Dr. Victor Carrión: How to Heal From Post-Traumatic Stress Disorder (PTSD)
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Welcome to the huberman lab podcast, where we discuss science and science space tools for everyday life. I Andrew huberman, and i'm a professor of newbie logy and optio logy at stanford school of medicine. My guess today is doctor Victor carrion.

Doctor Victor carrion is a professor and the vice chair of psychiatry and behavioral sciences at stanford university school of medicine. He is one of the world's foremost experts on post traumatic stress disorder, in particular the treatment of post traumatic stress disorder in children in adolescence. Although his knowledge and today's discussion certainly extends to adult P T, S, D.

As well, doctor carreon is also the director of the stanford d early live stress and resilience ts program. In today's discussion focuses on the psychological and the neurobiological underpinnings of P T S D and which treatments are most effective for ptsd. We focus heavily on a particular therapy called q center therapy that was developed by doctor carreon and colleagues that has been shown to offset the triggering by words or events or memories that often are the precursors to P T, S.

T. episodes. And this has been shown to be effective in both children and adults. Today's discussion explores the difference between anxiety, stress and trauma. We talk about how those things, of course, are related, but how they can be separated out to Better understand if indeed somebody has trauma, and how to best approach the treatment of that trauma.

As you'll soon see, what makes the Carriers work so unique is that IT combines the psychological, the neurobiological, but also practical tools such as mindfulness. IT relates mindfulness and cardinal behavioral therapy to the underlying biology. And what's known about the psychic and psychology ptsd at its different stages, depending on the trauma, the age of the person at seta today, dr.

r. Carrion clearly explains all of that, so that by the end of today's conversation, you really understand what P T, S, D is and is not. And of course, the best ways to treat IT.

Before you begin, i'd like emphasize that this podcast is separate from my and researchers at stanford. IT is, however, part of my desired effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, i'd like to thank sponsors of today's podcast.

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Again, that's waking up dot com slash huberman to access a free thirty day trial. And now for my discussion with doctor vitor carrion, doctor Victor, Carry on. welcome.

Thank you. Thank you so much for having me.

I'd like to talk today about P T S D post traumatic s stress disorder, in particular in Young people, but also in adults. But before we do that, can you educate us on the definition of stress and maybe distinguished between short term stress and long term stress? And then perhaps we can segway into ptsd.

That's a very good way of starting, because in reality, my main interests was the role of stress and the role of stressors and how stressful really would activate the gene, make up and make us vulnerable to things that we might be vulnerable. Um but at the time when I was training everything, psychiatry as a fuel was very diagnosis space. So you needed an anchor.

And hence I use b tsd to communicate what I was really referring to. But the reality is that the experience of stress, as we now know, is a spectrum from beneficial to not beneficial to traumatic. So IT really stress Operates in our lives as and inverted, you shape, curve.

The more stress we have, the Better we perform, the Better we do. If we don't care about that exam that we're gonna have tomorrow, we will probably fail. So it's good to be someone stress right back sees are is stress in the system.

So um we'll talk about this, I hope, but i'm very concerned all about the overprotection of kids to to protect them from any type of stress because IT is through this experience of early stress that of us develop our problem solving abilities and we become aware of our coping mechanisms. We become aware of our support system. How can I manage that stress? And we can we can manage stress because in the same way that through the process of homeostasis we progress um we have a range of temperatures writing, which we can live the same thing with stress.

We can actually cope up to a certain point after a certain point is not homeostatic anymore. And IT turn turns into what we go out of status when when he really starts having a psychological cost to the body. So in that inverted you shape curve, there's that optimal point. Or your health, your happiness, your performance, everything is Better because of the stress you've been having. But after that optimal point, all of those outcomes, health performance start to decline, happiness starts to decline.

And IT is seen that second part of the curve where we find traumatic stress, traumatic stress being a type of stress that is not only something you have to cope with, but IT actually puts your physical integrity in your party, is a threat and and you have to manage that. And when you experience traumatic stress, many outcomes are possible. When is that? You're resilient.

And we'll tell a little bit about that as well, I hope. Um but another one is that you may develop symptoms of posta metics stress disorder. And the reason that I didn't anchor on the diagnosis right away from the outset and I was interested in uh studying stressors is because many kids we were seeing many kids that, that had symptoms of P T S D.

Without having the diagnosis that we're demonstrating functionally impairment. So they were not doing well in school. They were not doing well with their relationships.

They were experiencing distress, right? So their function was affected yet they didn't have the diagnosis. So the diagnosis is is good and that is there.

And I need IT is a behavioral al definition that we can anger. But but there's more nuance to that. So then that that chose the whole, the whole spectrum.

Of course, we can come out of P, T, S, D, and we can go back to that optimal point. So we don't want to get rid of stress, but we just want to return to that optimal point. And treatment is is available and and people can recover from P, T, S, D, and specially kids can recover from P, T, S, D.

But there's one thing that really gets in the way, and that's something that in my team we call, we have a phrase that we say P, T, S D feed on avoidance. If we pretend that something that didn't happen. If we pretend that IT will go away, if we pretend that treatment and is not necessary, then that that when he gets complicated and he gets complicated with a substance abuse, he gets complicated with self injurious behaviors, and then at that point, IT becomes harder to treat.

Is IT also possible that P T S D gets worse? If we tend to look at IT over and over again, ruminate on IT in the absence of any structured clinical support, meaning if people perseverate on their traumas, can the negative impact of those traumas actually um root deeper into us? Is interesting .

that you used the were perseverate because one of the characteristics s of trauma when IT affects children is that IT robs them from play. Play is something that essential in development, is how we grow socially, emotionally, physically. But when play becomes dramatic, play IT becomes no joyful m but IT becomes perseverance and repetitive.

This is the attempt of the individual to try to make sense of what happened. And the reason why is not good to be alone with IT and kind of perseverate on IT by oneself is that we're probably not looking at the right insult. So in our experience are usually petish ity doesn't resolve from that one traumatic event.

We all Carry a backpack and we can all Carry the oldest stressors that have come our way, like we were saying before. But if you're five, six, seven years old and that backpack gets really heavy, you can fall backwards. And when you fall backwards, that's because you don't have the tools really to Carry that.

But what i'm saying is that, that IT is the accumulation of stressors. Some of wish may be traumatic that cause the symptoms of P D S C. So for example, um some of us went to hate after an earthquake, right? And I was starting my program at that time.

I was very Young, all ready to talk about earthquakes and know everything about earthquakes. IT was the last thing they wanted to talk about. They saw the earthquake as an opportunity to talk about the violence they had been experiencing, the poverty, the lack of education. So they were talking to me about everything they were Carrying that lets some of them to develop symptoms of P, T, S, D.

I see, as you describe, these other aspects of one's life that can have negative impact, poverty, violence. That said, a um I get the impression that ptsd can be caused by a single event or trauma, but that there's a cumulative aspect to IT. So is that the case that in children, because their brain is far more plastic, we know this brain circuits are modified even by passive experience. In childhood were as adult, t IT requires focus attention in order to learn, unless it's a negative event, for Better or worse, that in kids, IT takes far fewer or less intense negative experiences in order to create P, T, S, D, because the brain is so plastic. Or is there a similarity between youth and adult ptsd?

Pd, equal studies, your assertion. Children, we think we, we usually know one line that I really don't like is children are resilient. And because children are really not they're more vulnerable. They have the opportunity to become resilience ent if we help them and we tell them what tools to use and how to develop and all of that, but they are more vulnerable to be tsd and part of IT might be that neural blasts city and and this is why we care for them, right? This is why we protect them and give them safety because they are vulnerable.

Um by the same token, that meal plasticity can work both ways because if P T S D is teaching us that the environment can have an impact on biology, that's the only lesson right environment can have an impact. Biology in P T S D is a negative impact because of a negative stress or accumulation of stressors. But that also means that if the impact is positive, as in a good supportive system or as in psychotherapy, that recovery can actually happen in an easier way.

Before we talk about theriot interventions, i'm curious about genetic previous position and topic that comes up a lot anytime the the letters ptsd are stated in that order um is trans generation trauma. I can imagine at least two forms of trans generational trauma.

One is a generation of what are now grandparents or great grandparents or parents are impacted by some trauma if they're in the family or maybe in culture or you know even broader scale. And then discussions about that pass through generations impact the children, and therefore their adult life. I could also imagine, and I think this is Normally what people are referring to when they talk about trans generational trauma.

This idea that somehow the genome is modified by the trauma, such that even if kids are raised by parents that dopted them, or they have no contact with the grandparents or a great grandparents that experiences the trauma, but somehow they are more vulnerable to, or in some cases, the idea has been put forward, Carry that trauma in air quotes such that their life is more difficile, even though they never had a direct experience of that trauma. What are your thoughts about trans generational passage of trauma? Both forms, both the narrative passage as well as the potential for epi, genomic or genomic passage of trace generation.

This a very interesting subject. The jury is still out if genomic changes that resolved as a consequence of stress can be passed from one generation to the other. But certainly the genes that made one generation vulnerable are being passed to the next generation as well that we know so IT can be passed that way.

Um but what happens is that there's also this impact of learning. And I have treated kids that come to me with all of the symptoms of P, T, S, D. And there's no trauma. I cannot find the trauma and the parent cannot find the trauma. And the kid was then reported trauma, but when i'm talking with the parent, the trauma becomes evident in the history of the parent.

So the parent has developed petie sly and behaves in a way that has been learned by the new generation, always like Aidance, or the experience, or hyper violence, or lack of trust, you know, things like that. So certainly there are pathways in which you can go from one generation to the other. And and we know that the battle between nature and nature is pretty much over, right? We know that that they both influence vulnerability and that they both interact. And I imagine that's what's happening in in some of these situations .

in terms of stress, you always think of stress as both a response within the brain and a response within the body. And are not alone in that belief that I think we know that a drennan epinephrine is released from the apronless, but also from areas of the brain like los ruiz, so that there's this parallel effect of elevated states of mine, more alert, more focused on locations in space and time. And the body is also prepared for action.

I think this is what undersized, the increase heart rate, the shaking. In some cases, sweating is essentially a preparation for action. With ptsd, I often hear that some of the symptoms are more of the opposite end of the spectrum in terms of automation, ic, sal, my things like association, fatigue, kind of checking out, which I realizes, association, but things that are, are more keen to kind of paris sympathetic, right?

For those that don't know the sympathetic, sympathetic represents the continue of authority and interaction. Sympathetic, having nothing to do with emotional synthetic, all fighter flight type responses, although at lower levels, it's what's responsible for us being alert here but not in fighter flight, in per synthetic, being more of the rest and digest even leading into sleep type responses. So you know, if somebody experiences a big dresser, a trauma or chronic stress to the point where IT becomes P T S D, is there a tendency for them to be more hypervigilant, you know, start to response um to I have their head on a swim all the time looking for danger or to be more society or kind, both sets of final types exist in the same person.

