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

1. 0:00 – 1:56

   Dr. Victor Carrión

   1. AHAndrew Huberman0:00

      (peaceful music) Welcome to the Huberman Lab Podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. Victor Carrion. Dr. Victor Carrion is a professor and the vice chair of psychiatry and behavioral sciences at Stanford University School of Medicine. He is one of the world's foremost experts on post-traumatic stress disorder, in particular, the treatment of post-traumatic stress disorder in children and adolescents, although his knowledge and today's discussion certainly extends to adult PTSD as well. Dr. Carrion 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 cue-centered therapy that was developed by Dr. Carrion 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. Carrion'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, et cetera. Today, Dr. Carrion 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.

2. 1:56 – 6:19

   Sponsors: Eight Sleep, BetterHelp & Waking Up

   1. AHAndrew Huberman1:56

      Before we 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 with cooling, heating, and sleep-tracking capacity. Now, I've spoken many times before on this podcast about the critical need for us to get adequate amounts of quality sleep each night. That's truly the foundation of all mental health, physical health, and performance, and one of the best ways to ensure that you get a great night's sleep is to control the temperature of your sleeping environment, and that's because in order to fall and stay deeply asleep, your body temperature actually has to drop by about one to three degrees, and in order to wake up feeling refreshed and energized, your body temperature actually has to increase about one to three degrees. Eight Sleep makes it incredibly easy to control the temperature of your sleeping environment by allowing you to control the temperature of your mattress cover at the beginning, middle, and end of the night, and it turns out the ability to do so allows you to get the maximum amount of deep sleep, slow-wave sleep, and rapid eye movement sleep at the different stages of the night. I've been sleeping on an Eight Sleep mattress cover for nearly four years now, and it has completely transformed and improved the quality of my sleep. Eight Sleep has now launched their newest generation of the Pod Cover, the Pod 4 Ultra. The Pod 4 Ultra has improved cooling and heating capacity, higher fidelity sleep tracking technology, and even has snoring. If you'd like to try an Eight Sleep mattress cover, go to eightsleep.com/huberman to save up to $350 off their Pod 4 Ultra. Eight Sleep currently ships in the USA, Canada, UK, select countries in the EU, and Australia. Again, that's eightsleep.com/huberman. Today's episode is also brought to us by BetterHelp. BetterHelp offers professional therapy with a licensed therapist carried out entirely online. I've been doing weekly therapy for well over 30 years. Initially, I didn't have a choice, it was a condition of being allowed to stay in school, but pretty soon I realized that doing regular quality therapy is an extremely important component to overall health. In fact, I consider doing regular therapy just as important as getting regular physical exercise, including cardiovascular exercise and resistance training, which of course I also do every single week. There are essentially three components to excellent therapy. First of all, excellent therapy should provide good rapport with somebody who you can trust and talk to about all issues in your life. Second of all, it should provide support in the form of emotional support or directed guidance or both. And thirdly, expert therapy should provide useful insights, insights that can allow you to do better not just in your emotional life and relationship life, but of course also your relationship to yourself, your professional life, and all of your career and life goals. With BetterHelp, they make it very easy to find an expert therapist with whom you can build all three of these effective components of therapy. If you'd like to try BetterHelp, you can go to betterhelp.com/huberman to get 10% off your first month. Again, that's betterhelp.com/huberman. Today's episode is also brought to us by Waking Up. Waking Up is a meditation app that offers hundreds of guided meditation programs, mindfulness trainings, yoga nidra sessions, and more. I started practicing meditation when I was about 15 years old, and it made a profound impact on my life. And by now, there are thousands of quality peer-reviewed studies that emphasize how useful mindfulness meditation can be for improving our focus, managing stress and anxiety, improving our mood, and much more. In recent years, I started using the Waking Up app for my meditations because I find it to be a terrific resource for allowing me to really be consistent with my meditation practice. Many people start a meditation practice and experience some benefits, but many people also have challenges keeping up with that practice. What I and so many other people love about the Waking Up app is that it has a lot of different meditations to choose from, and those meditations are of different durations, so it makes it very easy to keep up with your meditation practice both from the perspective of novelty, you never get tired of those meditations, there's always something new to explore and to learn about yourself and about the effectiveness of meditation, and you can always fit meditation into your schedule even if you only have two or three minutes per day in which to meditate. If you'd like to try the Waking Up app, please go to wakingup.com/huberman where you can access a free 30-day trial. Again, that's wakingup.com/huberman to access a free 30-day trial. And now for my discussion with Dr. Victor Carrion.Dr.

