Psychiatry & Psychotherapy Podcast - Emotional Shutdown—Understanding Polyvagal Theory

Episode Date: July 10, 2018

Polyvagal theory by Stephen Porges explains three different parts of our nervous system, and their responses to stressful situations. Once we understand those three parts, we can understand our emotional reactions to trauma or high amounts of stress. Why is polyvagal theory important? For therapists, and pop-psychology enthusiast alike, understanding polyvagal theory can help with: Understanding trauma and PTSD Understanding the dance of attack and withdrawal in relationships Understanding how extreme stress leads to dissociation or shutting down Understanding how to read body language By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. All right, welcome back to the podcast. Today I am joined with Dr. Kevin Ng. who is a psychiatry resident at UC Irvine,

and Adam Berechi, am I saying that right? Bereki, close. Very close, so close. This is an intentional joke we do every time. Yeah, it's a CK. Baraki. Adam Brecki is a research assistant in my sort of team associate.

He just finished his master's in ethics and is finishing out his fourth year of medical school. And Dr. Kevin Ng is a close friend. We've, I don't know, been on a lot of walks together, done a lot of life together during his medical school, and now he's out here at UC Irvine, so we're visiting him. And we have put together an episode on the polyvagal theory.

And it was once thought that there was just two systems, a sympathetic nervous system and a parasympathetic nervous system, and that it was kind of like, you know, your parasympathetic is rest and relaxation, and your sympathetic system is fight and flight. But now we kind of know it's three systems. And so it's the rest and relaxation parasympathetic. It's the fight and flight. That's the sympathetic nervous system.

And then the third system is the dorsal-varyl, dorsal-vagal parasympathetic, which is shut down, which is dissociation, which is the third system. And it's an unmyelinated system, unlike the other. their parasympathetic system. So today we're going to talk about these three systems and how to use this knowledge to sort of understand where clients are at, where patients are at, and how to use it therapeutically. We're going to talk about the history of it and talk about porges and how he sort of came to it. And we're going to talk about why it's important.

So I think it's really, really important to understand trauma, to understand the nature of trauma, to understand how people are moving through the sort of systems in a session. Like when they enter into the dissociative state, you can notice it if you're paying attention. And so we're going to talk about body language. We're going to talk about how to understand and how to identify the different systems. We're also going to talk about how in relationships conflicts will arise and one person will shut down and one person will get more into the attack mode and how both of those can be adaptive responses to reconnect.

We'll talk about how to be assertive, how to move out of shutdown and find a voice. We'll talk about animal behavior and human behavior and how some of those things are linked and the consistencies of those. And we will get into some of the points of, like, what is PTSD? How does this make sense of PTSD, actually?

And so Adam, Kevin, welcome to the, show. Oh, thank you, David. Thank you. It's good to be here. Yeah. So, yeah, I'm really excited. How about, um, Kevin, do you want to launch into defining, um, kind of the definition of the polyvagal theory a little bit and then maybe some of the history? Yeah, I would love to do that. Um, the polyvigal theory is a theory of the autonomic nervous system that was first, um, derived or come up with by Stephen. is a psychophysiologist and neurobiologist. And I suppose that's one sentence way of talking about the polyvagal theory is that it's kind of an organizing principle.

It's a way to think about the anatomy of the autonomic nervous system in a way that helps you to understand the various, the three various neurobiological states that people can exist in as adaptive response. is to threat in the environment. And we usually call those connection. And then the second one is the fight or flight response, the sympathetic response. And the third one is something like dissociation. And that's kind of a breakdown of what we mean

when we talk about the polyvagal theory, describing those three states. Yeah. And I think about like if you watch a lot of animal planet and sort of animal documentaries, occasionally you'll see the hunt and you'll see the gazelle running and um or you'll see maybe the gazelle is sort of in the field okay first and then it here so it's kind of you know hanging out with his fellow gazelles and they're you know eating food and they're having a

good time out there in the field and then all of a sudden they get a smell of something or they hear something and they like perk up and it's like when one perks up all of them perk up and so they all just kind of have this orienting response. So what would that orienting response be in the midst of this continuum? Well, I think the orienting response, which is, I think it was come up with, or Sokolov was one of the neuropsychologists that thought of the orienting response in the first place. And it's kind of the first response of the body to any kind of novel stimulus, you know, potentially something rewarding and helpful and possibly a threat.

and it kind of turns all the body's energies and sensory focus towards whatever the novel stimulus is. And it's associated with increased sweat production in the skin that can be measured by the amount of electrical skin conductance that the skin produces. And that's kind of a first start. Is what you guys are saying here that this is something that is not only present in the gazelle, for example, but it's also present in us probably for different reasons, but it's a similar principle that kind of exists throughout the animal kingdom?

Yes. Okay. Okay. Maybe for us it's more socially adapted as opposed to the predatory responses. Is that kind of what I'm getting at? Like a threat or it could be something novel. Like you're a medical student on rounds and someone starts to raise their voice and it's like, whoa, okay, I'm orienting now to what's going on.

Is there a potential threat? Yeah. Any other sort of thoughts on the oral? orienting response? I think when you think about the difference between the orienting response and sort of a restful

state of a gazelle eating grass, you tend to think of the orienting response and alert and senses and increased sweat production as primarily a sympathetic response. And I think that would be accurate to say that you're kind of getting your body into a state that's more adapted to mobilization.

Right. Activating the body's resources in case you need to move fast either towards or away from whatever that's novel stimulus is yeah and i think that like speaks to the theme of the polyvagal theory as a whole in other words it gives a physiological basis for something psychological it it kind of grounds our experience in our within our bodies is that is that a fair assessment yeah and yeah absolutely and then the other thing about it is that there is like a mirror neuron effect from all the other gazelles around.

So one perks up and it's like the other ones don't need to hear the rustle or the thing, but they almost like, they see that bodily movement and their brain fires in a similar way. So it's kind of like this group collective like effect. And you'll see that in all sorts of different creatures have this as like a group. So like let's say they orient and they see the type. right and so now you have the gazelles like all running and you have this one gazelle running and the tiger takes off right the tiger like full speed at the gazelle so now you're in like this flight state okay yeah so you have the freeze which is the orienting response and then you have the the flight you have the running and um yeah anything you might add on that sort of state how it's physiologically there we're still thinking sympathetic nervous system.

The muscles are mobilizing, you know, the blood rushes to the muscles away from the GI track. Pupils dilate. Pupils dilate to take in more vision. The heart starts racing. The heart races. So then let's say the tiger wins. Okay, so the tiger pounces on the gazelle.

And you may have like a moment, where the gazelle tries to kick off the tiger. But usually what you'll see is soon, you know, let's say the tiger's got his fangs on the gazelle's neck. The tiger, the gazelle goes limp. And this is what we're talking about when we talk about sort of the shutdown state, the dissociation. This in the dorsal vagal part,

this is the, this is the dorsal vagal-vegal unmyelinated, Yeah. Shut down mode. There's a parasympathetic system. Yeah. That kind of like, I think when Dr. Porges was first coming on to this theory, back in 1992, he stumbled upon what you're talking about with infants in a NICU that kind of piqued his interest.

And he called this the vagal paradox. But Kevin, would you kind of explain maybe what exactly that means and how it kind of, how he found maybe two separate vagus systems, one that was. seemingly beneficial, but one that was seemingly harmful. Yeah, absolutely. So Porges is a psychophysiologist, which means that he is measuring, he's measuring physiologic data on psychological states. And it was in the early 1990s when Porges first describes a measure that he calls respiratory sinus arrhythmia. You can also call this heart rate variability.

