Psychiatry & Psychotherapy Podcast - Adverse Childhood Experiences Part 2: Measurement, Impact on Future Mental Health, Dissociation, and Timing of Trauma

Episode Date: February 2, 2024

In this week's episode of the podcast, Dr. Kuhn, Liam Browning, and Dr. Puder will continue their discussion regarding adverse childhood experiences (ACEs) and their influence on the development of future mental health disorders. The greatest predictive factor of the relationship between ACEs and future mental health disorders has to do with the severity, duration, and number of traumatic events. We'll explore the Childhood Trauma Questionnaire and the data of how ACEs increase the risk of certain personality disorders and psychiatric conditions. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

Welcome back to the podcast. I am joined once again with Liam Browning and Annabel Coon. Annabelle is a person that works in my practice. These patients out here in Florida with me. Liam Browning is a medical student who is and has worked tirelessly on the series. We are doing a series on adverse childhood experiences, also known as ACEs or ACE. That's Adverse Childhood Experiences. and this will be part two. And so this is going to be a series. I have some really exciting future guests coming on. I will keep you in suspense over who they are. But let's start out.

Liam, what is the current evidence on ACE's increasing risk of mental health disorders? Yeah. Before we sort of dive into the literature here, I wanted to preface by saying that there is a large, degree of heterogeneity in a lot of these studies, meaning like, as we're seeing an exponential increase in the number of studies addressing this topic, we're going to see studies that use different methods, and we're going to see studies that identify different metrics that they recognize as important. And what I mean by that is we're going to see studies looking at,

oh, there's hippocampal decreased volume. That explains the effect of ACEs on mental health. We're going to see studies looking at, oh, this is self-esteem problem. This is an inflammation problem. So we're going to see a whole number of studies finding one metric and trying to explain that as the most important thing explaining the association between ACEs and mental health outcomes. And as we start to see this effect, we should try to balance that with our clinical judgment and our real-life intuition because these are individuals that we're talking about here who have experienced these traumas and each person is going to be affected by their traumas differently, and that's going to lead to different outcomes. And you can't always just reduce their experience

down to these finite sets of metrics. And there's going to be so many different confounders and looking at how one-nace exposure leads to a psychiatric outcome. So I just want to preface all that by saying that there's a larger degree of heterogeneity in this literature, and we're going to do our best to look at the studies that are actually looking at, uh, what is reality and not getting too bogged down into the fine details of one particular study. Yeah, I think that's really important. I would add to that, you know, when you actually treat an individual patient, diagnosing them can be less important over time because it's almost like people are so unique and people have so many unique attributes and that people change too.

It's like, so what could be a very sort of rigid defense against, you know, emotion in the first year of treatment could change to something else. People change over time. And if you don't have an openness to experience the person of the room and kind of see them through a rigid lens, they will feel unheard and unseen. So, yeah, I think that it's important to realize we're looking at. at statistics because we want to know a little bit about how trauma affects the body and how it affects mental health and that it does affect mental health. Yeah, so over the past like couple weeks I've been thinking about like I think studies have to start somewhere. So they're going to like create a list of like, okay, these counts as adverse childhood experiences. And so like I was

just like exploring like what does count as an count as an adverse childhood experience and absolutely it's going to vary by each study and with that in mind like if people are looking on the internet like oh like how many aces do I have like take an ace quiz I like looked at some of those over the past couple weeks just to see what was going on and one thing that stuck out to me that was missing from a lot of them and like none of them are the same but like one thing that I noticed was that there's a lack of trauma that happens at school that was included in those, especially with the rise of school shootings, you know, anything can happen anywhere. And kids are kids at school.

And it's another place where they exist. So there must be trauma that happens there too. So, yeah, I just am curious about that. And I feel like that is left out of studies too. Yeah, definitely. Some studies will include bullying. So they kind of capture those school-related experiences. And some will actually pick up on like a chronic illness in childhood, including hospitalizations.

But it really depends on the type of study that you're reading. Every study is going to have different ways of conceptualizing ACEs. But the more commonly used metrics are the ACE score, of course, and then also the CTQ, which is the childhood trauma questionnaire. So that assesses like maltreatment based on physical abuse, emotional abuse, sexual abuse, emotional neglect and physical neglect. And that kind of can allow us to assess things for a lycurt scale. They look at the frequency and a degree of severity.

So that kind of allows us to look at a dose response relationship, essentially. Yeah, so I have an actual copy of that, and I've given that to patients. And at this point, I'm actually just, I'm hesitant to give it as an initial screener, because some of these questions are so personal. So it's almost like I would want to give it to them in session and then go through their answers with them in the here and now. But they have questions like, when I was growing up, I didn't have enough to eat.