Yeah no, this is very interesting. What we're talking about the letter is, let me say that a lot of people called matic express disorder, problematic stress injury, not considering IT is the soda, but considering IT something that where are fight or flight mechanism and the autonomic nervous system has been the sensitive and we need to regulate IT again ah and it's gonna hurt it's gonna painful is just like when you break your arms and go to the emergency room and IT hurts to be placed back in place, what is the cure is what cure said. So a lot of people visualized and sometimes how you do as an injury rather than as the .

holder post traumatic stress injury .

injury and and so what happened? So these autonomic system gets activated, we have our fighter flight reaction. But what happens to a Young kid because they're very little and they cannot fight.

They're also very dependent and they cannot fly. So there's stuck. There's talk there. So they freeze, they freeze. And this association is actually during development a healthy um defense mechanism, but very much like a White blood cell. That's very helpful. If you have too much of IT you develop a lukie a you can develop associative disorders if that's the only thing you have.

But he does help children cope with some of these situations, pretending this is not real or this is not happening to me is the only thing they have left um and because this arts of system is so key in the development of of this children um I thought that we should look at the hormone cortisol in in in the kids and and when I started, when I was fellow doing my shelf a GTI fellowship, I was seeing all types of kids with all kinds of issues. Uh, some had A D H D, some had O C D, some had P D S D symptoms. But I was getting a lot of kids with notes are from school saying this kid has A D H D place place on real land, right a stimulant medication.

And i'm like wild diagnosis has been made. There's so already a treatment plan. What am I training here for? Um bad in some instances they were right.

You know, all the kids had a hd, but in most cases, what happened is that that hypervigiLance that you are talking about was being misinterpreted as hyperactivity, and the association was being misinterpreted as inattentiveness. So the kids were getting a diagnosis that was not correct. Of course, there are other very complex cases where you have both A D H D and P D H D.

Also, A D H D can put you at risk to develop P D S D because you are not as attentive as to what's happening in your environment. But there are definitely two different conditions. And and IT was that clinical observation that made me think, well, people are know enough of our P, T, S, D, and certainly they don't know enough B, T, S, D in children. And we were having some research in adult around that time in terms of cortisol levels. They ve had people who you've had here, racial, yahoo, the bronze V A, looking at P, T, S D in adults.

But I said, but how does P T S D look early on what's happening in the hypothalamic peut aria reno access that is responsible for secreting cortisol and regulate cortisol, uh, when these children are Young, because this is a new access, is, is, is IT already not working, or is IT working right? And so we did a number of studies that demonstrated that the Normal are candian with messy of cortisol. What's there? IT is higher and early in the morning, which we need to join by to bed.

And as the day progresses, IT decreases. A very helpful IT goes up when we are stress, like when we have lunch after we have lunch or so goes up, right? So that weekend help manage the insole digest or whatever.

Um on this kids were having those levels, but something was happening in a number of studies and we noted that the prefet time level was higher. We are measuring IT at different times, are in the morning, free breakfast, free launch for dinner, prepare time. But he was a preset time level that wouldn't come as low as the healthy controls IT would remain high. And this was also important clinically because many of the symptoms of these kids we're having, we're happening at night, any races, right? But wedding nightmares, not sleeping deep enough, not sleeping long enough.

Um fears at that point, I felt a well, we don't know anything other than the court is not prepared, time is alleviated, right? Maybe they needed to be who knows ah but I was concerned about the work by sample ski right and Bruce mccue, his mentor, demonstrating the annual toxic that local cortical s can have in key areas of the brain areas in the olympic system, on the cortical system or uh which interestingly now have a lot of global cortical receptors. So then are we decided to look at brain structure and brain function in youth with P, T, S, the symptoms, and see how this cortisol would relate to that or not. And we did that through M R, I. Magnetic recent imaging.

Let's talk about quarters all for a moment. It's a topic that has not received enough attention in previous episode of the podcast. I'm just going to summarize a little bit of what you said, and you'll tell me where i'm wrong.

Court is all starts to rise just before we wake up in the morning, assuming a good night, night sleep and peaks of maybe out on a thirty and ninety minutes after waking for you, slow rises like me, probably little delayed, by the way, the height of that peak and the accelerate the I was say the steepness ss of the curve can be uh increased uh, by viewing morning sunlight. We know this bright light increases that course alp make you a Better early rider. But in any case, typically the pattern then is that IT rises through midmorning and into the early afternoon and then starts to taper off to lower levels.

And as you mention, will see bumps in court is all post meal. If there's a dresser, we get a disturbing text, we get a bump in court is all. But these aren't huge peaks unless it's a big stressor. correct. And then by evening, cortisol levels in healthy individuals are typically low, and that allows for transition into sleep, among other things, out for transition and to sleep. But you said in these kids with P, T, S, D, cortisol doesn't come down to low levels as much as IT does in healthy individuals are in the evening in nighttime and that imagine would lead to perseverate on stressors from the day this kid was mean, I have a test tomorrow maybe any dresser becomes more um intense in our mind and body as IT were um and that perhaps could lead to issues with quality or duration of sleep, which then could perpetuate this cycle.

Do I have that? correct? correct. okay.

So um has the direct intervention of just trying to suppress evening cortisol ever been done? You I mean, certainly there are a drugs that will do this. Has that approach ever been taken?

I thought about that when I had those high levels, but I I felt that we needed to understand Better. I I think I think, yes, that there were some attempts with some medications.

And I I don't think that LED to anything are in terms of over helping those kids um or just helping individuals in general and high levels of cortisol because of uh, traumatic stress um but night time, you're right, IT is a time when basically we fall asleep because we let IT go and and this kids hyper responsibility does not allow them to let IT go um so if these levels are high, as I was finding in a what impact are they having in brain development? And usually the Younger you are, the more univerSally distributed receptor. sorry. So gb tico receptors could be anywhere at that point. But as as we age, uh they become more localize and the courtesy receptors and cortisol is a type of um are more common in areas like they have a campus and the prefrontal of cortex, which I also found interesting because these areas relate to the symptoms right that that many individuals with .

ptsd have memory, anticipation of the future problem solving, context dependent problems solving so on .

and even those attention issues that make them overlap with. It's that have A D H D as well. Um so this front of limbic pathway, they be front of quarters communicating with this emotional areas of the brain, including the mic dollar, which is very close to the hyper campus. Um needed to be investigated in in in pediatric P T S D.

And what are you someone to go? Pediatric P T S says because post robotics are symptoms because as I mention there's a group of kids that half of strom tic symptoms do not fulfill criteria for D S M five P T S D, but their function continues to be in air sometimes that's because um of comparability. There's a high incidence of commodity with anxious and depression. So most of our studies that have look at P, D, S, the symptoms also look at the impact of the interventions that we are doing, an anxiety and depression as well.

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I definitely want to get into some of those interventions, including some of the ones that you've developed that are very novel and are um being used to great success. Um I want to just circle back for a moment this relationship between P T S D and in some cases inappropriate diagnosis of A D H D. As you mention these two things can co exist in the same person um so we don't want anyone who has been told that they have adhd um N P T S D or even just D H D to immediately assumed that that diagnosis is wrong based on what we're going to talk about but IT is possible um that the add that a child told they have is reflective of P T S D.

And I imagine that if that P T S D arises through something in the family structure or dynamic IT would be even harder to unmask because the parent perhaps would be less motivated to try try to understand that if they played some sort of role in IT. So realized this is a complex problem with a lot of layers. But um if you were to just throw out a number based on your experience, what percentage of pure A D H D.

Diagnosis would you like to see explored for the possibility of A P, T, S, D influences? Let's just keep IT kind of diplomatic that way. I supposed to saying, what percentage of adhd do you think is actually ptsd?

I firmly believe that D H D does exist. Um i'm i'm going to say two facts that we know in the field. One are kids getting overmedicated. The answer is a clear yet they are getting more medications that they need for for for anything in general. Kids now N A D H D, they're getting overmedicated, so that's the second fact.

So the first one is that if we look at kids overall in the field of mental health, those that managed to receive treatment, which access is something else we should talk about because like fifty percent of them do not get access to mental hel services. Um those that managed to get IT may end up with the appropriate treatment right and medication or a psychotherapy, but there's another subset of them that will be medicated no matter what they present with because they need to be seen fast or is a fast solution. So there are many reasons for that.

But are kids getting over medicated? yes. But within those kids, those that truly have attention deficit hyperactivity disorder are getting overmedicated. And that's because of that access issue because most of them were not identifying. And that's a pity because the first line of intervention for adhd is stimulant treatment.

IT does work and IT works very well uh for children that have the correct diagnosis but the first line of intervention for children that have a history of P T S D B acute or chronic. It's psychosocial, is a psychosocial intervention. So if you give a kid that has B, T, S, D and no ideas, the it's stimulant medication.

Not only is not taking care of the eagles, I don't have IT, but he adds to that hybridity. You know, that is manifested there from before. By the way, there are clinical ways of separating hyperactivity from this hyperactivity and hyper violence hyperactivity of, you see a kid that is not medicated and I has A D H D.

And they have the hyperactive symptoms and the hyperactive type. You're going na be hyperactive for most of the time that you are with them. The kid that has hypersensitive site, you will be more of an on and off phenomenon.

The the hyper violence and hyper ability comes more when they are presented with A Q that consciously or unconsciously reminds the body of the traumatic event or the traumatic experiences. Um what happens though is that usually we don't know what those cues are, right? So we just see a kid that's paradisal becomes um hyper violent or hyper aroused.

And then the other thing is, is hyper violence something that needs to be treated? You know, I learned this from a mother early in my career. She's like, I was giving some talk in the community and he came to me afterwards.

San said, listen, um we live in a tree that's very dark and he is very dangerous and my kid has to pass through that every day. I want him to be hyper violent. And if he has developed this trait of hyper violence, this is something that could be helpful to him.

And I said, you're right I said you're right is not only to him, to a lot of people, IT could become very helpful to be hyper visual and to assess the environment in which they're in. So the problem is not the hypervigiLance. The problem is knowing when to turn that on and when to turn that off, having the cognitive flexibility, right, to be able to say, yes, this is a dangerous situation.

And I Better respond this way if if I can give you an example of of of a kid, right? A kid that experiences domestic violence and has associated that with noise in the in the house learns that running and getting into the room is a safe thing for them because they're out of the picture, right? And they protect themselves in the room.

But a year later, they are in the classroom. And for some reason, the classroom gets this level of noise, the body without him knowing, right? The body reacts by the response.

That was helpful. This is classical conditioning, right? So he runs out of the classroom, but he's missing the context. The teacher is missing the context.