It's a measure of the degree to which the heart rate from beat to beat, how much that varies according to oscillations in your respiration. And what Porges found was that when he was looking at infants, neonates, the higher that that measure was, the higher that RSA was, the greater amount of variation in beat-to-beat interval according to the respiratory frequency. Right. that was a protective factor. It was actually something positive

and it was predicted with better outcomes, better development for the babies in the NICU. The interesting that had happened with him was that various neonatologists started to contact him afterwards and said, this is all very interesting, but you have just proposed this idea of this RSA. And RSA, by the way, is a measure of vagal tone. It's a vagal measurement that these neonatologists were saying,

saying. Actually, bradycardia, infant bradycardia and apnea in the NICU are also vaguely mediated and they're very destructive and dangerous. They cause death in neonates. And so that was the big paradox. How can a measure of vagal tone be both associated with both a positive, protective factor as well as a risk? And so what happened is that porges starts to pour through various amounts of data. He looks at two branches of data, comparative developmental neuroanatomy and neurophysiology, and he starts to uncover all these different examples of species that also have a strong vagal mechanism that is also associated with bradycardia and apnea, slowing down the heart rate. You can think of reptiles, fish, lower amphibians, all these animals that when there's a

threat, they sink into the water and stop. Frogs can go in the mud for several hours. Their heart rate can drop to a couple, you know, a couple beats per minute. Yeah. And you told me that, yeah, three to five beats per minute for some of these frogs in the frozen mud. Oh, man.

The, uh, let me just, uh, reemphasize what's something you said. So the heart naturally has kind of an undulating up and down. So like in the human heart, um, I put on a, a biofeedback device on on patients and you can see their heart rate kind of move up and down maybe from 70 to 80 okay and um as they breathe in what happens to the heart rate normally um as you breathe in uh normally the heart um rate goes up okay yeah and and you know and as you breathe out you know it's gonna go down okay and if you think about that it's um in medical school we talk about the these mechanisms all the time.

When you breathe in, you suck in a sense, you create more intratherastic pressure that pulls blood into the heart and oxygen. So your aortic outflow is not as great. Your baroreceptor is not as a response, so your brain doesn't sense as much of the blood pressure. So it tells your sinoatrial node, hey, we need to start beating faster. Because the brain's trying to keep

blood pressure constant. And so if it senses a little drop in blood pressure mediated by that thoracic pressure, it's going to adjust accordingly and increase or decrease the heart rate. Right. So normally you're, you have this nice undelating heart rate. And the more relaxed you are, the more actually it kind of goes up and down. So as you learn to breathe in bowel feedback, what's happening is you're learning maybe to move from a heart rate of 60 to a heart rate of 75 or 80. So you're not moving just 10 beats, you're maybe moving even 20 with slow, calm breathing. And when someone gets stressed out, when they get in more of a sympathetic state, it's more of a kind of a jagged lines and near the same heart rate.

So, you know, someone in a sympathetic state, they might be, their heart rate might be a little bit higher, 100, but it's not moving up and down in a nice undulating sort of fashion. that we see in someone in a more calm state. So that's what we're talking about when we talk about RSA. Yeah, and I think when you're in that elevated, more anxious state, when we say there's lower RSA, what we're saying is that the difference in the heart rate between when you're inhaling and when you're exhaling,

that difference in how high or how low the heart rate can be is smaller. So that's a lower RSA measurement. So if I go from 70 beats to 65 beats, my RSA, you know, about the difference is five, for example. Yeah. Okay. So, and I think it's slightly different for each person because I put a lot of the, you know, I'm not like a biofeedback expert, but it's something I played around with to teach myself how to calmly breathe. For me, it was a more of a sort of scientific approach than just learning to meditate and breathe calmly. and out. So for me, learning to meditate and do that calm breathing was watching the RSA and watching

the heart rate go up and down. Interesting. So is RSA good or good or healthy or bad? We want RSA. We want RSA. We want high RSA. Yes. Okay. I'm with you. But then the whole paradox thing with the infants was it's like there's this good vagal nerve and then bad vagal nerve. Is that kind of what I'm getting? Oh yeah. So let me finish that story really quickly. So as Porges was on one hand, he was looking at all these examples of animals that had vagal states associated with lower heart rates. And then the other thing he realized is that this RSA as a protective mechanism only occurred in neonates that were 30 weeks and later.

Huh. Yeah. And the interesting thing is that what happens at 30 weeks is that is that that's when you start to have the myelination process of the connected. ventral vagal state. So myelin is kind of a fatty layer that protects the neurons, axons of nerve cells. And so that process occurs at 30 weeks and continues on through like the first 18 months of life. So what Porges was realizing is that we've heard in biology classes,

ontogeny recapitulates phylogeny, right? that the developmental embryonic development process kind of recapitulates the phylogeny of species. He was realizing that, wow, yeah, babies also not till 30 weeks and later on, they don't develop a fully formed vagal nervous system that's adapted to social engagement. Oh, dang. So. Wait, so after 30 weeks, they develop the myelin. Yeah.

And so after 30 weeks is when they develop. the ability to have RSA. And that's when RSA, high measures of RSA are correlated with positive, protective, protective measures. Because I know that, like, you could be at term and you could still have D cells. Oh, of course. So, like, when you're, you know, like, why do women where, you know, cardiac monitors when they're giving birth is to look at the baby to make sure the baby isn't having a large amount

of D cells. Right. So when I say D cells, the baby's heart rate will drop for a period of time way down low. And it's like a neurogenic bradyacardi. I think what we're talking about there

is that sort of dorsal, vagal, you know, decreased RSA, like the baby's stressed. So that's like our ability to tell if the baby is stressed while the baby is in the mother's womb. Yeah, I think that's correct.

But, and so these D cells, these bradyacardias, apnias can occur throughout the development process. And they can continue happening even once you have the myonated Vegas as well, right? That system of depression doesn't go away. That's correct. I think all we're saying is that Porges, in his research, he found that it was until after 30 weeks that he saw that RSA could be correlated with being a protective factor.

Okay. That's really cool. So getting back to this gazelle. Okay, back to the gazelle. So the guzzle, the poor gazelle, right? He's got the lion has his fangs on the gazelle's neck, and the gazelle has gone completely limp. And the lion drags the gazelle off to his cubs, you know,

because the lion wants to teach his cubs how to, like, you know, attack this gazelle. Okay. And so the lion puts the gazelle down on the ground, and the gazelle is still limp, And the Cubs start to play with the, the lion Cubs start to play with the gazelle. Kind of, you know, jump on him and wrestle him a little bit, you know. And Mommy Tiger is paying attention. And then Mommy Tiger gets distracted for a second.

Okay. Okay. And then the gazelle goes, boom. Bam! He's out of there. Once again, takes off into a full blown sprint. Wow. Definitely seen that.

Suspensful. National Geographic. Like David. David. Burrow status. Right? You've seen this also with cats playing with mice. Oh.

The mice will go limp. And I've actually seen it with lizards. We catch lizards, me and my daughter. And the lizards, after a while of playing with them, they will not try to escape right away. So they'll kind of go limp. They'll go docile. But eventually, when they see kind of like, okay, this is a potential escape, they'll make a burst of energy. It'll be an incredible burst of energy.

and the other thing you'll see is you'll see them start to shake and shiver afterwards and it's like the stress response coming out of their system okay and actually Peter Levine was the one who I heard this from and I kind of brought I was at a psychotherapy conference and he kind of told this story and I read subsequent stuff and kind of pulled other thoughts together as well So the idea, though, here is that the dorsal vagal system, this ability to freeze is adaptive. And if you think about it, like if the gazelle kept fighting with those fangs on its neck, it would potentially die. Because it may actually not be adaptive to continue to fight a tiger. Right?

It parallels this other study by this guy named Gelhorn, and this is all the way back in the 60s, and he used cats. And this must be pre-ethics laws for animals or something, because these guys are kind of wrecking these poor animals. But what Gelhorn did was he used cats as models, and he put up little sensors on their sympathetic and their parasympathetic systems, right? And then he would like exfixiate them in these little boxes, right? So in other words, he would cause them immense stress. And what he found was that there was a point in which as the cats were starting to, you know, lose oxygen, their sympathetic system started to go crazy, like super spike. But when stress got to such an extreme, suddenly the parasympathetic overwhelmed the sympathetic. And the cats went completely limp in what you're saying.

So that parallels with the gazelle because you're stressed, you're running from the tiger, your sympathetic modes in overdrive. but when stress reaches a maximum point, complete shutdown mode takes place. And you have this dorsal, unmyelinated, you know, ancient Vegas kind of kick in, put the whole animal in an adaptive shutdown. So it's kind of like an adaptive response to an escapable threat, a threat that's so threatening that there's no escape. Yeah. You can't fight your way or flight your way out of it.

