconds,
link |
and then continuing until five minutes is up.
link |
Subjects report, and our data indicate
link |
that people feel a heightened level of autonomic arousal.
link |
In fact, I can feel it right now,
link |
even from that very brief
link |
cyclic hyperventilation bout I just did.
link |
You feel a heating up.
link |
You feel a, some people will perspire.
link |
Some people get wide-eyed.
link |
Some people feel agitated.
link |
That's adrenaline being released into your system.
link |
Now, I'm not suggesting everyone run out and do this,
link |
and if you have a predisposition to panic attack
link |
or anxiety attacks, please don't do this,
link |
because it is very stimulating
link |
and can trigger those sorts of attacks,
link |
but this five-minute-a-day protocol
link |
of cyclic hyperventilation does lead to big increases
link |
in autonomic arousal, so it's stressful, in air quotes,
link |
but to bring us back to the,
link |
my colleague David Spiegel's quote,
link |
it really was him that said it, not me.
link |
It's not just about the state that you're in.
link |
It's about the state that you're in,
link |
plus how you got there
link |
and whether or not you directed entry into that state,
link |
and that point of that one directs their own entry
link |
into a state deliberately is really key
link |
and I think has an important implications
link |
for whether or not there's stress relief
link |
and fear relief and trauma relief
link |
from bringing oneself into a state
link |
of increased autonomic arousal.
link |
Because of the way that that fear
link |
and trauma circuitry is organized.
link |
If you recall, it's got these components
link |
of how external events can trigger
link |
an internal stress response and fear response
link |
and trauma response,
link |
but there's that top-down prefrontal component
link |
that can inhibit certain aspects
link |
of that fear and threat circuitry.
link |
Now, earlier we were talking about that prefrontal circuit
link |
being engaged through narrative,
link |
through self-directed deliberate narrative.
link |
It's the person deliberately retelling the story.
link |
Here, we're talking about a deliberate reactivation
link |
of the sensations in the body.
link |
So where I think this is all going,
link |
meaning where my laboratory and the Spiegel Laboratory
link |
and other laboratories out there are taking this,
link |
is you can imagine a very brief five minutes a day,
link |
two weeks was the time that they did this
link |
for five minutes a day for two weeks,
link |
intervention in which people with the support
link |
of a clinician, we would hope,
link |
would deliberately induce a physiological state
link |
that's very stressful, right?
link |
Not shying away from the stress response,
link |
but increasing their own stress response deliberately,
link |
and maybe in conjunction with recounting
link |
the traumatic or fearful circumstance.
link |
This is far and away different
link |
than the kind of state of mind and body
link |
that would come about in a ketamine-assisted,
link |
trauma-induced psychotherapy session,
link |
or a MDMA-assisted trauma psychotherapy session,
link |
or in a purely narrative-based psychotherapy session
link |
aimed at alleviating fear or trauma.
link |
The reason I like these sorts of interventions is that,
link |
A, they are very low cost or even zero cost, right?
link |
One could, you could imagine doing this while journaling
link |
or while recounting a particular experience.
link |
Again, they're very compact.
link |
Five minutes a day for two weeks
link |
is what was done in this particular mouse study.
link |
We don't know if that translates directly
link |
to the human study or not.
link |
What was interesting is that
link |
if they used a longer daily bouts of stress,
link |
like 15 minutes a day, that actually exacerbated the trauma
link |
and exacerbated the fear.
link |
So one has to be very careful.
link |
Stress and deliberate entry into stress
link |
and self-stressing are very potent tools.
link |
They're very sharp blades that it does appear,
link |
or it's likely can help alleviate trauma and fear.
link |
But how long to do this, exactly what the protocol should be
link |
is still something that needs to be cultivated.
link |
I know there are going to be people out there
link |
that nonetheless are going to want to experiment
link |
with some of this.
link |
I will say that I do not think it matters
link |
how one gets into that stressed state,
link |
provided it is self-directed.