When the teacher sends him to the principles office, the principal doesn't have the context right, that this response was actually adaptive at one point and helpful at one point, and the body has had a hard time. Letting IT go to ask that kid to give us the only response that he has is not the way to help him. We need to help you develop new competitive responses so that the experience of the other responses then extinguish that response. That was adaptive at one point, but now is more adaptive, by the way, is the in its traumatic sy twice again, we still want them to use. We still want them to run and get out of there in spite of that hyper vision that does protecting them in a way it's .

so interesting. You said, if I understood correctly, that in kids with genuine add, the hyperactivity is fairly persistent across environments and with different people. That said, a.

i'm sure to everybody, if I could add, the attention comes and goes because we all know is that have idea that you give them the right video game, all of us said, and they have become attentive, right?

This is a very important point. When I did the solo episode on A D H D, I was um Frankly shocked to learn but I was validate by the literature and certainly by the responses from the audience, that kids with A D H D and adults with A D H D for that matter absolutely have the ability to sharply attend to something if it's something that's very engaging to them, really exciting, something that they typically enjoy.

But their ability to directly maintain attention in other environments that are required for Normal life progression, school work relationships at a is very diminished compared to those without adhd. So what I have in my mind is a step function, meaning an increase in a steady state of hyperactivity in a kid with adhd, but then a jagged line beneath that of attention. This is, I believe, the picture were painting here, but that in ptsd, the hyperactivity is a jacket line IT really needs a queue, as you said, loud noise or maybe it's the presence of a particular voice.

I once attended a um a trauma IT wasn't trauma release as much as a genuine a trauma treatment center out in florida? Front of mine runs the center and I was out there learning about the practices they use in order to in form potential uh experiments for intervention in my lab back at stanford and um and he said something really interesting. He said, you know, when you bring people in to the sort of environment and they they ve all had trauma, you see A A pretty rich ray of of responses to even just the same conversation.

And then at one point, perhaps because he said that I I noted that a woman raised her hand, and he said that particular timbers of voices in the room, we're really activating her. This was important. IT wasn't just what was being said.

IT wasn't that people were yelling at each other, or even the volume of the voices, but that even just the the frequency, the the loneness of the highness of the voice, as IT were, was trigger ing something in her brain that was giving her these bodily sensations. And IT was a very important insight for her to be able to then start to direct interventions. So I guess we all hear the kind of now stereotypical ple of, know, the veteran who experiences combat comes back and here's a car, backfire, then they hide, discover, we read about this and hear about this.

But IT seems like it's much more subber than that that sometimes accused for this hyperactivity. This hypervigiLance is very much link to something that sometimes, even the person with ptsd doesn't recognize until they start to be put into that environment again and again and then they can pinpoint IT. My question now is if they can pinpoint what the q is, do they stand a Better chance of recovery?

Um as opposed to somebody they are just like feels like i'm hyperactive, then i'm exhausted, i'm wired tired. And and now I also imagine that in kids they don't have necessarily the verb proficiency to be able to express what's going on for them. And in fact, many adults don't really know because we don't have a great language for expressing this body mind thing.

In any event, a lot of questions there. But what are your thoughts about the requirement for being able to understand what the cues, what the trigger are in order for child and or adult to be able to start to make inroads into their P. T. S. D?

First, a word on the vietnam am american, because there is a very important study that was both a years ago that demonstrated that those veterans that had a history of child maltreatment and went to war had P. T. S.

D. At higher prevalence than the ones that did not have a history of child male treatment. So child .

maltreatment, yeah, I see. So they were traumatized before they went to combat.

And and and maybe they did not develop p tis d. But once again, that point of the accumulation right of of the stressors at different times. And i'm just mentioning that because you may have a veteran and you're waiting to look at the classical cues were in fact in might be more like a voice, like the example that you were giving that triggers them what trigger on individual is very personal.

So cues are usually neutral, and they are usually related to our senses. And I know you like senses a lot. So what we see, what we here, you know, all of these things, the senses are really the the window to the central nervous system, right? This is how we get information the first time.

So in this state of hyper sbility, when something trauma tizer is happening, our senses are really, I could be aware of what's going on, and they are making sense of the insult, but they also are register ing everything that's related to that. So these cues usually are neutral, so they're not like a gun, for example, because a gun is not A Q, is a threatening, is a threat, right? But is usually a color.

So there was a red car park near where they were. So the color red, maybe A Q, maybe a trigger IT was raining the data that happens. So rain, maybe A Q, maybe a trigger.

And to answer your question, identifying those kills are important because they let you know when you're symptoms are coming. They let you know that they're not coming out of nowhere. They let you know that you're not a problem or that you're crazy or that you are bad, which is sometimes the messages that kids get when they go to that principle.

Soft, okay, but they let you know that they learn themselves. This is a Normal response, right? I've learned through mycal social intervention, i've learned that this is a cue that triggers a response from me, trigger a response that was helpful at one time, and through classical condition.

And we do teach classes condition into the kids. Those responses then become a and become condition, right? Uh, when the q is there, when the trigger that.

So yes, to answer your question, IT is important to know the cues now what happens. And we're gonna know all the cues, do everything to all of our behaviors. And this shift in mood that sometimes we have during the day, and we don't know why, right? No, the answer is no.

We're not gona, we're not gonna know all the accused. But the beauty of this is that if we can just learn about one or two or three years, what are responses? There's more of a forgiveness to ourselves in that when we responding appropriately, we can think, well, maybe I was exposed to a cute right, because i've learned all of this about cues and classical conditioning. Maybe that's what what's happening here.

Yeah, i'm thinking again about post traumatic stress injury. The reason I like that term, even though I realized i'm using IT non clinically, is that if we understand that the automatic nervous system, this sea sawing back in forth, or this push pull between the sympathetic fighter flight and paris sympathetic rest and digest, loosely speaking, systems, are always at play in us. When we sleep, more pair sympathetic.

When we're alert and calm, more sympathetic. And when we're stressed or having a panic attack, extremely sympathetic. If we understand that as a biological system, which IT is that deploys hormones in a shapes, our patterns of thinking and what's available to us in our memory.

then P T, S, I.

post traumatic stress injury, I, I feel like IT liberates us of IT to understand that you have, this automatic system has been disrupted in a way. And if I think about the automatic system as a cesar, which I often do, I think about the sea are having a pivot point with the, with a hinge.

It's almost like the post traumatic stress injury is to create the tendency for that hinge to be too tight, and sometimes that makes IT more like associated more exhausted and how to checked out. And maybe IT creates the hints to be too tights such that were more on the sympathetic, excuse me, that sympathetic the way for those listening i'm using my hands, but you don't want to see that to understand that the alerta system is locked in place. It's hard to get out of that.

And I almost feel like the injury that is post rama's stress injury is a tightening down of the hinge with the sea saw tilted too much to honor the other side. And as a biologist, I I just wish that we understood what that deregulation was or is chances are it's not one location in the brain or body. It's going to be a network phenomenon.

But um I feel like the word disorder the D N P T S D is so dal because IT highlights the importance and the pervasiveness of this thing but that the eye and post traumatic stress injury hopefully we will give people certainly is giving me some some sense of relief for liberty and understanding that these are nervous system injuries that need treatment and that there isn't something wrong or crazy with us because of because of the fact that we, you know, suddenly feel like we're having a antic attack. I've had people I know close in my life said i'm having a panic attack. What you mean? What happened? I like, nothing happened. That's the point.

Well, how do you sleep? Okay, you know, and you start doing the the curbside diagnosis that neither of us is qualified to do, right? But this is what we do is as caretakers for each other in our lives.

And IT very well could be that their audino ic system just got that hint, just just locked in place for whatever reason. Maybe it's one step too much of coffee. Maybe it's one sip too little.

It's probably something or a bunch of things. Does my I realized him getting outside my expertise because i'm not a clinician. But I feel like this P. T S, I think is, is, is sticky and important for for people to hear about IT certainly changing the way .

that I think about P, T, S, D. Yes, no. And I like the variation of your, see.

So in the example of the hinge, because IT IT IT reminds me of that cognitive flexibility, right? Is not there is kind of stuck. It's kind of tight, too tight.

And and in some individuals, they just experiences the association. They're like stock. And on the bottom right thing, on the bottom of the wherefor, the other individuals are hyper house all the time. Then you have everything in between. But but now IT does a very good representation of IT.

and I feel like a good .

night's sleep allows .

some recollections of the tightness of that. inge. Put differently, any time we don't sleep well or long enough, we're not good psychologically. A good .

night's leave is good for everything.

We're finally at the point history where we where everyone seems to accept that I really have to tip my hat to doctor Matthew Walker from U. C. Berkeley for writing the book why we sleep.

And there was only a few years ago that book came out. And he deserves such a token of praise for that because prior to that, there was this all sleep when i'm dead mentality. I I think people knew sleeve was important but they didn't really understand.

And he had to come out as kind of the um kind of the downer message like, listen, you know this is serious stuff left you Better sleep. But I think we're there now. I think in in twenty twenty four where there, I think people understand .

and I think people have their own experiences with sleep, right? We've all felt that cold that's coming. And and if we really sleep those eight hours, we may be able to fight in because we've strengthened our immune system. If we don't, we will get sick.

Yeah, absolutely. Well, let's talk about some of the treatments that you use and have developed for P, T, S, D. And Young people. And maybe we should define Young people. Are we talking about you have the eighteen and under just because that's .

typically what we think about. So in pediatric psychiatry, we have three different populations. We have the Price scholars, we have school age and we have the teenagers, and they're all very different.

There all have responses and defenses that are very different. The projects that i'm describing happen mostly with the school age, school age children. So high .

schoolers are going to be essentially, I think, of kindergarten starting at five. So we turned about zero more to to more less five or six years old as the preschoolers, kidders, gardeners and then transition point, right? And then for the kids were about to talk about really talking about what's six years old until about and of at the lessons.

Yeah, fifteen and and and then yeah, then the teenagers later on. okay. So I worked mostly with the school, this college kids, and like I said, when we started doing magnetic resonance imaging to look at the impact of cortisol, we have a number of studies really demonstrating that those kids with higher levels of cortisol had a less volume of the hypo campus.

That the first story that we did in that was section and there was no difference and he gave me A A lot of hope that there would be a window of opportunity there where we could intervene um because what we were seeing chronic pity as the in adults, was that there was a moderate volumes of the hyper campus which help us process memories and have strong connections with the emotional center of the reindeer migdalia and also with the prefrontal of protect and um and what what we found was that was sectioned that was not this difference but we also follow a small sample unutterable and there we saw a correlation between that higher private time cortisol and the smaller hua, ample volume uh more impact of was a functional imaging study. Uh as as many of your audience members know, with magnificent imaging, we not only can look at the structure, but we can also give tasks uh of memory, for example, or of executive function on different tasks that tap at the at the areas that we are interested in looking. Uh so when we look uh when we give a memory task and we looked at how children with bostrom tics for a symptoms were behaving compared to kids that do not have symptoms or others, I agree, diagnosis, we were seeing that the healthy kids were activating a lot of more boxell or units of the imaging of the of the hao campus.