3. 6:19 – 11:41

   Stress, Post-Traumatic Stress Disorder (PTSD), Avoidance

   1. AHAndrew Huberman6:19

      Victor Carrion, welcome.

   2. VCVictor Carrión6:22

      Thank you. Thank you so much for having me.

   3. AHAndrew Huberman6:24

      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.

   4. VCVictor Carrión6:46

      That's a very good way of starting because in reality my main interest was the role of stress (laughs) 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 used PTSD 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 U-shaped curve. The more stress we have, the better we perform, the better we do. If we don't care about that exam that we're gonna have tomorrow, we'll probably fail. So it's good to be somewhat stressed, 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 star- 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 jeopardy. It's 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 interested in ex- 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 the diagnosis. So the diagnosis is, is good in that it's there and, and it, it is a behavioral definition that we can anchor in, but, but there's more nuance to that. So then th- that, that shows 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 wanna 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 that, that's when it gets complicated, and it gets complicated with, uh, substance abuse, it gets complicated with self-injurious behaviors, and then at that point, it becomes harder to treat.

4. 11:41 – 16:13

   Stressors, Perseverate; Children & PTSD

   1. VCVictor Carrión11:41

   2. AHAndrew Huberman11:41

      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?

   3. VCVictor Carrión12:03

      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. It's how we grow socially, emotionally, physically.... but when play becomes traumatic play, it becomes non-joyful, but it becomes perseverant 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 pers- severate 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 traumatic, that cause 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, all ready to talk about earthquakes and know everything about earthquakes. It was the last thing they wanted to talk about. They saw the earthquake as an opportunity to talk about the violence they had been experiencing, the poverty, the lack of education. So they were talking to me about everything they were carrying that led some of them to develop symptoms of PTSD.

   4. AHAndrew Huberman14:04

      I see. As you describe these other aspects of one's life that can have negative impact: poverty, violence, et cetera, 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?

   5. VCVictor Carrión14:57

      Epidemiological studies confirm what your assertion. Children, we think, we, we usually, you know, one line that I really don't like is, "Children are resilient." (laughs) Because ch- 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 on biology. In PTSD, it's 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.

5. 16:13 – 19:20

   Transgenerational Trauma

   1. AHAndrew Huberman16:13

      Before we talk about therapeutic interventions, I'm curious about genetic predisposition. And a topic that comes up a lot any time the w- the letters P-T-S-D are stated in that order, um, is transgenerational 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 passed through generations impact th- um, 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 experienced 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 trauma?

   2. VCVictor Carrión17:45

      Yeah. 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 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 report a 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 hypervigilance, 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.

6. 19:20 – 27:17

   Post-Traumatic Stress Injury (PTSI); Children, Dissociation & Cortisol

   1. VCVictor Carrión19:20

   2. AHAndrew Huberman19:20

      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 coeruleus 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 is 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 or flight type responses, although at lower levels it's what's responsible for us being alert here but not in fight or 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 have a, you know, startle 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?

   3. VCVictor Carrión21:11

      Yeah. No, this is very interesting. While 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 gonna hurt, it's gonna 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 it's the cure. It's what cures it. So a lot of people visualize, and then sometimes I do, as an injury rather than a disorder. Um-

   4. AHAndrew Huberman21:52

      Post-traumatic stress injury?

   5. VCVictor Carrión21:54

      Injury.

   6. AHAndrew Huberman21:54

      Interesting.

   7. VCVictor Carrión21:55

      And so what happens? So this autonomic system gets activated. We have our fight or 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 these sit- situations pretending this is not real or this is not happening to me. It's the only thing they have left. Um, and because this arousal system is so key in the development of, of these 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 child 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 Ritalin." 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?" (laughs) 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 PTSD. Also, ADHD can put you at risk to develop PTSD 'cause you're not as attentive as to what's happening in your environment, but they're definitely two different conditions. And, and it was that clinical observation that made me think, "Well, people don't know enough (laughs) 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, Rachel Yehuda at the Bronx VA, looking at PTSD in adults. But I said, "But w- how does PTSD look early on? What's happening in the hypothalamic-pituitary-adrenal axis that is responsible for secreting cortisol and regulate cortisol, uh, when these children are young?" Because this is a new axis, 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, e- 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 (laughs) of digestion or, or whatever. Uh, and these 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 pre-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. Enuresis, right, bedwetting, 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 pre-bedtime is elevated, right? Maybe they need it to be. Who knows? Uh, but I was concerned about the work by Sapolsky, right, and Bruce McEwen, his mentor, demonstrating the neurotoxicity that glucocorticoids can have in key areas of the brain, areas in the limbic system and the cortical system, where w- uh, which, interestingly enough, have a lot of glucocorticoid 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.