And then you answer never true, rarely true, sometimes true, often true, very often true. And so you can see how this is a five-point scale, very often true being five. Some of these are reverse-coded. And so you can get, a much bigger gradient of numbers compared to a dichotomous scale yes or no right and so yeah there's they ask different types of questions around childhood and some of them are like I felt loved

you know I felt loved okay when I was growing up I felt loved very often or never true another question that I think about is like I wonder how many people don't realize that they've been traumatized and I wonder how many people, like, if they were to approach the scale, don't know what the right amount of food is. Or, like, they don't know what it means to feel loved. And I wonder if they say yes, not knowing that they've actually been very much traumatized. I think the hope of a good questionnaire is to catch through different questions, people with varying levels of insight into what happened. So, for example, on the sexual abuse questions, there's like, someone tries, someone tried to touch me in a sexual way or tried to make me touch them. And there's also somebody molested me, took advantage of me sexually. So there's different ways of asking the question to potentially elicit, you know, a composite score on sexual abuse, right? What was the other one on sexual abuse, just to give people an idea.

Oh, yeah. Someone threatened to hurt me or tell lies about me unless I did something sexual with them. Right. So there's like the blackmail sexual act, right? Someone molested me, took advantage of me sexually. Someone tried to make me do sexual things or watch sexual things. So even if they had you watch sexual things, you might score that one. I believe that I was sexually abused.

So there's a bunch of different questions around the different domains. I recommend you take this yourself and see how you score. I think it will help you understand the content of this episode to kind of see, you know, whenever I am trying to read a study, I try to pull up a PDF of the actual questions because it kind of informs me on what the answers mean. So, David, I was curious about how you use this questionnaire in your clinical practice.

Well, sometimes you don't really catch things in the same way, right? Mm-hmm. And so, you know, you may ask a basic question around sexual abuse or physical abuse, but I think a neglect is a little bit harder to ask. So sometimes just going through it, it's like a good way to ask a neglect question or like the emotional contact or the warmth. You know, like some of these questions like people in my family felt close to each other.

Well, that's an interesting question because it's not how you felt necessarily. It's like the family as a whole system. I have, there was nothing I wanted to change about my family. right it's not an abuse question per se or it doesn't sound like an abuse question right off right off the bat but it kind of gets to like there was something going on you know that you wanted to change that you knew you wanted to change so yeah makes sense so yeah sometimes it's like the way the question is asked can kind of like be helpful and then starting a larger conversation okay liam anything else So shall we move into odds ratios?

Yeah, let's move into the odds ratios. That sense. Did you want to actually read off these numbers here, or did you want to leave this for anyone to look out? Well, let's start off with, like, this is like one or more adverse childhood experience, right? This is a table of having only one adverse childhood experience. And so what we're going to talk about is, like,

most people didn't have just one. and if you've had multiple, your risk goes up even more. But it's interesting to see how almost every diagnosis goes up with more adverse childhood experiences. Interesting, sad, tragic. Let's list off some of them, and then we'll slow down maybe and talk about it. Sure. So for substance use disorder,

based on prospective studies, the odds ratios are about 1.3 to 4.3. And there's actually some evidence to suggest that more ACEs increase the risk for earlier on substance use, and then also for more frequent use and polysubstance use. And the next would be psychotic disorders. And the odds ratios for these are 1.65 to 2.8 based on prospective reports. I think that's important because we often think of like schizophrenia as just genetic, right? One thought is like I know that in the questionnaire about ACEs, having a parent with like a severe mental illness is considered an ACE. And I wonder if like this genetic, if there's like a genetic link like just because yes, it is hereditary and also living with a parent living with a mental illness.

It's like in and of itself can increase the risk. I wonder if they were able to parse that out. Right. You can imagine if you had a patient with untreated mental illness, you might answer, you know, sometimes true, often true, very often true to many of these questions based off of that type of environment. If they were untreated, I've had a number of patients with, or parents with untreated schizophrenia. And, you know, it's like, and this isn't to say, like,

I have many patients who are living with a psychotic illness. They're treated and they're amazing parents. And so I just want to make that clear from what I can see with their interactions with their kids in my clinic. And just because you have a mental illness doesn't mean you're going to cause problems for your child at all. Right. That's right. Yeah. As I say, untreated.

Right. Poorly treated. And often, you know, homes with drugs in the home as well. Like, yeah, it's going to be a higher-A's home. Yeah. A unipolar depression is around two. So the odds ratio of having unipolar depression is twice as much if you had one ace. Anxiety is about two.