It's like a near-death experience, right? Right. So for humans, what sort of conflicts lead a human into this state? You know, and I would say it's a near-death experience. And often, you know, patients will describe if they were being raped, they'll describe this sort of place where they froze. And often they'll feel a lot of shame about that freezing. Yeah.

Because they don't realize it was an adaptive response towards the trauma that they were undergoing. Right. And so they will freeze. And that freezing instinct allows them to potentially, you know, not be killed, not be hurt, right? Not be hurt in a way that they couldn't repair. And other situations, you know, and trauma, people feel that they cannot escape, that they're held down. Like maybe they were in a car accident and they were stuck in the car. I've had a couple of patients like that where they're just stuck and they're unable to escape the car and they feel like they're going to die.

You know, maybe there's a fire next to them, right? And there's this real danger of like, I am going to die. Right. And that sort of leads to this dissociative space. Other people in military describe this as like they got shot or they were in the battle. Different situations happened. and maybe even someone next to them was shot. So there was this real sort of feeling of like being stuck, being pinned down.

One of my patients, a person's body was basically had fallen on them and they were in the midst of this firefight and they thought that they were going to die with this other guy who was dead. I've heard similar situations from San Bernardino attack. which is nearby where I work, has some patients who went through that. Wow. And it was, you know, being sort of unable to move, right, frozen in fear. And so if I'm telling you any of this stuff

and all of a sudden you feel a little bit more frozen, right? It's amazing that, I mean, humans have the capacity as they even hear the stories of this happening, they may start to, you may start to dissociate, right? So feel your feet on the ground, right? Feel your butt on the chair. Turn it off if you're in the car driving, right? You know, like, so trauma is contagious in that way.

Yeah. And trauma contagious in a way like, when a patient is telling you this story, like if you're not trained and understand what's going on, it may be as disorienting for you as it was. for the patient. So as someone tells you the part of the trauma, which is where they were feeling immobilized, you may feel immobilized and you may actually need to fight through that in the session. And I think for me, understanding this, one allowed me to understand where the trauma actually

was in the stories, but it also helped me feel more powerful knowing what was going on and knowing how to make sense of it as it was going on and knowing how to move out of it in the session for my own sort of countertransferential experience of that, you know? That's pretty amazing. I think I find it pretty interesting that even in the 90s and even now really, we call PTSD post-traumatic stress disorder,

rather stress as in like a fight or fight rather than a post-traumatic dissociating or freezing disorder. And even all the language up until recently about stress was, it was only the language of fight and flight, as if a sympathetic response was the only response that you could have to trauma when in reality a vast number of patient reports were not describing symptoms of fight or flight, but rather dissociation, shut down,

feeling alienated from your body and your emotions. And now we kind of are beginning to understand the basis for that, you know, on a physiological level. Like I think I read regarding that dissociation syndrome that blood is diverted away from parts of your brain. And so you literally, you know, that kind of facilitates this like blackout experience or almost like a dissociative coma in some ways. Yeah, right into your singe of it, right, corpus callosum. The parts of the brain where you experience body sensations, the parts of your brain where you experience emotion. the amygdala decreases activity, the frontal lobe decreased activity.

So there's parts of your brain that have decreased brain function. They have decreased metabolism. They've decreased glucose uptake. And interestingly, how they got this data was they had Vietnam vets, I think it was, vets of some sort, write out their trauma narrative

and they stuck them in a fMRI, functional fMRI, so they looked at their brains and what was going on in their brains, and then they had them read through the trauma narrative while they were in the brain scanner. And when they got to the parts of the actual trauma where they actually felt the bodily, you know, or this feeling of near-death experience, that's when parts of the brain decreased activity.

Oh, wow. And I'll say for my experience, it's the first, the first year or so of talking to vets, you know, they'll tell you everything about the trauma story. Interesting. So they'll tell you everything around the trauma. And they often have a narrative that is prescripted and almost, they almost find joy in telling you part of it.

But if you pinpoint them, like, hey, tell me the part of the story that you don't tell people. Huh. They don't want to go there. and it takes a lot of trust and I would say don't go there unless you have the time and unless you have the trust of a person because it can be it can be really tough

it can be it's if you go there if someone goes there and they feel they will feel some dissociation they will feel some level of trauma if they go there and it's just the same and they feel

helpless and hopeless and there's nothing different that they feel that will be a re-trauma of their trauma and good examples of this are um i've had some patients who have been raped and it's you know truly unfortunate and they go to talk to their parents about it and the parents like either shame them or dissociate as well and so have like nothing to give them huh and that only almost becomes the second trauma that therapy needs to potentially help. So when they come to, when they come to you, if you're able to listen and connect to them, empathize with the distress, not be dissociated, okay? Yeah. And allow them to express things that maybe they weren't allowed to express in the traumatic memory. That can be very healing. I've heard people say that psychotherapy can be almost

as, you know, more invasive than surgery even. And now I think I understand why. Yeah. Yeah, especially, I mean, hopefully it's invasive in a way that's... In a different way, but... Just like surgery, it can be very helpful. Right. You know? Right.

And it's interesting because I think once people resolve a traumatic memory, they can go on with their life. So what's different when you're sitting with them in the therapy versus, you know, a less healing experience? Versus one where they revisit the trauma and they experience a new trauma. versus what you're describing when they re-experience it and find healing? I think the difference is if you do not dissociate as well, then that's a good first step for you. Oh, man. So if you can sit there with them in the midst of their dissociation,

and if you can find your calm center, and a center that appreciates them and, you know, has compassion for them. And if you can empathize with their distress and then help them feel something different than dissociation. So, you know, often shame is the shadow of sort of the dissociative feeling. So anytime someone has talked to me about something that happened like this, they immediately feel shame.

Like I was, I went, you know, I was being raped and I went limp and I couldn't move. And, you know, I'll say to them, know, like that, that must be really, really hard to feel that way. And, you know, I, I could see that, you know, this was for you maybe the best option that you felt like you had, you know. And it's, it sounds like that was, that's really hard to say that that's what happened. You know, so I may just empathize with the distress and it's harder to do when, you know, you're not in the room with someone who's feeling it. Right.

But that might be one of the things that I tend to do. And then I'll look for the anger. So it's interesting, you'll see the micro-expressions of anger when someone is telling parts of the story. So the anger is there. It just has not been congruently expressed. So the anger has never been, the anger never had an outlet. So they were being raped.

They wanted to kick the guy. They wanted to punch the guy. and so I may try to tap into the feeling of anger and get them to feel that in a way that they weren't able to feel it because anger is energy to overcome the obstacle, right? So they had the energy, but the energy was not able to be manifested. So they froze instead. So, you know, sometimes, and I got this from some of the different body therapists,

but they actually have the, they ask the patient to move in a way that is desired based on the bodily sensation of the emotion. Well, an example of a movement. So I had a patient who was in a pretty bad car accident, and that wasn't the bad part. The bad part was when the EMS came and strapped her down to a board, and she went backwards, and she couldn't move. So she had just had an accident, and she wanted to move,

but she was strapped down and she couldn't move. And she had this thought, oh my God, I think I hurt my neck. I can't move, you know. Oh. And so, and the, the EMS people, you know, most are amazing, but this particular person was a little like, you know, just kind of nonchalant, like, you know, jaded or whatnot.

And his sort of brashness was another sort of feature of this dynamic. And so when she's in session telling me about this, she's obviously dissociating. And in her chest, she feels tightness. And I asked her, in what way would the tightness want to move? And at first when you ask people like, that question, they look at you like, like, what are you talking about? It sounds kind of fluffy.

It sounds weird, right? Sure, David. And she wanted to, but after I'm like, no, no, just kind of feel that sensation in your chest and see what your body wants to do. And she wanted to take her arms and extend them outward. Okay? So I had her do it very, very slowly.

Okay, and that's the crucial part, is they have to make a mindful movement, and not a fast movement, a mindful movement where they're able to make the movement, and they make it very mindfully and very slowly. So they really focus on the sensation of how it feels to move their arms or move the legs in the way that they desire to move it. and she felt this huge release of energy.

