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

welcome to the huberman Lab podcast where we discuss science and science-based tools for everyday [Music] life I'm Andrew huberman and I'm a professor of neurobiology and Opthalmology at Stanford School of Medicine my guest today is Dr Victor Kion Dr Victor kerion is a professor and the vice chair of Psychiatry and Behavioral Sciences at Stanford University School of Medicine he is one of the world's foremost experts on post-traumatic stress disorder in particular the treatment of post-traumatic stress disorder in children and adolescen although his knowledge and today's discussion certainly extends to adult PTSD as well Dr Karen

is also the director of the Stanford early life stress and resilience program and today's discussion focuses on the psychological and the neurobiological underpinnings of PTSD and which treatments are most effective for PTSD we focus heavily on a particular therapy called Q centered therapy that was developed by Dr kerion and colleagues that has been shown to offset the triggering by words or events or memories that often are the precursors to PTSD episodes and this has been shown to be effective in both children and adults today's discussion explores the difference between anxiety stress and Trauma we talk

about how those things of course are related but how they can be separated out to better understand if indeed somebody has trauma and how to best approach the treatment of that trauma as you'll soon see what makes Dr kion's work so unique is that it combines the psychological the neurobiological but also practical tools such as mindfulness it relates mindfulness and cognitive behavioral therapy to the underlying biology and what's known about the Psychiatry and psychology of PTSD at its different stages depending on the trauma the age of the person Etc today Dr Kon clearly explains all

of that so that by the end of today's conversation you'll really understand what PTSD is and is not and of course the best ways to treat it before you begin I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford it is however part of my desire and effort to bring zero cost to Consumer information about science and science related tools to the general public in keeping with that theme I'd like to thank the sponsors of today's podcast our first sponsor is eight sleep eight sleep makes Smart mattress covers

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again that's waking up.com huberman to access a free 30-day trial and now for my discussion with Dr Victor Kion Dr Victor Kion welcome thank you thank you so much for having me I'd like to talk today about PTSD post-traumatic stress disorder in particular in young people but also in adults but before we do that can you educate us on the definition of stress and maybe distinguish between short-term stress and long-term stress and then perhaps we can segue into PTSD that's a very good way of starting because in reality my main interest was the role of

stress and the role of stressors and how stressors really would activate the gene makeup and make us vulnerable to things that we might be vulnerable um but at the time when I was training everything Psychiatry as a field was very diagnosis based so you needed an anchor and hence I use BTSD to communicate what I was really referring to but the reality is that the experience of stress as we now know is a spectrum from beneficial to not beneficial to traumatic so it really stress operates in our lives as an inverted ushaped curve The more

stress we have the better we perform the better we do if we don't care about that exam that we're going to have tomorrow we'll probably fail so it's good to be so muchat stress right vaccines are a stress in the system so um we'll talk about this uh I hope but I'm very concerned also about the overprotection of kids to to protect them from any type of stress because it is through this experience of early stress that of us develop our problem solving abilities and we become aware of our coping mechanisms we become aware of

our support system how can I manage that stress and we can we can manage stress because in the same way that through the process of homeostasis we process um we have a range of temperatures right in which we can live the same thing with stress we can actually cope up to a certain point after a certain point it's not homeostasis anymore and it turns into what we call allostasis when when it really starts having a physiological cost to the body so in that inverted U-shaped curve there's that optimal point where your health your happiness your

performance everything is better because of the stress you've been having but after that optimal Point all of those outcomes Health performance start to decline happiness starts to decline and it is in that second part of the curve where we find traumatic stress traumatic stress being a type of stress that is not only something you have to cope with but it actually puts your physical Integrity in gibberty is a threat and and you have to manage that and when you experience traumatic stress many outcomes are possible one is that you're resilient and we'll talk a little

bit about that as well I hope um but another one is that you may develop symptoms of post-traumatic stress disorder and the reason that I didn't anchor on the diagnosis right away from the outset and I was interest in uh studying stressors is because many kids we were seeing many kids that that had symptoms of PTSD without having the diagnosis that were demonstrating functional impairment so they were not doing well in school they were not doing well with their relationships they were experiencing distress right so their function was affected yet they didn't have have the

diagnosis so the diagnosis is is good and that is there and and it it is a behavioral definition that we can anchor in but but there's more Nuance to that so then that that chose the whole the whole spectrum and of course we can come out of PTSD and we can go back to that optimal point so we don't want to get rid of stress but we just want to return to that optimal point and treatment is is available and and people can recover from PTSD and especially kids can recover from PTSD but there's one

thing that really gets in the way and that's something that in my team we call uh we have a phrase that we say PTSD feeds on avoidance if we pretend that something didn't happen if we pretend that it will go away if we pretend that treatment is not necessary then and that that's when it gets complicated and he gets complicated with uh substance abuse he gets complicated with self-injurious behaviors and then at that point it becomes harder to treat is it also possible that PTSD gets worse if we tend to look at it um over

and over again ruminate on it in the absence of any structured clinical support meaning if people perseverate on their traumas can the uh negative impact of those traumas actually uh root deeper into us it's interesting that you use the word perseverate because one of the characteristics of trauma when it affects children is that it robs them from play play is something that's essential in development is how we grow socially emotionally physically but when play becomes traumatic play it becomes non- joyful but it becomes pers and repetitive this is the attempt of the individual to try

to make sense of what happened and the reason why it's not good to be alone with it and kind of perseverate on it by oneself is that we're probably not looking at the right insult so in our experience uh usually PTSD doesn't result from that one traumatic event we all carry a backpack and we can all carry all the stressors that have come our way like we were saying before but if you're five six seven years old and that backpack gets really heavy you can fall backwards and when you fall backwards that's because you don't

have the tools really to carry that but what I'm saying is that that it is the accumulation of stressors some of which may be trauma atic that cuss the symptoms of PTSD so for example um some of us went to Haiti after an earthquake right and I was starting my program at that time I was very young already to talk about earthquakes and know everything about earthquakes it was the last thing they wanted to talk about they saw the earthquake as an opportunity to talk about the violence that had been experiencing the poverty the lack

of education so they were talking to me about everything they were carrying that led some of them to develop symptoms of PTSD I see as you describe these other aspects of one's life that can have negative impact poverty violence Etc um I get the impression that PTSD can be caused by a single event or trauma but that there's a cumulative aspect to it so is it the case that in children because their brain is far more plastic we know this I mean brain circuits are modified even by passive experience in childhood whereas in adulthood it

requires focused attention in order to learn unless it's a negative event for better or worse um that in kids it takes uh far fewer or less intense negative experiences in order to create PTSD because the brain is so plastic or is there a similarity between Youth and adult PTSD epidemiological study confirm what your assertion children we think we we usually you know one line that I really don't like is children are resilient because children are really not they're more vulnerable they have the opportunity to become resilient if we help them and we tell them what

tools to use and how to develop and and all of that but they are more vulnerable to PTSD and part of it might be that neuroplasticity and and this is why we care for them right this is why we protect them and give them safety because they are vulnerable um by the same token that neuroplasticity can work both ways because if PTSD is teaching us that the environment can have an impact on biology that's the only lesson right environment can have an impact in biology in PTSD is a negative impact because of a negative stressor

or accumulation of stressors but that also means that if the impact is positive as in a good supportive system or as in Psychotherapy that recovery can actually happen in an easier way before we talk about therapeutic interventions I'm curious about genetic predisposition and a topic that comes up a lot anytime the the letters PTSD are stated in that order um is transgener ational trauma I can imagine at least two forms of transgenerational trauma one is a generation of what are now grandparents or great-grandparents or parents are impacted by some trauma either in the family or

maybe in culture or you know even broader scale and then discussions about that pass through generations impact the uh children and therefore their adult life I could also Imagine and I think this is normally what people are referring to when they talk about transgenerational trauma this idea that somehow The genome is modified by the trauma such that even if kids are raised by um parents that adopted them or they have no contact with the grandparents or great-grandparents that experiened the trauma that somehow they are more vulnerable to or in some cases the idea has been

put forward carry that trauma put in air quotes such that their life is more difficult even though they never had a direct experience of that trauma what are your thoughts about transgenerational passage of trauma both forms both the narrative passage as well as the um potential for epigenomic or genomic passage of transgenerational no this is a very interesting uh subject the jury is still out if genomic changes that result as a consequence of stress can be passed from one generation to the other but certain certainly the genes that made one generation vulnerable are being passed

to the Next Generation as well that we know so it can be passed that way um but what happens is that there's also this impact of learning and I have treated kids that come to me with all of the symptoms of PTSD and there's no trauma I cannot find the trauma and the parent cannot find the trauma and the kid doesn't reported trauma but when I'm talking with the parent the trauma becomes evident in the history of the parent so the parent has developed PTSD and behaves in a way that has been learned by the

new generation ways like avoidance or re-experience or hyper vigilance or lack of trust you know things like that so certainly there are Pathways in which it can go from one generation to the other and and we know that the battle between nature and nurture is pretty much over right we know that that they both influence uh vulnerability and that they both interact and I imagine that's what's happening in in some of these situations in terms of stress you know I always think of stress as both a response within the brain and a response within the

body and I'm not alone in that belief I I think uh we know that adrenaline epinephrine is released from the adrenals but also from areas of the brain like Locus culus so that there's this parallel effect of elevated states of mind more alert more focused on narrow locations in space and time and the body is also prepared for Action I think this is what underlies the increased heart rate the you know shaking in some cases sweating it's essentially a preparation for action with PTSD I often hear that some of the symptoms are more of the

opposite end of the Spectrum in terms of autonomic arousal right things like dissociation fatigue um kind of checking out which I realize this dissociation but things that uh are more akin to kind of parasympathetic right for those that don't know the sympathetic parasympathetic represents the Continuum of autonomic interaction sympathetic having nothing to do with emotional sympathy it's all about um fight ORF flight type responses although at lower levels it's what's responsible for us being alert here but not in fight ORF flight and parasympathetic being more of the rest and digest even leading into sleep type

responses so you know if somebody experiences a big stressor a trauma or chronic stress to the point where it becomes PTSD is there a tendency for them to be more hypervigilant and you know a start response um to uh have their head on a swivel all the time looking for danger or to be more dissociative or can the both sets of phenotypes exist in the same person yeah no this is very interesting well we're talking about the letters let me say that a lot of people call post-traumatic stress disorder post-traumatic stress injury not considering it