Cluster A personality disorders. 1.5. It's cross-sectional. A little bit different schizetipels 2.3. Schizoid 1.3. Any thoughts on that, Liam? Yeah, these numbers were from. One cross-sectional study of, I think it was over 30,000 participants, yeah, 30,000 participants based on, yeah, again, cross-sectional reporting.

There are actually not many studies looking at personality disorders and ACEs in a prospective way. So I thought this was one of the best studies in looking at the relationship between ACEs and personality disorders, because we can compare across the different clusters. Yeah. So cluster A was one. point five cluster view was 2.0 borderline cross-sectional 2.3 and 1.6 for perspective and that's low because it's only one adverse childhood experience right specifically it'll jump way up when we get to four or more narcissistic personality sort of 1.7 histrionic 1.4 antisocial 2.2. So mostly around 2 for cluster B. And then cluster C is, these are a little bit lower.

Yeah. So the study found that having a cluster C diagnosis was only a 1.2-fold increased likelihood with 1A's. But for each personality disorder within this cluster, they're actually not significant. Yeah. And then PTSD is around two and complex PTSD is 1.6. This is only one ACE. So you get about, you know, think about twofold increase in the likelihood of having PTSD or complex PTSD. So in summary, it's around, you're twice as likely to have most, or if you had had only one adverse childhood experience, you're about twice as likely to have a lot of the different mental health issues that you could have.

So from a public health perspective, like, it would be important to minimize aces as to, like, minimize the need for more, like, health care exposure and, like, to minimize mental illness, it's a huge cost on, like, our society. And even, like, with just one ace, it's such a huge increase in risk. And so, like, thinking about that from that lens, how do we minimize this? How do we prevent it before it starts? That's a big question. There's no simpler. That's a huge question. It definitely relates to, you know,

really addressing parental mental health, too. Yeah. Prential mental health, parental addiction issues, you know, and there's no insurance company that's going to want to spearhead that kind of stuff because they're mostly focused on one year of insurance, you know. they're not thinking decades ahead of time. So I think this needs to be something that we as a society think decades ahead of time

and think about in our communities what we can do as well, right? So, okay. Let's talk about the increased risk of psychiatric diagnosis in a dose-dependent manner. So we talked about one-A's, but there is this dose-dependent manner. Liam, tell me about that. Yeah, I first wanted to start, like, talking about depression. I think there's one really good study. It was a meta-analysis. They looked at the relationship between the CTQ and depression diagnosis and then depressive symptoms.

So looking at diagnosis first, they had 39 studies here, and they found that the CTQ had an effect size of 1.07 for predicting lifetime diagnosis of depression. And then when they pooled 70 studies together, they showed a Z correlation of 0.35 between CTQ and depressive symptoms. So a Z correlation, essentially what this means is that for each one standard deviation and the CTQ, each one standard deviation increase, you'd expect the depressive scores to increase by 0.35 standard deviations. Just think about like a stairs. You know, like if we walk up the stairs a little bit with the CTQ, you're going to walk up a little

bit more with the depression. And so one stair height and then it goes out 0.35 standard deviation. So, you know, if it went up one standard deviation, it would be a lot bigger likelihood. But this is like stairs going up. So the more, the further outside the normal trauma, because standard deviations are, you know, if you go to standard deviations, now you're in that 95th percentile of people who have had trauma. So two standard deviations would then put you at like 0.7 standard deviations, 0.35 plus 0.35. So 0.7 standard deviations more likely to have depression.

Is that correct? Yeah, that's right. Saying that like people with more aces are more likely to have depression. Yeah. And that reminds me of our previous. episode where we talked about if you have one ace, you're likely to have more. Yeah. The ACE is clustered.

It reminds me of the last episode where we talked about if you have one ace, there's likely to be more and they're likely to cluster. Yeah. Okay. So there's this one table that we have in our handout where we talk about now when you go to two or three or four ACEs, what the odds ratio jump is. and it's pretty substantial for some of these things, don't you think? Like at four aces, you're... Remember we talked about, like, substance use was around two to four for one ace. Oh, wow.

Now it jumps to 15 odds ratio. So you're 15 times more likely to have a substance abuse problem if you have four or more aces. Yeah, and this is for children's health, too. These are with adolescents. So this dose response effect might actually be even stronger for adolescent mental health. So if someone has four more aces, they are 15 times more likely to develop a substance use disorder. Yeah.