And in subsequent sessions, when we went back through that memory, there was no dissociation and she was able to tell it as a narrative memory. So she was able to tell the narrative of it, and it wasn't like sort of her losing track of time or feeling dissociated in that state. So I've had other patients who have been raped

and they really wanted to punch the guy in the face. So we'll have them move their hands slowly forward because that's the movement that they wanted to make. And I see memory as kind of like, it's kind of like when you bring out a memory, every time you bring it out, the memory fundamentally changes. So if you can feel something differently, if you can feel anger where before you didn't have anger,

that's advancing in that sort of memory, right? And if you move the body in a way that the body wasn't able to be moved, then that can change the memory as well. Huh. Because it allows a bodily representation to be inserted into the memory. And also, I would say, like,

I probably did this more early on, but now if the patient feels connected with me in the midst of the memory, that in and of itself is probably the most effective thing I've found. Wow. Because they were alone in the traumatic memory, but they're present with me now.

So any way that I can increase my presence or help have the patient feel connected with me and be the tool of what gets then inserted into the memory in a way that fundamentally changed the memory. That is what I found is really helpful, really helpful. Connection. Yeah, kind of, connection. So it kind of reminds me of is kind of the stereotype of the psychiatrist on the couch asking about, you know, childhood experiences, childhood traumas that might be, you

you know, repressed? Is that something that's comparable to any of the situations you're describing? You know, I'm not digging. I'm not excavating. I'm not doing any archaeological digs here. And I think that that's, that's dangerous, honestly, is looking for something that isn't there. Interesting. One example, someone in the community saw, was seeing one of my patients and, you know, told the patient that they had sexually been abused, they were a child, and then asked the patient a series of questions that were very sort of like leading? Leading.

Yeah. Like, oh, your dad gave you a bath when you were a kid. Did he ever masturbate when he was giving you a bath? Oh, man. Stuff like that. It was kind of like the patient was disoriented by the therapist's introduction of this sort of weird content. Oh, man.

So that became actually the point of like, okay, this is not. I actually got some supervision from Dr. Farrid about this. And I was basically recommended, no, this is not appropriate. And it will damage the patient if a therapist continues to lead. And I've even had pastors in the community do something similar. This one pastor in particular. You know, it's like people get in their mind like one problem is like what everyone suffers from. Everyone's suffering from sexual abuse.

Yeah. You know, whereas like if the patient doesn't go there, then maybe it's not there. You know, so I never want to try to like take someone there when it's not there. No, the body will tell you, right? The body will like kind of pull someone that direction. I don't need to ask leading questions. If the person doesn't remember, you know, as you do the work, they will remember if it's important. Yeah.

And so I think that's like one of my guiding principles in psychotherapy is just to allow the patient to bring up what's important for them. And if other things do come up, then, you know, address those things. But realizing that if there is something psychologically damaging, it will come up in dreams or it will come up in their free associations, their memories. So we're getting deep into the thick of. Yeah, we dove straight into clinical applications there. Yeah, I think we should back up a little bit, though. Yeah. What do you want to hit?

Let's go back into the three systems. Okay. Okay. So let's talk about, yeah, let's talk about, actually, Kevin, can you talk a little bit about the phylogenetic or evolutionary evidence of this? Ooh. Oh. If we haven't touched on it. Sure.

Well, we've touched on it a little bit already, but. the idea of this three systems, at least the way poor just describes it, is that this is a, it's a hierarchical three systems. And by hierarchical, he means that there's kind of an order into which you go into a particular state related to how serious the threat is. So typically, as mammalian species, as human beings, we're a social, connected species. And so we tend to respond to threats or new challenges primarily in a state of connection at first. And if that doesn't work, if a threat arises, then we sort of downshift into a sympathetic

state. And if it's a really serious threat, if it's a really difficult state, then we still have the evolutionary toolkit that's been afforded to us to go into that final dorsal state. Hmm. So, and we could talk about a lot of different evidence that goes on to describe how these different states exist and how they're related to anatomy. But I feel actually it might be a good idea to, because we could make some comments about the middle ear and how that's related to the fossil record and gill structure and so forth. But maybe it's better to describe the anatomy of the three states first. Okay, sure.

Yeah. Yeah, let's go through. Let's talk about sort of the parasympathetic, myelinated, nucleus, rest in a relaxation state. So what, where do you want to start with that, Kevin? So, yeah, maybe we could start with that shutdown. No, the nucleus ambiguous, so the parasympathetic rest and relaxation. We'll start there, then go. Yeah, we'll go deeper.

So let's start there. So we're starting at the peak, Kevin. You just described kind of a progression. This is myelinated. This is very mammalian. This is ideal in some ways, would you say? Yeah, I think so. The way he describes it is that survival of the fittest, as Darwin said,

does not mean survival of the strongest. Actually, it's not the strongest because as mammals, we need each other. We need social relationships. we need to be connected and cooperative in order to survive and to not only survive but to flourish, to grow, to thrive, to adapt. And what that requires of us as animals is to be able to have relationships.

In order to have relationships, you have to have a certain level of proximity. In order to have a certain level of proximity, you need to be immobilized in a sense and immobilized in a sense where you don't feel any fear. Because if you're too heightened, you're too activated, your heart rate's racing too much,

then you can't enter into a close proximity social relationship with people. So when you talk about the connected state, we're talking about the ventral vagal system. The primary nucleus is the nucleus ambiguous. The nerve is myelinated. That portion of the vagus nerve is myelinated. which means there's a fatty sheath around the nerve so that it can conduct faster. That's right. And this vagus nerve is primarily the motor outputs are primarily going to organs

that are super diaphragmatic. So like as the med student in the room, you know, I'm expected to like learn how to do the physical exam, right? And so I remember thinking or learning that like the gag reflex, for example, is mediated, the efferent motor part is, you know, mediated by the vagus nerve originating in the nucleus ambiguous like you're describing. Is that related? And how does that relate to like the emotional components that you guys are describing? Yeah, as I've learned from Porges and for you as well, David, all the five primary cranal nerves that have some sort of motor outputs to the muscles of the face and head are all in a complex in the brainstem connected to the nucleus ambiguous.

So cranial nerves five, seven, nine, ten, and eleven. And the cool thing about that is, like when you're enjoying a meal with your friends, you're smiling spontaneously, you're laughing, you're, you know, the facial muscles are all able to be activated and expressive. Yeah. Okay. So when you're in that fight and flight mode, and when you meet someone who's chronically in the fighter flight or they're dissociated,

they just don't have much facial expressions. Yeah. They don't have much spontaneous smiles or laughter. They're more kind of in this like, you know, sort of inactive sort of facial expression mode, and it's actually a little bit harder to relate to them. Also, you can see this going a little bit deeper into the voice, right? So why as humans do we understand conversations and can sort of, relay conversations into our brain better than someone who's talking in more of a fight and

flight state. So we've all heard lectures from people who are in this sort of sympathetic overdrive state and it's really hard to actually take in what they're saying. Because what's coming out of their mouth is more staccato. The prosody is gone. It's not in that normal sort of relating state. And you feel activated by them as well, right? Because if they're talking really fast and they feel nervous and you can just you feel your heart racing, you feel the heart racing in their voice and it makes your heart race as well and you kind of feel that sense of the kind of gitteriness you feel anxious yeah and you may actually um have a hard time sitting in your seat yeah uh interesting i and i think what happens is people who are in that state they end up

um reading more from their powerpoints because they're stressed out to the point that they can't spontaneously think in a way that would be relational right interesting and so they end up reading the PowerPoint and they just go word for word. And then once they're reading something, right, it takes them further out of a way that our brains would naturally understand it. Right. Which is why I think things like podcasts and, you know, YouTube things are on the increase right now because it's,

the way that it's understood is a very sort of natural way that our brain was meant to take in stuff. Because we evolved for social interactions. And so that's naturally going to be. the way that we connect and, you know, go through the world. Yeah. And I think about like Shakespeare, like reading Shakespeare is very hard. Yeah. But you have to imagine when Shakespeare was like performed in a play,

it was performed by really the best of the best actors. And it was performed in a way where it could be comprehended by the people listening. Or the same thing for like the Iliad or the Odyssey. We read it and it's like, really hard to read it, but we're not hearing it as like an orator and a professional orator, right? And so, you know, like fight and flight. And so let's go into shutdown with the voice. When someone is in a shutdown state, they can't get their words out. And it's like, it's like they get choked up, you know? And so often you'll have speakers and they'll need more

water. Why do they need water? Why do speakers need water all of a sudden? It's because they're getting stressed out. What happens when they're stressed out? It's more of that sympathetic state. they're producing salivation, right? Yeah. So they're not wetting their palate more. And in that shutdown mode, when speakers go into that mode, it's like they're unable to get the words out. They feel choked up and they just, you know.