a disorder but considering it something that where our fight or flight mechanism the autonomic nervous system has been desensitized and we need to regulate it again uh and it's going to hurt it's going to be painful it's just like when you break your arm and go to the emergency room and it hurts to be placed back in place but is the cure is what cures it so a lot of people visualize it I do as an injury rather than a disorder traumatic stress injury injury interesting and so what happens so these autonomic system gets activated

we have our fight ORF flight reaction but what happens to a young kid because they're very little and they cannot fight they're also very dependent and they cannot flight so they're stuck they're stuck there so they freeze they freeze and that's dissociation it's actually during development a healthy um defense mechanism but very much like a white blood cell that's very helpful if you have too much of it you develop a leukemia you can develop dissociative disorders if that's the only thing you have but it does help children cope with some of the situations pretending this

is not real or this is not happening to me is the only thing they have left um and because this arousal system is so key in the development of of this children um I thought that we should look at the hormone cortisol in in in the kids and and when I started when I was a fellow doing my shell Psychiatry Fellowship I was seeing all types of kids with all kinds of issues uh some had ADHD some had OCD some had PTSD symptoms but I was getting a lot of kids with notes uh from school

saying this kid has ADHD please place on rolin right a stimulant medication and I'm like wow the diagnosis has been made there's already a treatment plan what am I training here for um but in some instances they were right you know the kids had ADHD but in most cases what happened is that that hypervigilance that you're talking about was being misinterpreted as hyperactivity and the dissociation was being misinterpreted as inattentiveness so the kids were getting a diagnosis that was not correct of course there are other very complex cases where you have both ADHD and pthd

also ADHD can put you at risk to develop PTSD because you're not as attentive as to what's happening in your environment but there's definitely two different conditions and and it was that clinical observation that made me think well people don't know enough about PTSD and certainly they don't know enough about PTSD in children and we were having some research in adult around that time in terms of cortisol levels David Spiegel who you've had here raciel Yehuda the Bronx VA looking at PTSD in adults but I said but what how does PTSD look early on what's

happening in the hypothalamic pituitary adrenal AIS that is responsible for secreting cortis and regulate cortisol uh when these children are young because this is a new access you know is is is it already not working or is it working right and so we did a number of studies that demonstrated that the normal circadian rhythmicity of cortisol was there it was higher uh early in the morning which we need to jump out of bed and as the day progresses it decreases uh very helpful it goes up when we are stressed like when we have lunch after

we have lunch cortisol goes up right so that we can help manage the insult of digestion or or whatever uh and this kids were having those levels but something was happening uh in a number of studies and we noted that the pre-bedtime level was higher we were measuring it at different times uh in the morning pre- breakfast pre- lunch pre- dinner pre- bedtime but it was the bedtime level that wouldn't come as low as the healthy controls it would remain high and this was also important clinically because many of the symptoms these kids were having

were happening at night anyes right bed wedding nightmares not sleeping deep enough not sleeping long enough um fears at that point I felt uh well we don't know anything other than the cortisol pret time is elevated right maybe they needed to be who knows uh but I was concerned about the work by sapolsky right and Bruce mchu and his mentor demonstrating the neurotoxicity that glucocorticoids can have in key areas of the brain areas in the lyic system and the cortical system where uh which interestingly enough have a lot of gluc coroy receptors so then uh

we decided to look at brain structure and brain function in youth with PTSD symptoms and see how this cortisol would relate to that or not uh and we did that through MRI magnetic resonance imaging let's talk about cortisol for a moment it's a topic that has not received enough attention uh in previous episodes of the podcast I'm just going to summarize a little bit of what you said and you'll tell me where I'm wrong cortisol starts to rise just before we wake up in the morning assuming a good night's sleep and Peaks a maybe I

don't know 30 to 90 minutes after waking for you slow risers like me uh probably a little delayed by the way the height of that Peak and the acceler the uh I would say the steepness of the curve can be uh increased uh by viewing morning sunlight we know this bright light increases that cortisol Peak it'll make you a better early riser but in any typically the pattern then is that it rises um through mid morning and into the early afternoon and then starts to taper off to lower levels and as you mentioned we'll see

bumps in cortisol post meal if there's a stressor we get a disturbing text we get a bump in cortisol but these aren't huge Peaks unless it's a big stressor correct and then by evening cortisol levels in healthy individuals are typically low and that allows for transition into sleep among other things allow for transition into sleep but you said in these kids with PTSD cortisol doesn't come down to low levels as much as it does in healthy individuals um in the evening and nighttime and that I imagine would lead to perseverating on stressors from the day

this kid was mean I have a test tomorrow maybe any stressor becomes more um intense in our mind and body as it were um and that perhaps could lead to issues with quality or duration of sleep which then could perpetuate this cycle do I have that correct correct okay so um has the direct intervention of just trying to suppress evening cortisol ever been done I mean certainly there are drugs that will do this um has that approach ever been taken I thought about that when I had those high levels but I I felt that we

needed to understand better I I think I think yes that there were some attempts with some medications and I I don't think that led to anything uh in terms of of helping those kids um or just helping individuals in general that had high levels of cortisol because of of uh traumatic stress um but nighttime you're right it is a time when basically we fall asleep because we let it go and and this kid's hyper arousability does not allow them to Let It Go um so if these levels are high why as I was Finding you

know what impact are they having in brain development and and usually the younger you are the more universally distributed receptors are so glucocorticoid receptors could be anywhere at that point but as as we age uh they become more localized and The glucocorticoid receptors and cortisol is a type of glucocorticoid um are more common in areas like the hypoc campus and the prefrontal cortex which I also found interesting because these areas relate to the symptoms right that that many individuals with PTSD have memory anticipation of the future problem solving context dependent problem solving so on and

even those attention issues that make them overlap with kids that have ADHD as well um so this frontal limbic pathway the prefrontal cortex community ating with these emotional areas of the brain including the amydala which is very close to the hypoc campus um needed to be investigated in in in a pediatric PTSD and what I sometimes call Pediatric ptss because post-traumatic stress symptoms uh because as I mentioned there's a group of kids that have post-traumatic symptoms do not fulfill criteria for dsm5 PTSD but their function continues to be inair sometimes that's because um of comorbidity

there's a high incidence of comorbidity with anxiety and depression so most of our studies that have look at PTSD symptoms also look at the impact of the interventions that we're doing in anxiety and depression as well I'd like to take a quick break and acknowledge our sponsor ag1 ag1 is a vitamin mineral probiotic drink that also includes prebiotics and adaptogens ag1 is designed to cover all of your foundational nutritional needs and it tastes great now I've been drinking ag1 since 2012 and I started doing that at a time when my budget for supplements was really

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try ag1 you can go to drink a1.com huberman to claim a special offer right now they're giving away five free travel packs and a year supply of vitamin D3 K2 again that's drink a1.com huberman to claim that special offer I definitely want to get into some of those interventions including some of the ones that you've developed that are very novel and are um being used to great success um I want to just circle back for a moment on this relationship between PTSD and in some cases inappropriate diagnosis of ADHD as you mentioned these two things

can coexist in the same person um so we don't want anyone who has been told that they have ADHD um and PTSD or even just ADHD to immediately assume that that diagnosis is wrong based on what we're going to talk about but it is possible um that the a DHD that a child is told they have is reflective of PTSD and I imagine that if that PTSD arises through something in the family structure or dynamic it would be even harder to unmask because the parent perhaps would be less motivated to try and understand that if

they played some sort of role in it so I realize this is a complex problem with a lot of layers but um if you were to just throw out a number based on your experience what percent percentage of pure ADHD diagnosis would you like to see explored for the possibility of a PTSD influence let's just keep it kind of uh diplomatic that way as opposed to saying what percentage of ADHD do you think is actually PTSD I firmly believe that ADHD does exist um I'm I'm going to say two facts that we know in the

field one are kids getting over medicated it the answer is a clear yes they're getting more medications that they need for ADHD for for anything in general kids now in ADHD they're getting undermedicated so that's the second fact so the first one is that if we look at kids overall in the field of mental health those that manage to receive treatment which access is something else we should talk about because like 50% of them do not get access to Mental Health Services um those that manag to get it may end up uh with the appropriate

treatment right a medication or a psychotherapy but there's another subset of them that will be medicated no matter what they present with because they need to be seen fast or is a fast solution so there's many reasons for that but are kids getting overmedicated yes but within those kids those the those that truly have attention deficit hyperactivity disorder are getting undermedicated and that's because of that access issue because most of them we're not identifying and that's a Pity because the first line of intervention for ADHD is stimulant treatment it does work and it works very

well uh for children that have the correct diagnosis but the first line of intervention for children that have a history of PTSD be acute or chronic is psychosocial it's a psychosocial intervention so if you give a kid that has PTSD and know ADHD a stimulant medication not only is not taking care of ADHD because they don't have it but it adds to that hyper arousability you know that is manifested there from before by the way there are clinical ways of separating hyperactivity from this hyper oability and hyper vigilance hyperactivity if you see a kid that

is not medicated and has ADHD and they have the hyperactive symptoms and the hyperactive type they're going to be hyperactive for most of the time that you're with them the kid that has hyper arousability it will be more of an on and off phenomenon the the hypervigilance and Hyper arability comes more when they're presented with a cue that consciously or unconsciously reminds their body of the traumatic event or the traumatic experiences um what happens though is that usually we don't know what those cues are right so we just see a kid that sporadically becomes um

hyper Vigilant or hyperaroused and then the other thing is is hypervigilance something that needs to be treated you know I I learned this from a mother early in my career she's like I was giving some talk in the community and she came to me afterwards and she said listen uh we live in a street that's very dark and it's very dangerous and my kid has to pass through that every day I want him to be hypervigilant and if he has developed this trait of hypervigilance this is something that could be helpful to him and I

said you're right I said you're right it's not only to him to a lot of people it could become very helpful to be hypervigilant to assess the environment in which they are in so the problem is not the hypervigilance the problem is knowing when to turn it on and when to turn it off having the cognitive flexibility right to be able to say yes this is a dangerous situation and I better respond this way if if I can give you an example of of of a kid right a kid that experiences domestic violence and has