So so there was concern here that yes, that plastically that you talked at the beginning was really affecting the development of the brain of the kids. And then with the prefrontal of cortex, we saw something uh similar in the um venturo media area of the prefrontal cortex. So but with other tasks, writing with tasks of executive function or or text of emotion. Looking at faces, for example, emotional faces, all of this to say that they probably have about functioning front striata pathway and front olympic. So front olympic, i'm sorry.

So um if we think of the amic della, for example, close proximity mity to the apple campus being involved in these hyper visuals, and we have some data to show that the amec dollar becomes active very quickly when you present emotional faces uh to Young kids um and that that hyperactive migdalia needs a uh a break of some sort that break comes from the street front til cortex. But if you have a free front of core tex that's not working that well either, then your break is not working right? So so then the issue came here.

Well, this is important information to know what we need to target with treatment. And can we target this with psychosocial interventions and the way that we provide treatment? And we decided to begin with what we discuss earlier with the cues, right? And teaching and having kids understand what kids are.

What about conditioning is um talking to them about the impact of drama? A talking to them about the impact of treatment and how recovery is possible, right? So an educational and educational peace, and something that I never thought I would end up doing was developing a treatment, right? I felt i'm here to investigate and use the treatments that we have.

But he became very clear to me that there were a population of kids that still needed a form of treatment that was not out there. So most treatments out there for trauma were targeting one traumatic event and not targeting that backpack. That all the study glowed also unripe fully. So most treatments were um requiring that their parents were involved in treatment as well.

I can see where that might be problematic when the parents perhaps were the source of .

the trauma and also when there is avoids, right I know when there's practicalities that they lose one day from work, they're onna get fired. So so sometimes the friends are just not available and the kids are totally ready to begin and do the work I wanted them to be able to do so.

So how can we devise a treatment that is hybrid? And by that, I mean multiple model that is not only cognitive behavioral therapy that IT brings all their elements that are important, like self efficacy and power man inside oriented work, and give IT a structure that I can be tested. And that's how we created q senta Q B C U E Q cental therapy for kids that have P T S D.

And we've had a number of trials with them. I need IT helps decrease symptoms of anxiety, symptoms of depression and symptoms of petsy. And not only as score by the student bottles, scorer by observers, by their parents.

And in one of the trials where we make sure actually how the parents were doing, parents that we're not participating in treatment, their own anxiety was decreasing as well. And that is he to understand, right? If your kid is doing Better, you're gna do Better as well.

Um so so that was very, very good to see, but then we wanted to see that last ticket too. Is this doing something to the activation of the brain? And that's when we brought functional nearing for red spectroscopy into the picture because it's cheaper than in marian is more portable. And ca to do IT only gives you a cortical and information he doesn't get into those interesting .

limb structures. So it's um just to just highlights process at the fmr functional magnetic resonance imaging is wonderful because IT allows a lot of um could imagine both on the superficial outer parts of the brain but also deep into the brain. My understanding is that and perhaps this is change in in recent years, that the space al resolution can be very good.

You can pinpoint very small areas if you have a powerful enough machine magnet. The temporal resolution, the ability to see changes in the neural circuit activation and the activation over time at one point was somewhat limited. But now some of those limitations have been overcome.

But then what you're talking about, near infrared spectroscopy is excEllent because IT can be taken to a school. You don't have to you couldn't bring enough mi machine to a school unless it's a medical school where there's the machine um is much less expensive. The downside is oh, excuse me, and my understanding is that the spatial resolution isn't quite as high as that.

The temporal .

resolution is very high, which is a huge advantage. And then there's this one disadventure ge, that you can only really image the outer portion of the brain, but none. There's there's a lot of information there. So a little technical lesson.

And the outside areas of the brain cortical area in the front, we're helping predict wis kids would do Better only for those kids that were having q center therapy and another gold standard treatment called trauma focus cognitive behavioral therapy when they were both compared to treatment. As usual.

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Slash huberman functions currently has a weight list of over two hundred and fifty thousand people, but they're offering early access to huberman lab listeners. Again, that's function health outcomes slash huberman in to get early access to function. I want to get into the q center therapy versus cognitive behavioral versus the no therapy conditions you just described. But before we do that, I just want to have a brief discussion about some of the neuroscience you mentioned because I think people will find this very interesting and certainly not just a listing off of names of structures. You said that the front olympic c pathway is important here, the limbic pathway, including the middle of other structures as well.

And my understanding, and I think that generally accepted understanding about these olympic pathways is that they create a response state, a state of alertness, a state of relaxation, that they um translate certain information that in pinches on them into a level of reactivity, either low, medium, are very high when I say reactivity a tendency to move toward or away from something or stay still put in, broadly speaking. Now the front piece, the feed, the feeding in of information from the frontal cortex, where context dependent decision making, and as you said, executive function takes place, is so critical for all of us as we mature. Even as I would say, if you look at a puppy, everything's a stimulus and then over time, they're gonna pick up everything in the room that without question, largely due to the development of this front of olympic c pathways and in children and and in humans, that is, it's the same.

I imagine that the signals coming from the frontal pathway of the limmers system are going to be somewhat cyp tic to people that aren't familiar with psychiatry and neurology. So maybe we could just throw a few of those out there. Here's an example.

Tell me if i'm wrong. But the way I think about this is okay. A kid is in a room and they're hyperactive and um or maybe something set them off and are particularly vigilant and stressed.

They're in the stress response. The frontal cortex is the pathway by which an internal dialogue could be delivered to quit at that limbic pathway. The message that would perhaps trigger that would be the kid recognizing because they learned this is okay.

I ve had this happen before IT passes or i'm supported. There's doctor carreon, there's my mom, there's my dad, there's my teacher, there's my friend. I'm supported because we know social support is important or it's Normal to feel stress every once in a while. So these kinds of thoughts are these internal dialogues that were told that you should do for ourselves from more stressed. I think we can be pretty certain that that's the kind of information that would trigger this front .

of olympics suppression. And can I comment on that dialogue? Because all of those are examples of positive thoughts, right but thoughts that are good um but they're not automatic thoughts.

There are thoughts that need to be practiced right negative thoughts unfortunately, that residing a reptile brain our automatic so that hyper response, i'm in danger type of situation when we evolved right, is responsible for our survival. So we learn the negative thoughts very well. I'm in danger.

I have to run. I have to get on top of the tree. The lions might come, whatever.

So only fifty million years ago, when without the frontal cortex, more positive thoughts came into the picture. And they're very helpful for all the reasons you're mentioning, but they're not automatic. Like then I get these ones are hopefully they will become. So what I tell the kids is if if they don't play guitar, I give you a guitar right now, would you be able to play me a song?

Absolutely not. I have absolutely zero minus one musical ability, but I love music.

But if you, if I gave you a guitar with guitar lessons and you practice, you probably will be able to play along a year .

from now me with some degree of proficiency with but everybody else yes.

a support the .

support system that's right and with enough practice hours and enough focus and determination, i'm convinced I could become at least proficient um even at forty nine years of age so we have .

a slogan in in my team which is practice positive of thoughts, all the thought you were mentioning, our good ones, and we have to practice them right? This is what i'm learning now. I'm not bad. This is happening because of the queue.

Even when the olympics system is not active. Should do you encourage your patients to practice positive thing all the time, even when they're not in the stress response? All the interesting .

is like is learning tool. So in this q center thuy, one of the lessons is that they have an empty tool box, and and this tool box gets filled with tools that they learn and practicing positive thoughts, the breathing, mindfulness, all of these most relaxations our tools that we teach them. But they decide and here's where the empower ment comes in.

They decide what the cues are. They decide what tools are they are going to put into their toolbox or they are not going to put IT in the toolbox. And by far, whatever tools they develop that have not been taught by mayor, anybody else work Better when they developed themselves interest.

And you know, I I had this case once, and they go illustrated really well bit when I I was in in one of the sessions, you teach them breathing exercise, as most of relaxation, things that we know help. And i'll talk a little with more about how we know that they help and and then they have like a week to practice and then they come the next week and we see where they are and what's in the tool box and things like that. And the next week when when he came, he was much, much Better, you know and I said I was very proud.

And like you've been practice in the tools right with us last week and just I know I actually don't remember anything you you said last time, but I came up with this thing that when I feel bad, i'm drinking a glass of orange juice every time. And at that moment I know I could go both ways. I could go, no, no, you must practice might or I could say how wonderful 邮费 等着 a tool that helps you to drink a glass of foreign juice， which obviously is what I did. And then he was able to have that in her, in her toolbox. And, and we have multiple examples like this.

so he would drink a glass sive or shoes in order to quill her anxiety.

And is this something .

that he would do even when he wasn't feeling stressed? I mean, it's kind of interesting, but I D suggest and IT completely scores res with everything I understand about profondo cortical limb c pathways, which is that they're highly subject to contextual learning, right? If anything, the frontal cortex is this incredible feet of evolution that um allows us to link essentially any stimulus with any none learned response in the body. I mean, this is what allows you know, soldiers to learn to overcome their fear of bomb blast and run, told them if if necessary I mean that I can put both ways of course um but .

for me and this still needs to be tested, is is nothing necessary about the glass or even the orange or the vitamin see or anything like that? It's about the fact that SHE has this message, has sent a message to herself, I can take care of myself because the best tool that I have is me, is my own body. Whatever these kids go in the future, there's something that's always going to be there with them wishes themselves. So they as themselves is the best tool that can have know their body that the way they think all of these things.

do you think this is why we hear the kind of classic and edt about the patient who has anxiety attacks, whose psychiatrists gives them A A couple of pills of medication that can help produce anxiety, and they decide to keep those pills in their pocket should they have an anxiety attack. And knowing they have those pills in their pocket allows them to control their anxiety.

yes, because they IT gives them a sense of control, right? And and they have control over this. And some people may choose to leave them in the fridge and some people may choose to put them elsewhere. But is what they decide is that decision they are making that gives them a sense of control that's important.

It's so interesting, the sense of agency in control over the non negotiable stress response I sometimes unfortunately get um in my opinion, incorrectly attach to ice baths. We have talked about cold water exposure on this pocket. Our colleague e heller at stanford, departmental of biology, phenomenal scientists, was on this podcast.

We talked about some of the beneficial uses of deliberate code exposure. There are a lot of arguments, does IT increase metabolic, doesn't seem like IT, does not very much, is IT useful for inflation tion perhaps. Um but the one thing that everyone agrees is that being in uncomfortable ly cold water makes you breathe fact faster, excuse me, and stress a bit.

In other words, that kinds socks it's uncomfortable. And I think one non negotiable fact about deliberate cold exposures that IT gives people an opportunity to explore their own stressed response if they're going to do IT safely, right? You take a cold shower, you have some control.

You can get out immediately. Obviously, you don't want IT so cold that you give yourself cardiac arrest, and you have to be careful with deliberate code exposure. But the adjournment in response to uncomfortable cold is non negotiable.