Wow. And I wonder about like non-substance related addictions. Like I think we were talking about like porn use last time or like gambling. I wonder, because I know those aren't necessarily a DSM diagnosis, but I wonder if those are. increase to that extent as well. Well, I think we have data to support that impulsivity will increase. Impulsive behavior. Also increasing ADHD, which we tend to think of ADHD as a very biological disease.

It's heritability is a lot higher, right? So you get a fourfold increase in ADHD if your A score is four or more. You're four times more likely to have ADHD. So, I mean, that's helpful to think like, okay, if someone's coming in with ADHD, maybe there's more than just medications that's going to help them. Maybe it's going to be like holistically treating the person and therapy and, you know, other types of modalities. Holistic treatment is usually a great answer.

Yeah, that's the answer to everything. Yeah, I wanted to mention that it seems like, dose is the most predictive measure for looking at the association between ACEs and psychiatric outcomes, meaning that there's no particular type of ACE that is going to predispose someone to develop depression more than another type of ACE. So if someone's abused, then they could develop a depression. If someone has neglect, then they could develop depression or another psychiatric disorder. So there are studies that are, they tend to find a specific ACE that predisposes to a later disorder, but I think you have to keep in mind that there are other studies showing

the complete opposite effect. And the most consistent finding that we're seeing is that it's the dose that's the most predictive. The dose and the duration, the intensity, the awfulness of it, you know, there was one study, Shalinsky at all 2016, which I looked at this morning, which found that if the trauma occurred over a longer period of time, if it started, earlier, there was more severe adult issues. And they looked at really three issues in particular, shutdown dissociation. And for shutdown and dissociation,

they found that there were types of abuse that better predicted it. And there were ages at which they predicted it better. So I think this is, what you'll find is that there's probably individual studies that find, slightly different things, right? And one way of thinking about that, when you blend all this big studies together in a meta-analysis, you're going to lose some of the potency of a particular

well-done study. Okay, because all the studies have slightly different ways of measuring things. They have different ways of recording things. So I think there is value in looking at like an individual study. I like this study in particular quite a bit. So when it comes to shutdown and dissociation in particular. They found that physical neglect at age five had had the highest importance. And so you can kind of think about the hippocampus development, especially as seems to be vulnerable at ages three to five for later developing dissociation and PTSD. So physical neglect, age five, emotional neglect throughout a bunch of different ages,

like four, six, eight, 13, had had some predictive strength. and nonverbal emotional abuse age 14 nonverbal can you do you guys know what nonverbal emotional abuse is the silent treatment I assume like not giving yeah yeah not giving attention turning your shoulder to the other person yeah or I'm imagining like this strange situation procedure

where like on your 14 year old it's like a it's like a like I'm upset at you so I'm gonna just stonewall you, you know. Yeah. Or I wonder about like unpredictability of like the parents' response to things. Yeah. And then sexual abuse at age 12, like the kind of the coming at eight, coming of early menstruation,

something about that specifically led to this shutdown dissociation. Wow. So I think that is kind of an important piece of, you know, thinking that we should put into, look, there are these sensitive time periods and, you know, age five, what are we doing? Like, are we fully engaged and present with our kids, you know, like attuning to them emotionally, physically? I'm curious to know, David, what is your approach when you ask patients about, like, if they've ever dissociated or if that's something that happens often for them? How do you go about

that? So, I mean, you know, if you remember back to my depersonalization, de-realization episode, you know, probably that's a more severe type of dissociation where they feel numb, they feel disconnected, they feel they're kind of walking through life in a haze, they feel that the world is unreal, right? There can be, you know, we can all dissociate when we drive our car home and all of a sudden you're home and you don't remember anything about your drive home, you're thinking about something, you know, So there's like a dissociation from what you were doing. Your eyes were taking in the visual stimulation.

You were moving the wheel, but your mind was somewhere else, you know? Is that like pathological? No. No, I'm saying we all dissociate. I actually think to some degree, most people don't realize that they dissociate from time to time. Yeah. I think the more severe end of dissociation, that is like you can literally feel lightheaded, disconnected from your body.

You can feel, you know, you'll hear stories of people when they're going through something traumatic. Maybe they're looking down at their body, kind of like an out-of-body experience. So if you think about like physical neglect, emotional neglect, it's an absence of something positive, right? It's not a presence. It's not a mirroring. So the way that I see dissociation is you don't have this like mirroring presence in your life, this attunement, this empathy. And so empathy can be really important for this type of person to feel like in the here and now.