Associated that with noise in the in the house house learns that running and getting into the room is is a safe thing for them because they're out of the picture right and they protect themselves in the room but a year later they're in the classroom and for some reason the classroom gets this level of noise the body without him knowing right uh the body reacts by the response that was helpful this is classical conditioning right so he runs out of the classroom but he's missing the context the teacher is missing the context when the teacher

sends him to the principal's office the principal doesn't have the context right that this response was actually adaptive at one point and helpful at one point and the body has had a hard time letting it go to ask that kid to give us the only response that he has is not the way to help him we need to help him develop new competitive responses so that the experience of the other responses then extinguishes that response that was adaptive at one point but now it's maladaptive by the way if they are in a traumatic situation again

we still want them to use it right we still want them to run and get out of there it's part of that hyper vigilance that that's protecting them in a way it's so interesting uh you said if I understood correctly that in kids with genuine ADHD the hyperactivity is fairly persistent across environments and with different people Etc I'm sorry to interrupt but if I could add the in attention comes and goes because we all know kids that have ADHD that you if you give them the right video game all of a sudden they become attentive

right right this is a very important Point uh when I did the solo episode on ADHD I was um frankly shocked to learn but it was validated by the literature and certainly by the responses from the audience that kids with ADHD and adults with ADHD for that matter absolutely have the ability to sharply attend to something if it's something that's very engaging to them really exciting something that they typically enjoy but their ability to direct and maintain attention in other environments that are required for normal life progression school work relationships Etc is very diminished compared

to those without ADHD so what I have in my mind is a step function meaning a you know an increase in a steady state of hyperactivity in a kid with ADHD but then a jagged line beneath that of attention this is I believe the picture we're I'm painting here but that in PTSD the hyperactivity is a jagged line it really needs a Quee as you said um a loud noise or um maybe it's the presence of a particular voice I once attended a um a trauma um it wasn't trauma release as much as it was

genuine uh trauma Treatment Center out in Florida a friend of mine runs this Center and I was out there learning about the practices they use in order to inform uh potential uh experiments for intervention in my lab back at Stanford and um and he said something really interesting he said you know when you bring people into this sort of environment and they they've all had trauma you see a pretty rich array of of responses um to even just the same conversation and then at one point perhaps because he said that I I noted that a

woman raised her hand and she said that particular tambers of voices in the room were really activating her you know this was important it wasn't just what was being said it wasn't that people were yelling at each other or even the volume of the voices but that even just the the the frequency the the lowness or the highness of the voice as it were was triggering something in her brain that was giving her these bodily Sensations and it was a very um important insight for her to be able to then start to direct interventions so

I guess we all hear that kind of now um stereotypical example of you know the the veteran who experiences combat comes back and he's a car backfire and then they hide that's kind we we read about this and hear about this but it seems like it's much more subtle than that that sometimes the cues for this uh hyperactivity this hypervigilance is um very much linked to something that sometimes even the person with PTSD doesn't recognize until they start to be put into that environment again and again and then they can pinpoint it my question now

is if they can pinpoint what the queue is do they stand a better chance of recovery um as opposed to somebody that just like feels like I'm hyperactive then I'm exhausted I'm wired and tired and and now I also Imagine That in kids they don't have necessarily the verbal proficiency to be able to express what's going on for them and in fact many adults don't really know because we don't have a great language for expressing this body mind thing in any event a lot of questions there but um what are your thoughts about the requirement

for being able to understand what the cues what the triggers are in order for a child Andor adult to be able to start to make inroads into their PTSD uh first a word on the Vietnam veteran because there's a very important study that was published years ago that demonstrated that those veterans that had a history of child Mal treatment and went to war had PTSD at higher prevalence than the ones that did not have a history of child Mal treatment so child maltreatment I see so they were traumatized before they went to combat and and

maybe they did not develop PTSD but once again that point of the accumulation right of of the stressors at different times and I'm just mentioning that because you may have a veteran and you're waiting to look at the classical cues where in fact it might be more like a voice like the example that you were giving that triggers them what triggers an individual is very personal so cues are usually neutral and they're usually related to our senses and I know you like senses a lot so what we see what we hear you know all of

these things the senses are really the the window to the central nervous system right this is how we get information the first time so in this state of hyper arousability when something traumatizing is happening our senses are really acutely aware of what's going on and they are making sense of the insult but they also are registering everything that's related to that so these cues usually are neutral so they're they're not like a gun for example because a gun is not a queue it's a threatening it's a threat right but it's usually a color so there

was a red car part near where they were so the color red made may be a que maybe a trigger it was raining the day that that happened so rain may be a queue maybe a trigger and to answer your question identifying those cues are important because they let you know when your symptoms are coming they let you know that they're not coming out of nowhere they let you know that you're not a problem or that you're crazy or that you're bad which is sometimes the messages that kids get when they go to that principal's

office okay but they let you know that they learned themselves this is a normal response right I've learned through my psychosocial intervention I've learned that this is a Quee that triggers a response from me triggers a response that was helpful at one time and through classical conditioning and we do teach classical conditioning to the kids those respon has then become uh present become conditioned right uh when the queue is there when the triggers there so yes to answer your question it is important to know the cues now what happens are we going to know all

the cues to everything to all of our behaviors and this shift in mood that sometimes we have during the day and we don't know why right no the answer is no we're not going to we're not going to know all the cues but the beauty of this is that if we can just learn about one or two or three cues what our response is there's more of a forgiveness to ourselves in that when we respond inappropriately we can think well maybe I was exposed to a queue right because I've learned all of this about cues

and classical conditioning maybe that's what What's Happening Here Yeah I'm thinking again about post-traumatic stress injury the reason I like that term even though I realize I'm using it non-clinically is that if we understand that the autonomic nervous system the seawing back and forth or this Push Pull between the sympathetic fight ORF flight and parasympathetic rest and digest Loosely speaking systems are always at play in us when we sleep more parasympathetic when we're alert and calm more sympathetic and when we're stressed or having a panic attack extremely sympathetic if we understand that as a biological

system which it is that deploys hormones and shapes our patterns of thinking and what's available to us in our memory and Etc then ptsi post-traumatic stress injury I I feel like it liberates us a bit to understand that yeah this autonomic system has been disrupted in a way and if I think about the autonomic system as a seesaw which I often do and I think about the Seesaw having a pivot point with a with a hinge it's almost like the post-traumatic stress injury is to create the tendency for that hinge to be too tight and

sometimes that makes it more like dissociative and we're exhausted and kind checked out and maybe it creates the hinge to be too tight such that we're more on the sympathetic excuse me sympathetic the way I uh for those listening I'm using my hands but you don't have to to see it to understand that the the the alertness system is locked in place it's hard to get out of that and I almost feel like the the injury that is post-traumatic stress injury is a tightening down of the hinge with the Seesaw tilted too much to one

or the other side and I I as a biologist I I just wish that we understood what that disregulation uh was or is um chances are it's not one location in the brain or body it's going to be a network phenomenon but um I feel like the word disorder the D in PTSD is so critical because it highlights the importance and the pervasiveness of this thing but that the eye in post-traumatic stress injury hopefully will give people it certainly is giving me some some sense of um uh relief or Liberty and understanding that like these

are nervous system injuries that um need treatment and that there isn't something wrong or crazy with us because of because of the fact that we you know suddenly feel like we're having a panic attack you know I've had people I know close to me in my life say I'm having a panic attack like what do you mean what what happened like nothing happened that's the point well how do you sleep well it's okay you know and you start doing the the curbside diagnosis that neither of us is qualified to do right but this is what

we do as as caretakers for each other in our lives and it very well could be that their autonomic system just got that hinge is just locked in place for whatever reason reason maybe it's one sip too much of coffee maybe it's one sip too little it's probably something or a bunch of things does am I am I I realize I'm getting outside my expertise here because I'm not a clinician but I feel like this ptsi thing is is is sticky and important for for people to hear about it certainly changing the way that I

think about PTSD yes no and I like the visualization of your seesaw and the example of the hinge because it it it reminds me of that cognitive flexibility right it's not there it's kind of stuck it's kind of tight too tight and and in some individuals they just experience the dissociation they're like stuck on on the bottom right sitting on the bottom on the seiso whereas for the other individuals they hyper arous all the time then you have everything in between but but no I that's a very good representation of it and I feel like

a good night's sleep allows some recalibration of the tightness of that hinge put differently anytime we don't sleep well or long enough we're not good psychologically a good night's sleep is good for everything we're finally at the point in history where we where everyone seems to accept that I really have to tip my hat to uh Dr Matthew Walker from UC Berkeley for writing the book why we sleep you know it was only a few years ago that book came out and um he deserves such a token of praise for that because prior to that

there was this oh I'll sleep when I'm dead mentality I I think people knew sleep was important but they didn't really understand and he had to come out as kind of the um kind of the downer message like listen you know this is serious stuff you better sleep you better sleep but I think we're there now I think in in in 2024 we're there I think people understand and I think people have their own experiences with sleep right we we've all felt that c that's coming and and if we really sleep those eight hours we

may be able to fight it because we've strengthened our immune system if we don't we will get sick yeah absolutely well let's talk about some of the treatments that you use and have developed for PTSD in young people and maybe we should Define young people are we talking about you know the 18 and under just because that's typically what we think about so in pediatric uh Psychiatry we have three different populations we have the preschoolers we have the school age and we have the teenagers and they are all very different they all uh have responses

and defenses that are very different the projects that I'm describing happen mostly with the school age uh school age children so preschoolers are going to be essentially I think of kindergarten starting at 5 so you're talking about zero more to to more or less five or six years old as the preschoolers kindergartener and then transition Point correct um and then for the kids we're about to talk about we're really talking about what six years old until about end of adolescence yeah 15 and and and then yeah then their teenagers later on okay so I work

mostly with the school age the school age kids and like I said when when we started doing magnetic resonance imaging to look at the impact of cortisol we have a number of studies really demonstrating that those kids with higher levels of cortisol had um less volume of the hypoc campus uh the first study that we did in that was cross-sectional and there was no difference and it gave me a lot of hope that there would be a window of opportunity there where we could intervene uh because what we were seeing in chronic PTSD in adults

was that there was smaller volumes of the hypoc campus which help us process memories and have strong connections with the emotion center of the brain the amydala and also with the prefrontal cortex and um and what what we found was that cross-sectionally there was not this difference but we also follow a small sample longitudinally and there we saw a correlation between that higher preet time cortisol and the smaller hipocampal volume uh more impactful was a functional Imaging study uh as as many of your audience members now with magnetic resonance imaging we not only can look

at the structure but we can also give tasks uh of memory for example or of executive function and different tasks that tap at the at the areas that we are interested in looking uh so when we look uh when we give a memory task and we looked at how children with post-traumatic stress symptoms were behaving compared to kids that do not have symptoms or other Psychiatry diagnosis we were seeing that the healthy kids were activating a lot of more voxels or units of the Imaging of the of the haboc campus so so there was concern