And I believe that whether not somebody decides to recite the alphabet or think about how cold IT is or whatever IT is, what they're doing is they are practicing this frontal control over olympic pathways. It's just sort of a general exercise for controlling olympic system through thought. But as our colleague David speel has said to me many times, he says, you know, it's not just the state that you're in here.

We're talking about stress as the state is how you got there. And in particular, did you have any control over how you got there and whether not you can get out? And I think that the kind of stress that you're talking about in post traumatic s dress disorder or in post traumatic stress injury is typically of the sort that people didn't have a choice. Certainly, these kids didn't have a choice about the initial exposure to the trauma stresses but that also the stress is showing up when they would least want IT to appear or when it's very inconvenient to appear.

So this this narrative is important is an important part of a recovery. Um but we feel feel that he needs to come after the education piece and after learning A A tool x having defenses because sometimes you can get very charge when you go through the narrative and you want to assess many things during the iraq. If you want to assess gaps of memory, you want to assess potential cues, you want to assess the emotions that are present.

So an and arrays should be one that cover is not only negative events, but also neutral ones and also positive events. And IT sounds like a lot right. But when you're talking about kids that have ten, eleven, twelve years, IT is doable. You know, you can really manage, by the way, with the cold showers, I I think you're get into the hinch of the sea. So I I think the cold shower probably does not the shower, what you IT could be from cold shower.

I always say that because often down to people think, oh, you know there just trying to sell cold plunges in the truth is you don't need that. I mean, the fact of the matter is, uh, is a independent of income actually, a cold shower will save you money on your heating bill. I'm not saying everyone should take a cold shower.

I I love a nice warm or hot shower. I sometimes use the cold shower as estimates, and I hate IT every time, but I always learn something each time. By the way, that feels great when you get out. So that's nice and IT does for many hours, especially if you end up with some warm water.

But the uh the learning, I believe, is in recognizing just how destabilized our patterns of thinking get when we have a journey in our body, which is what uncomfortable code does and IT deploys that a gentleman in the brain and body and IT also is a great learning. And seeing the return to a baseline, just seeing how that affects our psychology. And I to my mind, I can think of no other zero cost or even negative cost, meaning saves money approach that works the first time in every time.

You know that is safe enough, right? I mean, i'm not interested in anything that has to do with snakes. For instance, I don't mind spiders.

I'll pick up with my hands as long as it's not a black widow or a particularly large spider. And I put IT outside. But I don't like snakes and like thinking about, I like being near them. So you know, there are other stressors that one could use, but it's so individual where as cold water seems to be pretty uncomfortable for everybody.

I think you need some exposure of snakes in your cold.

No interest is so interesting. You know, these things get so firmly rooted. But i'd love to talk about this toolbox because, first of all, it's according to your work and this has been done repeatedly.

It's very effective. And I I love the idea that I can be customized. So the words that come to mind is a customized tool box for combatting stress and P T, S D. And the fact that can be customized and maybe even cover like we can have these tools inside us, we don't need to share them with anybody if we don't want to, but that they are very effective. I think that those are very compelling reasons for expLoring the the toolbox approach a bit more here. So you mentioned one way to go about this is to think about, or to have in mind some negative, some neutral and some positive experiences, and then to think about the different tools that one would deploy under those different conditions.

correct? So, so the exercise of the events is a lifeline that we do separate from the tool box. We actually work on the tool box first to identify coping mechanisms and coping tools that help.

So what would that look like would say, i'm a nine year old, I come in your clinic and I meet the criteria for P S I or psd. Um what sorts of questions would .

you ask? yes. So the first thing I would say when you're feeling a sudden way whatever way we're talking about, right? And in ancient, is there anything that makes you feel Better? Because the experience of having something and they bringing something is important to and sometimes they do, they say I listen to music or I played the guitar or I go to play, or my friends, or my friends or my teammates .

mostly .

make pula. I love that. Yeah, there's something about sports. And and sports is something that comes up a lot when we do the toolbox people put in their sports they're doing or talking to their coach or talking to their teammates or learning a new sport. Uh, sports are big. So that's an example that they give a talking to friends um uh planning is Sally over uh listening to music.

Different things like this. Are there any particular tools for when kids are stuck in a stress response? Yes, because I myself am familiar with, you know, the tool kit that I use, certainly teammates is is one of them. And I have others, including long excel breathing, physiological size, these things will be familiar to some of the listeners. But certainly there are times when we're stressed about something and we don't want to be, and we have a hard time pulling our thoughts and our emotions in the stress response you know out.

So that one side you mention are are some ideas that the kids bring with them. What we always try to do is we teach them, uh, exercises of relaxation. We have to be very careful with this because like like you say, is good to be personalized, right? Is good that is adapted to the kid.

And that's why we don't tell them put this in your toolbox. We tell them learn IT. And if that helps you, you aside, if you put IT in the toolbox or not.

So when I talk about the treatment being not so much about the what because there's many components here, like education narrative that are common right exposure we can talk about is not so much about the word, but is about the how it's about empowers kids to identify those cues, to say if the tool works or doesn't work, to develop their own tools. So but sometimes they are very stock, right? And and they need a little bit of help.

So we teach them breathing exercises, and we have a script for that. We teach them muscle relaxation, and we have a something for that. We teach them the positive thinking, for example, so that's a cognitive type of tool.

Um and we teach them mindfulness because of our other work in prevention that we can talk about a later in, in which um mindfulness has been helpful. And and and also yoga, very simple yoga exercises. So so nothing to complicate IT seems like the mountain pose, for example, can be quite helpful for some kids.

If anything that helps them are we assess the moment and and stop. And if we are going to think about IT in cognitive behavioral terms, kind of break break that chain of negative thoughts that happened one after the other, which can lead to a panic attack, right? That many times how a panic attack can start.

Well, what's so interesting to me about the stress response is that while it's quick to start, is slow to shut off for logical reasons related to our evolutionary trajectory. right? Want to be wonderful if you could stress when needed IT, and then I would turn off when needed. But what we're really talking about here is intervening in the stress response, either before or as is happening, but then also making sure that the tale of that stressed responses.

and too long, we're also talking about eradicating stress that causes this comfort right on, is this cause of the stress are not necessarily to live life without stress, or to get great completely of stress. The steps we would be impossible.

In certain cultures there are unaccepted practices that adults use to deal with stress, things like worry beats um and a few years back there were those over those over the little spinner things that kids had when those were popular. Maybe they're still popular. Did you observe any reductions and stress? You know, kids have a lot of energy, like sometimes I think we confuse energy and stress. Um wouldn't we all love to have the kind of energy that we had in childhood? I was observing this the other day.

You know, you will see a kid sitting cross like a listening in class, and then all of a sudden it's time to move across the room and they'll just pop up and move across the room like when was the last time many of us I popped up of our chair, unless we were particularly excited or scared as adults? Just that immediately to action um implies that there's a lot of energy in the system. So I could imagine that having some ways to cycle off some of that energy through, as far as I can tell, you know, things like wee beds or or figments or whatever those are called that I mean, they might rotate some adults around, but really they are pretty.

Think about IT. I like that you're not calling IT nervous energy because IT is just what you said is just energy is extra energy ah that needs to be plays somewhere and they're trying to find word to place.

I mean, we have colleagues that not all of them this not a requirement for being a professor stanford, but i've got colleagues that work eighty hours a week. You could argue that healthy or unhealthy depending on the context and their agreements with others, but you know, that requires a lot of energy. And I know they are not pretty eul ly happy working less.

So, you know, I think sometimes we are dismissive or kind of pejorative about physical energy and and shaking and moving. I see, I know someone in my life who you baLances or new while SHE works. And IT kind of makes me a little bit nervous.

But boy, does he have a lot of focus on energy, you know. So I mean, I think it's wonderful. In other words.

yes, and some of us, you know, choose to have meetings while walking rather than being in an office. Certainly my difference, you know, I go for a walk sometimes when I have a meeting. So, yes, so there there is increase energy, but there is increase energy, that of of, I feel like I need to do something.

And those increase energy that goes us a lot of discomfort. So for these kids, that kids that experience is comfort than they can look other toolbox and say which one i'm gonna use and and that gives them all so a choice which goes back to that sense of control. Again.

earlier meaning of microphone. We were talking about the fact that some people, indeed some kids, have a different tendency to anchor towards thinking or feeling or action when under stress. And um you're describing the four quadrant system.

Could you share with us this four quadrant system? Because I think it's both extremely valuable to children and to adults, certainly something that I planned to incorporate in to my life. yes.

So we have to be careful with a structured interventions because sometimes a structure interventions can break a little bit the fluidity um of their relationship that a therapist and a child may have or there are any patient. So is is Better to be semi structure and to really be attentive to the temperate that the kid brings into that relationship or into that session. And certainly with the tool box, as you mention, we see an example of that.

We also add that in q center therapy by exacting an examining a response. So for example, a child that breaks windows, or a child that screams, or a child that leaves the classroom running, we try to understand what's happening at that moment. And the way that we do that is by looking at a square.

And a square is composed of four corners. And the four corners are what you're thinking. So it's a competitive site to IT what you're feeling emotionally, what your feeling physically and what you are, are actually doing, what the action is. And and this is your classical triangle of going to behavioral therapy in terms of what you are thinking, what you are doing and how you are feeling. But but we felt IT was important to add that symmetry psychological component, because for many children, they don't have the vocabulary to talk about all of this.

They just tell you I have a headache, guys, I have a stomach ache and and there is no other medical reason that explains that, right? So depending on the kid that you're gonna start examining their response to one of those corners ers, so if the good is really brainy and likes to think about the things they think or don't, don't think, you start in the cognitive corner. You know, other kids are very attentive to their body and say, I feel my heart racing when when I engage in this behavior or in this response.

And you start with that corner. The beauty of this is that most of the time you don't have to work in all of the corners by just working in one corner. All the other corners change.

Any new response develops, okay. So if i'm thinking that i'm not in danger, maybe I don't need to live running. Maybe I can just tell the teacher i'm distressed by the amount of noise. All of a sudden, the kid has created a new square that's an north square.

So hopefully we take that one response to square and build a cube right of many potential responses so that when the queue happens, now there is and our monetary um of responses anytime to the stress to think what response to do. I can bring myself there by using my toolbox so IT all kinds of stars time together. And then as I have more responses, as I understand cues, I can begin talking about this narrative that I have, where I will fix some cognitive distortions.

Hopefully, like, IT was my fault. I made that happen to things like now he wasn't my fault, somebody else was responsible. And i'm just a survivor or, right, i'm not a victim. I'm a survivor. Thus another kind of distortion that can be fixed.

So so all of that, we've included all of this in a manual for therapies, right? So we have a manual series that is called q center therapy for youth with post dramatic symptoms, publish by oxford. But I believe that adults that want to reexamine their childhood or their history, or want to think about their kids are interested in trauma, can get a lot from actually examining this manner and study in this manner. And in fact I believe in so so strongly that we are um beginning the first steps of adapting IT not only for youth but also for adults in this four corner system.

