The Biology of PTSD

Post Traumatic Stress Disorder (PTSD) is recognized as a significant issue that can affect people in everyday life. The sum total of small traumas can have the same biological effect as those experienced in combat. It is important for therapists and clients to understand the biology of this process to best help those dealing with this potentially debilitating issue.    https://www.ptsduk.org/what-is-ptsd/the-science-and-biology-of-ptsd/ https://www.psychologytoday.com/us/blog/understanding-ptsd/202206/the-common-effects-complex-relational-trauma    Transcript: you're listening to psych with mike for more episodes or to connect with the show with comments ideas or to be a 0:06 guest go to www.cyclicmike.com follow the show on twitter at psych with 0:13 mike or like the facebook page at psych with mike now here's psych with mike 0:21 welcome into the site with mike library this is dr michael mahon and i am here again with intern michael and brett 0:26 newcomb once more dear friends into the fray that's what i i'm leaving into the breach into the breach yeah yeah 0:33 i hadn't started the quotation yet you you say that every time i never mind say that once 0:40 okay and then i say oh yeah you're a shakespeare guy and then you say no i'm not i'm not like oh yeah you always 0:46 quote shakespeare i'm a liar okay 0:54 all right so how's everybody doing today doing well um you 1:01 said some incredibly nice things about intern michael before 1:07 the mics were hot and you don't say those things to me and i'm jealous isn't that interesting isn't 1:13 that interesting i wonder why you're going to have so are you begging what do you want i think nicest not no 1:19 yes you are so 1:25 yeah i secure need those that's what it is i don't know i feel like i got a little post traumatic your wife has asked me to stop blowing smoke in your 1:31 direction you inhale too much of it your shirt looks nice today michael thank you 1:37 thank you i appreciate that so uh so speaking of ptsd speaking of 1:42 yeah um this is not your forte right 1:48 it's not a biology not this aspect right yeah um so you're gonna try and hang with it and see i'm waiting for clear 1:55 elucidation from michael yeah because i know all you'll do is build a clock well the reason why for me 2:03 the biology is important is because understanding the biology helps me to 2:10 understand the concept and i understand i get that that isn't everybody's cup of tea but i've had 2:17 clients who have said the reason that i come to you is because you understand the biology 2:23 really well and you are able to explain that and that's really meaningful and that's why uh i have always said you know there's 2:30 different therapists for different people not all therapists are going to be for everybody but 2:36 a person shouldn't assume that just because they go to one therapist and that wasn't for them that that means 2:43 that therapy doesn't work no i and i and i can conceptualize being able to get some 2:50 comfort from saying i'm really sorry about the way that i behaved when i lost my temper and 2:55 slapped you but it wasn't really me it was my amygdala i'm sure that will help her 3:01 that's not exactly what the article talks about oh it is exactly what the article talks 3:08 about it doesn't say that you say i'm sorry that i said no it doesn't say that it says you need to understand that your 3:14 amygdala is out of balance and that's why you have these reactions when your stress triggers are pulled well so 3:21 the idea here that i think is so important 3:27 for both clients but also for therapists to understand is that 3:33 instead of thinking about anxiety as a 3:39 thing what we really need to start doing as a i think as a community of helping 3:46 professionals is to start thinking about the difference between anxieties and 3:51 fear-based anxieties because the way in which those things operate in the brain 3:58 are vastly different okay 4:03 so i if i can paraphrase just a little bit yeah understanding of the biology can help 4:11 drive the therapeutic approach because fundamentally there are 4:17 different mechanics underlying what may appear to be the same consequence but isn't 4:23 necessarily the same concept exactly and and i don't hear this being talked about 4:28 a tremendous amount this is what i did my dissertation on and i don't hear this being talked about a tremendous amount 4:34 in psychology but i do believe that in the future we are going to see exactly 4:40 that distinction instead of talking about depression and anxiety as two 4:45 sides of the same coin i think we have to think about depression as a separate 4:50 entity anxiety as a separate entity but within anxiety the generalized anxiety 4:57 disorders and the fear-based anxiety disorders 5:02 okay okay so in a regular anxiety disorder so just the 5:08 kind of run-of-the-mill generalized anxiety disorder what i say is that those things operate on the concept of 5:16 cognitive dissonance so you have two