Trauma and Dissociation with Kristin Flanary (Lady Glaucomflecken)

Kristin Flanary: [00:00:00] Eventually I did start giving keynote speeches about it. I was writing about it, I performing onstage monologues about it and like as part of all of this, I'm playing the nine one one call over and over and over and over and over like. So it really is therapy and it was actually the most, yeah. So your exposure therapy.

Preston: Yeah, yeah. No, no, exactly. I'm a 

Kristin Flanary: genius 

Preston: how to be patient. Welcome back to How To Be Patient, the podcast where we learn how to, and, and to engage with patients. I'm your host, Preston Roche. I'm joined by Margaret Duncan and we have a guest today who will introduce themselves. 

Kristin Flanary: I am Kristin Flannery. I might be better known to your audience as Lady Glaucomflecken Flecking, which is Hi Kristin, ridiculous name and our, one of our producers.

That's right. I forget. I don't, I always, I do a horrible job of introducing myself. I'm just like, I don't know. I'm a girl. I do [00:01:00] things. 

Preston: Yeah. Well, I mean, so really this is just a discussion of producers today. So it's a round table. 

Kristin Flanary: There you go. You have all the 

Preston: big brains in one room. 

Kristin Flanary: Some are invisible and others are not.

Preston: Well, uh, today we have an interesting episode. We're gonna be talking a little bit about dissociation, especially as it pertains to trauma. Um, and I know that you're writing a book, Kristin, and with kind of like a cognitive neuroscience focus on that. So hopefully we'll have some relevant discussion there.

But before we get into that, we're gonna bring you into our tried and true tradition of having an icebreaker, okay. Like we do on every episode. So today's icebreaker is what is a recent daydream that you've had? 

Kristin Flanary: Oh, a recent daydream. Um, I daydream all the time about, uh, running away from my family, escaping to a tropical island.

Preston: And what, what's on this tropical island for you? 

Kristin Flanary: Just, you know, some my ties. A, [00:02:00] a lounger, some good books. Sunscreen. That's all I need. 

Preston: Oh, that, that sounds really nice right now. Yeah. Actually 

Margaret: Preston, when was your last vacation? 

Preston: Uh, uh, I think it was February. Yeah, that's a long time. It's been a little bit vacation.

So seven months or so vacation. But thinking about how I need vacation, I don't have one scheduled till January 

Margaret: daydreaming. What about you, Preston? What's yours? 

Preston: So, I, I recently watched The Secret Life of Walter Mitty. You guys know that movie? Um, it's a Ben Stiller film where this guy works at Life Magazine.

He's a, a negative process manager, so he like processes the negative photographs from film. He daydreams all the time. So he like creates these fantasies about like things he wants to go do and travel, and then he actually acts on them and does like, get to go out to Iceland, Andover, Afghanistan and like explore and get outside of his office.

I think I've been following his daydreams recently. Like for some reason I've been obsessed with like natural light not, and mo [00:03:00] mostly the lack of, I guess because for some reason in so many, like physician workrooms or just clinic workrooms, there's not a single window to be found. And that just like, it just like drives me nuts.

Margaret: That doesn't make you feel warm and fuzzy and ready to care. 

Preston: Yeah. I'm just like sitting in this dungeon basically, is how I see it. So I, I daydream a lot about like being a tour guide. I was like, how fun would it be to just like lead hikes in New Zealand and like I'll just, I'm just gonna abandon all of medicine.

And like, it doesn't matter if I don't get paid a lot, at least I'll get to be outside during the workday and I don't have to sit here like chain to a keyboard typing documentation all day and then leaving when it's dark out. 

Kristin Flanary: That's, that's very sad. 

Preston: So that, those are usually what my daydreams are about these days.

Kristin Flanary: Okay. So, 

Margaret: so vacation for you as well. 

Kristin Flanary: So far it's a strong escapism theme. 

Preston: Mm-hmm. Yeah. Yeah. Really. 

Margaret: I feel like, I feel like you're [00:04:00] not gonna like my answer, Preston. I feel like Preston's gonna be like, Maggie, you're lying and you're being annoying with this answer, but I promise you I'm not trying to be annoying.

Um, I recently got like, so I walk quite a bit for, to like commute to work in Boston and I. Recently got Pilates certified. And so I feel like what I daydream about now is I'll like put a playlist on and be like, what is my class gonna be to this in two weeks? Like, what is, like, these are the sequences, but it's like, I'm not doing it to plan.

Like I'm not formally planning, it's just I'll be walking and listening to music and that is where my brain goes. And I, I like it. So no, 

Preston: I, I do that all the time. Like I'll, I'll be listening to a song and be like, how would I look in a music video for this song? Or like, or, or like if I was in a movie and like this was the score right now, like what would be happening in the film?

Kristin Flanary: Yeah. Were you one of those kids, Preston, that like pretended that you were on a late night show and you would come up with answers to questions no one asked you and like, say them in the mirror? [00:05:00] Um, that's a nat. 

Preston: I dunno if I was the late night show host, it was most probably more like street interviews, the guest.

Oh.

I think, yeah. I think I always saw myself as like. Pushing away or hiding from paparazzi. Yeah, I, I would daydream about that. I don't, I don't think I ever made it to the, uh, the stage with Jimmy Kimmel, though. 

Kristin Flanary: Okay. At least you're of a Daniel a kind of figure. Yeah. 

Preston: Yeah, exactly. 

Kristin Flanary: Okay. 

Preston: No, I, I think that's a good, that's a good fantasy, Margaret.

Like, and, and I see how it has both like a therapeutic and like Utah function. 

Margaret: Yeah. I mean, I guess I feel like it's like not a fantasy 'cause it's like I then use it, some of it for the class, 

Preston: like I like mm-hmm. 

Margaret: I think if you'd asked me this six months ago before I got trained, it would've just been like a, here's what I would do if I was doing this.

Like, literally, this is like what would happen. I'd be like, well, if I, if I could go to a perfect class, it would be programmed like this and it would be this kind of music and I would like leave class and be like, [00:06:00] I wish it had been this way. And then you have like enough of that fantasy that eventually it's like I could actually just get trained in this.

Like I could actually do it. 

Preston: Yeah. 

Margaret: Kristen, leave your family. Preston. Leave medicine. That's what I'm telling you as you should. Yeah. 

Kristin Flanary: Good advice. A psychiatrist told me to, guys, I dunno what to tell you. Sorry. 

Preston: Yeah, there's no going back now and no refunds by the way. So this is a great segue into like kind of even just the definition of what, um, dissociation is because it's any amount of disconnection from your environment.

Um, so by definition daydreaming is a very mild form of dissociation, but it's one that you can easily, easily control and snap back out of and more to come on that. But, but before we kind of continue to, to dive into this topic, Kristen, I'm, I'm really curious about like what your relationship is with dissociation.

So to give everyone some background, um, Kristen actually came to us and said, Hey, I [00:07:00] have some questions about. Dissociation to personalization. I, I kind of wanna get to chat with you guys a little bit more about it, so inviting the listeners into this, this round table, let's catch them up on the conversation.

Kristin Flanary: Yeah. So I first got interested in dissociation, um, when it happened to me. So, um, 

Preston: reasonable. Reasonable. Yeah. 

Kristin Flanary: Uh, so five years ago, for those who don't know, um, my husband who, who's Dr. Glaucomflecken PL online, um, he had a sudden cardiac rest in his sleep and I did 10 minutes of CPR on him. And then, you know, it was three or four more days of like days.

Will he, won't he, you know, it's like first will he survive? Won't he survive? Then it's, will he have cognitive function, won't he have it? You know, so just a lot of kind of prolonged crisis mode. And then after he came home, I expected to just like. Feel better, [00:08:00] right? Like, relieved, yay, it's over. Mm-hmm. Um, and I was relieved that he was home, but for the most part, I just sort of felt nothing.

And, um, I sort of lost the ability to like, follow conversations. Like people would say something and I would hear it, like, the sensory input is fine, but it just sort of, kind of exits my mind a, a second or two after it entered. So, you know, I couldn't hold onto it in working memory long enough to really like, make sense outta what they were saying or to formulate a response back.