And forgive me because I called IT a four quadrant system but in this four corners of the square system you said they're thinking which is cognitive. There are emotions, then there's feelings which are some matic physical and then actions. So actions are straight forward. Thinking would be, for instance, for underside correctly i'm in danger um emotions would be i'm scared so it's it's A A verbal label. I'm depressed, i'm scared, i'm sad.

Yeah no native too. He Carries an emotion with IT.

And then in terms of the physical feeling, it's you of the body but I could include of the head too like I have a headache or my heart is racing or i'm I um or something like that sort. And then actions, of course.

the action that they I mean, action is a really fun one because you can imagine there some kids that are not psychologically mind that at all and they don't even want to engage in this with me. And they are like, okay, what is that that i'm doing? I'll do something different.

So they immediately developed the next square. So they cannot things talk too much about their emotions or how they're feeling physically, or look at the negative thought. But they say, oh, is the problem that i'm running out of the classroom? Well, what if I don't and they give you another action and and so some kids start without corner, so you can really start with any of the corners.

I love that earlier you were talking about practicing positive thinking even when perhaps especially when one is not in the stressed response or trauma response, but also, of course, when one is in the trauma response, I think is just so widely important for people to hear, certainly for for me to hear i'm not claiming to ptsd just but as a as a novel concept that i've not heard raised before um around these topics the other is this four corner system um which immediately a curse me is so powerful because IT breaks down on the a reflex arc of the stressed response into its component parts right?

What's of the body? What's of the thinking? Whats of the thinking, that emotional and what's the action? And you said, as soon as one identifies one of these corners and starts to kind of look at IT differently and consider some of the optionality that exists and alternative that all these other options cascade from that and I believe that in doing that you've described what for thousands of years really um but recently we've heard a lot about in the kind of mindfulness arena as creating space right like like this notion of creating space, not outer space, but creating space within us to a choose Better options is something that I think until right now as you've describe this has remained unfortunately very mysterious know people talk about, okay, you you know you want to be reactive IT excuse me, you want to be responsive, not reactive.

Responsive implies some optionality to your responsive. Reactive implies kind of a reflex art, just whatever the default was. But this notion of space is like too squshy for me as a biologist to really um to really be able to latch onto. I would argue given the prevalence of P T S D and stress, it's probably too squishy for most people. IT hasn't really LED anywhere specific, but I think what you're describing is ability to become responsive as opposed to reactive um assuming that the word responsive includes like some options within a and so this four corner system to me is genius because IT gives us an anchor point to start from. So could you say that if a child or adult is uncomfortably stressed, maybe about a trauma, but just is like caught in the stressed response that actually pulling out a pen, a pencil or crown as IT where and write and draw a square and just really think like what am I thinking like maybe it's just like this is terrible I don't like IT writing down um i'm embarrassed like i'm not with my friends like like not you know flush my cheek's are flushing whatever um i'm feeling like just weight down or something and then think what what are the actions I want to remove myself from the situation at that point is the suggestion that one find what is the the point of entry that feels most successful and to start there?

Yes, with one caveat, we usually use waters, emotional author momeby to measure where the kid is at. And he goes from like zero to ten or one to ten with different levels. Substance ss, and and is good to use something concrete because sometimes we think there are a ten and there are five advice. First.

we're very poor at assessing others internal states. We are, as our colleague carl drop has also been guess on this podcast I heard and want say this in a very large lecture. He said, you know, we're terrible, absolutely dreadful, at assessing other peoples emotions. In fact, most of the time, we don't even know how we feel.

yes. And true, true. But I would say if the kid at ten at that moment, the best thing is to use a tool from the toolbox and not to engage on the square at that moment until they come down a little bit and they can pay attention and they can listen to you, because then that there will be letting the information come in.

They are so emotionally charged right at the moment that that may not be the right time. We should also, by the way, is the same thing as as when you need to talk to kids about traumas that are happening in our society, right? Sometimes you just want to let them know that the door is open for a communication. You may want to talk about IT at the moment with the kid may not be ready, but you can let them know well when you are ready. We can talk about IT hear the same when you are ready, let's go over the square exercise or the example of the Kitty is already familiar with that or I have something to show you right and big his curiosity that way um but I would say use the third monitor to see if that's a good time right if if IT stand nine aid probably not wait till is like five, four, three and then engaged in that.

So the two box should be used essentially under any conditions, and the kid should generate their own tools to add to the tool box, customize the tools. And then the square can be used when they are at a slightly lower level of stressed. Because IT requires a certain level of cognitive intervention, they need to be able to think about and express their own state code. And is this something that you suggest kids only do with their therapist? Is this something that they can do on their own as well, assuming that they're old enough to write and .

to think about IT? Yeah well, our hope is that after a kid goes through q center therapy, that they can internalize a lot of these activities and exercises and like I said, become their own tool, like, like take those for life and continue to use them.

Yeah, i'm certain that many, many adults, not just children, can benefit from these tools. I mean, I mean, I would argue that most of the bad things that happen in the world are the consequence of this regulated domi function. Put a black yeah by direction.

right? Kind of making things worse once they happen impact the system even further.

yeah. I mean, I think most homicides are homicides of of jealous rage from what I have read I enough that's still true. But and of course then that is probably also true for all the things that are not as severe homicide but still dreadfully bad, like a things like that .

yeah and and it's interesting that you bring that all because I often think about we've been talking about how we experiences trauma as individuals, right? But we experiences trauma in our civilization. We experience tram in our history, we to a minor nation and how those in nation heal, how those a system heal. Well the steps are not that different.

Perhaps this is the appropriate time to um give you the opportunity to editor realize a little bit about social media and online behavior um setting aside really aggressive online behavior, bullying and things like that, which of course exists and is really serious.

Do you see the behavior of kids and adults online this sort of just maybe even the the addiction online um commenting in reading of comments and the kind of battling of issues back and forth that clearly isn't going anywhere. Some of IT goes some place functional but most of IT, I would argue, especially among the adult, is going nowhere. It's just very circular to my side verses your side, my side verses your side and emotions get really stored on there.

Yeah do you think that is reflective of um a lack of tools for self regulation? Um do you think like what we're seeing is the manifestation of of just a lot of chAllenges in the world and or an outlet for people to just event without the need to address their own internal state in what's underlying the venting? I know many very, very intelligent adults to eventually just had to quit social media in order to have any level of functionality in their life. IT comes down .

to that space you were talking about, and building that space and creating that mindfulness time that you need, which he's also gonna personalized, is gonna different for different people. Ah this spring I was in moroccan and I visited the mean. I was staying a demain a and I was overstimulated, as you can be, and enjoying IT.

But I imagine this is the state that teenagers are in all the time when they're with social media, bringing them information and little bits and different things that are happening all over the place. And very much like I founded restful to go to my hotel for a couple of hours before dinner, are people need to build that space. People need to create that space.

What I tell parents is that is important to remain member, that this was also a very helpful tool for us. When we were in the pandemic, right? The kids were interacting socially.

Academic school was happening, uh, through technology. So how can something so good be a time so harmful? And I remind them about when they brought hammers to their house, right? And they have little kids.

They had to teach them how to use them. This is a very important tool. When you need to nail something, or when you need to take a nail out, this can be dangerous, right? You don't run with sisters.

You have all these rules around other tools. We have to have these rules around social media as well. And and I and I think that's what the surgeon general is getting at when he talks about we need some regulations around IT.

Um but at the family level, I think parents need to say there are certain boundaries that we are going to have for. So a dinner time, for example, in these baskets, all the phones go into the basket and that's what we're going to do from now on. But IT is very difficult because when you establish rules like that, kids watch you like a hock.

So you have to model the behavior you are expecting, right the moment that you are apparent, the site, or know, I need to go to the basket, your dinner, I need to check this thing out, then IT breaks. So that's what I think. I think I can be quite helpful and and I think that IT can be dangerous. We've seen examples of that. And and IT is a tool like any other, like a knife that we need to learn how to use IT.

I think what you're describing to my mind a is a situation where the tool has become the terrain. It's like social media has become the landscape in which many people live as opposed to the real world. I mean, my original understanding of social media that one would experience and do things in the real world and then bring those to social media.

Not certain ly what I do, I teach on social media. Um I do the learning for that, teaching the drawing, in some cases, the preparation in the real world and then bring that to social media. But I feel like. It's almost like that the hammer has become the has become the landscape, the house yeah something like that.

The hammer has become the house yes that's a much more equant an appropriate um yeah that I feel like with social media that the two of social media has become the terrain in which people are living in so that just feels like A A closed loop is sort of an engineering example. It's like IT doesn't go anywhere like you can never actually get the relief that you're seeking. And I think we defaulted descriptions about dopamine and dope, dopamine hits.

And there is some truth to that. But the more I look at the literature on brain activation during social media use, IT doesn't really speak to dopamine and reward prediction error as much as IT does, just sort of a mindless compulsion and kind of just passive over you says, I post like rewards I got this is so cool and that so cool. I mean, I can be may have been watching some of the track and field races of the olympics. There's I mean, I was cheering out loud for a few of them, but it's usually something quite different.

Yeah I think I think if if you live in a virtual world all the time, then you're not living right? You're not in the real world. So it's like how can you use the verge? Are there ways of the virtual world can help you live the current world in a Better way? Yes, so that's that's why I think is helpful. But if you replace your life with a virtual live, then that's a pity. That's very sad.

I see that in a lot of adults as well as kids, let's talk about risk. You know, up until now, we've been envisioning a treatment situation or a study that you're running where a kid and perhaps parents as well are brought into the laboratory or clinic at stanford and you're talking to them, assessing them.

They're developing a custom tool box that's a wonderful opportunity for um kids who sadly A P T S D or P T S I to be assisting to develop tools that can really help them. That's been proven by the work of and others have done. But what about the many, many millions of kids and adults who are at risk, either because of lack of access, could be due to finances, geography, poverty, any number of different things or they simply don't even know what P T S D P T S I R. Their parents don't know um um what are some of the tools and interventions that you think could be implemented at the level of schools, families or even individuals that might help them?

So here we were in my program. We had created q center therapy right with value a training program for but we have accused center therapy training program. And I became increasingly concerned about my own staff and my own team, because this is the team, as so you can imagine, that we're seeing trauma every day, and I are seeing trauma in kids.

I was worried about the curious trauma and the impact that this would have in their health. So I remembered that when I was doing my recent and see, I took a course in hypnosis, and I was really struck by how much control one has during hy nosis. So is nothing like anyone is doing to anybody else is is really kind of having the control to relax yourself, yourself, direct type of his nosis.

And and I said, I would like to bring something like that. And I met a PHD, john red gar, that was a yoga instructor and also a lindholm instructor. And I brought him to the team and and he had other things to do.