link |
And that therefore could be cold shower.
link |
It could be ice bath.
link |
It could be anything that induces an acute,
link |
meaning a sudden onset of adrenaline and is self-directed.
link |
That's really the key feature here.
link |
So I'm very excited about these data,
link |
both the five-minute intervention data
link |
from the animal study,
link |
the work that's ongoing in my laboratory
link |
and Dr. Spiegel's laboratory,
link |
and the work that's being done on the insula,
link |
because I think what we're starting to see now
link |
is a picture of fear and trauma and PTSD
link |
that has this sensory component,
link |
what's happening in the world around us,
link |
this internal interoceptive component,
link |
how appropriate are the signals
link |
that are occurring in my body?
link |
I mean, let's face it,
link |
if you almost get hit by a car
link |
and your heart rate is 140 beats per second,
link |
and that lasts for a little while,
link |
and you're stressed out,
link |
and you don't get the best night's sleep,
link |
that's pretty normal.
link |
That means you have a healthy fear system.
link |
If that persists and you're dealing with a lot of issues
link |
a week later, six weeks later, two years later,
link |
then it's moved into the realm of trauma and PTSD.
link |
So we need to always be taking into account
link |
the different components of the circuitry.
link |
I do think that deliberate self-directed entry
link |
into these short bouts of stress
link |
is a very promising approach,
link |
and it's one that if people are going to experiment,
link |
I just, again, want to caution people with anxiety
link |
or panic disorders, be very cautious,
link |
probably don't do it.
link |
Ideally, you would do this in conjunction
link |
with support from a clinician,
link |
but I'm also aware that there are a lot of people out there
link |
that are dealing with trauma
link |
and dealing with post-traumatic stress of various kinds,
link |
and that they're desperate for various
link |
self-directed intervention approaches.
link |
So just very briefly,
link |
I want to touch on some of the lifestyle
link |
and supplementation factors that can impact things
link |
like fear and trauma and getting over fear and trauma.
link |
To make a long story short,
link |
there are many things that we all can and should do
link |
to support our overall mental and physical health.
link |
And these are the foundational elements
link |
of quality nutrition, what that means to you,
link |
quality sleep on a regular basis,
link |
ample sleep on a regular basis.
link |
We have an episode on how to master sleep.
link |
In fact, we have four episodes
link |
that you can go to Hubermanlab.com or elsewhere
link |
and scroll down, and you can find those episodes
link |
in order to get your sleep really dialed in, as they say.
link |
If you're sleeping regularly and for sufficient duration,
link |
all of the systems of your fear circuitry
link |
are going to function better,
link |
mainly because the autonomic nervous system
link |
becomes very dysregulated
link |
when we are not getting good sleep on a regular basis.
link |
Dysregulated means that out of nowhere,
link |
we can have a higher propensity
link |
to have sympathetic activation,
link |
or we can feel really tired and wired.
link |
That seesaw that I described earlier
link |
of alertness and calmness,
link |
of sympathetic and parasympathetic,
link |
in that analogy, we can imagine that seesaw has a hinge,
link |
and that hinge can neither be too tight nor too loose.
link |
If it's too tight, you can get locked
link |
into chronic activation of alertness or chronic fatigue.
link |
If it's too loose, you're bouncing all over the place
link |
and you might be a little tired and wired one moment,
link |
and then really hyper alert.
link |
Sleep resets that balance and resets that hinge
link |
to the appropriate tightness, if you will,
link |
so that all these circuits,
link |
and not just the circuits related to fear,
link |
but also the circuits related to cognition, clear thinking,
link |
to be able to spell out very clear, detailed narratives,
link |
to feel like you are in control,
link |
you are deliberately bringing yourself into these protocols,
link |
if that's what you intend to use.
link |
All of that functions much better
link |
when you're sleeping well and eating well.
link |
We talked about social connection.
link |
Those are all indirect supports of trauma relief
link |
and of getting over fear, but they are essential.