Um, and this was really curious to me because I, at the time was working, um, in communications and marketing, and so like, language was sort of a big deal for me. Like I mm-hmm. This was a problem, you know, like, 

Preston: like it's almost central to everything you do. 

Kristin Flanary: Exactly, yes. Yeah. And I'm like a writer and a speaker and it's, it's very central.

So, um. And then I had a background in cognitive neuroscience. So even in the moment, like at the time, I [00:09:00] remember kind of thinking, huh, this is interesting. Like, I wonder what's going on in my brain. Um, and I didn't know that it was dissociation at the time. Um, I called it the quiet place. Like that's how I described what I was experiencing because of that sort of loss of language.

And then also just sort of like, even my thoughts didn't have words, which was strange for me. Like it was just sort of white noise in my mind and I was sort of like staring off into the middle distance all the time. Um, so I was curious about it then, but then now it's five years out. And, um, like you mentioned, I'm writing a book about that whole experience and I'm bringing in that neuroscience piece, um, as well as some other, you know, pieces.

But I thought it'd be interesting to hear from you guys, um, what you know about it and, you know, get some free research while I'm here. 

Preston: That's actually the purpose of our podcast is free research. Okay, good. So you came to the right place. 

Margaret: Not wrong, [00:10:00] not wrong, 

Preston: yeah. You just hit, you hit F 12 on the vending machine for Yeah.

President Margaret's opinions and the old baggage chips is coming out anytime now. 

Margaret: F 13 is is a puppet. It's,

Preston: that one's broke out of order. That one's broken. Sorry. 

Margaret: One's not. Should we bring it back for season three? But Yeah. But it sounds like you, you, you mentioned not knowing it at the time and now thinking about it recollecting obviously over the last five years, but also in the specific process of writing.

Mm-hmm. Um, and I wonder at the time or close after was, did you put a name to this? Only in the last couple years, once you were sort of still noticing the pattern? Was there a thought that you had towards like, this was a traumatic experience? Am I experiencing like A-P-T-S-D type thing? What. What, what was the timeline on that?

Kristin Flanary: Um, well I called it the Quiet Place pretty early on. [00:11:00] Um, as is not surprising, I don't have great, like, memory of a good chunk of time after that. Mm-hmm. Um, I just have like little fragments, but, um, I wanna say, I could go back and look it up, but I wrote a, an article, um, published it in the Journal of Cardiac Failure, where I wanted to explain, this was very early on before I started talking about, um, co survivorship.

I think it was before I'd even found that term. And I wanted to explain to healthcare professionals what it is like, because at this point he had had cancer twice and now this cardiac arrest. Um, and so this was like my third experience of like a really serious. Illness, um, you know, going through it together and it's happening in his body.

So he's getting all of the, like he's the very clear patient, right? Mm-hmm. Um, and so rightly so. He's getting medical attention. He's getting, you know, all the [00:12:00] things that a patient should be getting. But it always felt to me like that's only half the story. Like, my life is just as impacted as his life.

His body maybe is more impacted, but our life together like that. Mm-hmm. You know, and I'm facing a different set of challenges. Like I'm facing the possibility of losing this person that I love and that I, you know, the father of my children. And the, we've built a life together. And so by the time it was, you know, the cardiac arrest and, and that one was the worst of all for me.

Well, for him too. Lemme be clear. Yeah. Um. I just really, I'd had so many bad experiences in clinics and hospitals. Um, you know, best case scenario I was ignored. Worst case scenario. Um, I, well, I'm gonna be writing more about this in the book, but, um, I, I don't talk publicly about it that much, but, um, you know, certain things happened while he was in the hospital for the cardiac arrest.

[00:13:00] Um, where I got scolded, I got, you know, it sounded almost like I was blamed. Cardiologist said when he was still in the, um, er and they were running all these tests to see like, what is it that happened? Um, it was a big mystery. And so he said to me, I would've liked it better if you had seen him collapse.

And I totally understood what he meant. Right. That like he meant I would like it. Cardiology, we knew how long it had been. 

Preston: Yeah. Most emotionally sensitive cardiologist, we 

Kristin Flanary: love 

Margaret: you guys. We know you, we can't do your job. Okay. But 

Preston: also, 

Margaret: yeah, stereotype Preston, I tweet and glasses. Okay. Sometimes the stereotypes that your husband does are, you 

Preston: don't, you wouldn't trust me with a wire.

Kristin Flanary: Yeah. Yeah. But yeah, that was, you know, so it, it felt really bad. So I was writing this paper, um, to try to explain to healthcare audiences what this perspective is, you know, this person that comes in with the patient and [00:14:00] why that's important for them to consider. And so I had to try to figure out a way to write about, you know, in a concise way.

This gigantic emotional experience that had really been seven years in the making. And so I, I just tried to describe the effect that it had on me to have done CPR on him. Um, and so in writing about that, that's where I came up with, you know, I had to, I don't know. I didn't have to, I guess, but I, I felt like I needed to call it something.

Preston: I mean, you kind of had to, like you, you had to find a name for this. Yeah. 

Kristin Flanary: I had to name the experience, this huge 

Preston: character in like the, you know, kind of the inability to process emotions or thoughts coming in and out of, out of your brain, 

Margaret: right. 

Preston: That was driving factor. 

Margaret: Yeah. I, I think there's also like quite a bit of focus, at least in the last couple decades on how do we be there for parents who are parents to kids who are terminally ill or how do we be there in like memory care for people.

Who [00:15:00] spouses or parents or whoever that they're taking care of are going into like hospice or losing memory. Yeah. And those kind of have established literature and, and in some high resource places they have different ways to support. But I think what you're saying is for something like this that's acute and sudden or for middle of life oncology concerns, there's not, well, even 

Kristin Flanary: then, we were like in our twenties, so it was okay.

Margaret: Yeah. So especially then, there's not a, like, it's a different set of questions and way of support than people, than these other groups of people that there has been more focus on. 

Kristin Flanary: Exactly. Yeah. There's little pockets in healthcare that have figured this out, right? There's child life specialists in pediatrics, there's palliative care, they're really good at this stuff.

Social work is really good at this stuff. But the problem is healthcare is so siloed and. Resources are sometimes [00:16:00] scarce. And so it's like, I would hear from people sometimes when I share my story that would say, oh, at my hospital we have a chaplain or something, right? Mm-hmm. And I'm like, mm-hmm, that's amazing.

But also, that shouldn't be a point of pride. That should be like a normal thing. You know? Like a little more interdisciplinary sharing of information would be really useful. Yeah. Sorry, Preston, I interrupted your, your question. 

Preston: Oh, no. Preston episodes I took board. No, I was just sitting here like giving a moment to think about how many problems will go unsolved in like the systems issues among hospitals.

Oh, I know. And, and we, we aren't trying, but progress is slow, I would say. Especially in like the non, um, academic areas. 

Kristin Flanary: Yeah. Well, and that's, that brings up a good point that I always try to make, which is like, I don't blame. Individual physicians. I don't even think that it is physician's responsibility as a group to like [00:17:00] provide psychological care to people.

Right. I want the physician focusing on the, the medical care. That's what you guys are best at. That's what I want to be happening. I just think that the system has a lot of gaps in it, as we all know. And this is one of them, you know, that that seems relatively easy and I don't know, maybe not too expensive to close because we have figured it out in these other, like certain parts of healthcare.

Preston: Yeah. So to kind of switch gears I and focus on this quiet place mm-hmm. That you talk about. So I imagine you kind of started doing some investigation as to what this might be, and I'm curious what you found. 

Kristin Flanary: I found a lot of nothing because what do you Google? You know, 

Preston: why is there a quiet place inside my head?

Kristin Flanary: Uh, right. Like 

Preston: our slash quiet place. I dunno. I get some 

Kristin Flanary: song lyrics or something. 

Margaret: It's 

Kristin Flanary: a 

Margaret: John Krazinsky moment. 

Kristin Flanary: So, yeah, [00:18:00] that, and that's part of why I talk about co survivorship a lot. 'cause it, I want there to be a term that people can Google, right? 'cause I didn't have one. Um, but the other thing is like, I'm, I did a little bit of investigating, but for the most part, I, I wasn't really that capable of it.