Oh, this is what I desire. Oh, these are my emotions. Because how do we know our emotions? How do we know our desire but through connection with other human beings? and then the nonverbal emotional abuse is kind of an absence too right which is kind of interesting it's an absence because um there's like this kind of something that should have been there maybe you know and that the person instead moved away and was not connecting right and then the sexual abuse at age 12 how could i make sense of that it's too much too fast it's like i mean it's

It's unwanted, it's a violation, and it's such, it's like such a vulnerable time period too. And so it's just, yeah, so how do you cope with it? You learn to dissociate. You learn to shut down. You learn to disconnect from your emotions, from your feelings, from your body, from pain, emotional pain. So that's how I think of dissociation shutdown. And I would say that along with these things, it seems like the more different types of traumas

and the longevity and the horrificness increases dissociation as well. There's a good question there, the DIS. You should read through some time to kind of get some unique questions you could ask people about dissociation as well. I think sometimes I'll have people who come in and they'll say, oh, I have ADHD.

And after working with them for a couple hours, I'll be like, I think they are a dissociator actually. more than ADHD. But they're like, no, the amphetamines work. And I'm like, yeah, amphetamines help people who dissociate too, you know. Not that I would give them as the primary treatment for someone to dissociation, but they, like, they will pull you out of the dissociation potentially. And so, yeah, and I've had patients who, they dissociate so much,

it's like every time they're in session they're dissociating for the first. I have one person in my mind in particular it was the first couple years of treatment it's like I could feel this haze of dissociation over them and they would talk really soft and they had a really hard time getting in touch with any emotions and so it's like what do you do with someone

who has a hard time getting in touch with their emotions if you ask them they may feel shame that they don't know and so you have to be really gentle and patient with the unfolding of their thought process because if you come in with your own agenda or you feel like I need to do this in order for this person to get better, it may not go well. And yeah, I would say this person definitely had physical emotional neglect, emotional abuse as well, some physical abuse as well actually.

So yeah, it's like multiple, multiple aces. Yeah. And early sexual stuff was going on, which was also a form of trauma. So yeah, I think people have, like, it just clusters, and it's like, you know, you could be one or two years into treatment and still not know the fullness of what they've been through. So that's the other thing is like sometimes when I read that there's just a questionnaire, it's like I'm like, yeah, but like I know people who like they didn't know until it was like much later in a treatment, you know?

So okay, we've spent a lot of time with that. One other thing from this study that jumped out. And I will leave the depression, the PTSD for the handout here. one other thing that jumped out was when you looked at the number of traumas and the level of the dissociation

it was not a linear line okay and that's really important to like understand like how that like that is a unique statistical phenomenon okay usually when we think of a correlation, we think of a linear line. This is not a linear line. So there's a jump.

So I consider this like a step, a big step up. When you go from three types of trauma to four, there's a big step up in the severity. And so you can think about this as like, it was so overwhelming that they didn't develop other types of defenses. And so the only defense they had against the traumatic situation. of their childhood was to dissociate, was to go numb, was to disconnect from reality. And that was adaptive for them. That was adaptive. We see the same thing with PTSD, actually. There's a big jump in the severity of PTSD symptoms when you go from three to four types of trauma. Depression, not so much. It looks more of a linear line. So that was really,

really interesting to me. And also it made sense of something, you know, like it's overwhelming. It's like there's an overwhelming amount of things going on in their childhood, and they're coping the best they can. They're doing the best they can, and sometimes just kind of checking out mentally is the best. Some of these people, they will not remember large chunks of their childhood. I was thinking about, and I know it's like a controversial topic, but like dissociative identity disorder. And yeah, like, what are your thoughts on how that plays in this? So dissociative identity disorder, formerly called multiple personality disorder.

Multiple personality disorder like 30 years ago, you'd find people on the psychiatric unit with, you know, that once in a while, right? Now it's like you almost never find it. The way that I see this is that there's, if the severity of the trauma is very, very, very high, then there will be parts of yourself that are kind of like split off. So you could have like a part of you that's like, this was the part of you that protected and fought back. This is the part of you that acquiesced and shut down.

To me that sounds kind of like this was the part of you that was fight or flight and this was the part of you that was shut down dissociation. I think you had some overzealous therapists. and this kind of like, and in their overzealousness, they might label them names. And, you know, there's been some therapists who, like, for some reason, they just see multiple people

with multiple personality disorder. It's like all of their patients have multiple personality disorder. It's like, is it helpful for you as the therapist to do that? It's helpful for the client. do the clients get more attention from you? So this is where like, it's like there's part of me that I'm just like, I don't know, I'd be curious.