So have you seen people in public speaking like that? And I think it's interesting. When you hear somebody say something like, oh, he wears his heart on his face or you can hear his heart in his voice, it kind of speaks to the fact that the same vagus, nerve that controls the muscles of the face and the voice also controls that sinus atrial note of the heart because yeah you say I can hear his heart in his voice what is what does that mean well it means you can you can feel when somebody's you can feel when

somebody's heart is racing as they're talking it means they're getting they might attack you they might run away from you and leave you abandoned you don't and so when you're trying to connect with somebody you don't have those cues of safety anymore right and then when you feel that sluggish monotone dissociative voice. You feel this person is dissociating from me. He's shutting down. They don't want to engage with me. The voice may drop.

And sometimes you'll see it on like when people are having a debate in the news. Yeah. And you have someone who maybe hasn't debated that much, their voice will drop. And they'll appear a lot less dominant. Yeah. And actually there was this one study recently where they looked at presidential candidates. and they found that the ones that had won had a more dominant sort of vocal range

when they were in debates. Oh, really? And the one that had lost, often more adapted the dominant, you know, the winners sort of way of speaking. Huh. And they're, you know, because we mirror people who are more dominant than us in some ways. All to subconscious level.

yeah yeah i was also i've been reading um some friends de wall book have you ever read he he's a primatologist and um he did some really amazing work that i think relates to this in how um the dominance hierarchy works for apes because it's not always the ape that that's the most strongest and the biggest who is at the top of the dominance hierarchy so in in the ape world you know the the top ape has, you know, his choice of females and his choice of, you know, food maybe first. But the smaller dominant apes will actually spend most of their time grooming the other apes. And we'll spend a lot of time relating and sort of building alliances.

Oh, man. And it's because if there's two apes against one, you're going to lose. No matter how big. No matter how big you are. and so if you're incredibly disagreeable but you're like the biggest strongest guy like your time is coming oh man he describes some of those fights

and it was it's ferocious you know it's like really just like you know the the sort of the the attacks so the most adaptive adaptive primate is the one who has

automated their use of this connected vagal state I would say the connected vagal state, but they also have learned to play and groom, right? And they spend a lot of time building relationships, which is, it's kind of a little bit, I think it also feeds into like our moral structures that we've set up, like making sense of the moral structures, and then also making sense of kind of how we value leaders who are sacrificial. You know, we don't value leaders who seem to be totally out for themselves.

And those people usually get attacked and sort of, you know, like there's a, there's sort of an understanding that people are very narcissistic will do well, you know, initially in their career, but then they'll hit their 40s and they burn so many bridges. Wow. That it's just like really, really hard.

And then they come in for depression. And because I think it's because if, people are, there are some people who are really wired for success and to climb those sort of dominance hierarchies. But if at the same time, they're, they don't have the moral compass that allows them to value other people and get along with other people. And so they kind of like, use other people or manipulate the situation, like their time is coming. You know, like, it's, it's like, it's not in the end the best situation for them. It's going to, it's going to catch up to them. Could this be one of the reasons why it's a stereotype for like politicians to like kiss babies?

They're, you know, like they're signaling something about, you know, their moral morality. They're signaling something about their ability to connect with, you know, something we consider valuable. I mean, this is like, you know, probably, you know, 15, 20 years ago, people would get away with that. Yeah. And people would see that on television and it would be very scripted and, you know, like nowadays, it's like, you cannot get with that because there's too many cameras. It seems too phony. Yeah. And politicians like, they go on their round to the soup kitchen. It's like, oh, God, come on. Have you even talked to a homeless person? Like, you seem, you know, completely disconnected from this. And so I think, like, nowadays we have, like, especially our generation of millennials are very skeptical. Yeah.

Are very, you know, very sort of just like, yeah, that doesn't look real. You know, we have really good BS meters. We detect that well. I think so. Yeah. Okay, so getting back into the parasympathetic of the rest and relaxation. So we have, we touched a couple things here. We've already touched the heart.

So you have the high heart rate variability and the, um, the lungs, you'll have sort of good expansion of the lungs breathing calmly. The GI system is, sort of optimized to eat, digest, you know? And this is also why like it's so important to have meals with people. You want to connect with. Interestingly, you know, we've been studying connection and the residency. And the residents will often say the attendings that pay for their meals are the ones

they connected the most with. That's amazing. And it's just, it's something so basic, right? Wow. But it's true. I mean, I think if you really think about it, I think I, heard somewhere that humans are the only animals that actually share our food or eat, other than mothers and fathers to their children. But even wolves, well, it's kind of like

whoever's first, the most alpha male eats first and just has their fill. And then the next one does. But in the ape community, what you'll have is you'll have the alpha male who will partition the food and supply it and give it to the other ones off sometimes. And so you have like the distribution and you'll have the sharing. And I think it's, I think it is kind of like in the more advanced mammalian, you know, species when there is that sort of collective unity, you know, there is that sort of sharing of this, of this meal, you know. So I don't, yeah, I don't know.

Well, yeah, I guess that doesn't get away from my point though, which is that, yeah, those, those animal species that have optimized this social nervous, social engagement. nervous system, the best are ones that, yeah, are also able to partake in meals together as social activities, which is kind of primordial essence of life, so to speak, to be able to eat and drink and share those resources with your close kids book. Yeah. Yeah, I've been reading a lot about hospitality recently. And this one book about this really great New York restaurant here. And for him, In creating hospitality, his emphasis was on the connection of the employees with each other.

Oh, really? So the person eating was not the first person. It was the employees being the first person. So his idea was like if everyone was enjoying the accompany, you know, of the sort of dynamic between the waiters and between the chef and all of the unity there, that would sort of bleed out into the way that other people experienced. Oh, it's so interesting. And so that was really interesting to me. But it's, you know, we're talking about eating. We're talking about enjoying meals together.

So if you get anything out of this, you know, have meals with people. Have meals with people as a way of enjoying their company and enjoying who they are and, you know, feed people. I think it's really important. Yeah. Yeah. And there's scientific backing now. You can think about this, you know, porges polyvagel theory when you do that. that's great so you have you have all these vaguely mediated cephalic stage of digestion the increased salivation

laryngeal pharyngeal ability to chew and swallow food all that activated your subdiaphromatic your gut your stomach is in a nice calm rest and digest state not over not sudden in terribly strong compulsions to defecate or urinate or other things associated with. That might ruin a nice meal, you know. Well, no, I think there is a, I think you need to be in a parasympathetic state, though, to defecate. Oh, yes.

Yeah, because I think, you know, to go to the bathroom, you have to relax. And I saw this with my daughter who would get anxious and sort of not be able to. And so it took her a while to figure it out, like how to calm her body and have a bowelman. movement. And, you know, so I think there is something about calm, you know, that system. So do you think that defecation is primarily associated with the dorsal vagal system or the no, it's not the dorsal vagal system? No. Well, interestingly, in the dorsal vagal system

with, you sometimes will vomit and you sometimes will defecate. But it's out of the, it's out of the sort of extreme fear response. Yeah. So, you know, scared shitless, right? I mean, like, the idea like... Yeah. Literally. Right.

Yeah. Yeah. So also, what? With, with erections, you have to be in a parasympathetic state. So we know that, like, orgasms are a sympathetic state. Yeah. But erections are. are parasympathetic state.

And so often I'll have patients who have issues with getting an erection because there's tons of different sort of commenting words, negative words that come into their mind about them. So it's either a confidence issue or they feel not safe in sort of the different dynamics that are happening. Yeah. If, you know, someone says a very demeaning word to them. Right.