Mm-hmm. Right? Like, it takes way more executive function than we think of, than you would think to, you know, figure out something like that. Any kind of self care really, like people would say to me, well, I hope you're, you're getting help for yourself. You know, I hope you're finding a psychologist or something.

And truthfully, I could not. Like that to find, to look for somebody in your area with this kind of general specialty that accepts your insurance, has availability. You know, that's a lot of steps of executive function. Mm-hmm. That is normally not a big deal, but in that state of mind I literally couldn't.

Right. And 

Margaret: [00:19:00] presumably you also increased care taking in some ways. Yeah. Even just in helping will adjust back to life. I don't know. Helping, you know, your kids deal with 

Kristin Flanary: Yep. 

Margaret: Yeah. 

Kristin Flanary: And his parents came up and my parents are here and you know, everybody's emotional and I still have my job that I have to go back to, you know, it's a lot.

Preston: Yeah. And it's tough because the symptoms of the disorder also, like you mentioned, impair you from actually treating it. 

Margaret: Yeah. 

Preston: Psychiatry is like one of those 

Margaret: psychiatry classic unique 

Preston: fields. Yeah. Where it's kind of like we, we, you know. Hold our own hand and put yourselves in the face. Right. At least as far as the disorder goes.

Like, imagine if like having like, I don't know, hyperlipidemia also like, made your brain just like hate PCPs. You know? You're like, you're like, these high levels of lipids in my arteries just make me like not wanna see the doctor. And we're like, darn it, pcp. But this, you're the one who needs to see it the most Lip, the voice lip.

They're [00:20:00] telling me he's an asshole. They're telling you not to take the statin. What's the sta Like, there's a steak. Like you go to a steakhouse and they Right. Like in barbecue sauce and they're like, don't take your statin. It's actually poison. 

Kristin Flanary: I mean, this isn't very different than the anti-vax argument, you know?

Preston: Yeah. Well, well, I, I kind of wanna offer some more clinical definitions. So I actually have, I have the DSM pulled up here. Look at this big boy. Ooh, I'm showing this. What are we on now? 

Kristin Flanary: I'm, I'm out of touch these days. Oh, okay. 

Preston: We're on the DSM five. Okay. But the, with the remix, the text revision. Yeah. Nice.

Kristin Flanary: Pr. 

Preston: So, um, I am on page 3 43 and this is alright, listeners to 

Margaret: open your DSMs. Yeah, yeah. So, 

Preston: well, it's all open to the same page. Okay. I'm gonna open to the page right now. You'll see at the bottom at 48.1 on diagnostic criteria for, uh, depersonalization derealization. So I'm, I'm gonna read you the definitions for these two kind [00:21:00] of subsets of dissociation.

Margaret: Wait. Before you read it, I want, Kristin, when you listen to it, I want you to pretend it's you five years ago. It's you a month after this all happened. And if these words, if they were said this way to you, if you would've recognized your experience or if, if the words wouldn't have been evocative enough for you to recognize yourself in this.

Okay, that's a good question. 

Preston: Experiences of unreality detachment or being outside observer with respect to one's thoughts, feelings, sensations, body or actions. For example, perceptual alterations, distorted sense of time, unreal or absent, self emotional and physical numbing. And then number two, experiences of unreality or detachment with respect to surroundings.

For example, individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted. 

Kristin Flanary: I would say about half of that, I, I would've been able to pinpoint as, yes, that's happening. [00:22:00] Like foggy jumped out at me. Um, time. Time was, what is time? Like, I don't know. Uh, there was no such thing.

It was just I was awake, I was asleep. Um, what were the Say it again and I'll, I'll. As we go, I'll say 

Preston: feelings of unreality attachment or being an outside observer with respect to one's. Okay. Yeah, so 

Kristin Flanary: definitely detachment. I felt very detached. Um, and I did sometimes feel like an outside observer that was more like during CPRI had one of those, like floating what out of body experiences, you know, where like mm-hmm.

Where our life so far just flashed before my eyes and you know, like that was during CPR. Um, I'm not sure that it was as much after the fact though. 

Preston: Mm-hmm. Mm-hmm. But 

Kristin Flanary: definitely detached and like numb I think was in there. 

Preston: So you had this almost like full dissociation or full like kind of detachment during the episode and then this numb lingering numbness and, um, [00:23:00] flexing or shrinking of time mm-hmm.

Afterwards. 

Kristin Flanary: Yeah. Yeah. And there were a few more things in there too, but I, I can't, I don't know. You'll have to tell me is a continued loss of memory. One of the effects of all of this? 

Preston: Well, we get into that. Or might just getting old either 

Margaret: way. I mean, I think, I think one of the things we haven't explicitly stated, and listeners, you know, I don't diagnose anyone on the show or in any way, but when we are talking about what you went through, especially that there were prior episodes of acute health concerns.

Mm-hmm. And just like whenever we're talking about dissociation or derealization or depersonalization, we're usually talking in the trauma field, right? So we're not necessarily only talking about PTSD, but we are talking about something that happened that made it, it was either a lot of trauma, people will say too much, too soon or too fast, is what we define trauma as that makes flight from the experience necessary.

[00:24:00] Um, the differential of this being, thinking about people who daydream more because they have a DHD at baseline or other attentional concerns. Um, but that, just to say that, that that is often the conversation we're having when we're talking about the topic that 

Preston: we are right now. 

Margaret: Yeah. 

Preston: Now that we've kind of like, at least set the stage for the, the players.

And, and to double clarify, we're not diagnosing Kristin with a dissociative disorder, but we're just saying that this is something that we define and that maybe she identifies a little bit with. So when we come back from this break, we're gonna actually talk a little bit about the neuroscience of dissociation.

And this is coming from me, who's not an expert, but did my best, um, to read about it. And feel free to grill us as we, we kind of roll through this. And then, um, Margaret's gonna help by talking a little bit about some of the therapy and treatment approaches that we have to dissociation and how it relates to trauma.

So see you soon.

And [00:25:00] we're back to talk a little bit about some neurobiology of dissociation. So. When, whenever I, or when you're in med school and you're kind of doing your flashcards, uh, I think most people come across this connection between ketamine and dissociation. That's, that's kind of like classically what we recall.

If you take a bunch of ketamine, it can like induce dissociation. The, the same can be true for anything actually that antagonizes this specific receptor called NMDA, which is mediated by glutamate. So like dextromethorphan or Robitussin also has a similar effect if you take it high enough of a dose. Um, not recommending that anyone does that, but that's buzz.

Is buzz. That buzz 

Kristin Flanary: sort of, that you feel, you, you feel kind of like Woo. Floaty. 

Preston: Yeah. Yeah. Maybe so like Robitussin. Has like three different levels of a high that you can get from it. We don't need to go into detail about this. This is not advice. The first Patreon of episode do association. Yeah. 

Margaret: It's just [00:26:00] breaking bad.

Anyway, yeah, so this is the beginning of our villain arc on this podcast. 

Preston: Yeah. Welcome to Evil Psychiatrist. We break into like what your drugs are doing. Um, yeah, but we do good psychiatry here. So I, I, that was kind of actually for a while how I best understood, uh, dissociation. I was like, okay, glutamate NMDA dissociation.

That's, that's about it. That's all I really know. And so I kind of like, for the last like day and a half or so, went on a bit of a journey trying to like really understand like what, what is actually being affected by glutamate and who's hosting these NMDA receptors to cause this like dissociative effect.

Yeah. And. In order to tell this story, I think that we're gonna step away from the neurotransmitters for a second and talk about how your brain works in its environment and how it produces memory. A small topic. Yeah, yeah. No, super easy framework, and, and I'm just gonna, I'm gonna do a great [00:27:00] job of distilling what I've read into a way that's, that's understandable to everyone else.

Well, I also try to understand it. So basically I, I want to start with the concept of salience. So if something is salient, it means, it's like it's important or it sticks out to you, you know, it's relevant and that's kind of the, the name of the game for a lot of our attention, or like things that we draw our attention to, we have something called a salience network that is essentially always scanning our environment and trying to figure out what's important and what's not.