here that yes that plasticity that you talked at the beginning was really affecting the development of the brain of the kids and then with the prefrontal cortex we saw something uh similar in the uh ventral medial area of the prefrontal Al cortex so but with other tasks right with tasks of executive function or or tasks of emotion um looking at faces for example emotional faces all of this to say that they probably have a malfunctioning frontal striatal pathway and front olymic so front olymic I'm sorry so um if we think of the amydala for example

in close proximity to the hypoc campus being involved in this hypervigilance and we have some data to show that the amydala becomes active very quickly when you present emotional faces uh to young kids um and that that hyperactive amydala needs a a break of some sort that break comes from the prefrontal cortex but if you have a prefrontal c cortex that's not working that well either then your break is not working right so so then the issue came here well this is important information to know what we need to Target with treatment and can we

target this with psychosocial interventions and the way that we provide treatment and we decided to begin with what we discussed earlier with the cues right and uh teaching and having kids understand what cues are what classical conditioning is um talking to them about the impact of trauma talking to them about the impact of treatment and how recovery is possible right so an educational an educational piece and something that I never thought I would end up doing was developing a treatment right I I felt I'm here to invest investigate and use the treatments that we have

but it became very clear to me that there were a population of kids that still needed a form of treatment that was not out there so most treatments out there for trauma were targeting one traumatic event and not TR targeting that backpack that allostatic load also and rightfully so most treatments were um requiring that the parents were involved in treatment as well I can see where that might be problematic when the parents perhaps were the source of the trauma and also when there's avoidance right and also when there's practicalities that if they lose one day

from work they're going to get fired so so sometimes the parents are just not available and the kids are totally ready to begin and do the work so I I wanted them to be able to do so so how can we devise a treatment that is hybrid and by that I mean multimodal that is not only cognitive behavioral therapy but that it brings other elements that are important like self-efficacy empowerment Insight oriented work and give it a structure that uh can be tested and that's how we created Q Center Q being cue Q centered therapy

for kids that have PT D SD and we've had a number of trials with them and it it helps uh decrease symptoms of anxiety symptoms of depression and symptoms of PTSD and not only as uh scored by the student but also scored by observers by the parents and in one of the trials where we measure actually how the parents were doing parents that were not participating in treatment their own anxiety was decreasing as well and that's is it to understand right if your kid is doing better you're going to do better as well um so

so that was very very good to see but then we wanted to see that plasticity too is this some doing something to the activation of the brain and that's when we brought functional near infrared spectroscopy into the picture because it's cheaper than MRI and it's more portable and it's easier to do it only gives you cortical information it doesn't get into those interesting lyic structure so it's um just to uh just highlight for a second the fmri fun functional magnetic resonance imaging is wonderful because it allows a lot of um uh Imaging both on the

superficial outer parts of the brain but also deep into the brain my understanding is that and perhaps this has changed in in recent years that the um spatial resolution can be very good you can pinpoint very small areas if you have a powerful enough machine magnet um the temporal resolution the ability to see changes in the neural uh circuit activation and deactivation over time at one point was somewhat limited but now some of those limitations have been overcome but then what you're talking about near infrared spectroscopy is excellent because it can be taken to a

school right you don't have to you couldn't bring an fmri machine to a school unless it's a medical school where there's the machine um it's much less expensive the downside is oh excuse me and my understanding is that the spatial resolution isn't quite as high as MRI but the temporal but the temporal resolution is very high which is a huge advantage and then there's this one disadvantage that you can only really image the outer portions of the brain but nonetheless there's a lot of information there right so a little technical lesson for people and these

outside areas of the brain the cortical areas in the prefrontal area were helping predict which kids would do better only for those kids that were having Q Center therapy and another gold standard treatment called trauma Focus cognitive behavioral therapy when they were both compare to treatment as usual I'd like to take a quick break and thank one of our sponsors function I recently became a function member after searching for the most comprehensive approach to lab testing while I've long been a fan of blood testing I really wanted to find a more in-depth program for analyzing

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uh versus the uh no therapy um conditions you just described but before we do that I just want to have a brief uh discussion about some of the Neuroscience you mentioned because I think people will find this very interesting and um certainly not just a listing off of names of structures you said that the frontolimbic pathway is important here the limic pathway including the amydala but other structures as well and my understanding and I think the generally accepted understanding about these lyic Pathways is that they create a response State a state of alertness a state

of relaxation that they um translate certain information that impinges on them into uh a level of reactivity either low medium or very high when I say reactivity a tendency to move toward or away from something or stay still for it put in uh broadly speaking now the fronto piece the feed the feeding in of information from the frontal cortex where context dependent decision-making and as you said executive function takes place is so critical for all of us as we mature even as a I would say if you look at a puppy everything's a stimulus and

then over time they're not going to pick up everything in the room that's without question largely due to the development of these fronto limic Pathways and in children and in um in humans that is it's the same I can imagine that the signals coming from the frontal Pathway to the lyic system are going to be somewhat cryptic to people that aren't familiar with um Psych patry and Neuroscience so maybe we could just um throw a few of those out there here's an example tell me if I'm wrong um but the way I think about this

is okay uh a kid is in a room and they're hyperactive and um or maybe something set them off and they're particularly uh Vigilant and stressed they're in the stress response the frontal cortex is the pathway by which an internal dialogue could be de delivered to quiet that lyic pathway the message that would perhaps trigger that would be the kid recognizing because they learned uh this is okay I've had this happen before it passes or I'm supported there's Dr Kion there's my mom there's my dad there's my teacher there's my friend I'm supported because we

know social support is important or it's normal to feel stress every once in a while so these kinds of thoughts are these internal dialogues that we're told that we should do for ourselves when we're stressed I think we can be pretty certain that that's the kind of information that would trigger this front to Olympic suppression and can I comment on that dialogue because all of those are examples of positive thoughts right positive thoughts that are good uh but they're not automatic thoughts they are thoughts that need to be practiced right negative thoughts unfortunately that reside

in our reptile brain are automatic so that hyper response I mean danger type of situation when we evolved right is responsible for our survival so we learn the negative thoughts very well I'm in danger I have to run I have to get on top of this tree the lion might come whatever so only 50 million years ago when we developed the frontal cortex more uh positive thoughts came into the picture and they're very helpful for all the reasons you're mentioning but they're not automatic like the negative ones are hopefully they will become so what I

tell the kids is if I if they don't play guitar if I give you a guitar right now would you be able to play me a song absolutely not I have absolutely zero minus one musical ability but I love music but if you if I gave you a guitar with guitar lessons and you practice you probably will be able to play a song a year from now well me with some degree of proficiency but not but everybody else yes a support system a support system that's right and with enough practice hours and enough deter focus

and determination I'm I'm convinced I could um become at least proficient um even at 49 years of age so we have a slogan in in my team which is practice positive thoughts all the thoughts you were mentioning are good ones and we have to practice them right this is what I'm learning no I'm I'm not bad this is happening because of the que even when the lyic system is not active should do you encourage uh your patients to practice positive thinking even when they're not in the stress response all the time interesting it's like it's

learning a tool so in this Q Center therapy one of the lessons is that they have an empty toolbox and and this toolbox gets filled with tools that they learn and practicing positive thoughts deep breathing mindfulness all of this muscle relaxations are tools that we teach them but they decide and here's where the empowerment comes in they decide what the cues are they decide what tools they're going to put into their toolbox or they're not going to put in the toolbox and by far whatever tools they develop that have not been taught by me or

anybody else work better when they develop it themselves interesting and you know I I I had this case once and and it got Illustrated really well when I I was in in one of the sessions you teach them breathing exercises muscle relaxation things that we know help and I'll talk a little bit more about how we know that they help and um and then they have like a week to practice and then they come the next week and we see where they are and what's in the toolbox and things like that and the next week

when when she came she was much much better you know and I said I was very proud I'm like oh you've been practicing the tools right that we discussed last week and she's like no I actually don't remember anything you said last time but I I came up with this thing that when I feel bad I'm I'm drinking a glass of orange juice every time and at that moment I knew I could go both ways I could go no no you must practice is my tools or I could say how wonderful you've identified a tool

that helps you to drink a glass of orange juice which obviously is what I did and then she was able to have that in her in her toolbox and and we have multiple examples like this so she would drink a glass of orange juice in order to quell her anxiety yeah if she felt bad and is this something that she would do even when she wasn't feeling stressed I mean it's kind of interesting it suggests and it completely squares with everything I understand about prefrontal cortical limic Pathways which is that they're highly subject to contextual

learning right if any the frontal cortex is this incredible feat of evolution that um allows us to link essentially any stimulus with any um non uh learned response in the body right I mean this is what allows you know soldiers to learn to overcome their fear of Bomb Blast and run toward them if if necessary I mean I mean it it can cut both ways of course um but for me and this still needs to be tested is is nothing necessarily about the glass or even the orange or the vitamin C or anything like that

it's about the fact that she has this message she has sent a message to herself I can take care of myself because the best tool that I have is me it's my own body whatever these kids go in the future there's something that's always going to be there with them which is themselves so they as themselves is the best tool they can have you know their body the the way they think all of these things do you think this is why we hear the uh kind of classic anecdote about the patient who has anxiety attacks

whose psychiatrist gives them a a couple of pills of medication that can help reduce anxiety and they decide to keep those pills in their pocket should they have an anxiety attack and knowing they have those pills in their pocket allows them to control their anxiety yes because it it gives them a sense of control right and and they have control over this and some people may choose to leave them in the fridge and some people may choose to put them elsewhere but is what they decide is that decision they're making that gives them uh a

sense of control that's important it's so interesting the sense of agency and control over the um non-negotiable stress response you know I sometimes unfortunately get um in my opinion uh incorrectly attached to ice baths uh we've talked about cold water exposure on this podcast our colleague Craig heler at Stanford Department of biology phenomenal scientist was on this podcast we talked about some of the beneficial uses of deliberate cold exposure there are a lot of arguments does it increase metabolism doesn't seem like it does very much is it useful for inflammation perhaps um but the one

thing that everyone agrees is that being in uncomfortably cold water makes you breathe F faster excuse me and stress a bit in other words it kind of sucks it's uncomfortable and I think one non-negotiable fact about deliberate cold exposure is that it gives people an opportunity to explore their own stress response if they're going to do it safely right you take a cold shower you have some control you can get out immediately obviously you don't want it so cold that you give yourself cardiac arrest you know you have to be care care f with deliberate

cold exposure but the adrenaline response to uncomfortable cold is non-negotiable and I believe that whether or not somebody decides to you know recite the alphabet or think about how cold it is or whatever it is what they're doing is they are practicing this frontal control over the lyic pathways it's just sort of a general exercise for controlling the lyic system through thought but as our colleague David Spiegel has said to me many times says um you know it's not just the state that you're in here we're talking about stress as the state it's how you