link |
I think of them sort of like the tide,
link |
when the tide is high enough, a boat can leave harbor,
link |
and if the tide is not high enough,
link |
then that boat is going to be stranded on shore.
link |
And in this analogy, the boat stranded on shore
link |
is your attempt or anybody's attempt
link |
to try and work through something.
link |
Very hard to do when we're sleep deprived,
link |
very hard to do when we're not fed enough
link |
or fed the proper foods for you,
link |
and that's a highly individual thing.
link |
And social connection, as we talked about earlier,
link |
creates a general sense of support
link |
for the ability to move through things,
link |
but also chemical support
link |
at the level of suppressing tachykinin, okay?
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So those foundational elements are absolutely key,
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but they are indirect.
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I just want to briefly mention a few of the things
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that some people find great benefit from
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in the supplementation realm
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as it relates to anxiety, stress, fear, and PTSD.
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But I want to point out that, again,
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these are somewhat indirect in their support,
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and most of them focus on reducing anxiety overall.
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The two that I want to focus on
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are two that I've never talked about on this podcast before
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because I've done podcasts before
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on stress and managing stress in the kind of shorter term.
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So we've talked about Ashwagandha in a previous podcast.
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Check out the podcast on stress
link |
if you're interested in how that might be relevant
link |
as well as other tools.
link |
But the two are interesting ones.
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The first one is saffron, of all things,
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but there are 12 studies, believe it or not,
link |
that orally ingested saffron at 30 milligrams
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seems to be a reliable dose for reducing anxiety
link |
on the standard inventories,
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the Hamilton Anxiety Rating Scale,
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for those of you that want to know.
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And these are significant effects,
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and these were carried out in both male and female subjects.
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Here, I'm only referring to human studies.
link |
Several of these were double-blind studies.
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There's a meta-analysis of the positive effects,
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meaning anxiolytic effects,
link |
anxiety-reducing effects, that is, of things like saffron.
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Definitely have to check with your doctor,
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make sure it's right for you.
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But they're fairly impressive effects
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when you really think about it,
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given that these are legal over-the-counter substances.
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Again, check with a doctor.
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The other one is inositol.
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Inositol has been shown to create a very notable decrease
link |
in anxiety symptoms.
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It's a fairly high dose that's used,
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but believe it or not, the potency of this effect
link |
is on par with many of the prescription antidepressants.
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That's pretty impressive.
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These studies, again, are double-blind studies
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that all showed decreases in anxiety.
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These were done in males and females.
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The age range is very broad, which is great,
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18 all the way up to 64 across the studies that I looked at.
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One of the more important things is that
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the dosages are quite high,
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18 grams of inositol taken for a full month.
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And it does take some time for these symptoms of anxiety
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The low dose range was about 12 grams of inositol,
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so as high as 18, as low as 12 grams.
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But then again, pretty impressive results
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considering that these are over-the-counter
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supplement compounds.
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There's even some evidence, I should just mention,
link |
that the inositol is also used for things like
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obsessive compulsive disorder.
link |
We will do a full episode on OCD in the future.
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You can count on that.
link |
But in the meantime, inositol does seem to have
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some positive effects on anxiety,
link |
and therefore it might provide a supportive indirect effect
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for people that are trying to work through trauma and PTSD.
link |
Now, the question is, when would you take it?
link |
Well, by the logic of what we spelled out today,
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you probably would not want to take it during a session
link |
or prior to a session where you were trying to
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amplify the intensity of an experience
link |
and the recounting of an experience
link |
in efforts to eventually extinguish that experience.
link |
Because if you put a drug or a compound of any kind,
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prescription drug or supplement of any kind,
link |
into your system, you are essentially short-circuiting
link |
the extinguishing effect, right?