Like, okay, if someone comes to me that way, I think I would explore it and be curious, but I wouldn't necessarily give it like a ton of energy. And so what I fear is that when a new diagnosis comes and you give it a ton of energy, you're going to get more of that thing because patients are unconsciously often responding to what they think you want them to do or what you're telling them you want them to

behave like. So people who are dissociated a lot are susceptible to suggestion. And so I wonder if in that susceptibility they grasp for narratives to make sense of their lives. And in that grasping for a narrative, like, oh, I have Lyme disease or oh, I have this problem or that problem, it's like, okay, I have a real physical issue. I can put my, I can put my head around that. That can make sense of my misery and suffering. And then the other thing is like, you know, if their system, their family system or their medical system supports that and gives them energy because of that, it's probably going to,

increase that as well, that narrative. So this is the larger conversation of like illness narratives. The stories we tell ourselves about our identity. And I would say your identity should be wrapped around your strengths, your abilities, your creativity, your aspirations, right? That's identity. Your spirituality, that's identity. The positive things.

whenever I meet a patient and the first thing that comes out of their mouth is a disease identity, that cues me into somehow this has given them a sense of meaning and purpose and help them survive. Help them survive, help them get their emotional needs met. And sometimes they get their emotional needs met in the medical system. Sometimes they get them in the psychological system. If I tell them they have to be a certain way to get their emotional needs met, they're probably going to do that more often. And so this is where it's kind of like, are we over, the words that we use and how we describe things matter.

And I would add, when we talk about adverse childhood experiences, this is where I like to have the positive spin of like, this is something that you've been through. It doesn't necessarily define your identity. We don't want you to walk away from this series thinking like, oh, this is my identity, this is who I am. This is the conflict portion of your hero's journey. This is the portion where you go into,

where you need a guide. You need someone to guide you through this portion, but you come out the other end, often with superpowers. And I really hope for my patients that they grow in empathy, that they grow in their compassion for other people,

they grow in their ability to connect with other people, and that they find meaningful things in their life beyond illness. So, and I think most people want that. Most people don't want to get stuck in illness, but illness has so many secondary gains, and it's a complicated subject, and people, when you hear this, you might be sensitive to this subject as well, so I want to be sensitive to that.

But it's like, and if you found connection in illness, that sometimes can be a good place to start from, But maybe it's not where you want to end as well. Or like, how rigid do you want to keep that label on yourself? So, yeah, any questions on those things? I know that's a lot. I think in my experience on my child psych rotations, I was noticing that a lot of the kids are like, right, like, giving themselves, like, the role of being, like, the kid who's in a mental hospital. Or, like, they're really, like, seeing themselves as that and kind of, like, clinging to them.

that identity and like when thoughts about let's go let's get back to school um how do we like make accommodations to get you to go back to school they kind of think that oh actually i'm i'm going to just stay here and inpatient and that's kind of it and it's like okay um you're a lot more than that you're a lot more than um unlike your mental illness and i think that's like such a big part of the conversation especially like when i've worked with kids in the past you know i would say maybe maybe they feel at home there maybe they feel good and so it's like hey there there there's something good going on here that you want to continue. And hopefully, let's get you plugged in with an outpatient provider.

And let's give you a sense of connection with a person, you know, because there's something good that's happened here between us. And you can find that outside. And, you know, there's friendships and relationships that you'll be able to have over the course of your life where you're able to touch and taste some of the goodness that has happened between us. And so what does it look like to find healthy friendships and relationships and mentors and guides. So I think there's a reason why they don't want to leave.

And it's probably not all bad. It's probably like, yeah. And it's like they might not want to tell you that all the reasons why either, you know. Right, they might be comfortable in that setting because it's what they've grown accustomed to. It's like, Annabel, you listen to me so well and you don't judge me. And I want more of that in my life. They can't necessarily say that as a teenager. Right.

Right. And that's why I think like sometimes there's like an institutional transference that develops. So it's like, well, you've trusted us here at this institution. I wouldn't use institution. I would use the actual word of the place, right? And maybe there's an outpatient person here that you would also connect with, you know, like that trained at this place, like I've trained at this place. And maybe they'll engage treatment in a partial.

program because you were there and you connected with them. So I always talked to the residents like, look, like your connection with them is so important because it's the feeling that they're going to have when they show up to partial, when they show up. And we used to have people who would just walk around the outpatient clinic, like when it wasn't their day. I would see them and I'd be like, hey, you know. And they would be like, hey, Dr. Peter.