7. 27:17 – 31:48

   Cortisol & Brain, Post-Traumatic Stress Symptoms

   1. VCVictor Carrión27:17

   2. AHAndrew Huberman27:17

      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 f- maybe, I don't know, 30 to 90 minutes after waking, for you slow risers like me.

   3. VCVictor Carrión27:42

      (laughs)

   4. AHAndrew Huberman27:43

      Uh, probably a little delayed. By the way, the height of that peak and the accelerat- 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 case, 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?

   5. VCVictor Carrión29:03

      Correct.

   6. AHAndrew Huberman29:04

      Okay.

   7. VCVictor Carrión29:05

      Yeah.

   8. AHAndrew Huberman29:05

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

   9. VCVictor Carrión29:16

      I thought about that when I had those high levels, but I f- 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-

   10. AHAndrew Huberman29:29

       Mm-hmm.

   11. VCVictor Carrión29:30

       ... 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 these kids' hyperarousability does not allow them to let it go. Um, so if these levels are high 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 hippocampus and the prefrontal cortex, which I also found interesting because these areas relate to the symptoms, right, that, that many individuals with PTSD have.

   12. AHAndrew Huberman30:38

       Memory, anticipation of the future, problem-solving, context-dependent problem-solving-

   13. VCVictor Carrión30:45

       Yeah.

   14. AHAndrew Huberman30:45

       ... so on.

   15. VCVictor Carrión30:46

       And even those attention issues that make them overlap with kids that have ADHD as well.

   16. AHAndrew Huberman30:52

       Mm-hmm.

   17. VCVictor Carrión30:52

       Um, so this frontal limbic pathway, the prefrontal cortex communicating with these emotional areas of the brain, including the amygdala, which is very close to the hippocampus, um, needed to be investigated.... in, in, in, uh, 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 DSM-5 PTSD, but their function continues to be impaired. 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.

8. 31:48 – 33:19

   Sponsor: AG1

   1. VCVictor Carrión31:48

   2. AHAndrew Huberman31:48

      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 limited. In fact, I only had enough money back then to purchase one supplement, and I'm so glad that I made that supplement AG1. The reason for that is even though I strive to eat most of my foods from Whole Foods and minimally processed foods, it's very difficult for me to get enough fruits, vegetables, vitamins and minerals, micronutrients, and adaptogens from food alone. And I need to do that in order to ensure that I have enough energy throughout the day, I sleep well at night, and keep my immune system strong. But when I take AG1 daily, I find that all aspects of my health, my physical health, my mental health, and my performance, both cognitive and physical, are better. I know that because I've had lapses when I didn't take AG1, and I certainly felt the difference. I also noticed, and this makes perfect sense given the relationship between the gut microbiome and the brain, that when I regularly take AG1, which for me means a serving in the morning or mid-morning and again later in the afternoon or evening, that I have more mental clarity and more mental energy. If you'd like to try AG1, you can go to drinkag1.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 drinkag1.com/huberman to claim that special offer. I definitely

9. 33:19 – 40:17

   PTSD, Attention Deficit Hyperactivity Disorder (ADHD)

   1. AHAndrew Huberman33:19

      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, um, 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 ADHD 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 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?

   2. VCVictor Carrión34:45

      I firmly believe (laughs) that ADHD does exist. Um, I'm, I'm gonna say two facts that we know in the field. One, are kids getting over-medicated? The answer is a clear yes. They're getting more medications that they need.

   3. AHAndrew Huberman35:03

      For ADHD.