So. If you kinda like, look around your desk right now, or if you're listening while you're in the car, try to like take into account how many pieces of stimuli that you're seeing right now. Like you, you maybe you see the steering wheel and maybe you see a car in front of you, maybe you see a tree, maybe you see a sign like that's like 10 you can count.

But if you were to expand that, you could go down to like the individual, like granules, like single pieces of hair everywhere. And [00:28:00] that's just your vision, right? So, so technically there's an infinite amount of things that you can visually take into, take into account. Same applies to your hearing, same applies to smell, touch.

Like your brain is always overwhelmed with, with essentially infinite stimulus. And then it has the job of like narrowing it down to like what's important and what's not. And, and then now you have like a bunch of stimulus that you've identified as important and you have to assign emotions to those things because we need to triage, like what do we wanna act on first, right?

Because let's say you're like out in the woods, right? A bear is charging at you. You, you, you may have managed to identify that, like the flower is an important stimulus. The tree is important Stimulus. Why 

Margaret: I wouldn't 

Preston: survive the, the cloud. Yeah. And the bear. So it's like, okay, all these are important, but like the fear emotion takes priority hopefully.

But for Margaret it might be whimsy. And she's like, whoa, whimsy, [00:29:00] maxing to the deck. Look at this. Daisy,

you, sorry. Yeah. I guess the point is that like we within the salience network use these emotions to kind of like triage and, and create a hierarchy of like what's most important to pay attention to at the time. And so that, that's kind of like one aspect of it. So you're, you're, you're assigning value to these things, but then at the same time you're also like.

By adding emotions to those things you are predicting what will happen. Because the other thing that your brain always is trying to do is predict what's gonna happen because we need to be proactive, not reactive, right? Like if I see a bear and it's charging at me, I, my brain's gonna predict that it's like going to attack me versus if I see it like sleeping or just like rolling around, you know, rubbing itself against a tree, like those should induce two different, like predictive models basically.

And that kind of brings me into our next, um, like topic, which is this kind of prediction and prediction errors, [00:30:00] which are like two things that kind of induce anxiety and emotion on us. So, so basically to summarize, we have infinite info. We have to narrat what's important. We have to prioritize it, and then we make predictions and we develop beliefs off of those predictions.

Does that, hopefully I didn't lose everyone. Does that, that all kinda makes sense. 

Kristin Flanary: That makes sense, yeah. 

Preston: Okay. Awesome. So now. This all applies to things that are benign, right? Like we're making predictions about whether or not like a pencil's gonna fall if I drop it. But when trauma gets involved, things kind of start to go awry, I guess.

And, and really what I found is that a lot of this stuff comes down to a really important part of our brain that's called the insular cortex or the insula. Yeah. Mar Margaret's like that girl. The insula. I love that girl. Yeah. 

Margaret: So she matters for eating dis disorders and chronic pain. I love, oh, okay. 

Preston: Yeah.

So, so the, the insula, it's in your temporal lobe and it kind of [00:31:00] basically does what I described as far as, um, taking into account all this different sensory information and then uniting it into your concept of self in space. So you're like, okay. I am, I'm getting all this sensory input from my eyes, ears, nose, taste buds from my, um, you know, skin and also my ideas about what exists around me.

So my, my, my prefrontal cortex, my memories, they're all kind of coming into your insula, which is like, okay, this is where I am in space and time. Like this is how I've got my bearings. And that is really closely linked to both your amygdala and your hippocampus, which manage your fear and, um, your memories.

So let's introduce like a traumatic event, like let's say like a car crash or something. You have this prediction error essentially because you're, I imagine you're surprised. So you're driving along, you're not expecting to be a crash, so you're trying to predict something. You have, you [00:32:00] air in that prediction.

And then, so you have a lot of extreme fear basically that like bathes the entire region. Um, of your insular cortex and your, your temporal lobes, your hippocampus, all with norepinephrine. And these regions are all rich in like beta receptors and alpha receptors that are all gonna basically be like hyperactivated by all this norepinephrine because you need to do it, but it's in such a high like drive that things start to kind of malfunction.

So now it's like the, basically the pathway has been short circuited and, and anytime you see something that reintroduces this similar memory that's been encoded it, it jacks it up again and it creates this huge like autonomic response. Which is also kind of a problem. So that's where kind of like the prediction errors come into play.

Like we, we are constantly predicting, but we don't wanna be wrong again. So we're [00:33:00] inappropriately assigning like 110% fear to random benign stuff that we see because we're like, for the love of God, like, I don't want to get in that kind of accident again. I'll do anything to avoid it, if that kind of makes sense.

Mm-hmm. And then now to kind of like come back to these like neurotransmitters, they are the ones that actually play a huge role in encoding memory, which is why it matters so much, uh, for like ketamine to induce dissociation. So, um, like I mentioned earlier, um, traumatic or strong emotional responses are very important to encoding memory.

We actually have, have known about this since like the Middle Ages. There was, uh. An old, old proverb that if you wanted like a child proverb, proverb, sorry, not religious. 

Kristin Flanary: I was gonna say either you're Canadian or you never were religious. Yeah. Old proverbs. 

Preston: Sorry. And one of them basically they were like, if you [00:34:00] want a child to remember a wedding better throw them in the river at the end of the day.

True. Because the trauma being thrown into the river is gonna like seal that sear the memory into their mind. So you're saying abuse children 

Margaret: to help them remember? 

Preston: Yeah. Yeah. It's point. Well maybe that's where spare 

Kristin Flanary: the rod, spoil the child came from Preston. That's another one you probably don't know.

Preston: Yeah. 

Kristin Flanary: No, I don't. You don't. 

Preston: So, um, sorry, I'm continuing with my monologuing here. Okay. Sorry. 

Margaret: Continue. It's a good monologue. 

Preston: Basically, basically you're, you're trying to encode these memories and when you have a strong emotional response, like say something firing from your amygdala, you have extended release of glutamate.

And the, that glutamate helps to encode the memory and especially it helps to encode these aversive memories. So it, it was super interesting. I, one of the studies that I came across, they had people taste like different objects. Like they would taste like bad tasting objects, like aversive objects and just like benign ones.[00:35:00] 

And then for the people tasting the bad objects, they split them into a ketamine group and a control group. And the people that took like small amounts of like dissociative, like doses of ketamine and then had the adverse experience were less likely to remember it as adverse than the people that did it.

And then they found that when they gave people like proco pro glutaminergic drugs, so things that like, like. There's actually glute re-uptake inhibitors, believe it or not, which I, which I learned about. They're not in practice. They be using studies, but 

Margaret: Yeah. 

Preston: Yeah. 

Margaret: Just kidding. I know that that's not that I know enough neurobio listeners to not actually think that, just to clarify.

Preston: Yeah. But those, those would actually help us, um, in code memories by, by using more glutamate. So, um, you might be like, okay, well where does association come into any of this? We basically just described that you have like a really strong reaction to memories now and, and what I'm functionally talking about is hyper vigilance, um, which is something that's described in PTSD, but [00:36:00] here's the problem is that this whole circuit goes on hyperdrive so long that it's almost starts to numb itself out.

Like you have to downregulate your response in the insula to all the super strong input that's coming in, but you can't really differentiate between where that's coming from. If that makes sense. You can't be like, oh, like I'm only gonna downregulate it when I see one of my triggers. You're like, I'm just gonna downregulate it all the time.

And then now we're starting to like block some of these pathways. We see less function insular cortex. And that's thought to be related to basically us starting to shut down these pathways that interpret our stimuli in order to basically like protect ourselves. But that leads us to numbing our emotional responses to things.

It leads us to losing our sense of self within like time and space. And it leads us to like having trouble monitoring our own bodily functions, which are all [00:37:00] symptoms of like dissociation functionally. So, so in, in short, we have a really extensive system that is constantly monitoring our environment, prioritizing it.

