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Aug 26, 2022

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. 



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