got there and in particular did you have any control over how you got there and whether or not you can get out and I think that the kind of stress that you're talking about in post-traumatic stress disorder or in post-traumatic stress injury is typically of the sort that people didn't have a choice certainly these kids didn't have a choice about the initial exposure to the trauma or stress but that also the stress is showing up when they would least want it to appear or when it's very inconvenient to appear so this this narrative is important

is an important part of of recovery um but we feel that it needs to come after the education piece and after learning uh a toolbox having defenses because sometimes it can get very charged when you go through the narrative and you want to assess many things during the narrative you want to assess gaps of memory you want to assess potential cues you want to assess the emotions that are present so and and the narrative should be one that covers not only negative events but also neutral ones and also positive events and and it sounds like

a lot right but when you're talking about kids that have 10 11 12 years it is doable you know you can really manage it by the way with the cold showers I I think you're getting to the hinge of that seao I I think the cold shower probably does not the cold shower what do you call deliberate cold it could be from cold shower I always say that because oftentimes people think oh you know they're just trying to sell cold plunges and the truth is you don't need that I mean the fact of the matter

is uh it's uh independent of income actually a cold shower will save you money on your heating bill I'm not saying everyone should take a cold shower I I love a nice warm or hot shower I sometimes use the cold shower as a stimulus and I hate it every time but I always learn something each time um by the way it feels great when you get out so that's nice and it does for many hours um especially if you end it with some warm water but the uh the learning I believe is in recognizing just

how destabilized our patterns of thinking get when we have adrenaline in our body which is what uncomfortable cold does and it deploys that adrenaline in the brain and body and it also is a great learning in seeing the return to a BAS line just seeing how that affects our psychology and I I to my mind I can think of no other zero cost or even negative cost um meaning saves money approach that works the first time and every time you know that is safe enough right I mean I'm not interested in anything that has to

do with snakes for instance I don't mind spiders I'll pick them up with my hands as long as it's not a black widow or a particularly large spider and I'll put it outside but I don't like snakes I don't like thinking about them I don't like being near them so you know there are other stressors that one could use but it's so individual whereas cold water seems to be uh pretty uncomfortable for everybody I think you need some exposure of snakes and you're cold no interest it's so interesting you know these things get so firmly

rooted but I'd love to talk about this toolbox um because first of all it's according to your work and um this has been done repeatedly It's very effective and and I I love the idea that it can be customized so the words that come to mind is a customized toolbox for combating stress and PTSD and the fact that it can be customized and maybe even covert like we can have these tools inside us we don't need to share them with anybody if we don't want to but that they are very effective I think that those

are very compelling reasons for exploring the uh the toolbox approach a bit more here so you mentioned one way to go about this is to think about or to have in mind some negative some neutral and some positive experiences and then to think about the different tools that one would deploy under those different conditions correct so so the exercise of the events is a Lifeline that we do separate from the toolbox we actually work on the toolbox first to identify um coping mechanisms and coping tools that help so what would that look like let's say

I'm a a nine-year-old I come into your clinic and I meet the criteria for ptsi or PTSD um what sorts of questions would you ask yes so I the first thing I would say when you're feeling a certain way whatever way we're talking about right agitated anxious nervous uh is there anything that makes you feel better because the experience of having something and they bringing something is important too and sometimes they do they say I listen to music or you know I play the guitar or I go to play or my friends or my friends

are my teammates mostly actually they say teammates teammates is pretty popular I love that yes there's something about sports and and and sports is something that comes up a lot when we do the toolbox people put in their Sports they're doing or talking to their coach or talking to their teammates or learning a new sport uh sports are big so that's an example that they give uh talking to friends um uh planning a sleepover uh listening to music uh different things like this are there any particular tools for um when kids are stuck in a

stress response yes so because I I myself am familiar with um you know the toolkit that I use um certainly teammates is is one of them and I have others including long exhale breathing physiological size these things will be familiar to some of the listeners but certainly there are times when we're stressed about something and we don't want to be and we have a hard time pulling our thoughts and our emotions and the stress response you know out so the ones I just mentioned are are some ideas that the kids bring with them what we

always try to do is we teach them uh exercises of relaxation we have to be very careful with this because like like you say it's good to be personalized right it's good that it's adapted to the kid and that's why we don't tell them put this in your toolbox we tell them learn it and if it helps you you decide if you put it in the toolbox or not so when I talk about the treatment being not so much about the what because there's many components here like education narrative uh that are common right exposure

we we can talk about uh it's it's not so much about the what but it's about the how it's about empowering kids to identify those cues to say if a tool works or doesn't work to develop their own tools so but sometimes they are very stuck right and and they need a little bit of help so we teach them breathing exercises and we have a script for that we te Teach them muscle relaxation and we have uh something for that we teach them the positive thinking for example so that's a cognitive uh type of tool

um and we teach them mindfulness because of our other work in prevention that we can talk about uh later in in which um mindfulness has been helpful and and and also yoga very simple yoga exercises so so nothing too complicated things like the mountain pose for example uh can be quite helpful for some kids if anything it helps them uh reassess the moment and and stop and if we're going to think about it in cognitive behavioral terms kind of break break that chain of negative thoughts that happen one after the other which can lead to

a panic attack right that's many times how a panic attack can start well what's so interesting to me about the stress response is that while it's quick to start it's slow to shut off for logical reasons related to our evolutionary trajectory right um wouldn't it be one wonderful if you could stress when needed and then it would turn off when needed but what we're really talking about here is intervening in the stress response either before or as it's happening but then also making sure that the tail of that stress response isn't too long we're also

talking about eradicating stress that causes discomfort right and is this causes this stress uh not necessarily to live a life without stress or to get rid completely of stress because that's would be impossible in certain cultures there are um accepted practices that adults use to deal with stress things like worry beads um and a few years back there were those what were those F what were the little spinner things that kids had um uh when those were popular maybe they're still popular Did You observe any reductions in stress um you know kids have a lot

of energy like sometimes I think we confuse energy and stress um wouldn't we all love to have the kind of energy that we had in childhood um I was observing this the other day you know you'll see a kid sitting cross-legged listening in class and then all of a sudden it's time to move across the room and they'll just pop up and move across the room like when was the last time any of us like popped up out of our chairs unless we were particularly excited or scared as adults um just that immediacy to action

um implies that there's a lot of energy in the system so I could imagine that having some ways to siphon off some of that energy through as far as I can tell you know um things like worry beads or or fidgets or whatever those are called I mean they might irritate some adults around but really they're pretty innocuous when you think about it I like that you're not calling it nervous energy because it is just what you said it's Just Energy it's extra energy uh that needs to be placed somewhere and they're trying to find

out where to place it I mean we have colleagues that not all of them this is not a requirement for being a professor at Stanford but I've got colleagues that work 80 hours a week you could argue that's healthy or unhealthy depending on the context and their agreements with others but you know that requires a lot of energy and I know they are not particularly happy working less so you know I think sometimes we are dismissive or kind of um pejorative about you know uh physical energy and and shaking and moving but you know I

I see I know someone in my life who bounces her knee while she works and it it's it kind of makes me a little bit nervous but boy does she have a lot of focus and energy you know so I mean I think it's wonderful in other words yeah yeah and and some of us you know choose to have meetings while walking rather than being in an office that's certainly my preference you know I go for a walk sometimes uh when I have a meeting so yes so there there is increased energy but there's increased

energy that of of I feel like I need to do something and there's increased energy that causes a lot of discomfort so for this kid that kids that experience discomfort then they can look at their tool point and say which one I'm going to use and and that gives them also a choice which goes back to that sense of control again earlier meaning off microphone we were talking about the fact that some people indeed some kids have a different tendency to Anchor towards thinking or feeling or action when under stress and um you were describing

the four quadrant system uh could you share with us this four quadrant system because I think it's both extremely valuable to children and to adults it's certainly something that I plan to incorporate into my life yes so we have to be careful with uh structured uh interventions because sometimes a structured interventions can break a little bit the fluidity uh of the relationship that a therapist and a child may have or a therapist on on a patient so it's it's better to be semi structure and to really be attentive to the temperament that the kid brings

into that relationship or into that session and certainly with the toolbox as you mentioned we see an example of that we also add that in Q Center therapy by dissecting and examining a response so for example a child that breaks windows or child that screams or a child that lives the classroom running we try to understand what's happening at that moment and the way that we do that is by looking at a square and a square is composed of four corners and the Four Corners are what you're thinking so it's a cognitive side to it

uh what you're feeling emotionally what you're feeling physically and what your are uh actually doing what the action is and and this is your classical triangle of cognitive behavioral therapy in terms of what you're thinking what you're doing and how you're feeling but but we felt it was important to add that somatic physiological component because for many children they don't have the vocabulary to talk about all of this they just tell you I have a headache or I have a stomach ache and and there's no other Medical reason that explains it right so depending on

the kid that comes you're going to start examining their response through one of those Corners so if the kid is really brainy and likes to think about the things they think or don't don't think you start in the cognitive corner you know other kids are very attentive to their body and they say I feel my heart racing when when I engage in this Behavior or in this response and you start with that corner the beauty of this is that most of the time you don't have to work in all of the corners by just working

in one corner all the other Corners change and a new response develops okay so if I'm thinking that I'm not in danger maybe I don't need to leave running maybe I can just tell the teacher I'm distressed by the amount of noise all of a sudden the kid has created a new Square that's another Square so hopefully we take that one response as a square and build a cube right of many potential responses so that when the Quee happens now there's an armentarium of responses and if I'm too distress to think what response to do