In the sexual encounter, they can deflate completely. Hmm. And so you have to be in a parasympathetic state to maintain an erection. Yeah. And you have to have a little bit of a sympathetic state to have that discharge, to have the orgasm. I don't want to get on this tangent, but, like, could that be in any way related to kind of the subculture thing? like with BDSM for example, trying to stimulate like a more of a sympathetic component

to the sexual experience to get off. Yeah, that's a little bit off topic. But it's honestly, like once you understand, you know, maybe there's one other neurological truths that sort of needs to get put in here to understand that is what fires together, wires together. Sure. So if you have in your sort of,

sexual repertoire, fired together aggressive acts with pleasure or aggressive acts with, you know, or being aggressively acted upon as like a form of pleasure. Then I think that's more the case. Okay. So like one of the famous sort of BDSM people came out and talked about how when he was a kid and he was in the hospital, and he was in a lot of pain for medical issues. One of the ways that he found pleasure was to masturbate. Okay.

And so he was in pain and he was masturbating. And so the sort of circuits got wired together over time. Got it. So that would be, I think, more of what's going on there. Yeah. Do you want to finish up with talking about more of the phases or talk more clinical pathology? Yeah.

Any other sort of systems that we haven't touched on parasympathetic? For the attachment phase? For the attachment phase, yeah. I think we discussed most of it. Maybe just one other thing is the sensory component. It's not just speaking and talking and facial expression, but it's also listening as well when you're in this attached, connected parasympathetic phase.

One thing that's really interesting is that detached middle ear bones are only present in the fossils of, I believe, mammals as distinct from some more ancient reptilian ancestors. What does that mean? And that's a detached middle ear lobes are, sorry, detached middle ear bones are something that we have. We have these inner ear bones and muscles that are attached to them. And if you think of a kettle drum,

that you can tighten the top of the drum, so that it beats at a higher frequency. In the same way, you have a detachable ear bone that can press down or release to tighten or dampen the eardrum-like structure of your ear. And what that does is when it's tightened, it increases the range of frequencies that the ear can listen to.

So from what we understand of audiology, when you're in a more receptive, of socially engaged state, your ear is modulated to hear inflections in the human voice at those frequencies. And that's something that you're more attuned to when you're in a safe, calm, engaged kind of state rather than an activated sympathetic state. So if I was to, you know, strap a couple sensors on a person in that state, I would be reading high vagal tone and high RSA. Is that what you're saying? Yeah, those are all associated with the connection mode. Okay. So let me get this right. So when you're, there's that little muscle and it's, it's, what is it doing when

you're more in the sort of the rest and relaxation parasympathetic state? Is it tighter or looser? From my understanding, it's tighter. So you have the cranial nerves five and seven, which are, you know, associated with the tenserty and the stapedias muscles, and those allow you to hear higher frequencies which are associated with the human voice. Typically, predators are lower frequencies, at least lower larger animals than you are. Yeah. Wow. I wonder, because sometimes when I'm lifting really heavy weights, there's like almost the music goes down an octave. Do you think that's from the pressure? Or do you think that's from this going on? Oh, that's interesting.

I don't know. I don't know. I don't have to think about that. Could be from both. That's, you know, and there's something about having a conversation with someone who's a very stressed out person. It's like they hear your words differently. It's harder for them to listen. Oh, for sure.

Some people in a chronic sort of sympathetic or shutdown state, it's like they don't. They're not the best listeners and they almost focus on their own issues more, which may be possibly related to how they're orienting in the world in an emergency mode all the time. So it may not be that they're narcissistic or that they don't care about you, but they're just kind of like in that fight and flight. And so they're just not able to. Or even perceiving your ideas and your words as either threatening them or abandoning them or putting them in danger in some way.

Yeah. Like on that note, like Gopman, the famous like marriage, you know, therapist, right, he found this behavior he called like stonewalling, right, which seems to be a form of this shutdown mode. Yeah, I would say that's a shutdown mode. Yeah. And he found that highly linked with, if he saw couples in this like stonewalling state with each other, that was highly correlated with, you know, future divorce rates.

So define stonewalling the way that he defined it. Do you, can you do that? for us? Yeah. So he would say that in the party in an argument who is, quote, you know, shut down and is unresponsive is considered to be stonewalling. So he described it as like a defense

mechanism that was triggered by fear. Right. So in this case, it's an example of our human and our socialness using a mechanism that might have evolved for something, you know, more of a threat or a predator response that gets, you know, used in a

marriage situation. Yeah. And I've seen this when I've done couples therapy specifically I've seen it with it can be either the female or the male patient and it's almost like if it happens in the session

the partner that is not stonewalling it's crazy making and it's like they can't get through to their partner and the partner is just shut down their face is flat they're sloped down in their chair it's like they're zoned out

And it's like the other partner is often very angry. And it's like the anger is trying to reconnect with their partner. That's the purpose of their anger. And then the shutdown is there as an adaptive way to try to not do damage to the relationship. So it's also there to reconnect in a form. And once the partners, and this was emotionally focused therapy, Sue Johnson, her work, is that once she got the partners to realize what was going on in the dance, that was very helpful to them.

Interesting. Yeah. So I like both Gottman and Sue Johnson and how they sort of, they're talking about the same things, you know, in different ways. Right. That's amazing. Just how much it can help to understand that all these different strategies are really, they're adaptive approaches in some sense.

And when you understand that, it can do a lot to help. help you understand your own behavior in traumatic situations, as well as how to navigate your own relationships. And I think as a therapist, it's also a way to release any judgment towards the person in front of you. Is to think, like, how is this behavior that they're doing adaptive? Or how was it adaptive historically? Because sometimes behaviors were adaptive when they were three, four years old.

But now are just very maladaptive, but they continue to do it. So it's like thinking through, like, how was this once adaptive? and that the meaning, right, that's there. That can be very, very sort of, it can be both meaning-making for the patient. Right. It can also be incredibly soothing to your own sort of internal critic

to come back to that point, even when the behaviors seem very destructive. I mean, that just seems like such a motif in all of medicine where you have an adaptive response that was supposed to be, you know, survival-inducing, like your immune system, it goes haywire and starts attacking, you know, your own body or it's dysregulated, and it leads to a pathology that seems to be what we're describing here on an emotional level. Yeah, and there's some evidence to show chronic stress

leads to, you know, an autoimmune disease forming. Chronic stress, you know, you're fighting foreign invaders, and then like you just have to fight something that's good that you you have in your body, right? Yeah. And so I sort of see those things sort of linked together. Now there could be a strong epigenetic, biological, genetic component of the autoimmune disease as well. So I'm not saying that they're all from stress, but stress can definitely worsen it.

And stress can influence it, too. Right. Like in my reading of like PTSD, often it seemed like what Corgis was trying to say was somebody would have a traumatic encounter. And then following that encounter, their nervous, their nervous system, their autonomics would become disregulated. So in the sense that their threshold for inducing a response was a lot lower. So then they'd hear, you know, a car backfire. And suddenly they were back.

They were back in Vietnam, right? Because their nervous system is trying to protect them by, you know, looking out. It's becoming much more like sensitive to their environment. But in this way, it's become a problem. Yeah, and I also think about like panic disorder, which sometimes occur, you know, usually it's in a patient, true panic disorder is usually in a patient who doesn't have a history of a lot of psychiatric issues. So they don't have history of trauma. They don't have history of depression or anxiety disorder. And then in their 20s, they develop severe panic episodes.

And that's the first thing that happens. And then those panic episodes as they're experienced are almost felt as if they're in a traumatic situation. So they're experiencing something in their brain as if they were in a near-death experience and they may actually need to do trauma therapy for those experiences once the panic attacks have been treated either biologically or through psychotherapy. And I often think that that's something that's really interesting to me is that without the as humans

without the fear of death we can experience the fear of death and that's really scary yeah for patients something that might explain why there's a lot of evidence that like things

like yoga like activities or like psychotherapy like you're describing they may be kind of exercising their autonomic nervous system to normalize the like damage that was caused by an abuse. So it kind of helps them re-learn to self-regulate. And I know you've talked about that, David, in the past with weightlifting, being a

potential way to kind of decrease your baseline sympathetic tone. Yeah. And I think yoga or meditation or, you know, the effect size for mindfulness is, you know, 0.6, 0.7 and meta-analysis. So, yeah, for a lot of people, it's very effective. and I think the breathing component of the yoga is really, really important. If you're not getting the breathing while you're doing the stretching, then it's probably not as effective.