conflicting thoughts that causes distress in the human brain trying to 5:23 resolve that is what creates the energy for anxiety that 5:28 most people feel so i want to go to the grocery store but i have agoraphobia 5:34 and i don't want to go to the grocery store so that conflicting thought is going to cause me a lot of anxiety 5:43 even easier for i worked with a lot of adolescent males that's typically what i 5:48 do and when an adolescent male comes in and says hey i want to ask this girl out but 5:55 he treats it as if it's a schrodinger experiment where he wants to ask her out but he's afraid of creating 6:02 the answer so he lives in this perpetual world of i could ask her out but i could 6:09 also you know then be uh what do you call it rejected and then 6:15 then you know that's scary so i don't ask her out now i'm living with both of those things potentially available to me 6:23 i could ask her out and or i could not ask her out and and that's what i think is generalized 6:28 anxiety so that operates on the same kind of top-down brain function where your the 6:36 the cortex of your brain operates on the information and then informs your limbic system whether or not there's a reason 6:41 to become excited and then if there is a reason to become excited then your adrenal gland tells or or your pituitary 6:49 gland tells what gland to distribute the hormones to start an emotional reaction 6:55 that's slow responsible yeah yes exactly so that's typically the way the brain works is top down in ptsd or in 7:02 fear-based anxieties that gets flipped on its head so that the immediate activation 7:09 of the brain are the fear-based response areas like the cerebellum like the 7:17 medulla oblongata and then that causes a fight-or-flight response to be initiated 7:24 over which the person has no rational control so an individual who's been in 7:31 combat and has seen horrible horrible things and then gets triggered by a car 7:37 back firing the response that gets activated in that person is not a 7:43 top-down response it's a bottom-up response and so in those fear-based anxieties the 7:50 way in which the individual is triggered is radically different and if you don't 7:56 appreciate that in therapy then you could be treating that 8:02 inaccurately and appropriately or ineffectively so that's my my 8:07 conceptualization in a nutshell so you're following me so far i think so okay do you agree with that 8:13 or yeah absolutely okay i don't have any trouble understanding the concept i have trouble understanding how to 8:18 apply it um in counseling clients which is my 8:23 primary frame of reference i also have 8:28 some issues and been able to sort out anxiety from depression because they're often 8:34 comorbid and if you in my experience if you deal with one of them if you can alleviate a level of 8:40 intensity for anxiety the depression explodes then you have to do that and you need to 8:46 tell the client this is likely to happen and when it does it doesn't mean what we're doing is not 8:52 working it doesn't mean that you're unable to change it means that's part of what's stuffed down inside you and we're 8:58 going to have to come to grips with yeah then you have taught me a lot 9:05 over the years about the biology of depression and the issues there 9:11 in terms of chemical responses and so on it's just really um 9:19 an incredibly complicated challenge to then say however much of that i understand 9:25 how do i apply what i understand to hearing the client accurately and being helpful to them and that's where i get 9:31 lost in this conversation so for me and and what i would say is 9:37 the extent to which an individual therapist understands or wants to understand 9:43 better the biology of these different disorders is whatever it is and and i'm not saying 9:50 that everybody has to be a neurobiologist but what i am saying is that specifically 9:55 in the venue of anxiety it is very very important to identify 10:01 whether you think the anxiety is just a generalized anxiety disorder or it's fear i see that 10:07 uh and i see the value of the merit and saying okay this is a 10:13 reflex driven fear anxiety that you'll see triggered in this way when a car back fires or when a door 10:19 slams a loud noise goes off so 10:25 if we know that you're susceptible to that can we take that piece out and work on it loud noises anticipating it 10:33 responding to it differently because you're conditioned by the trauma experience to have this response 10:39 immediately overwhelmingly then the generalized anxiety is is a different issue 10:45 that we want to approach differently is am i understanding what you're saying absolutely and and so then when we think about 10:52 individuals who have experienced childhood traumas right so for a person 10:58 who has been abused by a family member sometimes it's hearing the creaking of 11:04 the floorboards yeah there's some research that shows that that's imprinted on these children if it happens in an early enough