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So you could imagine doing this outside of that session
link |
as a way to kind of bring your system
link |
back to baseline, perhaps.
link |
So if you're going to use these sorts of things,
link |
you want to think about them logically.
link |
And this also really points to the fact that
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many of the things that people are doing out there
link |
to self-medicate, overuse of alcohol or other substances
link |
to try and calm themselves,
link |
because they have fear, anxiety, and PTSD,
link |
are actually driving that fear, anxiety, and PTSD
link |
deeper into their system,
link |
or at least is not allowing it to relieve itself
link |
through any attempts to recount or replay
link |
and using these top-down narrative circuits
link |
or other approaches.
link |
And the last compound I want to mention
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is a particularly interesting one
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because it's neither an anxiolytic,
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nor is it something that increases
link |
overall levels of stress and alertness,
link |
but it has some kind of MDMA-ish like contour to it.
link |
It does not produce, as far as we know,
link |
the same mental effects or physical effects as MDMA
link |
but that's the substance that I'm referring to,
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Kava has been shown in eight studies
link |
to have a very potent effect on reducing anxiety.
link |
But what's interesting about kava
link |
is that kava functions by increasing GABA,
link |
this inhibitory neurotransmitter in the brain.
link |
Remember, GABA is the inhibitory neurotransmitter
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that is used, that's employed by the very neurons
link |
in the prefrontal cortex
link |
that serve to inhibit the threat reflex.
link |
So it seems to increase GABA,
link |
but it also increases dopamine.
link |
And that's a somewhat unusual compound.
link |
I'm not aware of many compounds
link |
that simultaneously increase GABA and increase dopamine.
link |
And as you recall, that threat reflex has outputs
link |
that tap into the dopamine system.
link |
Now, that's a big leap to go from a compound
link |
that increases GABA and dopamine
link |
and look at a circuit spelled out on paper in front of us
link |
and say, oh, well, there's GABA and dopamine in this circuit
link |
and therefore this is a good compound to take.
link |
But the effects of kava in human studies
link |
are pretty interesting as it relates to anxiety,
link |
stress, PTSD, and fear.
link |
I'm not going to summarize all of these
link |
because there are eight studies that I'm aware of,
link |
but I'll just mention again,
link |
these are double-blind studies.
link |
So the trial design is solid.
link |
The age ranges are anywhere from 18 to 64,
link |
which is a nice broad age range.
link |
The number of subjects is quite high, both men and women,
link |
no signs of hepatotoxic signals,
link |
so meaning a liver toxicity,
link |
although of course, check with your doctor.
link |
But what was interesting is that after a period
link |
of about three weeks of treatment
link |
with anywhere from 150 milligrams
link |
of what are called active kava lactones.
link |
Okay, so there are dosages that relate to that kava.
link |
So 100 milligrams of extract of kava
link |
is a kind of a reasonable typical dose in these studies,
link |
but that spells out to a certain amount of kava lactone.
link |
So you have to kind of boil down
link |
to what is the appropriate dosage.
link |
And it turns out it's extremely broad.
link |
You'll see evidence of 50 milligrams.
link |
You'll see evidence of 300 milligrams.
link |
It's kind of all over the place,
link |
but each of these studies alone and together
link |
point to the fact that kava does seem to produce
link |
a very potent anxiolytic and general kind of improvement
link |
in depressive symptoms and reduction
link |
in generalized anxiety across the board.
link |
So it's an interesting compound.
link |
I've never actually tried any of the compounds
link |
I just mentioned, kava, saffron, or anisotol.
link |
So I can't report on them personally.
link |
I just know that a number of listeners of this podcast
link |
are interested in supplements
link |
and legal over-the-counter approaches
link |
to their biology and psychology.
link |
And so that's why I mentioned them.
link |
Those were the three for which I found
link |
the most convincing evidence
link |
and the largest bulk of evidence.
link |
So if you're interested in exploring those,
link |
proceed with caution, but they do seem quite interesting.
link |
So today we've reviewed a large amount of information
link |
about the biology of pathways in the brain and body
link |
that underlie the fear response
link |
and that give rise to chronic fear
link |
and in some cases to trauma and PTSD.