Creating a hierarchy from it and then encoding it to memory with emotions. But when you hit it with one that's so strong, the whole thing gets kind of thrown outta whack, then you kind of just start to turn off the faucet so that you don't have to deal with it. I think that's, that, and that analogy of itself is like, I think a great way to describe to patients like what their experience is like and why they start to become so emotionally numb.

Kristin Flanary: Yeah. The, so the first question that pops to my mind, and I don't, it's okay if you dunno the answer 'cause I didn't give this to you ahead of time. Um, so the, in my case, the acute crisis part was, you know, a few days and then the dissociation was like once years. So like how, if [00:38:00] we're just talking about like regulating neurotransmitters, like at what point is it like, well now they're totally depleted and so, you know, like, does that ever, I would assume we're trying to get to homeostasis all the time.

Right? So. So I'm curious about the, the time difference, the duration difference between the two states. So 

Margaret: I guess I'll, let me, lemme take a crack at this Preston, and then mm-hmm. You can correct me if I'm wrong. Um, so there's a bunch of things that lead to what we're talking about neurotransmitters, but really what we're talking about is neuro circuits, um, which are modulated by neurotransmitters.

Preston: Mm-hmm. 

Margaret: Um, and that's, I think that's important because there's a lot that goes into what an individual's circuit that makes them higher risk or lower risk for developing PTSD or d personalization derealization in this, like, when something happens, like, so for example, one of the things we know from a population level when it comes to like trauma related disorders is [00:39:00] that the, when a natural disaster happens, um, so when a lot of people go through a sudden event that is, can be called a trauma.

About 90% of people will not go on to develop symptoms of PTSD. And I think what's important about us thinking about this from the neurotransmitter perspective, but is thinking about everything that one person's circuitry will do when there's this modulation and how the learning sticks or doesn't stick.

Because what Preston's talking about is a neuro transmission, but it's also kind of a rewiring, which is why mm-hmm. The symptoms can last so long after a single event, which was also not really a single event. From what you're saying, it was that event. Yeah. But was also's true events before. Yeah. Right.

And so it, you know, if just that had happened, would you have developed these symptoms? Maybe if it had, if, if you only had the first event, the first time he got sick in that way with that support system or not, would you have had it happen? It didn't happen till this [00:40:00] time. 

Preston: Yeah. So 

Margaret: I think that's just in terms of like not over.

It's hard to kind of explain these things about neurotransmitters while also recognizing that neurotransmitters are like adding a bunch of switches to a bunch of wires that we only kind of sketchly know are connected together so far. 

Preston: Mm-hmm. Right. 

Margaret: And then press and correct me please. Thank you. 

Preston: No, no, I, I agree.

Like what? I'm using neurotransmitters to talk about what is heightened sensitization of Yeah. Certain circuits that we're describing. So like the fact that it would be expected that some of them are lingering, but like Margaret said too, it, if it affects everyone very differently, so it's, it's hard to just kind of like call out or guess what the timeline would be.

Margaret: Yeah. Preston, are you telling me I got a Neurobio question? Right. 

Preston: Yeah. Yeah. First I thought she did. I thought she did a good job of describing that. 

Margaret: Thank you. 

Preston: Also, and also, neither of us are neuroscientists, so we're just like, 

Margaret: yeah, we're not, but also have people online who are like, I'm a neuroscientist.

Aren't actually, aren't neuroscientist 

Preston: either. So. Good point. [00:41:00] Yeah. I mean, every time I do this, I just picture my brother-in-law, Jonah, who's like a, he's like a PhD neuroscientist at Harvard, and he always just says, the brains too complicated for any of us to know. 

Margaret: Period. That's like that. And then he ends.

Preston: So he's probably listening to this going like, yeah, Preston, the brains too complicated to describe like this. 

Margaret: And we agree with him. We agree with that. That's like literally every, and Jonah, 

Preston: we agree. My patients 

Margaret: are so sick of me being like some, someone was like, how does an SSI work? And I was like, well, I spoke for five minutes.

And I was like, and that's actually a pretty bad probably explanation of how they work. Yeah. And they were like, why if I even try 

Preston: to explain this to you, I'll make it worse. 

Margaret: Like there's. Clinically, I need you to trust me bro. A little on this. 

Preston: It's actually probably better for you to think it's magic. 

Kristin Flanary: Um, 

Margaret: did that answer 

Kristin Flanary: your 

Margaret: question?

Kristin Flanary: Yeah, I think so. I mean, I don't know, it's like also kind of an impossible question. So, but yeah, that's, that is a good point. That it's not just the neurotransmitters they're doing other stuff. 

Preston: Yeah. Well, I think her question was [00:42:00] fundamentally like, okay, well I'm, if I still have these like lingering symptoms at association, how long can I expect them to last?

And Margaret, and I just said, I have no idea. 

Kristin Flanary: The brain is too complicated for us to know. 

Preston: Yeah. How dare you? 

Margaret: I mean, I think one of the, the question, if the question is how long will they last? I mean, I think the clinical question becomes observational studies on people who have these, if, if this symptom is related to other symptoms and we look at like trauma disorders, what do we do when we compare groups who have.

Not gotten treatment and just, you know, natural through time. If someone has these symptoms at five years out, what is the likelihood that they'll have the symptoms 10 years from now, 20 years from now? Which again, I will not diagnose you, um, but would would be interesting from the PTSD data in terms of PTSD is not really known as a like recurring remitting illness, but [00:43:00] it can certainly improve over time for many people.

Um, whether that's because for, 

Preston: for most people, 

Margaret: for most, does ptsd TS D give that? I mean, like for ptsd, TS D Yeah. Really? 

Preston: Yeah. So like 

Margaret: what is, let's, my understanding is that 

Preston: like, even without treatment, like a lot of times PTSD symptoms will like slowly improve over time 

Margaret: because I can think of many, I don't know.

I feel like it depends. Prob I mean that's, that's a shitty answer. I'm gonna, I'm gonna be quiet. Um, yeah. I mean, most part does do get better over time and it's not like an episode of depression that was like unprompted. I can also just think of many people who the PTSD untreated just worsens it. And so that's why I'm like, are you correct or not?

Preston: Well, yeah, I'm not, I'm not saying that like taking someone off treatment, like obviously that that's, but I guess what I'm saying is like your PTSD close to the event versus 10 years out. Right? Like it's not like, right. It's not like the PTSD TSD is twice as worse, twice. Like, it doesn't, it doesn't gain momentum with time and deteriorate continue to get [00:44:00] worse like you would see in like a dementia syndrome or like schizophrenia or bipolar schizo effect.

You know what I mean? Yeah. I guess, guess that's like what I'm comparing to. Oh, I 

Margaret: see what you're saying. Yes. These are, 

Preston: those are progressive illnesses that will continuously get worse without treatment. Like obviously PTSD will get worse if you do not treat it or like take away treatment from it. Mm-hmm.

But it doesn't progress in the way those other illnesses do. 

Margaret: Agree. Okay. Yeah. I see what you're saying. I see what you're saying. Yeah. Um, I think. We should take a quick break and then we can talk a little bit about approaches to this to help people with it clinically. And also I think it's important for us to say a little bit more about, obviously we don't read the DSM book to our patients, so how we describe this kind of thing to help people mm-hmm.

Understand a little bit more of like what, what we're talking about. Because I think that the definition, like many things, and Preston, you talk about this quite a bit. Like you can't just be like, do you want to end your life via suicide [00:45:00] as the only way you address hopelessness or suicidality or self-harm?

Like you need to have a different kind of language to actually talk to people in our work. Um, surprisingly, 

Preston: I'm like it says here yeah, that depressed people are hopeless. Are you, are you hopeless? Are you pathetic? That's, there's no pathetic in there. I'm just kidding. That's not a criteria, but let's, that's like how, that's how a lot of people take it, you know?

They're like, I'm no, I'm, I'm not hopeless. Like, 

Margaret: do you feel, okay, we'll be right back. Okay. On that note, we'll be right back.

Preston: Because, because I mean like the, the definition of hopelessness is to be without hope. And, and 

Margaret: we're back. And Preston's still talking. 

Preston: Yeah. Sorry. Sorry. And another thing about hopelessness, like the definition of hopelessness is to be without hope. So to think that, and hope is the belief that things may improve in the future or that there's like, hope 

Margaret: this thing with feather 

Preston: or, what's that?