age 11:10 and so their response to that almost as hardwired in your brain yeah but it is hardwired when i i think 11:17 you're asking the question how do i use this to guide my practice yeah uh and maybe one way that i'm seeing 11:24 uh as an opportunity here is to think of the brain as taking the path of least resistance with different experiences 11:32 so in the instance of ptsd right we're saying that we no longer have to involve 11:37 the the prefrontal medial cortex right we no longer have to involve this expensive 11:42 part of the brain to deal with the same reaction as a brain 11:48 that we would around certain events so car backfiring is gunshot 11:54 floor creaking is fear in a child right um for whatever abusive reason 12:01 maybe as a clinician understanding that that is the current path of least 12:06 resistance says exactly what you're saying already we need to take that out look at that as a part and find other 12:13 paths that work better because that's no longer serving okay right no longer 12:20 this is actually more resistant and i think that that really fits in very well with your idea of emotional 12:28 economics so is this old behavior too expensive yeah yeah 12:33 yeah and and would you like to try and investigate other avenues that helps i 12:39 mean i have to have a way to frame it i have to have a way to hear it and when i read these articles 12:44 that in what happens to me so i need a better 12:52 modulator no not not analogy so much as uh i need a better understanding of how 12:59 this is applicable as you were suggesting i think one of the places that uh i i am by no means an expert 13:06 right but one of the things that i see keep popping up um is bessel vander kulk's work 13:12 the body keeps the score um he's a medical doctor that's gone into this foray of of um 13:18 psychology really one of the trauma i mean trauma informed therapy is his whole deal exactly one of the foundational uh creators and 13:25 understanders of ptsd as a as a condition um and i really did like that book i think 13:32 that book does help frame an idea of why is some of the biology important or like 13:38 how can it drive my practice so i have met and talked with and read a 13:44 book by dr mark gordon who's a neurophysiologist and he does a lot of work on traumatic 13:51 brain injury for the military and much of that work is focused on what's his name 13:57 mark gordon and much of his work is focused on 14:03 the biochemical aspects of the brain and where the brain injury occurs and how 14:09 the system adapts and responds and what needs to be rebalanced 14:14 biochemically so that you can then do other things it's a it's a whole area that i don't know 14:21 enough about to talk about or do work with but i think it's in line with what we're discussing i think it 14:28 comes back to some of the philosophies that i have around psychiatry right psychiatry is 14:34 a medically assisted therapy overall right it's drug assisted therapy but 14:39 overall the point is still the therapy right i would hope 14:44 we know that a lot of the time uh antidepressants or anti-anxiety or even 14:50 things like antipsychotics aren't as effective as they could be they they're they have 14:56 a five percent difference in the overall efficacy without therapy included 15:03 so i look at understanding the biology as just another tool to help assist this idea of getting 15:09 somebody back to a place of security and getting somebody back to a place of um being in control of what they want 15:16 exactly okay so let's take our break and when we come back i'm going to ask you a question brett all right 15:23 well one of the reasons that i want to participate in this show is because it gives me an opportunity 15:29 to clinically review my understanding of what therapy is and 15:34 how it works especially for the consumer so my hope is that we will find 15:41 conversations that broaden my understanding of that and my hope is that we do that in a way 15:49 that is useful but also entertaining for people so that they want to listen 15:56 not only because they're getting good psychology information but because they 16:01 just enjoy the show easy listening with an informational twist 16:06 that's a new tagline they're not sitting there going huh easy listening with an informational twist i'm really good at 16:12 this i'm a professional you're a professional if it's friday it's psycho 16:18 okay we're back and so uh does the idea or the the language of the 16:24 emotional economics does that make that the the what what yeah that all makes 16:29 more sense to me that's the language i can hear yeah i get bogged down in the analysis of the prefrontal cortex and 16:36 the amygdala and all that that to me is not a language i'm comfortable 16:41 and you make a great point though that that therapists who are doing therapy to the extent that they're not comfortable 16:47 with that then they're not going to hear that message all i'm talking about is the first thing you got to