But one of the main goals was to take care of the team. And we started regularly practicing yoga and practicing mindfulness as we were seeing all these cases and working with drama so forth. And I was able to see first hand how helpful IT was for me personally and for my team at the time.

We were doing some work in israeli, doing some of the schools. We're doing some proponent counsellings because with another problem, many of the schools have no councillors, right? So um and but this was so a while by this like ten years ago yeah .

the east palo school district for those they don't know IT palelo I guess IT could be called west paleo is a separate city and county from his pale pale to is not exclusively but is known for least note is just be Frank, fairly tremendous affluence relative to most places in the world put bluntt east palo to a separate county.

Different school district police system has for as long as I can remember having grown up um in palo um has always been stricken with far fewer resources and while there been tremendous efforts to improve the the situation there IT is still at a steep disadvantage financially. Um but of course um many amazing people working there and living there and you know and growing up there was some exchange across um that um east palo west paleo border as they were in the school district. But they're pretty separate domains when IT comes to resources.

And IT is not now but many years ago he was the number one murder capital in the us. Um is also the place where facebook is now. So so and I kia there, there is people that bring some employment to the area, but also bring some other problems in that area.

Where a is used to be called the remembers is called the whisky gulch, three years out of terrible name, right? But there was a start contrast to write as you literally cross the train tracks heading towards highway one a one um in that case, that portion pilot question park an extreme of wealth to an extreme of poverty in in literally distance of ten meters.

And of course there are a wonderful families. There course are that support the kids. There is a ravenwood, which also the other name for a sport auto family health center, uh, that that really provides a lot of good resources to the area, and there is a good school district.

But at this time, he was missing councillors. So we had some presence there. We decided to to bring some of the things that that we were learning in terms of yoga and in terms of mindfulness. Ss, to two of the classrooms. At the end of about three months, I get called to the principle office.

I have to go to the principles office too, because the principal was interested in finding out what was going on in there, because none of those kids in those classrooms had gone to her office in all that time. They had gotten, they had not gotten in trouble. So I explain what IT was, and we decided to do, you know, a bigger scale h study and and eventually we partner with a group called pure power.

Pure power ink dorg are developed in a yoga and mindfulness curricular for students at schools. At that time, we started bringing yoga instructors into the classroom. Would be, we very quickly learn that the best approach to this would be to teach the teachers and have the teachers teach the students, because the yoga structures had no training on how to control a classroom, and the teachers did. And some of these posters were so elemental that, you know, IT was okay if they were not a yoga structure. So anyway, we tested this curriculum and and there was a piece about IT in the new shower.

I think I might still be there and I get this um wonderful phone call by a this family in new york that wants to see how they can help me spread this further to not only the classroom that I was working but um to the whole school or the school district and I knew at that point that two things were important not only that they wanted and I wanted but that the school district should want IT and also that at this time we would need to do a very depth study to to see what our intervention was on what a deal colum was because mindfulness can be the named that you give too many different things. So we wanted to make sure that our intervention of yoga and mindful as exercises that now pure power Carries um is really what we are be in tested. So they were very, very helpful in helping sponsor not only the dissemination of this curriculum through the school district, but iran, thise control trial where we actually had a whole other district that would also be trained. But only after this study was over. He was a demographically compared on school in in san hui, in in the city of santo, say, a near enough for us to conduct the study but far enough there were there wouldn't be um too much um dissemination from one district to the other and he was good that we did A A district wide control because if we would have done done IT by classroom or by school IT wouldn't have worked because there was so much diffusion of what the kids were learning into the their friends and their family and the other classes and the other people in the community that was beautiful to see what he would have ruined a control study so you needed .

literally physical and demographic separation so you went with what used to be called the peninsula, the south, the east palo to and then sano say far enough apart that the kids weren't talking enough to uh blur the the treatment groups exactly .

so we demonstrated feasibility and we were able to do IT. We demonstrated acceptability. The kids liked the kids would do IT. Some schools actually had A A room specifically for them to to go and do IT even if if the teachers were not doing IT in the in the classroom I need range IT was like a twice to three times a week for fifteen or fifty minutes of this curriculum in the, in the classrooms. Can I start in trouble?

Can I ask you a little bit more about the curriculum? M, you said five. A, you said are fifteen to fifty five, zero minutes, two to three times per week.

And did the kids have to, like, change over to the yoga clothes? The reason I ask is that um I could think of a number of real world barriers to getting something like this implemented. I feel like going jogging usually get little sweet, need running shoes, you know there other forms of exercise and regard that less.

But um these days, as far as I know, not every school requires physical education. When I was growing up and through high school, you had to literally suit up, get to go in the locker room, put on your your pe clothes as as IT were, and then you'd run or play. boy.

But whatever the P. E. Teacher told you do, you have to do if you want to get a decent grade? Is the yoga being done? He said IT could be in the classroom or at a separate location. But are the kids basically getting up out of their chairs and just write in their school clothes to. Doing this for fifteen to .

fifteen minutes so they they stayed the same clothes um but we had match they had met. Every student had a met and is interesting that you mention p because the first suggestion was let's do A D N P class and i'm like now that that you know rolling from poll to you to Peter um until I learned that p like you said was not happening so which I couldn't believe and if anything I think this study has helped for them to bring pee back and the classes, which are these lessons and yoga movements and mindful ness, we're really taking place in the classroom.

Dad, whatever teacher learnt is so if he was the math teacher, he was taken to mean a society to do IT. If IT was the P E and p was not happening there, they may dedicate the fifty minutes um to do the yoga and the mindfulness. So um we we have a number of assessments that we did IT like I mention, yes, IT was acceptable and in improve move and on all of that. But I think the biggest finding that we publish from that study was that IT increased seventy three minutes of sleep. Are seventy three, seventy three minutes of .

sleep extraordinary high .

on average for for the students I need increased the depth of sleep. So something that we did in this study was that we also did parable police annotation phy. And IT was not in a sleep center.

IT was in their own house. So collaborating with rutha hara from the department, we were able to assess their sleep. And and deeply ly is very important. That's where you process the events of the day. So these kids were increasing R M, total sleep, deep sleep, doing much Better.

And then another thing, because of our previous studies that we've talked about in terms of brain function, this isn't being published, but we have some preliminary data demonstrators that those kids that went through the intervention before and after the intervention were able to decrease the activity of their amec della, which is was very powerful and also very helpful. So many of these kids adapted this into their daily practices. After this study was over, we went to our control rouen, and we told those lessons there.

And now IT has serve to identify even more tools that we can put in the toolbox of c city. So so we utilize some of the things there in here. So pure power and our program have been collaborating a lot because IT covers the risk group and the treatment group.

So sometimes when we go to school, school and we do training, we are barnet with them so that we have the yoga demand for this and the q center therapy. And and and I by no means mean these are the two things that everybody should be using. I said, these are two more tools. In fact, I think we need more development, more development of interventions, both for treatment and for intervention. And how do we identify who needs what and and how is where we are moving next?

Well, what spectacular results mean? Seventy three minutes more of sleep is like, I mean, talk about effective medicine, you know, I mean, we agreed at the outset that sleep is the foundation of mental health and physical health and all forms of cognitive and physical performance. I insist we know this.

That study done IT stanford will be at a small one of having athletes just get a bit more sleeper, even just stay in bed a bit longer, no, not on their phones, but just lying quietly with eyes closed and resting or sleeping. More improved shot accuracy in baseball players. This has been shown in so many domains of cognitive and physical.

It's like not even worse spooling off all the examples, but that is spectacular. IT also makes me think I should start doing some yoga because I do get enough sleep. But that's significant.

What do you think of the barriers to having the sort of thing implemented at national scale? Now I always think about this, you know, okay. So the results are in maybe to study, maybe it's too, but you're talking about a basically a harmless intervention and actually it's a very therapeutic intervention.

sure. There are some people that won't be able to do all the poses that but there's always something somebody can do um even people that are immobilized. There are certain forms of believe IT or not um cognitive yoga that friend of mine who works with people who are a quarter plagiary they can do certain things to keep nava system function online but no essentially anyone can do this.

Um what are the barriers from taking IT from the east palo to school to a study to another study? Okay to school. Now let's say you get all in naka or you know neighbors counties. Um you know what does IT take to get something implemented at national scale so that the work can really ripple out and benefit all these kids who are, of course, are going to become adults?

Well, we need to this right? We need to prioritize education for starters, right? We we're talking about class is not even having physical education or arts, for example, uh, and we need to prioritize mental health.

And IT needs to start early. And I think when we work our national budget, IT needs to be uh there needs to be earmarked for these two areas and that should go to the department of education. Department of education should make this priority.

Um teachers are really, really overwork. Um they they are under resource and like Patricians many times are responsible for doing somebody else is work right? Everybody tells them this will only take a minute, or this will only take two minutes.

Or if you make this assessment, you know, you can do that. But but if the time is finite, right on the space is fine out. So they need more space, they need more time, they need more support teachers. And then this needs to be a priority from districts to really implement programs like this.

So parents and and even non parents talk to the teachers in the school, talk to the principles in the school. And i've been learning about the power of the telephone um for lobbying. This has been around some things i've been involved with, with the veterans community.

I mean, the ability to look up and call your congressman men or congresswoman and tell them that you are really concerned about, are excited about a particular program does have impact. I mean, I at first I didn't think this was true, but I realized that when they start getting fifty hundred a thousand messages about a particular topic that people are passionate about, they pay attention. Maybe it's because they just wanted get reelected. Maybe it's because they are genuinely um concerned about helping people like I like to think it's the latter, but regardless of which they run those messages up the flag pole when they bring your shoes.

So so let me tell you what we just started doing. And put a reo i'm from put a rego, but put a rego and put rego put recent students have gone through a number of natural disasters that started with hurricanes and continue with other hurricanes and and also with earthquakes. And and this has LED to violence, and there's interpersonal violence.

So some of the kids and put we go have gone through a lot um but also the whole island of put a rego is one of the largest school districts in the us. Uh the whole island is one district. Meaning that if you do something like a program like the one we're talking about, you can implement the island wide.

Um currently we are launching a project in put go where all the teachers will be trained in the yoga mindful this curriculum and all of the councillors will be trained in q center therapy. The kids are being assess at baseline, then they go through their yoga and curricula at a time too when they get assess to see how they're doing after that. Um we also screen those that have P T S S but from my express symptoms that cause implement and then those go through the train councillors and then they get assess again at the in the later part so that the goal is for us to although we've talked about IT to treatments, we've never really uh have both of them happen simultaneously. And we want to do IT in a large scale like this because if if this works, if if, if sustainable, if it's feasible, we can actually then bring IT to other large school districts like you like ally, for example, and and start disseminating this.