Margaret: Where's that? We just, [00:46:00] we just split into our, it's, it's a butterfly types again. Yeah. Um, okay Lana. 

Preston: So anyways, if you're like, if you're like, I have no optimism or belief that anything will improve in the future. That is like by definition not having hope, which is hopelessness, but people often like will then equivocate hopeless to like an adjective of something that's like pitiful.

Margaret: Right. Preston, I feel like this, even though I didn't design this episode. I think this might be a good example to do a two minute role play where I pretend to be a patient experiencing this. And you interview me for two minutes and then we'll have Kristen weigh in and see what she thought of the interaction 

Preston: all.

Oh boy. Let's, let's do it. You, you know, I'm always ready for a quick role play. 

Margaret: Stop. Do I need to leave the room? Where's hr? I drank some. 

Preston: I had uh, I had some kombucha before this episode, so I'm, so I'm just gonna try my best not to burp. 

Margaret: Like do you, are you ever, uh, let's just, [00:47:00] okay. Um, I'm gonna give you 

Preston: that, that was an imitated.

I'm gonna give you a clinical 

Margaret: vignette. Are you ready? 

Preston: Okay. 

Margaret: Clinical vignette. Um. It is going to sound somewhat similar to what we were talking about with Kristen, but I'm going to change details. And this is not reflective of your situation, but I wanna make it a little similar so you can see how you would talk to you to someone presenting after, during co survivorship.

Okay. 3-year-old female referred to you from her primary care doctor after, uh, unintentionally weight loss over the last year of 10 pounds with decreased appetite, decreased interest in prior hobbies, hanging out with female friends, um, sense of kind of overwhelming anxiety with taking care care of two kids of note spouse had significant, um, illness, oncology.

You don't need to know what it was, uh, is now as of a month or two ago, as of two months ago, is in remission overall, like doing well, [00:48:00] patient coming in a couple weeks ago to primary care, wondering why they're still feeling, quote unquote off feeling not as present and wondering. If there's something wrong with them, if there's fatigue or they need like vitamins checked, vitamins, all normal, tested, all the labs, uh mm-hmm.

Things look fine from EKG. Is normal EKG normal? Yeah. 

Preston: No anterior drawer test. 

Margaret: What the what 

Preston: For the interior. Oh, 

Margaret: what? 

Preston: Yeah. 

Margaret: How your knees, why are you asking that? 

Preston: What's, what's menstruation like? 

Margaret: It's, it's fine. You are coming in now and you are asking her for your focused exam about the fatigue and the sense of overwhelming anxiety that the PCP report too.

You have two minutes. Okay. 

Preston: So, um, when I was looking over the, the notes from your primary doctor, they, they mentioned something about feeling tired all the time. Can you tell me more about that? 

Margaret: Yeah, I mean, I, [00:49:00] you know, I have two kids. I'm busy, I'm working. Um, I'm, I think they mentioned to you that my partner has been sick for the last.

Over, a little over a year. He is better now. Um, so I've got a lot going on and I was, I would get tired before, but now it just feels like everything's always kind of, I don't know, fuzzy. It feels like I just can't like focus or be as like, present to things, even like my kids as I, I was, you know, the rest of like, a couple years ago, 

Preston: like, you want to be there, but you don't feel like you're there.

Margaret: Yeah. It's almost like, it's almost like I have to get myself to like, like keep refocusing back in. 

Preston: Hmm. 

Margaret: And like, otherwise my, like, I just feel like I, like I'm getting anxious and thinking about other things. 

Preston: Gotcha. So, uh, when you're in this moment where you feel you're taken away from the present, what anxious thoughts come into your mind?[00:50:00] 

Margaret: It's like, it's not even necessarily like, fully formed, like thoughts, like, 

Preston: mm. 

Margaret: It's. It's just like, I feel sort of, uh, at like, it feels like something's wrong, but I like don't know what's wrong. Mm-hmm. And like, I'm trying to figure out why I feel like something is about to happen and like, it makes me like when I'll like, feel it sometimes it'll make me be like, oh, do I need to like double check the lock or do I need to like text my partner and, and just double check that his like day at work is going okay.

Or like 

Preston: something bad's about to happen. But you can't put a name to it. 

Margaret: Yeah. And 

Preston: you go and, and try to find solutions to that thing. 

Margaret: Yeah. Or it feels like when I'm like with my kids, like it almost feels sometimes like they're playing and they're trying to talk to me and I'm like, like I'm hearing them, but I'm like not actually with them.

Like, I almost, I don't feel [00:51:00] like outside myself, but I 

Preston: Does it ever, ever feel like, um. Things are almost dreamlike or like there's like a screen between you and other people. 

Margaret: Yeah, it's, it's, it's almost like I feel kind of like numbed to other people, like they can't actually reach me. 

Preston: Mm-hmm. 

Margaret: Okay. Time.

Okay. 

Preston: I think the next place I was gonna go with that is like, try to get at like how you feel emotions and, and I know you mentioned like feeling numb, but like, really, like when's the last time you've like, felt anything? Or like, do you feel joy? Okay. Well let's 

Margaret: give us one more minute then fear. Okay.

Okay. Uh, I mean, I think I like feel fine most times. The last time I like really felt something was probably like sitting in the hospital or in the clinic when he got diagnosed. Like I feel like the last time I felt something vivid, it was horrible. 

Preston: Does anything happen during the day that brings you back to that memory?

I mean, what does, like, [00:52:00] 

Margaret: nothing that makes sense. Like I've had to like. Put different pic, anything that reminds me of it, I try to like, put out of sight, but I, I mean, I think about it like, I don't know, 20, 30 times a day on a good day, everything, he reminds me of it. 

Preston: Mm-hmm. 

Margaret: Okay. Now time. 

Preston: Okay. 

Margaret: Okay. 

Preston: So yeah, actually I didn't have to do that much.

You did a great job of kinda like describing all those symptoms. So in you saying this, this like, I, I feel numb, I feel like I'm not there with my children. Or like, the emotions aren't like going in. You, you're pretty effectively describing these like feelings of attachment with re or detachment with regards to one's thoughts, feelings and bodily sensations.

Feeling like you're going through the motions with your children, but you're like not actually present or there. So like. That'd be something that like, almost kinda seems like this like conversation, but like we're pulling, I guess the DSM [00:53:00] criteria from the things that she's describing. 

Margaret: Well, and you can see how clinically someone could present like this.

And like if I was in a primary care clinic where there's like 40 other things they're trying to do with you, it could easily be chalked up to like, oh, it's depression. Or it's like, oh, you know, if we're, I love pcp, so I'm not gonna put this on them. But if we're in a prior like sexist kind of way of viewing health, like, oh, all moms are tired.

Like you've been through a lot. Like, you just need to sleep more and dah, dah, dah, dah, dah. Like you could, yeah. Do you know 

Kristin Flanary: how many times we heard that over all seven years? It was like, he's tired. I'm tired. Well, that makes sense. You're in school, you're in training of kids, whatever. Mm-hmm. It's just like you're twenties and thirties, so you're not sick.

You're just tired. Right? Mm-hmm. And you can see 

Margaret: how 

Kristin Flanary: with 

Margaret: less time or with less ability to ask questions of put language to this. That it could easily be chalked up to, oh, you're tired and you're like kind of down and anxious. Let's start you on a medication. And, and granted that a medication may still like, people don't have to have diagnostic exact clarity for a medication to still [00:54:00] help with this kind of thing, but it wouldn't lead us to the kind of clarifying discussion that would maybe help you the most.

Preston: Right. Yeah. And, and like I think different from other specialties in psychiatry, the act of giving someone a diagnosis is therapeutic in itself. 

Kristin Flanary: Yep. 

Preston: Like if I like explained to you and wrote out their criteria and said like, this is what I think you have and that like actually fits and is reflective of your experience, like that is treatment in and of itself.

Kristin Flanary: That's something I talk about all the time and that's why I like share that word a lot, is that it is the diagnosis. Right. And there's something really powerful about language that if we have a name for something in a box, we can put it in. All of a sudden we feel like we. We, it's, it's resolved in some way.