   4. VCVictor Carrión35:03

      For, for anything, in general, kids. Now in ADHD, they're getting under-medicated. 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, 'cause like 50% of them do not get access to mental health services. Um, those that manage 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 it's a fast solution. So there's many reasons for that. But are kids getting over-medicated? Yes. But within those kids, tho- th- those that truly have attention deficit hyperactivity disorder are getting under-medicated, and that's because of that access issue, because most of them were not identifying. And that's a pity because the first line of intervention for ADHD is stimulant treatment. It does work, and it works very well, uh, for children that have the correct diagnosis. But the first line of intervention for children that have a history of PTSD, be acute or chronic, is psychosocial. It's a psychosocial intervention. So if you give a kid that has PTSD and no ADHD a stimulant medication, not only is not taking care of ADHD 'cause 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 arousability and hypervigilance. 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 gonna 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-... hyper vigilance and hyperarousability comes more when they're presented with a cue that consciously or unconsciously reminds the body of the traumatic event or the traumatic experiences. Um, what happens though is that usually we don't know what those cues are, right? So w- we just see a kid that sporadically becomes, um, hyper vigilant or hyper aroused. And then the other thing is, is hyper vigilance something that needs to be treated? (laughs) 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 hyper vigilant, and if he has developed this trait of hyper vigilance, this is something that could be helpful to him." And I said, "You're right." (laughs) I said, "You're right. It's not only to him, to a lot of people, it could become very helpful to be hyper vigilant to assess the environment in which they are in." So the problem is not the hyper vigilance. 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 I- if I can give you an example of- of- of a kid, right? A- a kid that experiences domestic violence and has associated that with noise in the- in the house, learns that running and getting into the room is- is a safe thing for them because they're out of the picture, right? And they pr- 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, uh, 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 us, 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 is maladaptive. By the way, if they're 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.

10. 40:17 – 47:49

    PTSD & ADHD; Identifying Cues, Triggers & Interventions

    1. VCVictor Carrión40:17

    2. AHAndrew Huberman40:17

       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, et cetera.

    3. VCVictor Carrión40:30

       I'm sorry to interrupt, but if I could add the inattention comes and goes because we all know kids that have ADHD that you- you... If you give them the right video game, all of a sudden they become attentive, right? (laughs)

    4. AHAndrew Huberman40:41

       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, et cetera, 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- we're, um, painting here. But that in PTSD, the hyperactivity is a jagged line. It really needs a cue, 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, uh, in order to inform, uh, potential, uh, experiments for intervention in my lab back at Stanford. And, um, he said something really interesting. He said, "You know, when you bring people in to this sort of environment and they- they've all had trauma, you see a- a pretty rich array of- of responses, um, to even just the same conversation." And th- then at one point, perhaps because he said that I- I noted that a woman raised her hand and she said that particular timbres 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 fr- 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 the kind of now, um, stereotypical example of, you know, the- the veteran who experiences combat comes back and hears a car backfire, and then they hide. That's kinda... 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 hyper vigilance is, um, y- 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 cue is, do they stand a better chance of recovery-

    5. VCVictor Carrión43:33

       Yeah.

    6. AHAndrew Huberman43:34

       ... 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-

    7. VCVictor Carrión43:45

       Mm-hmm.

    8. AHAndrew Huberman43:45

       ... 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.

    9. VCVictor Carrión43:51

       Mm-hmm.

    10. AHAndrew Huberman43:51

        In any event, uh, 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 and/or adult to be able to start to make in-roads into their PTSD?

    11. VCVictor Carrión44:06

        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 maltreatment and went to war had PTSD at higher prevalence than the ones that did not have a history of child maltreatment. So s-

    12. AHAndrew Huberman44:27

        Child maltreatment?

    13. VCVictor Carrión44:28

        Yeah.

    14. AHAndrew Huberman44:29

        I see. So they were traumatized before they went to combat.

    15. VCVictor Carrión44:31

        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 hyperarousability 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 cue, it's a threatening, it's a threat, right? But it's usually a color, so there was a red car parked near where they were, so the color red may be a cue, may be a trigger. It was raining the day that that happened, so rain may be a cue, may be 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 are 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 cue 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 responses then become, uh, present, become conditioned, right, uh, when the cue is there, when the trigger's there. So yes, to answer your question, it is important to know the cues. Now what happens? Are we gonna 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 gonna 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 cue," right? Because I've learned all of this about cues and classical conditioning, maybe that's what, what's happening here.

11. 47:49 – 53:11

    PTSI, Autonomic Nervous System Seesaw; Sleep

    1. AHAndrew Huberman47:49

       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, this see-sawing back and forth or this push-pull between the sympathetic fight or 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 et cetera, 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 see-saw, which I often do, I think about the see-saw 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 of checked out, and maybe it creates the hinge to be too tight such that we're more on the sympathetic... Excuse me, (laughs) sympathetic the way I, uh, for those listening I'm using my hands, but it d- you don't have to see it to understand, that the, that 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 see-saw tilted too much to one or the other side. And I, I, as a biologist, I, I just wish-

    2. VCVictor Carrión49:46

       I like that.

