Latest / Radically Genuine / 204. The Nocebo Effect and How Doctors Unknowingly Create Chronic Conditions

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204. The Nocebo Effect and How Doctors Unknowingly Create Chronic Conditions · Radically Genuine

• Roger K. McFillin, Psy.D, ABPP (00:02.356) Welcome to the Radically Genuine Podcast. I am Dr. Roger McFillin. What I do love about this show is that we challenge the reductionist approach that has become the norm in Western healthcare. We refuse to accept simple labels, surface explanations. We tend not to segregate conditions into neat little boxes without attempting to understand their root causes. Because here's what we know, and we know this to be true. The mind. environmental stressors, psychological factors, lifestyle, they don't just impact the body. They may very well be the root cause of many chronic conditions that are labeled in our medical centers. The limitation of our paradigm has never been more apparent. The mind, the body, the spirit in connection with our environment are critical in understanding when the body is in a diseased state. and how ultimately we are able to achieve healing. I think today's conversation is gonna exemplify this philosophy. We're going to talk about very specific conditions that are often labeled as chronic and even incurable. They affect millions. You may be introduced to these names, these labels for the first time like PPPD, persistent postural perceptual dizziness. or MDDS with stipular migraines. Like here's the thing, these intimidating medical terms are really just labels for a collection of symptoms. They might describe what's happening, but really don't give us a whole lot of information into why it is occurring. My guest today is Dr. Yonit Arthur. She spent years working with people who've been told that possibly the dizziness and balance disorientation are these neurological conditions potentially even incurable. And I'm always interested in what happens then when that expectation is provided. Dr. Younid Arthur received her doctorate in audiology from Purdue University and is a licensed audiologist and coach. She's board certified to the American Board of Audiology and holds vestibular rehabilitation, advanced vestibular rehabilitation and concussion certifications through the American Institute of Balance. Roger K. McFillin, Psy.D, ABPP (02:28.064) She's also has this extensive training in other modalities that cross over with the work that I do, including internal family systems, inference-based cognitive behavioral therapies, exposure and response prevention, emotional expression and awareness, mindfulness-based techniques. She's also a certified strength coach. Dr. Yeo, as she's affectionately referred to on her YouTube channel, which is an excellent resource, the Steady Coach, where she's also built free comprehensive courses for people who are dealing with chronic dizziness. Dr. Yunit Arthur, welcome to the radically genuine podcast. Dr. Yonit Arthur, AuD (03:11.879) What a pleasure to be here. Thank you so much for that very comprehensive and impressive introduction that you just gave me. Roger K. McFillin, Psy.D, ABPP (03:20.854) Well, it's an honor to have you on the show. Really interested in picking your brain, but I think we have to at least introduce our audience to maybe an understanding of what you're actually working with. So I threw out some names there, PPPD, MDDS, vestibular migraines. Can you give us an overview about your areas of expertise, the type of clients and symptom profiles that you're working with? Dr. Yonit Arthur, AuD (03:44.98) Absolutely. those three diagnoses often are given to the people I work with, but more broadly, I'm working with people who have what I call medically unexplained chronic dizziness and other multisensory symptoms, which essentially means these people are suffering from often debilitating chronic symptoms. So not just, you know, I'm a little lightheaded when I get off the treadmill. We're talking complete states of paralyzing terror, 24 seven symptoms, often a sense of constant movement, being unable to track moving objects, having constant blurring or inability to fixate on things, seeing trails after everything they see, a sense of derealization, dissociation, difficulties walking, moving. I I could go on. These people are dealing with essentially a collapse of sensory reality. often they will describe their symptoms in general as dizziness, but it really, it's more of a, again, a multi-sensory collapse. So what will often happen, obviously these patients or my clients will experience something like this. They'll have maybe an attack of vertigo to kick things off or not. It'll just start with the symptoms I just described. They'll go to the doctor, they'll go to the emergency room and nothing. And then they'll go through specialists. mean, I have worked with people who have seen upwards of 20, 30, even 40 specialists just trying to find an answer. They will have every test known to man and nothing will be found that explains their chronic