And it just, there was something peaceful about the place. maybe for them, you know? So I think that's the ideal situation. I mean, obviously we make mistakes and not all situations will be, like, there will be some situations that are really hard and, you know, we're imperfect in our ability to help people. But maybe they can cling on over time to the good. And that would be, that would be my hope. Okay, let's end on this, Liam. Go for it. ACEs increase all psychiatric disorders? That's kind of what we've been talking about, right? How could they increase both narcissism and depression and anxiety and borderline for size disorder? Yeah, this is going to be sort of a teaser into the direction of the next couple episodes and

talking about how ACEs can influence the risk for a psychiatric disorder diagnosis. And many people conceptualize this as, you know, ACEs through some effect, whether that be through a bottom-up, meaning a physiological effect or a top-down effect, there is some effect that leads someone to be vulnerable to a later stressor in their life that leads them towards not being able to recover from the stressor and to a mental illness. So from this bottom-up perspective, you can think about, you know, looking at the HBA axis. this stress response system. If there's disruption there, then maybe this person can't withstand the stressor. They can't work through it. Or if they don't have, you know,

they experience severe neglect and abuse in childhood. And for some reason, there are neural circuits that are involved with social functioning. Maybe these don't work correctly or executive functioning. So there's this idea that trauma could cause these biological deficits. Before we move on there, it's like of course of course they do i mean imagine you're in an in a neglect situation you're not interacting with other humans you're not connecting and so when you're not connecting you're not

forming patterns of how to connect with other human beings um and and that that leads to other issues you know so yeah keep going yeah definitely and that is reflected in their psychology too And from the psychological perspective, like you guys were mentioning with the identity, an individual, if they identify with the person who is in a mental institute, if they identify as someone who's not worthy because of what they're taught in childhood. And that becomes sort of an automatic reaction of how they think about themselves. And that's going to lead to a harder time dealing with the stressor. That's going to lead to a harder time working through a mental health disorder. order. If they don't believe in themselves and that they can work through these things, then obviously they're going to have some more difficulties. So looking ahead, we're going to

talk about these bottom up and top-down perspectives. Hold on. Hold on. One thing about belief. For people who are like, ah, I don't know, is it really about belief? Think about the placebo. Why does the placebo work so well? People are believing that I'm going to take this thing and this thing is going to make me better and it's given by a professional. You know, in psychiatry, placebo's work really well, really well. And it's because of belief. And some of the placebo effect, of course, is people spontaneously getting better. But some of it is, of course, the connection with the person that you're working with.

Some of it is belief that comes through the connection. And that portion of belief is very powerful. Like there's even like studies on Parkinson's medications. Parkinson's is like low dopamine in the brain and they have like that resting tremor and they're not moving as much and they take a placebo and the dopamine increases in their brain from belief alone. Like that's powerful guys. And so yeah.

I've heard of like medication being thought of as like a transitional object. So if someone has a good experience with their provider and they, oh, this like great provider gives me this medication. I'm sure it's going to help because they said it would. Yeah, absolutely. It's like interesting to think that like healthcare is like, you got to sell the medication and give them hope that it'll help. Well, also like correct data and info about it, like not overhyping it, but yeah.

I mean, there's- There's people who give highly diluted water to people as a medication and the people believe it's going to help and it helps if it's mild to moderate. And I talked about this actually with some students the other day. I showed them this study on deloxetine. And as the depression got worse, the placebo effect stayed about the same. But the real medication got more powerful as the depression got worse. It's like because it was actually doing something.

You know, it was actually changing the brain in a positive direction. So, yeah, there is a placebo effect. It is belief. And we don't want to leave people hopeless. We don't want to, like, not believing that a treatment is going to help is not a good place to be. And so I think understanding,

hopefully the big picture of how trauma affects the body, how you can get psychotherapy to overcome a lot of this stuff, how, you know, exercise impacts things positively more than, it's not just the belief in the exercise, is actually the exercise, right? I think all of these things together can give people a, sense of hope that they can make some changes, that they can get back, headed the right direction, overcome. Yeah. And I think even with like multiple, multiple traumas, right? Like I was just

talking to a friend about this today. I've seen this one person for about nine years. And there was a period of time where we could not touch her trauma at all. Like we touched it and she would decompensate. It was like she had to experience, she actually had a conversion into a spiritual, a healthy spirituality. And it stabilized her with friends and community. And then also, I think the years of trust built up to the point where now we can talk about it once a week, a little bit, and it doesn't decompensate her. She's like overcoming, forgiving. She's my forgiveness episode, that really helped her. It's like a pathway, right?