I can bring myself there by using my toolbox so it it all kinds of starts tying together and then as I have more responses as I understand cues I can begin talking about this narrative that I have where I will fix some cognitive distortions hopefully like it was my fault I made it happen to things like no it wasn't my fault somebody else was responsible and I'm just a Survivor right I'm not a victim I'm a Survivor that's another cognitive distortion that can be fixed so so all of that we we've included all of this

in a manual for therapist right so we have a manual for therapist that is called Q Center therapy for youth with post-traumatic symptoms published by Oxford but I believe that adults that want to reexamine their childhood or their history or want to think about their kids or are interested in trauma can get a lot from actually examining this manual and studying this manual and in fact I believe in so so strongly that we are um beginning the first first steps of adapting it not only for youth but also for adults in this four corner system

and forgive me because I called it a four quadrant system but in this four uh corners of the square system you said there's thinking which is cognitive there are emotions then there's feelings which are somatic physical and then actions so actions are straightforward thinking uh would be for instance uh if I understand correctly I'm in danger um emotions would be I'm scared so it's a it's a a a a verbal label I'm depressed I'm scared I'm sad I'm yeah and it way is cognitive too right but it carries an emotion with it and then in

terms of the physical feeling it's you know of the body but it could include of the head too like I have a headache or my heart is racing or I'm I um or something of that sort and then actions of course is the action that they an action is really fun one because you can imagine there are some kids that are not psychologically minded at all and they don't even want to engage in this with me and they're like okay what is it that I'm doing I'll do something different so they'll they'll immediately develop the

next Square so they cannot things talk too much about their emotions or how they're feeling physically or look at the negative thought but they say oh is the problem that I'm running out of the classroom well what if I don't and they give you another action and and so some kids start with that corner so you can really start with any of the corners yeah I love that earlier you were talking about practicing positive thinking even when perhaps especially when one is not in the stress response or trauma response but also of course when one

is in the trauma response I think that's just so vitally important for people to hear certainly for for me to hear um I'm not claiming to have PTSD it just but as a as a novel concept that I've not heard raised before you um around these topics the other is this four corner system um which immediately occurs to me is so powerful because it breaks down um the kind of reflex arc of the stress response into its component parts right what's of the body what's of the thinking what's of the thinking that's emotional and then

what's the action and you said as soon as one um identifies one of these corners and starts to kind of look at it differently and consider some of the optionality that exists an alternative that all these other options Cascade from that and I believe that in doing that you've described what um for thousands of years really um but recently we've heard a lot about in the kind of mindfulness Arena as creating space right like like this notion of creating space not outer space but creating space within us to to uh choose better options is something

that I think until right now as you've described this has remained unfortunately very mysterious you know people talk about okay you um you know you want to be uh reactive excuse me you want to be um responsive not reactive responsive implies some optionality to your responses reactive implies kind of a reflex arc of just whatever the default was but this notion of space is like too squishy for me as a biologist to really um to really be able to latch on to and I I would argue given the prevalence of PTSD and stress it's probably

too squishy for me most people it hasn't really LED anywhere specific but I think what you're describing is the ability to become responsive as opposed to reactive um assuming that the word responsive includes like some options within it and so this four corner system to me is genius because it gives us an anchor point to start from so could you say that if a child or adult is um uncomfortably stressed maybe about a trauma but just as like caught in the stress response that actually pulling out a pen or pencil or crayon as it were

and and write and drawing a square and and just really like what am I thinking like maybe it's just like this is terrible I don't like it writing down um I'm embarrassed like I'm not with my friends like I'm like not you know I'm flush you know my cheeks are flushing whatever um I'm feeling like just weighed down or something and then think well what what are the actions I want to remove myself from the situation at that point is the suggestion that one find what is the the point of entry that feels most accessible

and to start there yes with one caveat we usually use um Wagner's um emotional thermometer to measure where the kid is at and it goes from like 0er to 10 or 1 to 10 uh with different levels of stress and and it's good to use something concrete because sometimes we think they are a 10 and they're at five or vice versa yeah we're very poor at assessing others internal states are as our colleague Carl dth who's also been a guest on this podcast I heard him once say this in a very large lecture he said

you know we're terrible absolutely Dreadful at assessing other people's emotions in fact most of the time we don't even know how we feel yeah he he always says that and it's true it's true but I would say if the kid is at 10 at that moment the best thing is to use a tool from the toolbox and not to engage on the Square at that moment until they come down a little bit and they can pick pay attention and they can listen to you because then that they will be letting the information come in they're

so emotionally charged right at the moment that that may not be the right time um which also by the way is the same thing as as when you need to talk to kids about traumas that are happening in our society right sometimes you just want to let them know that the door is open for communication you may want to talk about it at the moment with the kid K may not be ready but you can let them know Well when you're ready we can talk about it here the same when you're ready let's go over

the square exercise or the example if the Kitt is already familiar with it or I have something to show you right and pick his C curiosity that way um but I would say use the thermometer to see if that's a good time right if if it's 10 98 probably not wait till it's like 543 and then engage in that so the toolbox should be used essentially under any conditions um and the kid should generate their own tools to add to the toolbox customize the tools and then the square can be used when they are at

a slightly lower level of stress because it requires a certain level of cognitive intervention they need to be able to think about and and express their own State correct okay and is this something that you suggest kids only do with their therapist or is this something that they can do on their own as well assuming that they're old enough to to write and to think about it yeah well our our hope is that after a kid goes through Q Center therapy that they can internalize a lot of these activities and exercises and like I said

become their own tool like like take those for life and continue to use them yeah I'm certain that many many adults not just children can benefit from these tools I mean I mean I would argue that most most of the bad things that happen in the world are the consequence of disregulated autonomic function put kind of bluntly Yeah by directional right kind of making things worse once they happen they impact the system even further yeah I mean I think most homicides are homicides of of jealous rage from what I have read I don't know if

that's still true but and of course then that it's probably also true for all the things that are not as severe as homicide but still dreadfully bad like assault and things like that yeah um and and it's interesting that you bring that up because I often think about we we've been talking about how we experience trauma as individuals right but we experience trauma in our civilization we experience trauma in our history we experience trauma in our nation and how those in nation heal how does a system heal well the steps are not that different perhaps

this is the appropriate time to um give you the opportunity to editorialize a little bit about um social media and online behavior um setting aside really aggressive online Behavior bullying and things like that which of course exists and is really serious um do you see the behavior of kids and adults online the sort of um just maybe even the the addiction to online um commenting and reading of comments and the kind of battling of issues back and forth it clearly isn't going anywhere some of it goes someplace functional but most of it I would argue

especially among the adults is going nowhere it's just very circular it's my side versus your side my side versus your side and emotions get really stirred on there yeah um do you think that is reflective of um a lack of tools for self-regulation um do you think like what we're seeing is the manifestation of of just a lot of challenges in the world um and or an outlet for people to just vent without the need to address their own internal State and what's underlying the venting I I know many very very intelligent adults who eventually

just had to quit social media in order to have any level of functionality in their life it comes down to that space you were talking about and building that space and creating that mindfulness time that you need which is also going to be personalized it's going to be different for different people uh this spring I was in Morocco and I visited the Medina was staying at the Medina and I was overstimulated as you can be and enjoying it but I imagine this is the state that teenagers are in all the time when they are with

social media bringing them information and different tid bits and different things that are happening all over the place and very much like I found it restful to go to my hotel for a couple of hours before dinner uh people need to build that space people need to create that space what I tell parents is that it's important to remember that this was also a very helpful tool for us when we were in the pandemic right the kids were interacting socially Academic School was happening uh through technology so how can something so good be at times

so harmful and I remind them about when they brought hammers to their house right and they had little kids they had to teach them how to use them this is a very important tool when you need to nail something or when you need to take a nail out this can be dangerous right you don't run with scissors you you have all these rules around other tools we have to have these rules around social media as well and and I and I think that's what the Surgeon General is getting at when when he talks about we

need some regulations around it um but at the family level at the family level I think parents need to say there are certain boundaries that we are going to have for so a dinner time for example in this baskets all the phones go into the basket and that's what we're going to do from now on but it is very difficult because when you establish rules like that kids watch you like a hawk so you have to model the behavior you are expecting right the moment that you as a parent decide oh no I need to

go to the basket during dinner because I need to check this thing out then it breaks so that's what I think I I think it can be quite helpful and and I think that it can be dangerous we've seen examples of that and and it is a tool like any other like a knife that we need to learn how to use it I think what you're describing to my mind uh is a situation where the tool has become the terrain it's like social media has become the landscape in which many people live as opposed to

the real world I mean my original understanding of social media is that one would experience and do things in the real world and then bring those to social media that's certainly what I do I teach on social media and um I do the learning for that teaching the drawing in some cases the preparation in the quote unquote real world and then bring it to social media but I feel like the it's almost like the the hammer has become the um has become the landscape the house or yeah or something like that the hammer has become

the house yes that's much more eloquent and and and appropriate um yeah I feel like with social media the tool of social media has become the terrain in which people are living in so that just feels like a um a closed loop is sort of an engineering uh example just like it doesn't go anywhere like you C you can never actually get the relief that you're seeking and I think we default to descriptions about dopamine and dop dopamine hits and there's some truth to that but the more I look at the literature on brain activation

during social media use it it doesn't really speak to dopamine and reward prediction error as much as it does just sort of a Mindless compulsion and um kind of just P passive overuse as opposed to like rewards like oh this is so cool and that so cool I mean it can be I mean I've been watching some of the track and field races of the Olympics and there's a I mean I was cheering out loud for a few of them but it's it's usually something quite different yeah I I think if if you live in

a virtual world all the time then you're not living right you're not in the real world so it's like how can you use the virt are there ways that the virtual world can help you live the current world in a better way yes so that's that's why I think it's helpful um but if you replace your life with a virtual life then that's a Pity that's very sad I see that in a lot of adults as well as kids let's talk about risk you know up until now we've been envisioning a a treatment situation or

a study that you're running where a kid and perhaps parents as well are brought into the laboratory or clinic at Stanford and you're talking to them assessing them they're developing a custom toolbox and that's a wonderful opportunity for um kids who sadly have PTSD or ptsi um to be assessed and to develop tools that can really help them that's been proven by the work you've and others have done but what about the many many millions of kids and adults who are at risk either because of lack of access it could be due to finances geography

poverty any number of different things or they simply don't even know what PTSD and ptsi are uh their parents don't know um what are some of the tools and interventions that you think could be implemented at the level of schools families or even individuals that might help them so here we were in my program we had created Q Center therapy right we develop a training program for it we have a Q Center therapy training program and I became increasingly concerned about my own staff and my own team because this is a team as you can

imagine that are seeing trauma every day and are seeing trauma in kids I was worried about vicarious trauma and the impact that this would have in their health so I remember that when I was doing my residency I took a course in hypnosis and I was really struck by how much control one has during hypnosis so it's nothing like anyone is doing to anybody else is is is really kind of having the control to relax yourself self-directed hypnosis self-directed uh type of hypnosis and and I said I would like to bring something like that and