do when 16:53 you're dealing with an anxiety is to identify whether or not it's generalized anxiety or fear-based anxiety and then 16:59 and the most obvious way for you to know that is what well for me what i would say is 17:05 whether or not you think that the anxiety is based on cognitive dissonance 17:11 so is it is it what i'm hearing is if it's a global reflexive response boom 17:17 yes then that's on the floor ptsd yeah yeah uh yeah and so when i'm talking about kind of 17:23 distance you know do you see the anxiety as based on two conflicting thoughts 17:28 that the individual is trying to harbor give me an example 17:34 so uh uh i want to ask a girl out but i'm afraid to ask her out okay so that's not you know that's not 17:40 interesting anxiety okay yeah that's generalized anxiety and then you know i'm i hear the floor creek and i'm 17:48 terrible that's like albert ellis with rational emotive therapy uh the experiment that he offered you 17:54 know a guy that claimed i could never have sex with him and he said i want you to stand on the street and ask the first 100 women that 18:00 walk by if you can you have sex with me and you'll get slapped you'll get rejected 18:06 the police may be called but you know four out of 100 they'll say sure let's go and you're not going to know whether 18:12 it's real or not unless you do it mm-hmm so he would give people assignments like that 18:18 which you couldn't do today but well you can't really well yeah yeah 18:23 you have to deal with the clarification anticipatory set right right so uh 18:29 in my view then if you are if you've identified that you are dealing 18:36 primarily with a post-traumatic stress disorder then the first thing that you 18:41 have to do is to try and find some way into that because 18:48 what you have to recognize is that a lot of the techniques that we use in therapy 18:54 are directed at talking to the person's cortex you got to have rational thought 19:00 so cbt is an approach that's often recommended for post-traumatic stress yeah may not 19:06 be as effective because that's not really the right part of the brain yeah you're not talking about exactly exactly 19:12 so then we get things like emdr emdr here's where we start to move into let's get out of the head and start 19:19 feeling the feelings we we're having a good conversation about this earlier yeah well and feel those feelings 19:26 and you don't understand those feelings and find a way to redirect that energy 19:34 but i also think that that brett's idea of emotional economics when he talks 19:39 about that what i hear and i don't know if this is what you intend but 19:45 what i hear is that that's affective aff ect emotion-based therapy that's not 19:52 cognitive behavioral therapy when you're talking about emotional economics that is the way to approach the 19:59 post-traumatic stress disorder when we're talking about it's an activation of those baser areas of the brain you're 20:06 not going to approach that by talking to somebody's cortex you're going to approach that by talking to their limbic 20:12 system to their emotions so we're back to what does the therapist need to know in 20:17 order to do what they're doing and how much of that is even relevant for the client to know so if i'm talking to you about emotional 20:24 economics i'm not going to have this more extended exactly you don't have to now yeah i would i know you know but for 20:31 me that's a waste of time i know okay and well i think part of that conversation is valuable right in in 20:37 behavioral economics and emotional economics we talk about the idea that people have biases and those biases 20:42 aren't necessarily rational right and maybe we stare away from the word rational it's also a 20:48 message of power there's an empowerment if i say to you okay you could choose to behave differently 20:54 if you wanted to and if you could afford it you know i could choose to drive a corvette 21:00 but do i want to can i afford it uh what would i do i want you to fight can i afford it yeah what am i willing 21:06 to give to have one so that allows you a weigh-in 21:11 that isn't a direct challenge that they can rebut or refuse to hear 21:17 because you come up with an example or they come up with an example of some behavioral choice driven by cost 21:27 and you know so for me i don't really it doesn't bother me whether the therapist 21:33 talks about the biology or talks about emotional economics as long as they understand that when i am looking at 21:40 this presentation trying to do regular cbt is probably not 21:46 going to be as effective because that's not the area of the brain that this person is operating out of and i think 21:52 that the ubiquity of cbt and now we're talking more and more about trauma and i 21:58 think that there's going to be less effectiveness of that 22:04 of those treatment outcomes because that's not the area of the brain that that person's operating in yeah that 22:10 makes sense ultimately the goal is to move someone