    3. AHAndrew Huberman49:46

       ... that we understood what that dysregulation, uh, was or is. Um, chances are it's not one location in the brain or body. It's gonna 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 I in post-traumatic stress injury, uh, hopefully will give people, it certainly is giving me some, some sense of, um (smacks lips) a relief or liberty in understanding that, like, th- these are nervous system injuries that, um, need treatment, and that there isn't something wrong or crazy with us-

    4. VCVictor Carrión50:26

       Correct.

    5. AHAndrew Huberman50:26

       ... because of, because of the fact that we, you know, suddenly feel like we're having a panic attack. You know, I- I've had people I know close to me in my life say, "I'm having a panic attack." I'm like, "What do you mean? W- w- what happened?" They're like, "Nothing happened. That's the point." "Well, how'd 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. Maybe it's one sip too much of coffee. Maybe it's one sip too little. I- i- it's probably something or a bunch of things. Does, am I, am I g- 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.

    6. VCVictor Carrión51:17

       Mm-hmm. 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 of the seesaw. Whereas for the other individuals, they're hyperaroused all the time, and then you have everything in between. But, but no, I, i- it does a very good representation of it.

    7. AHAndrew Huberman51:51

       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.

    8. VCVictor Carrión52:06

       A good night's sleep is good for everything (laughs) .

    9. AHAndrew Huberman52:09

       (laughs) 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.

    10. VCVictor Carrión52:19

        Yes.

    11. AHAndrew Huberman52:19

        You know, it was only a few years ago that book came out.

    12. VCVictor Carrión52:21

        Mm-hmm.

    13. AHAndrew Huberman52:21

        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, (smacks lips) kind of the downer message. Like, "Listen, it's, you know, this is serious stuff."

    14. VCVictor Carrión52:44

        You better sleep.

    15. AHAndrew Huberman52:45

        Yeah. You better sleep. But I think we're there now. I think in, in, in 2024, we're there. I think people understand.

    16. VCVictor Carrión52:52

        And I think people have their own experiences with sleep, right? We, we've all felt that cold that's coming, and, and if we really sleep those eight hours, we may be able to fight it-

    17. AHAndrew Huberman53:02

        Mm-hmm.

    18. VCVictor Carrión53:03

        ... 'cause we've strengthened our immune system. If we don't, we will get sick (laughs) .

    19. AHAndrew Huberman53:08

        Yeah, absolutely. Let's

12. 53:11 – 1:02:37

    PTSD, Brain Development & Kids; Cue-Centered Therapy

    1. AHAndrew Huberman53:11

       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?

    2. VCVictor Carrión53:24

       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 (laughs) . They're 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.

    3. AHAndrew Huberman53:47

       So preschoolers are gonna be essentially, I think of kindergarten starting at five, so you're talking about zero more to, uh, to more or less five or six years old is the preschoolers, kindergartners, and then transition point.

    4. VCVictor Carrión53:58

       Correct.

    5. AHAndrew Huberman53:58

       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?

    6. VCVictor Carrión54:07

       Yeah. 15 and, and, and then, yeah, then the teenagers later on.

    7. AHAndrew Huberman54:12

       Okay. Great.

    8. VCVictor Carrión54:13

       Uh, so I, I work mostly with the school-age, the school-age kids, and like I said, when w- 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 hippocampus. Uh, the, 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 hippocampus, which help us process memories and have strong connections with the emotional center of the brain, the amygdala, and also with the prefrontal cortex. And, um, (smacks lips) 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 pre-bedtime cortisol and the smaller hippocampal volume. Uh, more impactful was a functional imaging study. Uh, as, as many of your audience members know, 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 hippocampus. 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, um, ventral medial area of the prefrontal cortex. So, but with other tasks, right? With tasks of executive function, uh, or, or, or tasks of emotion. Um...... looking at faces, for example, emotional faces. All of this to say that they probably have a malfunctioning frontostriatal pathway and frontal limbic. So, frontal limbic, I'm sorry. So, um, if we think of the amygdala, for example, in close proximity to the hippocampus, being involved in this hyper vigilance, and we have some data to show that the amygdala becomes active very quickly when you present emotional faces, uh, to young kids. Um, and that, that hyperactive amygdala needs a r- a, a break of some sort, that break comes from the prefrontal cortex. But if you have a prefrontal cortex that's not working that well either, then your break is not working.