I met a PhD John redger that was a yoga instructor and also a mindfulness instructor and I brought him to the team and and he had other things to do but one of the main goals was to take care of the team and we started regularly practicing yoga and practicing mindfulness as we were seeing all these cases and working with trauma and so forth and I was able to see firsthand how helpful it was for me personally and for my team at the time we were doing some work in East paloalto in some of the

schools we're doing some prono counseling because this another problem many of the schools have no counselors right so um and this but this was a while back this like 10 years ago yeah the East Palo School District for those that don't know paloalto I guess it could be called West paloalto is a separate city and county from East paloalto pal Alto is not exclusively but is known for at least nowadays let's just be frank fairly tremendous affluence relative to most places in the world put bluntly um East paloalto a separate County different School District police

system has for as long as I can remember having grown up um in pal Alto um has always been stricken with far fewer resources and U while there have been tremendous efforts to improve the um the situation there it is still at a um steep disadvantage financially um but of course um many uh amazing people working there and living there and um you know and growing up um there was some exchange across uh that um east palto west palalo uh border as it were uh in the school district but they're pretty separate domains when it

comes to resources and it is not now but many years ago it was the number one murder capital in the US um it's also the place where Facebook is now so so in Ikea and there there's people that bring some employment to the area but also bring some other problems yeah that area where Ikea is used to be called do you remember it was called whiskey Gulch they didn't know for years a kind of terrible name right but it was a stark contrast to right as you literally cross the train tracks heading towards Highway 101

um in that case that portion of palalo Crescent Park an extreme of wealth to an extreme of poverty yes in in literally a distance of 10 meters and of course there are uh wonderful families there of course uh uh that support the kids there's a Ravenswood which is also the other name for is paloalto Family Health Center uh that that really provides a lot of good resources to the area and there's a good school district but at this time it was missing counselors so we had some presence there we decided to to bring some of

the things that that we were learning in terms of yoga and in terms of mindfulness to two of the class rooms at the end of about 3 months I get called to the principal's office I have to go to the principal's office to because the principal was interested in finding out what was going on in there because none of those kids in those classrooms had gone to her office in all that time they hadn't gotten in trouble they had not gotten in trouble so I explained what it was and we decided to do you know

a bigger scale uh study and and eventually we partner with a group called Pure power uh pure power inc.org uh developing a yoga and mindfulness curriculum for students at schools at that time we started bringing yoga instructors into the classroom but we we very quickly learn that the best approach to this would be to teach the teachers and have the teachers teach the students because the yoga instructors had no training on how to control a classroom and the teachers did and some of these poses were so Elemental that you know it was okay if they

were not a yoga instructor so anyway we tested this curriculum and and there was a piece about it in the newsour I think it might still be there and I get this uh wonderful phone call by uh this family in New York that wants to see how they can help me spread this further into not only the classrooms that I was working but uh into the whole school or the school district and I knew at that point that two things were important not only that they wanted and I wanted but that the school district should

want it and also that at this time we would need to do a very in-depth study to see what our intervention was and what the curriculum was because mindfulness can be the name that you give to many different things so we wanted to make sure that our intervation of yoga and mindfulness exercises that now pure power carries um is really what we're being tested so they were very very helpful in helping sponsor not only the dissemination of this curriculum through the school district but a randomized control trial where we actually had a whole other District

that would also be trained but only after the study was over it was a demographically comparison School in in San Jose in in the city of San Jose uh near enough for us to conduct a study but far enough that were there wouldn't be uh too much um dissemination from one District to the other and it was good that we did a a districtwide control because if we would have done done it by classroom or by school it wouldn't have worked because there was so much diffusion of what the kids were learning into the their

friends and their family and the other classes and the other people in the community that was beautiful to see but it would have ruined a control study so you needed literally physical and demographic separation so you went with uh what used to be called the peninsula the South Bay East pal Alto and then San Jose far enough apart that the kids weren't talking enough to uh blur the the treatment groups exactly so we demonstrated feasibility you know we were able to do it we demonstrated acceptability the kids liked it the kids would do it some

schools actually had a a room specifically for them to to go and do it even if if the teachers were not doing it in the in the classroom and it ranged it was like uh twice to three times a week for 15 or 50 minutes of this curriculum in the in the classrooms can I sorry to interrupt but can I ask you a little bit more about the curriculum um you said five uh you you said or 15 to 50 5 Z minutes um two to three times per week and did the kids have to

like change over to their yoga clothes the reason I ask is that um I could think of a number of real world barriers to getting something like this implemented I feel like going jogging usually you get a little sweaty you need running shoes you know there are other forms of exercise that require that less but um these days there as far as I know not every school requires physical education when I was growing up and through High School you had to literally suit up you had to go in the locker room put on your your

PE clothes as it as it were and then you'd run or play volleyball whatever the PE teacher told you to do had to do if you wanted to get a good a decent grade um is the yoga being done you said it could be in the classroom or at a separate location but are the kids basically getting up out of their chairs and just right in their school clothes doing this for 15 to 50 minutes so they they stay with the same clothes um but we had mats they had mats every student had a mat

and it's interesting that you mentioned PE because the first suggestion was let's do it during PE class and I'm like no that that's you know rowing from Paul to to Peter um until I learned that PE like you said was not happening so sad which I couldn't believe and if anything I think the study has helped for them to bring PE back and the classes which are these lessons and yoga movements and mindfulness were really taking place in the classroom that whatever teacher learned it so if it was the math teacher she was taking 10

minutes aside to do it if it was the p and B was not happening there they may dedicate the 50 minutes uh to do the yoga and the mindfulness so um we we have a a number of uh assessments that we did and like I mentioned yes it was acceptable and and it improved mood and and all of that but I think the biggest finding that we published from that study was that it increased 73 minutes of sleep uh 73 73 minutes of sleep that's EX extraordinarily high on average for for the students and it

increased the depth of sleep so something that we did in the study was that we also did portable polysomnography and it was not in a Sleep Center it was in their own house so collaborating with Ruth oara from from the Department we were able to assess their sleep and and deep sleep is very important that's where you process the events of the day so these kids were increasing RM total sleep deep sleep doing much better and then another thing because of our previous studies that we've talked about in terms of brain function uh this hasn't

been published but we have some preliminary data demonstrating that those kids that went through the intervention before and after the intervention uh were able to decrease the activity of their amydala which was very powerful and also very helpful so many of these kids adapted this into their daily practices after this study was over we went to our control group and and we taught those lessons there and um and now it has served to identified even more tools that we can put in the toolbox of CCT so so we utilize some of the things there in

here so pure power and our program have been collaborating a lot because it covers the risk group and the treatment group so sometimes when we go to schools and we do trainings we um partner with them so that we have the yoga and the mindfulness and the Q Center therapy and and and I by no means mean these are the two things that everybody should be using I'm saying these are two more Tools in fact I think we need more development more development of interventions both for treatment and for intervention and how do we identify

who needs what and and how is where we're moving next wow what spectacular results I mean 73 minutes more of sleep is like I mean talk about effective medicine you know I mean we agreed at the outset that sleep is the foundation of mental health and physical health and all forms of cognitive and physical performance I mean it's just me we know this the study done at Stanford albe it a small one of having athletes just get a bit more sleep or even just stay in bed a bit longer and know not on their phones

but just lying quietly with eyes closed and resting or sleeping more improved shot accuracy in basketball players this has been shown in so many domains of cognitive and physical it's like not even worth spooling off all the examples but that is spectacular it also makes me think I should start doing some yoga um because I I do get enough sleep but that's significant what do you think are the barriers to having this sort of thing implemented at national scale and I always think about this you know okay so the results are in maybe it's one

study maybe it's two but you're talking about a basically um harmless intervention and actually it's a very therapeutic intervention sure there are some people that won't be able to do all the poses Etc but there's always something that somebody can do um even people that are immobilized there are certain forms of uh believe it or not um uh cognitive yoga and and that friend of mine who works with people who are uh quadriplegic they can do certain things to keep nervous system function online but you know essentially anyone can do this um what are the

barriers from taking it from this East pal Alto school to a study to another study okay San Jose school now let's say you get all of Santa Clara or um you know neighboring counties um you know what does it take to get something implemented at National scale so that the work can really Ripple out and benefit all these kids who of course are going to become adults well we need to prioritize it right we need to prioritize education to to for starters right we were talking about classes not even having physical education or arts for

example uh and we need to prioritize mental health and it needs to start early and I think when we work our national budget it needs to be uh there needs to be ear marks for these two areas and that should go to the Department of Education the Department of Education should make this a a priority um teachers are really really overwork uh they they are under resource and like pediatricians many times are responsible for doing somebody else's work right everybody tells them oh this will only take a minute or this will only take two minutes

or if you make this assessment you know you can do that but but it the time is finite right and the space is finite so they need more space they need more time they need more support teachers uh and then this needs to be a priority from districts to really Implement programs like this so parents and and even non-parents um talk to the teachers in the school talk to the principles in the school and I've been learning about the power of the telephone um for lobbying this has been around some uh things I've been involved

with with the veterans community I mean the ability to look up and call your Congressman or congresswoman and tell them that you are really concerned about or excited about a particular program does have impact I mean I I at first I didn't think this was true but I realized that when they start getting 100 a thousand messages about a particular topic that people are passionate about they pay attention um maybe it's because they just want to get reelected maybe it's because they are genuinely um concerned about helping people I I like to think it's the

latter but regardless of which they run those messages up the flag pole uh when they bring issues so so let me tell you what we just started doing in Puerto Rico I'm from Puerto Rico uh but Puerto Rico and Puerto Rico Puerto Rican students have gone through a number of natural disasters that started with hurricane Maria and continue with other hurricanes and and also with earthquakes and and this has led to violence and there's interpersonal violence so some of the cases in Puerto Rico have gone through a lot uh but also the whole island of

Puerto Rico is one of the largest school districts in the US uh the whole island is one District meaning that if you do something like a program like the one we're talking about you can implement it islandwide um currently we are launching a project in Puerto Rico where all the teachers will be train in the yoga and mindfulness curriculum and all of the counselors will be trained in Q Center therapy the kids are being assessed at Baseline then they go through their yoga and curriculum and at time too when they get assessed to see how

they're doing after that um we also screen those that have uh ptss postraumatic stress symptoms that cause impairment and then those go through the trained counselors and then they get assess again at the in the latter part so the the goal is for us to although we've talked about the two treatments we've never really uh have both of them happen simultaneously and we want to do it in a large scale like this because if if this works if if it's sustainable if it's feasible we can actually then bring it to other large school districts like