link |
We also touched on a large variety of approaches
link |
to dealing with fear, trauma, and PTSD
link |
that currently exist in the clinical landscape out there.
link |
I also touched on some of the emerging themes.
link |
For instance, this short five-minute a day
link |
deliberate self-directed stress of any kind
link |
through respiration or other approaches
link |
of increasing adrenaline as an approach
link |
that might be viable, I should emphasize might be viable
link |
for enhancing the speed or the potency of treatments
link |
to reduce fear or eliminate trauma.
link |
Most important I believe is to understand
link |
and really think about the logical structure
link |
of the circuits that underlie fear and PTSD.
link |
Because in doing that, each of us, all of us
link |
can think about what sorts of treatments and approaches
link |
make the most sense for them.
link |
I also hope that it will help people
link |
lean into certain practices involving re-exposure,
link |
provided that's done in a supportive environment,
link |
re-exposure to a given traumatic event
link |
in an attempt to extinguish that.
link |
Obviously you want to do that safely,
link |
meaning psychologically safely and physically safely.
link |
There are great practitioners out there
link |
that can help you with that work.
link |
There are also a number of people out there,
link |
I am certain, that are carrying certain traumas
link |
or certain fears that they would like to alleviate
link |
that are not in the extreme clinical realm.
link |
And that's the reason why I touched on a number of things,
link |
including some self-directed practices
link |
that might be useful and reasonable for them to explore.
link |
I realize we covered a lot of information today.
link |
If you're enjoying and or learning from this podcast
link |
and you're not traumatized
link |
by the amount of information covered,
link |
please subscribe to our YouTube channel.
link |
That's a terrific zero cost way to support us.
link |
In addition, please subscribe to the podcast
link |
on Apple and Spotify.
link |
And on Apple, you have the opportunity
link |
to leave us up to a five-star review.
link |
If you have suggestions of guests
link |
you'd like us to host on the podcast,
link |
or you have topics that you'd like us to cover,
link |
please put that in the comment section on YouTube.
link |
Also, please check out the sponsors that we mentioned
link |
at the beginning of this episode.
link |
That's a terrific way to support us.
link |
We also have a Patreon, it's patreon.com
link |
slash Andrew Huberman,
link |
and there you can support this podcast
link |
at any level that you like.
link |
On this podcast episode
link |
and in many previous podcast episodes,
link |
I describe supplements.
link |
While supplements aren't necessary
link |
and perhaps aren't right for everybody,
link |
many people derive great benefit from supplements.
link |
It is important, however,
link |
that if you're going to use supplements,
link |
that they be a very high quality
link |
and that you can trust that the amounts of supplement
link |
listed on the supplement bottle
link |
are actually what's contained in the bottle.
link |
It's a serious issue with a lot of supplements out there.
link |
For that reason, we partner with Thorne, T-H-O-R-I-N-E,
link |
because Thorne has the highest levels of stringency
link |
with respect to the quality of their supplements
link |
and the amounts of the supplements listed on the bottle
link |
are actually what are contained in the bottle.
link |
They've partnered with all the major sports teams
link |
as well as the Mayo Clinic,
link |
so we have a very high degree of trust with Thorne products.
link |
If you want to see the Thorne products that I take,
link |
you can go to thorne.com
link |
slash the letter U slash Huberman,
link |
and there you can see the supplements that I take.
link |
You can get 20% off any of those supplements,
link |
and if you navigate deeper into the Thorne site
link |
through that portal, thorne.com slash U slash Huberman,
link |
you can also get 20% off any of the other supplements
link |
that Thorne makes.
link |
If you're not already following Huberman Lab
link |
on Twitter and Instagram,
link |
there I do short neuroscience tutorials,
link |
I offer a lot of tools,
link |
oftentimes that don't overlap
link |
with the content of the podcast.
link |
And last but not least,
link |
thank you for your interest in science.
link |
I'll see you in the next one.