    9. AHAndrew Huberman57:31

       Mm-hmm.

    10. VCVictor Carrión57:31

        Right? So, so then the issue came here, well, this is important (laughs) 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 (laughs) I would end up doing was developing a treatment, right? I, I felt I'm here to 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 tra- targeting that backpack, that allostatic load. Also, and rightfully so, most treatments were, um, req- requiring that the parents were involved in treatment as well.

    11. AHAndrew Huberman58:59

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

    12. VCVictor Carrión59:04

        And also when there's avoidance, right? And also when there's practicalities that if they lose one day from work, they're gonna 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 Cue Center, cue being C-U-E, Cue Center Therapy for kids that have PTSD. And we've had a number of trials with them and it, it helps re- uh, decrease symptoms of anxiety, symptoms of depression, and symptoms of PTSD. And not only as, uh, scored by the student, but also s- 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 easy to understand, right? If your kid is doing better, you're gonna 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 someth- doing something to the activation of the brain? And that's when we brought functional near-infrared red spectroscopy into the picture, because it's cheaper (laughs) 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 limbic structures.

    13. AHAndrew Huberman1:00:56

        So it's, um, just to, uh, just highlight for a second that fMRI, functio- functional magnetic resonance imaging is wonderful because it allows a lot of, um, c- 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 ha- 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-

    14. VCVictor Carrión1:02:00

        But the temporal resolution is good.

    15. AHAndrew Huberman1:02:01

        ... 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.

    16. VCVictor Carrión1:02:15

        Yeah. And, and these outside areas of the brain, the cortical area and the prefrontal area were helping predict which kids would do better, only for those kids that were having Cue Center Therapy and another gold standard treatment called trauma focus, cognitive behavioral therapy, when they were both compared to treatment as usual.

13. 1:02:37 – 1:04:25

    Sponsor: Function

    1. AHAndrew Huberman1:02:37

       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 blood, urine, and saliva to get a full picture of my heart health, my hormone status, my immune system regulation, my metabolic function, my vitamin and mineral status, and other critical areas of my overall health and vitality. Function not only provides testing of over a hundred biomarkers key to physical and mental health, but it also analyzes these results and provides insights from top doctors on your results. For example, in one of my first tests with Function, I learned that I had too-high levels of mercury in my blood, which was totally surprising to me. I had no idea prior to taking the test. Function not only helped me detect this, but offered medical doctor-informed insights on how to best reduce those mercury levels, which included limiting my tuna consumption, because I had been eating a lot of tuna, while also making an effort to eat more leafy greens and supplementing with NAC, N-acetylcysteine, both of which can support glutathione production and detoxification, and worked to reduce my mercury levels. Comprehensive lab testing like this is so important for health, and while I've been doing it for years, I've always found it to be overly complicated and expensive. I've been so impressed by Function, both at the level of ease of use, that is, getting the tests done, as well as how comprehensive and how actionable the tests are, that I recently joined their advisory board, and I'm thrilled that they're sponsoring the podcast. If you'd like to try Function, go to functionhealth.com/huberman. Function currently has a wait list of over 250,000 people, but they're offering early access to Huberman Lab listeners. Again, that's functionhealth.com/huberman to get early access to Function.

14. 1:04:25 – 1:12:34

    Limbic Pathway, Inner Dialogue, Therapy Toolbox

    1. AHAndrew Huberman1:04:25

       I want to get into the cue-centered therapy versus cognitive behavioral, uh, versus the, um, 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 fronto-limbic pathway is important here, the limbic pathway including the amygdala but other structures as well, and my understanding, and I think the generally accepted understanding about these limbic 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, f- uh, 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 gonna pick up everything in the room. That's, without question, largely due to the development of these fronto-limbic (laughs) 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 limbic system are gonna be somewhat cryptic to people that aren't familiar with, um, psychiatry 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 limbic 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. Carrion. 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 or 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 fronto-to-limbic suppression.

    2. VCVictor Carrión1:07:06

       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.

    3. AHAndrew Huberman1:07:18

       Mm-hmm.

    4. VCVictor Carrión1:07:18

       They are thoughts that need to be practiced, right? Negative thoughts, unfortunately, that reside in our reptile brain, are automatic.

    5. AHAndrew Huberman1:07:29

       Mm-hmm.