And there's probably actually a value in doing it with a group. And I've heard from a lot of my patients, the person that's doing it is really, really important. So you can have a really good yoga instructor who can take the group and to find these calm places. And I think what they're doing is they're helping them get into this sort of high RSA state in different body postures. And if you're able to do that in a state,

so Bess and Fandek will talk about like how doing that in positions similar to a trauma that occurred to you and learning how to be calm in that position can be a very, can be very difficult at first, but very therapeutic. Yeah. So yeah, I'm open to that kind of stuff from just the sort of the physiological standpoint that it may be helpful. Now, that being said, I've seen a lot of people who are heavily involved in yoga come in and not be enough, right? Yeah. And so they're still having lots of issues, and they still need to do the hard work of going back through the trauma. Yeah, okay.

Sounds like trauma is definitely a mystery. It takes more than one approach to understand and perfectly treat with all the different forms of trauma. It just like shows me, like, I think of how integrated we are. Like, we can use physical means to get to our mind and our mind to get to more physical means. One thing I guess I would say from my understanding of porridge is that we as human beings all experience all three of these states all the time throughout the day. and what's adaptive is being able to easily move from one state to another. And when you feel yourself in the sympathetic state, knowing how to get back to a connected state,

or when you're feeling dissociated, knowing how to feel inside your body again. And so all these different forms of therapy, yoga, biofeedback, meditation, massage, and so forth seem to be ways that can help you to practice, the neural exercise of moving from one state to another. And if you do it, if you learn how to do it with another person, somebody in a group or somebody who's really good at leading you, then you're in a sense you're co-regulating one another's neurological states.

And if you can do that with another person and co-regulate, then you can learn to auto-regulate. And it's all part of the process of exercising those motions that dance through the different states, depending on what the circumstances. would you say that's a kind of a way to describe that? Yeah, yeah, I would say that's accurate. I would add to it in saying,

in early child development, the child doesn't know how to regulate the highs and the lows of their emotions. And so you as a parent, finding words to describe different emotions and helping them put words to that can be very helpful. So, you know, I use very basic words to, you know, like fear, anger,

sad, pain. And when they're feeling those things, I may repeat it several times. And so my kids know what those different emotions are because I'm repeating it when they're feeling the different ways that they're feeling. So they know how to verbally represent something that is bodily, bodily felt.

And that as they progress, if they're able to then put it to words, that helps them integrate their brain. Right? Because just like you said, like when we're in that shutdown state, our verbal centers are not there. If they can then move into and express things verbally, that helps them integrate their brain,

integrate their experience. And they can't be completely shut down if they can put words to things, if they can talk about it, which is, I think, the power of the psychotherapy and putting it to words and putting into words with other people, you know, real people. Also in psychotherapy, we know that, you know,

if you have a good therapeutic alliance, then the therapy is more effective. And that's across all therapy modalities, CBT, you know, psychodynamic therapy, all the different therapies, we found that to be true. And so part of the effect size and the effectiveness of psychotherapy is just two people, or the patient feeling connected to the therapist, and maybe the therapist feeling connected to the patient as well.

And now it sounds like that would make sense in terms of the polyvagal theory. Can you kind of bridge the two, how good therapy can have a physiologic basis? Yeah. So just like I said, like when you're accessing memories, you're going back into memories in the past, if the memories fundamentally change each time you access them. Yeah. Especially if you access them in an authentic way. Right. So a lot of the time, people are not getting into the full memory, but the more they talk about a memory, the more they access it.

And the more they access it, the more they're going to feel what it felt like. Okay. Yeah. And if they're connected to the therapist, then they can, then that gets integrated into the memory. So, you know, this is the corrective emotional experience that they occur. This is, this is the person in the room that is the, you know, part of the change that occurs. This is why people need people, you know? Like, this is why CBT alone with some sort of app is not going to cut it, you know, being, or, um,

Like when I do telepsych, I've had a couple experiences of telepsych. It's like it's harder. It's harder to feel someone else's emotions. It's harder to feel physically present with them. Now, that being said, when you watch a video, you can, you will feel some of the emotion of the person you're watching on a screen. So it's not completely detached from the systems and how they work, but it's a little bit more detached.

Yeah. So it gives me hope for psychiatrists' job security. in terms of not being taken over by robots? I think it would be, yeah, it would be really hard for robots to be human. Yeah. And to, and I think that even with the best AI, it's going to be hard to replace a good psychotherapist. Yeah.

It's going to be really, really hard. Well, I think there's a couple other clinical applications to maybe touch on. Sure. one would be assertiveness, right? So when we think of assertiveness and we think of training someone to not shut down, we're essentially training them to have a voice and to have boundaries and to be able to put that into words and be able to act upon maybe the part of them that would be more of the fight, you know, rather than just the flight, rather than just shutting down,

we would be we would be training people to get in touch with their actual needs or desires in a bodily sense and be able to put words to that in a way that would effectively move them forward yeah so how would how how how how does that fit in the polyvagal theory I think I think it fits in um in thinking through how people uh want to stay connected with other people and so If you want to stay connected with someone and you're a very high agreeable, so Big Five trait agreeableness, if you're really high in that, then you value relationships and you value, and it's going to be maybe harder for you to state something that you disagree with the person if you feel like it may thwart a relationship in some way. okay and so people who are highly agreeable need to be trained how to be a little bit honest in the way that the honesty will actually protect the relationship long term so an example would be like a patient who you know is allows their their family to continually overrun their

life, ask demands of them that they cannot meet and they continue to meet the demands. You know, they continue to rise and do those things, even knowing that there's no way they can actually continue to do this and like survive. Yeah. Right. So example would be a patient who, you know, is taking care of their family member who maybe has some significant medical issues and the brothers and sisters are telling them, no, you need to. You need to. You need to. You know, to do it. We can't, we can't be there, you know. And so they're like the sole person taking care of this person day in and day out. And maybe this person has dementia. And now they're up in the middle of the night with this dementia patient night after night, you know, and they cannot meet this need, right?

Right. But because, but it's like hard for them to have a voice maybe, right? So maybe when they come up and have this discussion, maybe they can't even have the discussion. Maybe they're like stuck in more of a shutdown state. You know, or maybe they're not. able to get in touch with the anger that would allow them to protect themselves and to protect their, you know, parent. And so it's, it's, it's, it's in them. It's physiologically in them to have that like fight, fight sort of response. But they're unable to access it. So then you as a therapist, you hear their story, you see that, you can kind of identify hopefully what the issues are and you can help them tap into that physiology to benefit them.

instead of handicap them. Is that kind of what you're saying? To benefit them and to, you know, like, imagine this continued for 20 years. What would it be like then? Would you have any relationship with any of these people? Probably not. Yeah. So, yeah, assertiveness and learning to have a voice, learning to have boundaries,

allows them to move out of that sort of stuck state where they feel shut down. Then, you know, if they feel that sort of like unable to have a voice and they feel that they're kind of stuck in the state of shutdown, As that progresses, they'll develop depression or all sorts of issues that sort of compound with that chronic stress, not being able to move out of that chronic stress. So a certainness training is in a sense a properly adaptive use of your sympathetic ability that's within you. That's good. For the right for the in the proper context. I wonder if that has some relationship between when we talk about the play circuit actually.

You know, Yacht Panksep, who discovered the play circuit. And if you think about play, playing tag, rough and tumble play, it's sort of like, if we think of dissociation as immobilization with fear, and fear, sympathetic fear is like mobilization with fear, then play is actually mobilization without fear. It's kind of the proper use of your sympathetic tone in the context, in some sense, a safe context, but because you have that context, you have the ability to exercise the use of that in a way that will allow you to use it in the future when you need it to some kind of threat. One of the studies that I love of is, is he watches rats and how they wrestle. And so you have a bigger rat who will lose to the smaller rat on purpose and will allow the little rat to actually win about 25 to 30% of the time.

and this occurs across, you know, different rats. So it's like built into their biology to be able to play because rats love to play. And they'll be wrestling and they'll be, you know, throwing each other around the little room. But the big rat will not win all the time. And I think that's really important. Like, why is it important though?

Like what? Because imagine if you're that little rat and you can pin down every time and you're immobilized every time. Right. What does that teach you? don't wrestle with the big rat. Right.