Like we can deal with it now. 

Preston: Yeah. Like one, like one of the strangest experiences I've had in medicine, especially like when I was on internal medicine and you would diagnose patients with cancer who were like, had this huge like unknown [00:55:00] workup, they almost like had relief when they got the diagnosis of cancer after like months of going through these like battery of tests and like in a lot of them they would say, at least I have a name for it now.

At least I know what it's, and like that was healing for them. Yeah. And, and the same is true for psychiatric disorders 

Margaret: I think as well, right? Like it's, it's such a confusing, if we think about, clinically speaking, we think about these definitions of trauma and what causes someone to experience dissociation.

If we think of that, then one of the, the principles of like trauma informed or trauma sensitive care are giving autonomy, giving language, giving space for like self definition. Um, and all of that in a good diagnostic process can help people have more choice and more sense of their own story. Which, as you're saying, Preston can be in, in itself, like the help healing to some extent as well as [00:56:00] being useful in terms of direction of support aid, clinical help that someone might need.

Mm-hmm. 

Preston: Yeah. And, and then all that aside, like having the right, um, diagnosis or correct diagnosis helps guide you to medications that are more effective. So like you can use SSRIs to treat, um, PTSD or, or trauma related disorders, but SNRIs are often more effective. 

Kristin Flanary: What is like, gimme some examples of SNRIs.

Preston: Yeah. So something like. Cymbalta or, uh, duloxetine or venlafaxine or, uh, Effexor. Those are the kind of the, the two names for those. Um, the two different medications, brand name, and the generic, they are, are serotonin and norepinephrine reuptake inhibitors. 

Kristin Flanary: Is that the same as Wellbutrin? Mm-hmm. 

Preston: So Wellbutrin actually is on the other end.

Um, it, it's, uh, a norepinephrine dopamine retake inhibitor. 

Kristin Flanary: Oh, okay. So N and D, not S and n, [00:57:00] yeah. 

Preston: Yep. So some people call it an NDRI. 

Margaret: Okay. 

Preston: So I, 

Margaret: I do wanna say there are a lot of people on sertraline for p ts and it is equally evidence-based as the SNRI is, just in case anyone's listening. 

Preston: Yes. So, so I was actually gonna, I, I'll get to that too, which is like, SSRIs have different, uh, effies, like different SSRIs.

So like fluoxetine and sertraline are like more effective for PSD than something like Lexapro, for example. That has to do with like some of the like other sub receptors that are hit by sertraline and some of the sub receptors that are hit by fluoxetine. So Fluoxetine actually has a lot of activity on the norepinephrine reuptake.

It's, it's kinda kinda an SNR light, I guess. Um, and then sertraline hits a lot of doping receptors, a lot of sigma receptors, um, and, and other things like that augment in a different way. So yeah, Margaret's right, like sertraline has equal evidence, uh, to support P-T-S-D-I-I, I actually didn't, I haven't read a lot of papers [00:58:00] on this hypothesis, so this is like, kinda like Preston's hypothesis, but, but my thought is that if you have basically manipulation or change of how you encode memory from a traumatic experience when you're like basically bathing your temporal lobes and adrenaline from having, like experiencing trauma, then if you have an SNRI like.

The re-uptake of norepinephrine, which you think would be stimulating it, it actually helps like desensitize or downregulate some of like the post-synaptic reactivity to noradrenaline, which, which may help augment some of the traumatic experience. So, big asterisk on that. It's just presence hypothesis for why SNRIs work.

Margaret: I don't, I dunno. 

Preston: I 

Margaret: I don't disagree with your hypothesis. I also though think that a lot of this data comes from funding through the va, um, for PTSD and in terms of population studies, we're not studying necessarily kids. And if we are studying people in the [00:59:00] VA population, there's a high preponderance of comorbid chronic pain.

Um, I, I don't disagree with your hypothesis, but I think there are just many factors here that could be why SNRIs. Which have more efficacy for chronic pain, um, and chronic pain and trauma, uh, have a strong inner relationship in terms of like nerve signaling and increased central sensitization. 

Preston: So yeah, it could be both.

And like central pain, sensitization, doesn't a lot of that happen in the insula? 

Margaret: It does, yeah. Yeah. So, 

Preston: yeah. So yeah. So maybe it's just two birds, one stone kind of situation. But, but who knows? We're just, we're just a guy and a gal hypothesizing about stuff. 

Margaret: I mean, I, I wouldn't under credit that that, I mean, at least what I said is based in some real discussion on like, I dunno, um, interesting theories though.

Yeah. And then you should talk a little bit about [01:00:00] like clonidine, razin, although I, for, for dissociation, I don't know how much. And the other thing we're not talking about, which is the most evidence-based for this is therapies. Like for specifically for dissociation and, and depersonalization. 

Preston: Yeah. And I, I guess Margaret, I'll, I'll let you cover the therapies for dissociation.

'cause I think I'm only really familiar with like, um, desensitization therapy for PTSD that indirectly helps with dissociation rather than like, directly 

Margaret: Yeah. 

Preston: Addressing the dissociation. 

Margaret: Well, I, I mean, I think that for dissociation it's not, I don't, there's not necessarily a therapy that's directly gonna be like, let's get them in their body.

Like, we'll directly help it. Um, I think like an 

Preston: exorcism, 

Margaret: get them back in their body. 

Preston: Where in the room are you looking down on us. I'm gonna grab you and stick you back in your head. 

Kristin Flanary: Stick. Um, this brute brings up a good point though. Like, what about things like EMDR? The whole like, I don't know. There's, I don't know the names for them.

Yeah. But like, grounding [01:01:00] techniques, you know, I'm, I'm 

Margaret: not gonna publicly speak on. Some of these therapies. 

Kristin Flanary: Okay. I have no idea. I'm just genuinely curious. Yeah. EMDR 

Margaret: is evidence-based for treatment of PTSD. Um, there I think are valid components of these, like what they're called somatic or bottom up therapies that we have historically ignored.

Um, the actual mechanism of some of these things as they are currently purported, lacks some, there are questions that different parts of the. Uh, neuropsychiatric community have about the validity of the purported mechanisms of like EMDR. Um, 

Preston: I'll, I'll speak on it. 

Margaret: Let's hear it. 

Preston: So, so the, the desensitization part of it is like really what we know is effective, and that gets back to what I was talking about earlier, which is you're assigning this huge fear stimulus to something you see in your environment.

So, so by basically exposing you [01:02:00] to it, which is gonna induce a fear response and then seeing that nothing bad happened and then exposing again and nothing bad happened, like you're getting reps in to almost like extinguish that hyperactive response that you're having over and over again. 

Kristin Flanary: You know, this is so funny because I have always joked that my therapy, 'cause remember I told you I couldn't like arrange therapy for myself.

But eventually I did start giving keynote speeches about it. I was writing about it. Mm-hmm. Was performing onstage monologues about it and like as part of all of this, I'm playing the nine one one call over and over and over and over and over like. So it really is therapy and it was actually the most, yeah.

So you exposure therapy. 

Preston: Yeah, yeah. No, no, exactly. I'm a 

Kristin Flanary: genius. 

Preston: Hey, 

Margaret: it's, it's like called prolonged exposure therapy for like trauma. So you, you quite literally, uh, had some of the most active ingredients in doing that. I think. I think one other [01:03:00] thing therapeutically that we have to think about is that for someone who's had a trauma and their primary concern is dissociation or derealization, we have to be very mindful that in this exposure based work, which is the most helpful for kind of desensitization to the stimuli and relearning, we.

There's nothing physic, like someone getting mad at me or like avoiding talking about something or not showing up for appointments. I can tell that's happening. Some people are very good at dissociating and it looking like nothing's different at all. And so I think establishing rapport and letting things be patient led is always a good idea, but especially if this is the way that someone responds to the trauma, like trigger stimulus.

Preston: Mm-hmm. 