from that external locus of control to 22:15 that internal locus of control yeah with cbt emotional economics they're all saying the same thing right of 22:22 i'm putting the power back in your hands to make a choice of this thing which is one of the goals we have when we talk 22:28 about increasing your level of your sense of security if you have the power and the autonomy to make the choices if 22:34 you're free to choose you can freely choose to behave differently and i think that that's the goal so the internal 22:41 locus of control as opposed to the external locus of control is the goal but that's a rational concept so 22:49 initially that person may not be thinking in that area of the brain and 22:54 so you you that may be the goal for the therapist right but that isn't the way you go in to the therapy so the way you 23:02 go into the therapy is through that affective aff ect the the emotional 23:08 economic way however that makes sense to you as a therapist but you have to apply 23:13 some kind of effective therapy so not ptsd per se 23:20 but i had an adolescent male client that was on the autism spectrum and he was really in trouble a lot 23:26 because he would decompensate and act out because kids bullied him and picked on and what have you 23:32 uh and i had to work with the school the teacher the family and the student to 23:38 say is there a way we can get a handle on this and achieve different outcomes 23:44 and it wasn't useful at all to understand or explain where why how is he autistic 23:53 what makes that happen it was more useful we found that to say 23:58 can we find a way to characterize this for him where he can 24:04 feel a sense of power and where he can choose from that power to make different 24:10 choices and so i was able to ask him i said do you want to be popular do you want to be 24:16 liked and he was like yeah i said you have any idea why people don't like you no 24:22 i said well you're a snot sucker you make these horrible noises all the time and people react negatively to it 24:29 and you don't even see it you don't even notice it you just do what you do and i had to work with the teacher on 24:35 like a red card or a yellow card whenever he would suck snot and she could hold it up and he would 24:42 consciously learn to recognize after the fact oh i did that 24:47 and then we worked on could you do something instead like burn your nose is this just a reflexive habituated 24:54 behavior or is there some do you know we need to go to an ent and find something to deal with this which isn't going to 25:01 change the autism spectrum but it can change your acceptability level right and your 25:07 intensity level to maybe a better place sure and and what i would say is that that is an 25:13 example of behavior modification right which is a different 25:19 kind of therapy that we haven't talked about but but at least in this show 25:24 but the initial way you went in was through emotional economics yeah so you 25:31 didn't you didn't start with the behavior modification you started with the presentation of the emotion 25:37 life sucks and you're screwed right you know it it helps to say we can do something with this if you'll work with 25:43 me and if your system will tolerate it yeah and and it goes back to the what michael was talking about when you were 25:50 moving him from an external locus of control to an internal locus of control and all of those things are i mean those 25:57 are the goals of therapy but if you are talking to a part of the brain that 26:03 isn't being triggered it's going to be less effective i'm not saying that no one ever got help through cognitive 26:10 before post-traumatic stress through cognitive behavior therapy but i'm saying that if you think about what the 26:16 biology is my sense my my understanding of human 26:22 pathology tells me to be informed by what i think is the biology and then use 26:30 that to help me to devise a treatment plan that i think is going to be most effective efficient effective economical 26:38 sure yeah then i think further about um other types of therapy modality uh like 26:43 drug assisted therapy so if we look at things like psilocybin assisted therapy or ketamine assisted therapy these are 26:49 really getting a lot of attention right now in the ptsd community and understanding that 26:55 neurobiology and the neurobiological effects of the different drugs what are those pharmacodynamics of those 27:02 different drugs um we can build are you better tool kit are you asking or is that rhetorical it's 27:08 rhetorical okay because you go into 30 minutes 27:13 no i took your addiction and treatment yeah yes and and you know and and i'm not saying that that isn't 27:21 going to be a breakthrough i think that especially for me you know when you're talking about the 27:27 medically assisted treatments for anxiety or for post-traumatic stress 27:32 i think psilocybin is a is a is a more effective molecule than the ketamine i 27:37 agree but uh but there are