Love your thoughts on something. You know, i'm so impressed that you are able to bring this from a study or set of studies to a much larger scale in porter eo. I could be wrong here, but I feel like in the united states, we have such a culture of fame and popularity and reward around people who are extreme performers. You know, we hear about, you know these NBA stars and right now were seeing a lot about these incredible track stars and were um or we have these tech innovators that found huge companies, we they used to all unicorn companies, but all these incredible um successes. And um I wonder sometimes if the hyper emphasis on these extreme performers has LED to the conclusion in Young people that unless you're going to be Michael Jordan or lebron James or mark zk berg or elon mosque or win an olympic gold medal, that the practices that feed up to becoming those sorts of people like mindfulness meditation or becoming a yoi for that matter. I feel like there's been a push towards hyper specialization and performance to the point where people are riding off that the incredible utility of physical activity, mindfulness, you know, learning math, science, literature and the arts.

the arts, music.

right, even for people like me, I mean sure they always give me the triangle because I could manage that one. I insult the triangle players. I'm sure it's much more complicated then um i'm giving the impression is but the point is that I feel like there's been a not so gradual disintegration of the idea that there is utility.

Indeed, there is great benefit to doing things not with the intention of becoming a high performer, but just doing them for sake of how IT enriches us in a number of different ways, including our mental health. And I wonder whether not the lack of pe is sort of a well, if you're not going to run track and try medal or something and you know or go to championship meets them, like what's the point? I don't I certainly don't subscribe to that. I'm curious to what your thoughts are.

Um well, I think we need to redefine success and what that means to be successful. I I think that we're currently describing IT with the examples that you just gave, which probably was not the way that we were describing IT in the sixties or the seventies. But IT IT is harming individuals that which is most of us that cannot attain that level of proficiency in an area.

And in fact, the individuals, they are choosing to have a broader belonging ing. In a way, I. protected. I I worry about those southern individuals do that have that very personalize, not personalize, was very, very individualize unique component in their life, where they dedicate everything .

to that one thing. They trust me. They they often suffering one or more of their other domains of life. Some don't, but I would argue most do.

But the the idea belonging right is that you have, you belong to many different facets of life. He, you are a sports person, you a community person, you a student, you are a father, you are you know and and your different things um when you're only one thing and that fails, your holy dentist is gone. IT doesn't even have to fail if you have to perceive that IT has fail, and that's enough to throw you, of course.

And so with the current definition of success, we are not doing service for those that attain that definition and those that do not attain that definition. I think he needs to be broader. I think belonging needs to be included.

I think the way that we care, not only for ourselves but for the rest of our citizens, needs to be included. Citizenship is important. Um so IT is dynamic. So far, IT has been dynamic, how we define success. And hopefully he will change again.

I I agree hardly. Let's talk about resilience. Earlier you said, you know kids are not resilient, but you also implied, maybe even stated IT out right, that they can become resilient. What is resilient and what are some of the paths to resilience?

Resilience is a physical term, right? IT means you bounce the coil, bounce back to where I was. I originally, I I like to think of the word adaptation, because IT means not only you bounce back, but you bounce back to a Better place.

A guy like to think that we adapted during the experience of the endemic other than we were resolving end of IT. Yes, we were resulting. And because we survived that some of us did not all right, some of us have to deal with the grief of what happened during that time.

Um but adaptation means that not only we go back to where we were before the pandemic, but that now we've learned from that experience to be in a Better place. Now we know very little about resilience, and we definitely very little biology about resilience. We know that having a sense of humor is good. We know that perseverance is good.

We know that the presence of an adult in a child's life that was there to give them opportunity or or to talk to them about things they were going through, let's pray, the best known you know receiving an factor um but what if is not the presence of of that adult but there's something in that child that makes them sick and maintain that type of relationship right? So I feel that we need to start looking the biology of resilience. And one way that we've done that in my program is through a collaboration with alex urban from our department and from genetics and Carolling per man whose in his lab and one of his post dogs um they work with organize and I don't know if you've mention organize .

before to your audience. I one of my good friends and colleagues at stanford geo pak as one of the world leaders and organizes and we hope to host them on this podcast soon. But please um educate us on organize. They are also cool and also science fiction. Y but they are also real.

Yes, so so we have stem cells that can be converted to any type of cell under the appropriate nutrient and environments that we want to examine. Uh so for the idea, of course, the interests to turn them into neurons and not only they can grow in a pet redish, but they grow suspended so is is almost like a three d and and sergio uses um the term assembly y for when he actually assembles them further to create build more organ specific mini brains.

Mini brains is the term that I like yes um so these many brains are these neurons that are growing up in a in a circle like the brain. And they communicate with each other and they are active with each other and we can study. So in conversations with alex and now that you will know my previous work with cortisol and all that I was telling him and Caroline, well, why would happen if we expose some of these organizes to cortisol um and of course we need to to come up with, oh, what would be the right amount, you know, that would mimic trauma.

So we also involve robbers and forky to help us come up with a concentration that would be trauma matic. And so we expose a number of organize to different levels of cortisol for some of them able to tra, for others, they were not exposed than half of that amount or much less of that amount was a trigger the q right? So some had the trauma and the q some had no exposure, some only had the key.

And then we compare what was associated um with really um well, the first thing that they needed to do was identified that these neurons actually had these look cortical receptors and that they were active and they did have them and they were active. So we looked through A P genetic analysis. I just the way is the royal we write is more alex and Caroline.

They look at the genes that were change that their activity change because of this cortisol exposure through a genetic analysis, which is the space no between DNA and R N A and like metal lation patterns and all that. And some genes activity changes, some turn on, some turn off. So interestingly, the majority of the genes that we found there, where genes that have been addressed in the literature as potentially being related to put dramatics, stress disorder, things like they look, they go recept our genes and things that you would think of.

But there was another subset of genes that we identify that were novel, and I was very interested in those because of my interest in accelerated aging, because of stress. And those were genes that are related to college information. And we know that author's glosses has been related to stress, for example.

And as and we know that isolated aging, not only in P, T, S, D, but in mental health conditions overall, individuals that suffer from severe mental illness chronically in their live, end up dying twenty five years Younger than the rest of the population. That's very significant. And so stress and isolated aging, interesting.

okay. So these are interesting findings in organize. But but when you have those, what you do as you move on to a population study, so these kids input a legal that are going through this interventions, besides me checking on their P T, S, D, they are anxiety, their depression, they're giving me a bocal swap.

And in the bocal swap, the superior cells, we can actually take them through a be genetic analysis and see those kids are time, one that even though they've gone through all this trauma, may not be fearing that much worse as other counterparts, and compare them. And not only that, we can actually also look at response, treatment, response for the intervention for the yoga, and mindful this preventive intervention and for the treatment for the q center therapy. So that's the plan. That's the plan in trying to bring more light into what is the biology of resilience and and how can we understand resilience and Better.

What a spectacular study goodness. And if any of you miss some of the underlying mechanics or just quickly break up, these organizes are little brains in the dish that came to be by virtue of taking fibre bus or other cells. So skin cells essentially put into dishes provided for water culture inscription factors.

These are the future inscription factors that you manoa won the noble prize for identifying that reverts those cells into stem cells, and then a few other goodies, molecular goodies, that then allow them to become neurons in particular, then they grow into little mini brains. And then, as dr. Carreon was explaining, are exposed to cortisone at appropriate concentrations to mimic cortisol exposure in the whole person. And then from that, the genome of those cells and the epi genomes are analyzed to identify potential targets.

The results are brought back to these kids importer eo, such that the genome of all these kids experiencing different levels of stress in yoga, mindful ness interventions, not maybe there in the control group, the outcomes can be assessed, and then one can address, hey, what are the genes that are protective against stress? A K, what are the genes that are protective against? High levels of court? Is all and a bunch of other, surely, to be very transformative, an important facts about how stress impacts the Young brain, either give rise to P, T, S, D.

Or not. I must say, as you described that study, I had three thoughts. One, wow, how awesome is this that you can bridge across so many different levels of analysis? I mean, because you're talking about molecular genetic ics all the way up to yoga in school, children in porter, ego and P T.

S. D. You know, this is a complex disorder. I was also thinking to myself, um wow, what an incredible place stanford is that such a collaboration is possible, right? Makes me delight in the fact that colleagues like you exist in sergio and I forget me. The names of the other colleagues are not for .

urban and Caroline permit.

Thank you. And the third thing is how important IT is to bridge across these different levels of analysis. I think this is the first time on this podcast where somebody has discussed an experiment that bridges across so many levels of analysis, literally, from fiber blast in cells in a dish all the way to a complex psychiatric condition, and in an attempt, excuse me, to create novel therapeutics.

So it's just truly spectacular. So if people are sensing a um even further surge in my energy, this is the kind of thing that gets me so excited because in the landscape of signs, we often see a study or we hear about organize are we hear about a yoga intervention, and these things tend to exist in silos, in isolation. But the ability to bridge across these levels analysis, I believe IT uh critical. And so um yeah kudos to you for for being a part of this incredible collaborations.

Collaborations are key, right, because the world is so complex now that there is no way that a single lab could have all these expertise so you are right, a place like stanford laws for these communications to happen, for these collaborations uh to happen uh in twenty eighty years that i've been there, I have never heard. No, i'm not interested in that.

And we say at stanford, especially if two scientists meet for more than thirty minutes, what comes out of that is a collaboration. As a final question, i'm gna ask you to limit IT to one answer, but i'm sure that there are many. Um the question is if you had a magic one and you could get any message out to the whole world about P T S D, in P T S I, in particular in kids, in Young people, but also in adults. What is that message? What do you want people to know about post traumatic stresses disorder, stress and post traumatic stress injury?

The first thing that comes to mind is the importance of of listening and listening to what kids and adults have to say about their experiencing and really creating a space for them or they or us don't feel isolated, that they feel supported and that they feel that they can identify their own strengths and their own capabilities of of making themselves Better.

Um you know every everyone knows who has heard about psychiatry, and everybody think oba with your psychiatric and psychiatry, this smart things to say to people that help them with their life. But the best psychiatrist that I know actually say very little, they listen. So I would say that listening to the experience that people have is is key.

Well, thank you so much for that and doctor Carry on Victor. Thank you so so much for the work you do. Thank you for having me ah it's it's spectacular work um at so many levels.

It's also very bold and brave work to tackle such a big problem with such um you focus and to really give people agency this notion of a custom tool box I think is profound to give kids and adults as they were agency over their own interventions in an effort to really help themselves. Um I appreciate you coming here today more than I can express. I know the listeners and views of this podcast appreciate as well.

Um you are involved with stand for clinically. You involved running studies, clinical studies that you know great importance. So for you to take time to educate us with these tools as absolutely spectacular and is really appreciated, please keep us updated on your progress and please come back until us more about that progress when the time is right.

Thank you so much.

Thank you for joining me for today's discussion about post traumatic stress disorder and its treatments with doctor Victor. Carry on. To learn more about doctor Carries work, please see the links in the shown o captions.

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