New York like La for example and and start disseminating this I'd love your thoughts on something you know I'm so impressed that you were able to bring this from a study or set of studies to a much larger scale in Puerto Rico I could be wrong here but I feel like uh in the United States we have such a culture of Fame and popularity and reward around people who are extreme performers you know we hear about you know these NBA stars and right now we're seeing a lot about these incredible track stars and we're um

or we have these Tech innovators that found huge companies they used to be called unicorn companies but all these incredible um successes and um I wonder sometimes if the hyper emphasis on these extreme performers has led to the conclusion in young people that unless you're going to be Michael Jordan or Lebron James or Mark Zuckerberg or uh Elon Musk or win an Olympic gold medal that the practices that feed up to becoming those sorts of people like mindfulness meditation or becoming a yogi for that matter you know I feel like the there's been a push

towards hyp specialization and performance to the point where people are writing off the The Incredible utility of physical activity mindfulness um you know learning math science literature and the Arts you know talk about the Arts studies music right even for people like me you know I mean sure they always gave me the triangle cuz I could manage that one and I don't want to insult the triangle players I'm sure it's much more complicated than uh I'm giving the impression is but the point is that I feel like um there's been a uh not so gradual

uh disintegration of the idea that there is utility indeed there's great benefit to doing things not with the intention of becoming a high performer but just doing them for sake of how it enriches us in a number of different ways including our mental health and I wonder whether or not the lack of PE is sort of a well if you're not going to run track and try and medal or something and you know or go to Championship meets then like what's the point but I I don't um I certainly don't subscribe to that I'm curious

what your thoughts are um well I I think we need to redefine success and what it means to be successful uh I I think that we are currently describing it with the examples that you just gave which probably was not the way that we were describing it in the 60s or the 70s um but it it is harming individuals that which is most of us that cannot attain that level of uh proficiency in an area and in fact the individuals that are choosing to have a broader belonging in a way are more protected I I

worry about those other individuals too that have that very personalized um not personalized but very very individualized unique component in their life where they dedicate everything to that one thing they trust me they they often suffer in one or more of their other domains of life some don't but I would arue most do but the the idea of belonging right is that you have you belong to many different facets of life um you are a sports person you're a community person you're a student you're a father you're you know an ant you're you're different things

um when you're only one thing and that fails your whole identity is gone it doesn't even have to fail it has you have to perceive that it has fail and that's enough to throw you of course and so with the current definition of success we're not doing a service for those that attain that definition and those that do not attain that definition I think it needs to be broader I think belonging needs to be included I think the way that we care not only for ourselves but for the rest of our citizens needs to be

included uh citizenship is important um so it is dynamic so far it has been Dynamic how we define success and hopefully it will change again I I agree wholeheartedly let's talk about resilience earlier you said you know kids are not resilient but you also implied maybe you even stated it outright that they can become resilient what is resilience and what are some of the paths to resilience resilience is a physical term right it means you bounce the coil bounces back to where it was I originally I I like to think of the word adaptation because

it means not only you bounce back but you bounce back to a better place like I like to think that we adapted during the experience of the pandemic other than we were resilient of it yes we were resilient because we survived it some of us did not all right some of us have to deal with the grief of what happened during that time um but adaptation means that not only we go back to where we were before the pandemic but that now we've learned from that experience to be in a better place now we know

very little about resilience and we definitely know very little biology about resilience we know that having a sense of humor is good we know that persever perseverance is good we know that the presence of an adult in a child's life that was there to give them opportunity or or to talk to them about things they were going through that's probably the the best known you know resilient Factor um but what if it's not the presence of of that adult but there's something in that child that makes them seek and maintain that type of relationship right

so I feel that we need to start looking at the biology of resilience and one way that we've done that in my program is through a collaboration with Alex Urban from our department and from genetics and Caroline Perman who's in his lab and one of his post dogs um they work with organoids and I don't know if you've mentioned organoids before to your audience I have not but um uh one of my good friends and uh uh colleagues at Stanford Sergio pasca is one of the world leaders in organoids and we hope to host them

on this podcast soon but uh please um educate us on organoids they are oh so cool and oh so science fictiony but they are also real yes as well so so we have stem cells that can be converted to any type of cell under the appropriate nutrients and environments that we want to examine uh so for a psychiatrist of course the interest is to turn them into neurons and not only they can grow in a Petri dish but they grow suspended so is it's almost like a 3D and and Sergio uses um the term asem

bloid for when he actually assembles them further to create build uh more organ specific mini brains mini brains is the term that I like yes um so these mini brains are this neurons that are growing uh in a in a circle like the brain and they communicate with each other and they are active with each other and we can study so in conversations with Alex and now that you all know my previous work with cortisol and all that I was telling him and Carolyn well why would happen if we expose some of organoids to cortisol

um and of course we needed to come up with oh what would be the right amount you know that would mimic trauma so we also involve Robert saoli to help us come up with a concentration that would be trauma mimetic and so we expose a number of organoids to different levels of of cortisol for some of them it was a trauma for others they were not exposed then half of of that amount or much less of that amount was a trigger the Q right so some had the trauma on the Q some had no exposure

some only had the queue and then we compare what was Associated um with really um well the first thing that they needed to do was identified that these neurons actually had these glucocorticoid receptors and that they were active and they did have them and they were active so we looked through epigenetic analysis I wi is the Royal Wii right is more Alex and Carolyn they look at the genes that were change that their activity change because of this cortisol exposure and through epigenetic analysis which is the space you know uh between DNA and RNA and

there's like methylation patterns and all that and some gen activity changes some turn on some turn off so interestingly the majority of the genes that we found there were genes that have been addressed in the literature as potentially being related to post trumatic stress disorder things like the glucocorticoid receptor genes and things that you would think of but there was another subset of genes that we identify that were novel and I was very interested in those because of my interest in accelerated aging because of stress and those were genes that are related to collagen formation

and we know that atherosclerosis has been related to stress for example and as and we know that accelerated aging not only in BTSD but in mental health conditions overall individuals that suffer from severe mental illness chronically in their life end up dying 25 years Young than the rest of the population that's very significant and um so stress and accelerated aging interesting okay so these are interesting findings in organoids but but when you have those what you do is you move on to a population study so these kids in Puerto Rico that are going through these

interventions besides me checking on their PTSD their anxiety their depression they're giving me a vocal Swap and in the vocal swap those epithelial cells we can actually take them through epigenetic analysis and see those kids a time one that even though they've gone through all this trauma may not be fairing that much worse as as their counterparts and compare them and not only that we can actually also look at response treatment response for the intervention for the yoga and mindfulness preventive intervention and for the treatment for the Q Center therapy so that's the plan that's

the plan in trying to bring more light into what is the biology of resilience and how can we understand resilience better what a spectacular study goodness and if any of you miss some of the underlying mechanics I'll just quickly recap these organoids are little brains in dish that came to be by virtue of taking fiber blasts or other cells so skin cells essentially put into dishes provided four what are called transcription factors these are the four transcription factors that uh yamanaka won the Nobel Prize for identifying that reverts those cells into stem cells and then

a few other goodies molecular goodies that then allow them to become neurons in particular then they grow into little mini brains and then as Dr k was explaining are exposed to cortisol at appropriate concentrations to mimic cortisol exposure in the whole person and then from that the genomes of those cells and the epigenomes are analyzed to identify potential targets the results are brought back to these kids in Puerto Rico such that the genomes of all these kids experiencing different levels of stress and yoga mindfulness interventions or not maybe they're in the control group the outcomes

can be assessed and then one can address hey what are the genes that are protective against stress AKA what are the genes that are protective against high levels of cortisol and a bunch of other surely to be very transformative and important facts about how stress impacts the young brain to either give rise to PTSD or not I must say as you described that study I had three thoughts one wow how awesome is this that you can Bridge across so many different levels of analysis I mean because you're talking about molecular genetics all the way up

to yoga in school children in Puerto Rico and PTSD you know it's just a complex disorder I was also thinking to myself um wow what an incredible Place Stamford is that such a collaboration is possible Right makes me Delight in the fact that colleagues like you exist and Sergio and forgive me the names of the other colleagues I'm not familiar Urban and Caroline Perman thank you and the third thing is how important it is to bridge across these different levels of analysis I think this is the first time on this podcast where somebody has discussed

an experiment that Bridges across so many levels of analysis literally from fiber blast skin cells in a dish all the way to a complex psychiatric condition and in an attempt excuse me to create novel Therapeutics so it's just truly spectacular so if people are sensing a um even further surge in my energy this is the kind of thing that gets me so excited because in the landscape of science we often see a study or we hear about organoids or we hear about a yoga intervention and these things tend to exist in silos and isolation but

the ability to bridge across these levels of analysis I believe is uh critical and so um yeah kudos to you for for being a part of this incredible collaboration and collaborations are key right because the world is so complex now that there's no way that a single lab could have all this expertise so you're right a place like Stanford allows for these communications to happen for these collaborations uh to happen uh in 28 years that I've been there I have never heard no I'm not interested in that how we say at at Stanford especially if

two scientists um meet for more than 30 minutes what comes out of that is a collaboration as a final question I'm going to ask you to limit it to one answer but I'm sure that there are many um the question is if you had a magic wand and you could get any message out to the whole world about PTSD and ptsi in particular in kids and young people but also in adults what is that message what do you want people to know about post-traumatic stress disorder stress and post-traumatic stress injury the first thing that comes

to mind is the importance of of listening and listening to to what kids and adults have to say about their experiencing and really creating a space for them where they or us don't feel isolated uh that they feel supported and that they feel that they can identify their own uh strengths and their own capabilities of of making themselves better um you know every everyone knows or has heard about psychiatrist and everybody thinks oh what would your Psychiatry say and psychiatrist have these smart things to say to people that help them with their life but the

best psychiatrist that I know actually say very little they listen uh so I would say that listening to the experience that people have is is Key Well thank you so much for that and Dr car on vict thank you so so much for the work you do thank you for having me here yeah it's it's spectacular work um at so many levels um it's also very bold and brave work to tackle such a big problem with such um you know focus and to really give people agency this notion of a custom toolbox I think is

profound to give kids and adults as it were agency over their own interventions in an effort to really help themselves um I appreciate you coming here today more than I can express I know the listeners and viewers of this podcast appreciate it as well um you are involved with Stanford clinically you're involved running uh studies clinical studies of you know great importance so for you to take time to educate us with these tools is absolutely spectacular and is really appreciated um please keep us updated on your progress and please come back and tell us more

about that progress uh when the time is right thank you so much thank you for joining me for today's discussion about post-traumatic stress disorder and its treatments with Dr Victor Kion to learn more about Dr kion's work please see the links in the show note captions if you're learning from and or enjoying this podcast please subscribe to our YouTube channel that's a terrific zeroc cost way to support us in addition please subscribe to the podcast on both Spotify and apple and on both Spotify and apple you can leave us up to a five-star review please

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