real reasons why that happens and they're based in 27:44 biology i mean the way in which that the psilocybin molecule opens up the 27:50 connectedness of the brain can allow you to have a conversation with that person 27:57 in a different way that isn't necessarily triggering for them and they can get realizations out 28:04 of that experience that they might not get any other way and and so i think that can be very 28:09 effective is the reverse true for depression with ketamine being the predominant or ketamine is the preferred 28:15 for depression yes and and um i don't know i i don't know my my sense is that the 28:24 reason that ketamine was the initial breakthrough drug was because it was the 28:29 one that they were able to aerosolize and be able to deliver in the context of 28:35 the doctor's visit and the ketamine is a 15-minute reaction 28:41 rather than a six-hour reaction so i mean if you're going to do drug the these these 28:47 psychedelic drug-assisted molecule therapies you're talking that's an all day just 28:52 stay there for 90 minutes afterwards so don't you for the ketamine yeah yeah it's yeah just to make sure that there are no 28:58 adverse reactions but you don't have to stay there for six hours yeah if you took silicibe and you'd be there for all 29:03 day all day oh and just uh just to reiterate that this is another tool in the toolbox right i see a lot of 29:10 instagram ads or snapchat ads for this idea of ketamine assisted therapy 29:16 on people saying oh i feel so much better i feel so much better and there's a real danger in that 29:21 advertisement i think it's important to understand that this is another tool 29:27 in a large toolbox um and isn't the only thing to reach for and might be 29:33 one of the last things you start to reach for other work has to occur first that's right i see the same conflation 29:40 with emdr right people look at the exercise of tapping and they look at different um the light bar exercises and 29:47 that is just so far down the line in emdr and so far removed from the actual 29:53 work that's taking place the emotional lifting that's taking place and especially with what you're saying 29:59 with the the you know the ads but to me that's just like any pharmaceutical agent it's not the 30:07 patient's job to decide what medication is best for them yes and it really burns 30:13 my behind that you have ads on television for any pharmaceutical talk to any physician in america they say the 30:20 same thing about any drug that somebody comes in because they've watched all these ads on tv oh i want this truck and 30:26 that is exclusive to the united states yes um other countries don't not allowed to do it well because it doesn't make 30:32 any logical sense no it's economic yeah i mean a controlled market even if you 30:37 are a doctor you're not supposed to devise your own treatment plan and if you're not a doctor you don't really 30:44 have the informed ability to decide that this medication is a right fit for you 30:49 so yeah i but that point is well taken just because you 30:55 even if you anecdotically know somebody who had psilocybin treatment and that 31:01 person said oh it was great for me it may have been great for them that doesn't mean it's a great choice for you 31:07 but if it is something that you are interested in it is a growing network what happens all the time 31:13 think back about your years of doing therapy with adolescents on adhd medicines right and their family members 31:19 would say oh joey takes this bill why don't you give it to bobby it'll make him better yeah and not involve any kind 31:25 of professional medical or psychological in that loop 31:31 yeah well and this is apropos of nothing but what really burned my behind is that 31:37 i always wanted to know this would always happen or most commonly would happen 31:43 at the end of high school when the person was getting ready to take the act or the sat yeah and then they'd say oh 31:48 well this medication take it on wait a minute no if you're just going to use this as a performance enhancing drug that's not 31:56 the point of the medication yeah but a lot of people used it for that 32:02 tisk disk disk so how how did this strike you 32:08 was the conversation okay uh yeah because we got away from and 32:13 intense analysis of the chemicals in the amygdala and we talked about how that knowledge is useful to a therapist and 32:21 to a person in therapy good good so hopefully good article right we've 32:26 taken something from it to us exactly that's always a good thing 32:33 so hopefully that was helpful for other people in the audience as always if you have any questions or comments you can get us at psychwithmike.com we would 32:40 love it if you would go to apple podcasts and find psych with mike and leave us a comment and a review but most 32:46 importantly the thing that is most helpful for us is for you to go to the internet and find us on the youtubes 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