So it's like not always the same with each person. And so even if you're listening, you're like, I can't even like touch my trauma with the pole, I'll decompensate, I've tried that, it doesn't work. It's like, okay, yeah, that's where you're at today. But maybe after, you know, a couple years, maybe some skill based approach, maybe you'll be able to,

like maybe you do CBT for a couple years and get some, like, like, maybe exercise and get some of the other lifestyle stuff in place, you know. And then you can go back and do some of the deeper work. Yeah, to me, I sort of conceptualize, you know, you need to change your automatic method of thinking and your identity. And I compare that to like learning a language where it takes so much time. Like if you want to learn Japanese, say, for example, it is so different from the way

you normally think. And it takes thousands of hours to learn Japanese well or some other language. And it's not going to happen overnight or with even 100 hours. You know, starting it through school, you learn an hour a week. How much is an hour a week of therapy going to help change your identity? So it is going to be, it's going to require a lot of intensive work to learn Japanese and also to learn this new conception of yourself and to be able to work through that. I think an hour a week of therapy could actually be incredibly impactful. And maybe it's a little different from like a link. Well, no, it's probably similar.

But I think people who are actively involved in therapy are practicing what they learn during that one hour and applying it in so many areas of their life throughout that week. And there's homework and there's other things too. And so yeah, it's an interesting analogy. And I'll think on that one. But yeah, I think weekly therapy is amazing. and I would want to discount that. Yeah, so, you know, how long does therapy take, right? Yeah.

It depends on the issue, but there are studies that look at how long it takes, you know, 10 sessions, maybe 30% get better. Half a year of therapy, about 50%, one year of therapy, about 75%, you know, this is like probably just depression, anxiety, like, types of things. But it's that polytrauma, you know, when you start getting up in the ACE scores, it might take more years. It might take a bigger dose. Liam, the idea of once-a-week therapy may not be for everyone. I mean, that's why I recommend partial for a lot of patients who have a need for something more intense because they get that dose response.

That's like, you know, in the partial program that I help run within six months, they might have had, you know, nine hours a week, times what, 20 weeks? It's a lot of therapy. It's a lot of hours of therapy. Now, not all that time they're devoted on their self, which is kind of good, actually, sometimes. They're devoted on listening to others,

connecting with others in the group, and they feel this intense connection by the end of the program with their classmates, which is really powerful as well. So I think dose is important to think about with like what therapies work and we'll get we'll get into the more of the details um the other thing is just once an hour once a week is not just an hour once a week because they're often thinking about and processing and applying the things that are coming out of that hour and so they may be doing

the work even when you're not together so another piece too that I love to think about and tell my patients when they're like approaching therapy for the first time is there's no diagnosis that requires weekly therapy for your entire life or any amount for your entire life. And I think it's good to know that, yeah, like, this can be a time-limited resource that teaches people's, like, tools and skills and builds, like, connection and trust so that they are able to do that with other people in their life. And that's right. Sticking with that language analogy like once you acquire the skills of the language then you keep it for life pretty much yeah you have to keep up on a little bit um but for the most part you're not going to forget how to

um like say a certain basic phrase it's the same thing with therapy once you develop those skills then you know you have to keep up with them but they're probably not going to go away yeah that being said i may be in therapy the rest of my life just just to like have like a connection point, you know, and, and I don't know. But it's like, it's, it's been important for the last 10 years in my life, that's for sure, on and off, right? On and off intensity wise. But just having a plastic, it's, you know, it's like mental thriving, right, as well. Because I don't think therapy ends with, or good therapy ends with like all your symptoms are gone. Good therapy ends with, good therapy ends with, you know are you are you experiencing life fully like are you enjoying like your friends and your

relationships and are you thinking introspectively about yourself like do you have access to your shadow and like know how to make sense of it and maybe propel you forward into a place of of thriving and not hurting other people you know so i don't know i think that there's like different types of therapy and therapists have different capacities and abilities to tell people. And I would say good therapy may not need to go on forever, but there may be a value in it. Yeah. Especially if you're a mental health professional. I mean...

Oh my gosh. I can't imagine being a therapist without seeing a therapist in my own. It's so helpful, so important. Because we hear vicarious trauma every day. If we're doing it in therapy with patients, we are hearing their traumas. We're feeling it and we need our own help. So if I can encourage my audience,

it's funny because I say this over and over again, but I get emails where it's like, Dr. Puter, because of you, I started seeing a therapist and it's been three years and I'm so happy that I actually did that. And thank you so much. And I started exercising and I now squads. and deadlift and my body feels so much stronger and I feel happy with that you know and so I get these emails and that's meaningful so okay guys let's leave it there for today thank you and um yeah excited

about getting into some of the biology and the neuroscience as time goes on so see you guys soon