Right. So it's almost like, it's almost like if you're, you need to be willing to, to lose a little bit. To allow play to occur. Right. So with my son,

my son chases me and then I chase him. Right. Chases me like tonight he was chasing me with a tennis racket and I had a tennis racket and he would try to hit me with the tennis racket. And when he would hit me against my tennis racket, I would like fly backwards. And he would laugh and laugh and laugh and laugh.

And I would like fly onto the couch. And I would like make this like like, oh, you know. And then he would like giggle and giggle and giggle and giggle. And then I would, you know, so it's kind of like this allowing him to play both sides of the role. You know? Oh, that's so interesting. It's like I'm just thinking of like the importance of like, you know, kids. I think like Piaget talked about the importance of.

kids like playing house in the sense where they they see their role models their parents they're they embody these roles for a future date in which they'll they'll need to learn those skills yeah yeah yeah and allowing and you know like allowing them to be whatever role in the house they want to be yeah that's that's that's that's fun um and it's all part of co-regulation of each other states learning how to use all the kind of biological equipment afforded to you in the social context in which you live in a way that's adaptive to each situation. So maybe without that, we would have a harder time. We would be handicapped in our ability to have the connection mode,

the high RSA, the myelinated Vegas ability to connect meaningfully with others that really facilitates meaning in human relationships. Yeah. Yeah, I think so. Yeah, I think so. Anything else we wanted to touch upon that we haven't touched upon? I found some stuff on... borderline personality disorder.

Okay. You want to quickly touch on that? Let's go there. So just quick recap, borderline personality disorder. Individuals with this, they exhibit affective or emotional instability, intense and tumultuous relationships, difficulty controlling anger, impulsivity, lots of suicidal tendencies and self-mutilation behaviors. So something poor just suggests is that this may result from traumatic experiences early in life. kind of like we talked about earlier, that then leads to autonomic dysregulation.

So then any relationship that they attempt to form is kind of carries the, maybe like the mark of that earlier trauma. And so any little thing, they hyper respond in that sense. So we would say that their vagal system is dysregulated in that sense. Yeah, a couple things on that. So I like Beatrice Beebe's work, and I'm trying to get her to come on the podcast. Oh, shout out. So she looked at four-month-old infants interacting with mothers, and she videotaped them.

And she was able to predict whether that diad would lead to the child having a secure attachment at one year or a disorganized attachment or an insecure attachment. And the disorganized attachment style is found to have later disarmine. association, which is in the teen years. And so this is what is the link between, in my mind, early attachment with the mother and what's going on in the home with what could be potentially borderline personality disorder in adolescence and then later in life. Because essentially the way that I see it, because borderline personality disorder are people who have higher propensity to disarmament.

and to get stuck in dissociation. So often, before they hit the hospitalization, if you get the history of someone who's borderline personality disorder, they've been dissociating for a couple weeks. Wow. Straight. And it may look, and I think that's why it gets misdiagnosis like bipolar, because when they're in that dissociative state,

they're not acting themselves. They're more impulsive. They're more anger. You know, they're volatile. But after being in the hospital, after one or two days, they snap back to normal. and the social veneer comes back on

and they actually look completely normal. And they're no longer suicidal, they're no longer want to hurt themselves for other people. And so I see dissociation as something that they can get stuck in. And to speak to the disorganized attachment style and why I think it may be linked to someone

with a severe borderline personality disorder is like, do they have ways of connecting and reconnecting that actually allow them to maintain those relationships or do they have no organized way of reconnecting? So I've had several patients that I could tell that they hadn't connected with very many people at all in their life, maybe no one in a significant way.

And so that's where, you know, the different therapies really address this type of issue. You know, you have Marshall Anaham with the dialectical behavioral therapy. It has mentalization as a way of helping them learn how to regulate their autonomic nervous system, right? So mental is, or not mentalization, sorry, mindfulness, which is like the different breathing stuff and being able to focus and concentrate on a single task. And then they also have the behavioral component of doing things that would be enjoyable, that would sort of pull you out of this dysfunctional state. and then they have a lot of like interpersonal effectiveness stuff built into it so what do you do with your anger how do you be interpersonally assertive how do you you know sort of regulate these emotions so that that's one therapy that works the other therapy that works probably equally as well is mentalization based therapy so in that therapy you have um you have fornegie in bateman in england and maybe it's a little bit less popular in the u.s but i still think it is really worth reading into and diving into in deeper levels.

And essentially, what they're doing is they're helping the person understand their internal experience and the internal experience of people that they're with in a more accurate way. Because that is one of the basic malfunctions in the disorganized attachment, is to misunderstand other people and themselves. And then the third type of therapy that has been found to be helpful is transference-focused therapy. And there's some really good long-term studies of that for borderline personal eye disorder as well. And transference focus therapy is a psychodynamic therapy that was twice a week. And essentially what they're looking at is the relationship between the therapist and the client,

which is a very here and now relationship in which if the client feels negative emotion towards the therapist, the therapist talks about that and the therapist goes there and the therapist. Wow. So the here and now, the emotional sort of dynamics that go on between you and the client get spoken to and get sort of negotiated. So you can think about how all those three different types would address the polyvagal theory and the sort of dysfunction that we're talking about. Yeah. No, totally. Those things to me would like kind of recalibrate that vagal breaking system that might stop the,

the uninhibited social, like, disorganization from taking over their relationships. So instead of reacting in a zero to 60 in a second, you know, they might, hey, mentalize. They might put themselves in the shoes or they might, you know, catch themselves. So let's draw this to a close because it's a longer than normal session, but I think it was good. And Dr. Ng here is starting his first day of residency tomorrow. So we want him to get some good sleep tonight. Wish me luck. Good luck.

final thoughts or big takeaways that you have in studying from this and how you interact with people or sort of interact with your own sort of physiological system? I think for me just kind of to zoom out and take a big picture approach, the whole polyvagal construct, it reminds me of Antonio Demosio's book, Descartes Error, right? Descartes Error that you lent me that kind of deconstructs this like mind-body dualism in a sense that we all just kind of assume, right? So we think that our minds and our bodies are very you know, disintegrated entities. But this theory, this polyvagal construct helps me see just how like radically connected those two things are and how patterns and neural circuits and, you know,

things that happen to us can manifest themselves physically. And then it's bidirectional, right? So you have it go both ways. And that's how things like breathing exercises can calm our, you know emotional processes as well Kevin sounds great what are some of your big takeaways how do you practically apply this to your life or you know

just on a purely theoretical sort of basis no I think at the end of the day I'm glad that there's kind of an organizational hierarchy that I can use to both understand the physiology as well as the different places that I know I have myself go through on a day-to-day basis as well as I see others go through as they process the different stresses and traumas in their lives. And it's exciting to see how the future of different kinds

of trauma work and somatic focus therapies and other kinds of therapies will incorporate these insights to help us get better at treating people who've gone through some terrible experiences. Yeah. Very good. Yeah, I've shared a lot of how I use it. But just on personal note, in my life, I definitely use it to auto-regulate myself to some degree when I'm with my kids or my wife when arguments come, you know, thinking through like what's going on or am I, am I shutting down or she shutting down? Am I, which roles are we playing? And then how do I, you know, see what's occurring as like we're both adaptively trying to

reconnect and having that be the main narrative rather than, you know, blaming the other person for what's happening or myself for what's happening, you know, how are we using these systems to adaptively reconnect and then like getting back to like, what is my main goals? If it is to reconnect, then how do I do that best rather than shutting down or rather than, you know, fighting or saying something. So that's how I. So you're your firsthand testimony. Yeah. That's my first hand testimony right though, yeah. We'll get your wife in here and have her comment too. Yeah.

Actually, I'm going to have her come on in the future and talk about boundaries and assertiveness because that's something that she's really right. That'll say. That'll be good. Yeah, it'll be good. And then I'll have my brother come on sometime and talk about the path of the warrior

and how he used it when in his ultimate fighting. Fun episodes down the pipeline. Yeah. So stay tuned. We will throw up the notes on, if you follow the show notes, the website. We'll put the notes up there. and if you have any questions, throw it up on the website's comment section

or one of my social medias. And yeah, really excited. Kevin, I'm really excited for you to start residency and for the good things to come and I'm sure we'll stay connected. Yeah, man. Absolutely. I'm sure we'll hear more from Adam in the future

and we've got some other sort of topics to discuss in the future. So thanks guys. Yeah, thank you, David.