    6. VCVictor Carrión1:07:29

       So that hyperresponse, "I'm in danger" type of situation, when we evolved, right, it's responsible for our survival. So we learned 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 the, with evolved 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, uh, if they don't play guitar, if I give you a guitar right now, would you be able to play me a song?

    7. AHAndrew Huberman1:08:14

       Absolutely not. I have absolutely-

    8. VCVictor Carrión1:08:16

       (laughs)

    9. AHAndrew Huberman1:08:16

       ... zero minus one musical ability, but I love music.

    10. VCVictor Carrión1:08:20

        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.

    11. AHAndrew Huberman1:08:30

        Well, me, with some degree of proficiency, but not much.

    12. VCVictor Carrión1:08:32

        (laughs) With a lot of help.

    13. AHAndrew Huberman1:08:33

        But everybody else, yes. (laughs)

    14. VCVictor Carrión1:08:35

        (laughs) A support system.

    15. AHAndrew Huberman1:08:36

        A support system.

    16. VCVictor Carrión1:08:37

        (laughs)

    17. AHAndrew Huberman1:08:37

        That's right.

    18. VCVictor Carrión1:08:38

        And-

    19. AHAndrew Huberman1:08:38

        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.

    20. VCVictor Carrión1:08:48

        (laughs) 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 cue."

    21. AHAndrew Huberman1:09:03

        Even when the limbic system is not active, should- do you encourage, uh, your patients to practice positive thinking-

    22. VCVictor Carrión1:09:08

        All the time.

    23. AHAndrew Huberman1:09:09

        ... even when they're not in the stress response?

    24. VCVictor Carrión1:09:11

        All the time.

    25. AHAndrew Huberman1:09:12

        Interesting.

    26. VCVictor Carrión1:09:12

        It's like- it's learning a tool. So in this cue 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 a- they're gonna 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.

    27. AHAndrew Huberman1:09:59

        Interesting.

    28. VCVictor Carrión1:10:00

        And, you know, I, I, I had this case once and, and it got illustrated really well w- 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 sh- 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..." (laughs)

    29. AHAndrew Huberman1:10:41

        (laughs)

    30. VCVictor Carrión1:10:41

        "... 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. (laughs) I, I could go, "No, no, you must practice my tools."
15. 1:12:34 – 1:18:11

    Agency & Control, Deliberate Cold Exposure, Narrative

    1. AHAndrew Huberman1:12:34

       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?

    2. VCVictor Carrión1:12:57

       Yes, because it g- 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 it's what they decide. It's that decision they're making that gives them, uh, a sense of control. That's important.

    3. AHAndrew Huberman1:13:17

       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 Heller 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? Mm, perhaps. Um, but the one thing that everyone agrees is that being in uncomfortably cold water makes you breathe fact- faster, excuse me, and stress a bit. In other words, it kind of sucks.

    4. VCVictor Carrión1:14:03

       (laughs)

    5. AHAndrew Huberman1:14:03

       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 careful 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, w- what they're doing is they are practicing this frontal control over the limbic pathways. It's just sort of a general exercise for controlling the limbic system through thought. But...... as our colleague David Spiegel has said to me many times, he 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 stressors, but that also the stress is showing up when they would least want it to appear, or when it's very inconvenient to appear.

    6. VCVictor Carrión1:15:33

       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 seesaw. I, I, I think (laughs) the cold shower probably does... Not the gold shower. What do you call it? The cold-

    7. AHAndrew Huberman1:16:32

       Mm-hmm. Deliberate cold.

    8. VCVictor Carrión1:16:33

       ... thing?

    9. AHAndrew Huberman1:16:33

       It could be from a cold shower. I always say that because oftentimes people think, "Oh, you know, they're just trying to sell cold plunges." And, and the truth is, you don't need that. I mean, the fact of the matter is t- 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.

    10. VCVictor Carrión1:17:02

        (laughs)

    11. AHAndrew Huberman1:17:02

        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 baseline, just seeing how that affects our psychology. And, uh, 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 'em 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.

    12. VCVictor Carrión1:17:53

        (laughs)

    13. AHAndrew Huberman1:17:53

        I don't like thinking about 'em. 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.

    14. VCVictor Carrión1:18:03

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

    15. AHAndrew Huberman1:18:05

        (laughs) No interest. It's so interesting, you know, these things get so firmly rooted. But

16. 1:18:11 – 1:26:32

    Custom Toolbox Development; Energy

    1. AHAndrew Huberman1:18:11

       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?