Margaret: Um, yeah, 

Preston: because it, it is a really effective coping mechanism in a way. Like you, you, if you literally learn how to just like suck yourself out of it. Mm-hmm. So you're like, [01:04:00] oh no, like, like, like, you know, I can go back in my turtle shell, or I guess out of my turtle shell, like, why, why would I want to try to expose myself to that?

Even though that's the way that you like, kind of learn how to not have that reaction again. 

Kristin Flanary: Do you think it gets easier to, like, can you pop in and out once like. The 

Preston: avatar state? 

Kristin Flanary: Yeah, 

Preston: I don't know. 

Kristin Flanary: Wait, say more. What do you mean by 

Margaret: that question? 

Kristin Flanary: I feel like I never, I had never experienced anything like that before the really big episode.

Right. And so, but then since then, I feel like, and I don't know if there's like scientific validity to this, but just the lived experience feels like I'm kind of pulling myself out sometimes. Like if things are really, there's a lot of sensory input all of a sudden, or, uh, heightened emotions around me or things like that.

Like I will just sort of and kind of disconnect a little bit. Yeah. [01:05:00] I mean, I think, but I don't know if that's like a real, like legit thing that, that like once you do it, I mean it's like getting back to the neuro circuit. You've right president, like now am I just like better at, at doing that now because I have the circuitry.

Your body 

Margaret: knows that your brain, body, whatever, like knows this is an option. So like, is it ever a hundred percent necessarily, like I can just choose to thinking about things on the internet that I like? Well 

Preston: mean you can't choose to go into the avatar state. You know, like something has to really set 'em off.

That's 

Margaret: fair. Like, but I do think, I mean, clinically speaking, there are patients who will be like, I know I can, Preston wants me to care about the, his reference is so bad. Uh, but I think like, again, it's not a hundred percent volitional, but anecdotally and clinically, a lot of patients will say like, I know I can just like dissociate.

Like I know it's an option. Okay. Yeah. Um, 

Preston: yeah, I, I agree. [01:06:00] Like anecdotally I've seen that as well. 

Margaret: I mean, I think it's like if you kind of like you, you know, you can actively like. Unfocus your eyes. It's not quite, yeah, I mean it's like that, but your brain, your, your spouse would probably not, like if I said it's not quite as simple as that, and he'd be like the eyes like, oh, you'd get a lecture.

Yeah, whatever. He's fighting a different war right now. He's gonna like put us up next on 

Preston: podcast, spreading information. 

Margaret: I mean, he came on a couple episodes and was like, Preston, why are you saying that my medical humor content is bad. 

Kristin Flanary: Oh yeah, I remember that. 

Preston: Yeah. I was like, oopsie. 

Margaret: Sorry, dad. That 

Preston: wasn't meant to be directed like that.

Margaret: The last thing I'll just say, because I know we need to wrap up the episode soon, is just, I think we've been circling around this as well in the episode, but our brains are good at doing things to help us establish patterns and to survive. [01:07:00] And I think a lot of people who go through something that makes this a concern for them, like makes dissociation a concern, have in many ways, whether it's like what you went through in the hospital being scolded, or kids going through traumatic things are somehow made or given the message that the pain and the suffering is their fault, and therefore there's something broken about their brain or themselves.

Mm-hmm. And while we can help and we give this a diagnosis and not everyone experiences it, I also think there's something to be said that there's something deeply human and protective in the brain doing its job, um, when these things occur after trauma. 

Kristin Flanary: Right. Because it's too much. Like it's just protecting you from the Too much.

Preston: Mm-hmm. Yeah, exactly. It's just like everything is on fire, so let's just like shut the door and snuff out the oxygen. 

Kristin Flanary: Yeah. Yeah. Like if there's nothing you can do about it, then well at least we can just not feel it. 

Preston: Yeah. Yeah. Or, or I guess even like a better analogy, be like, you know, like a circuit breaker.

The, [01:08:00] the voltage gets up too high and the circuit breaker is gonna flip the switch. 

Kristin Flanary: Yeah. 

Preston: And everything kind of shuts, shuts off for a second. Right. It all still works, but you have to like manually flip it back on. 

Margaret: Yeah. 

Preston: Let things start to, to restart. 

Margaret: Kristen, I'm wondering if you have any final kind of thoughts, especially given your experience as you're writing this book, things you'd like our listeners to know, either about their patients or, you know, they themselves as people who have probably been through things, seen things working in healthcare, um, and, and your experience.

Kristin Flanary: Yeah, I, so one of the things I always end my talks with, it feels relevant here is like, you know, I talk about how patients and families and, you know, we've experienced this trauma and what the effect is, but, and I'm talking to healthcare audiences, but I'm also fully aware healthcare professionals see so much trauma every single day.

Sometimes, you know, you might see more in [01:09:00] a day than some people see in their entire lifetime. And then, you know, you're just expected to sort of normalize it and move along. And, um, so I don't know, I'm, this is maybe the mom in me, but like, I just always am like, please take care of yourself. Like, it's okay to feel your feelings and be a human being.

Like before you're a doctor, you're a human. And like, that's good and wonderful. 

Preston: Yeah. Being, being a human is an incurable condition. That's right. We all share 

Margaret: interpretation. Sometimes we don't have to just learn how to be patient, but be a patient. See, that's what you kind

producers 

Preston: play. Red Redtail hawks out. 

Margaret: Maggie too. Nice.

Oh, all right. Okay. 

Preston: Well thank you everyone for listening. Um, I know a lot of people were kind of asking us [01:10:00] about, uh, doing an episode on dissociative disorders. This is kind of us really, um, I think more so wetting our feet with it. There's a lot of other things we can talk about, and I think a lot of people are requesting that.

We, we discuss more around borderline personality disorder and complex PTSD, which I think is a topic that deserves its own episode or several episodes. But this is kind of our start to talking about, you know, some of the mechanisms or, or treatment options around dissociation. As it pertains to trauma, if you guys like these types of shows, if you like having Kristin on here, if she has time to come back and do other episode, don't tell.

If you don't, us don't 

Kristin Flanary: just keep it to yourself. 

Preston: Yeah, yeah. Um, or you, or you can tell us in the secret. We won't tell Kristen. There you go. Um, you can come chat with us or we'll talk then DM us on Instagram at How to Be Patient. You can find us on our website at How to be patient pod.com. You can always see stuff from Margaret at Bad Art every day, but it's really, it should be medium art every day [01:11:00] considering it's getting better, I think.

Okay. And if you haven't done bad art for today, find something you do. Don't make some bad art. Yeah, I, I started to do paint by numbers. 

Margaret: I got one too. I was in, I was hashtag influenced by Preston. Can you believe it? You 

Preston: that guys, I, I can influence Margaret to do things. 

Margaret: I found it once in one year. You can always find me on, 

Preston: you can, you can always find me on TikTok at its prerow, um, or I'm preez on TikTok at its prerow on my YouTube, which is where also all of our episodes will be listed.

Shouted again to everyone leaving the kai and feedback in comments. Um, and everyone who also leaves other comments too, like someone was just, someone just said too many ads and they were like, period, pre-roll YouTube ads, like you 

Margaret: capitalist pigs. 

Preston: I was like, um, you know, it's all feedback, so I appreciate you saying that.

Um, I also like the guy comments 

Margaret: first every time on the, on the YouTube videos. He's our number one. Yeah. 

Preston: I like you, man. Number one hero. If you're commenting first, shout out. Yeah. [01:12:00] It's different people, but shout out to you. Oh, I thought it 

Margaret: was, well, 

Preston: might, it might just be one on YouTube. I'll, I'll find your, I'll find your name and I'll, I'll, we'll have you on as again, I'll call you up by name next time.

Yeah. We're your host, Preston Roche and Margaret Duncan. Our executive producers are me, Preston Roche, Margaret Duncan. Will Flanary, Kristin Flannery. Hey here. Corny. Rob Goldman and Shahnti Brooke. Our editor and engineer is Jason Portizo. Our music is Bio of nv. To learn more about our program, disclaimer and ethics policy submission verification and licensing terms, and our HIPAA release terms, go to How to be patient pod.com or reach out to us with any concerns at how to be patient@humancontent.com.

How to be patient is a human content production.[01:13:00] 

How to.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [01:14:00] background.