    2. VCVictor Carrión1:19:02

       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.

    3. AHAndrew Huberman1:19:17

       So what would that look like? L- let's say I'm a, a nine-year-old. I come into your clinic, and I meet the criteria for PTSI or PTSD.

    4. VCVictor Carrión1:19:23

       Mm-hmm.

    5. AHAndrew Huberman1:19:24

       Um, what sorts of questions would you ask?

    6. VCVictor Carrión1:19:28

       Yes, so I... The first thing I would say, "When you're feeling a certain way," wh- whatever way we're talking about, right? Like-

    7. AHAndrew Huberman1:19:36

       Anxious.

    8. VCVictor Carrión1:19:36

       ... agitated, anxious.

    9. AHAndrew Huberman1:19:38

       Yeah, yeah. Nervous.

    10. VCVictor Carrión1:19:38

        Uh, "Is there anything that makes you feel better?" Because the experience of having something and then 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-

    11. AHAndrew Huberman1:19:53

        "My friends."

    12. VCVictor Carrión1:19:53

        Or, "My friends or my teammates," mostly, actually.

    13. AHAndrew Huberman1:19:58

        They say teammates?

    14. VCVictor Carrión1:19:58

        Teammates is pretty popular.

    15. AHAndrew Huberman1:20:00

        I love that.

    16. VCVictor Carrión1:20:01

        Yeah. There's something about sports, and, and sports is something that comes up a lot when we do the toolbox. People put in there 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 a- an example that they give. Uh, talking to friends, um, uh, planning a sleepover, uh, listening to music, uh, different things like this.

    17. AHAndrew Huberman1:20:33

        Are there any particular tools for, um, when kids are stuck in a stress response?

    18. VCVictor Carrión1:20:40

        Yes.

    19. AHAndrew Huberman1:20:40

        So, because, uh, 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 sighs. 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.

    20. VCVictor Carrión1:21:09

        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, e- exercises of relaxation. We have to be very careful with this because like, like you say, it's good to be personalized, right? It, it, 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 tea- 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 s- 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 gonna 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.

    21. AHAndrew Huberman1:23:12

        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 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.

    22. VCVictor Carrión1:23:37

        We're also talking about eradicating stress that causes discomfort, right? And it's this, causes this stress. Uh, not necessarily to live a life without stress or to get rid completely of stress 'cause that's, would be impossible.

    23. AHAndrew Huberman1:23:55

        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 are those fi- what were the little spinner things that kids had?

    24. VCVictor Carrión1:24:08

        Mm-hmm. Mm-hmm.

    25. AHAndrew Huberman1:24:08

        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?

    26. VCVictor Carrión1:24:39

        Yeah.

    27. AHAndrew Huberman1:24:39

        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, uh, siphon off some of that energy through, as far as I can tell, you know, um, things like worry beads or, or-

    28. VCVictor Carrión1:24:55

        Yeah.

    29. AHAndrew Huberman1:24:55

        ... fidgets or whatever they're, those are called, I mean, they might irritate some adults around, but really they're pretty innocuous when you think about it.

    30. VCVictor Carrión1:25:00

        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.
17. 1:26:32 – 1:32:59

    Tool: 4-Corner Square Response, Understanding Cues

    1. VCVictor Carrión1:26:32

    2. AHAndrew Huberman1:26:32

       Earlier, um, 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.

    3. VCVictor Carrión1:27:03

       We have to be careful with, uh, structured, uh, interventions because sometimes structured interventions can break a little bit the fluidity, uh, of the relationship that a therapist and a child may have or a therapist and a, and a patient. So it's, it's better to be semi-structured 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 cue center therapy by e- dissecting and examining a response. So for example, a child that breaks windows or a child that screams or a child that leaves the classroom running, we try to understand what's happening at that moment and the way that we do that is by looking at a square. And a square is composed of four corners and the four corners are what you're thinking, so it's a cognitive side to it, uh, what you're feeling emotionally, what you're feeling physically, and what you 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's, 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 gonna ex- 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, and build a cube, right? Of many potential responses so that when the cue happens, now there's an armamentarium of responses and if I'm too distressed 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 therapists, right? So we have a manual for therapists that is called Cue Center Therapy for Youth with Posttraumatic 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 steps of adapting it not only for youth but also for adults.

    4. AHAndrew Huberman1:31:30

       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 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, uh, a verbal label. "I'm depressed. I'm scared."

Episode duration: 2:26:58