symptoms. So at that point, they're given one of these diagnoses that you named PPPD, MDDS, vestibular migraine. sometimes other diagnoses, complex migraine, post-concussion syndrome, visual snow syndrome, and they're given medications, sometimes psychiatric medications because they're obviously also in a great deal of distress from these symptoms. And they're told these symptoms are chronic and curable and you can only learn to manage them at best. You may have some better days, basically. Roger K. McFillin, Psy.D, ABPP (06:08.67) Yeah, let me ask you about that. How did they come to that conclusion that it would be chronic and incurable and how accurate is that in your experience? Dr. Yonit Arthur, AuD (06:15.711) You are cutting exactly to the heart of the issue. So, okay, let me see if I can separate what we know from research and my opinion. I'll start with my opinion. My opinion is the reason they're told this is because the problems that they're having are ones that conventionally trained medical professionals mostly just don't know how to treat. and that reflect a problem that is not the result of a tissue damage or an acute medical condition that can be treated through pills, surgery, and medical procedures. So because that sort of lands these folks who at this point are still patients, I don't always refer to them as patients, but at this point in the process, they're still patients, it lands them basically outside the realm of of where most conventionally trained providers can help them. So basically they say, you don't have a problem that I can treat and therefore it's untreatable and good luck to you. The conclusions that they're drawing are also based on some very poor evidence. So, Essentially, the research that we have shows that the current treatments that we're using aren't super effective. But it's a fallacy to then draw the conclusion from that evidence that these conditions aren't treatable. And in my opinion, based on what I've seen to answer one of your questions here, they are absolutely treatable. They're treatable and people can fully recover from them and to claim otherwise reflects a lack of intellectual curiosity and ignorance. And also, I think downplays the effect that statements like these, like this isn't curable and you can only manage it, have on the actual outcomes that someone is capable of achieving. Essentially, these patients are being nocebo'd by medical providers, well-intentioned often, by the way. But they're being nocebo'd into believing that they can't recover. Roger K. McFillin, Psy.D, ABPP (08:38.113) Which is an important point. I just finished reading a book, Mind Over Medicine by Dr. Lisa Rankin, which was fascinating to me because it was all the available research regarding our own ability to heal and the power of the mind in healing. So certainly there was a lot about the placebo effect, the nocebo effect, which you just mentioned, like what happens when a medical professional creates an expectation or a belief system occurs that the treatment will not work. and how that actually leads to that very outcome. And it's fascinating to me how little the general medical, traditional trained medical professional fails to understand that important connection between mind and body, between expectations and outcome. So how damaging has that been for the clients that you work with when they are actually told that it is incurable? Dr. Yonit Arthur, AuD (09:37.644) Before I go into that, I just wanna follow up on something you said and say, I recognize your audience is a lot more open-minded than the average audience, but I also want to say for those of you out there who are conventionally trained and may find this conversation somewhat uncomfortable, what I just said about people's wellbeing being affected by what providers tell them and also this idea that the brain can create symptoms and can uncreate symptoms even in the absence of physical damage. These are all based in solid neuroscience. This is not based in wishful thinking or spiritual belief. This is based in solid neuroscience and the leaders in the world of clinical neurology and neuroatology are are coming around to this perspective because it is based in science. So felt it was important to say that before I start talking about the damage that's done. It is hard for me to describe how horribly people are affected by this. So as you mentioned at the beginning, I have a YouTube channel. The reason I have a YouTube channel is because five years ago, if you had Googled PPPD recovery, you wouldn't have found anything other than reputable medical websites saying things like it's incurable and chronic. I knew that wasn't true. And so it became my mission to contradict that using evidence. And so one of the most important things I do on my channel is record success stories. I have over 50 of them and I have a whole bunch more slotted for recording and I will keep recording them as long as I possibly can because I think it's so important when people Google the names of these various conditions I've already mentioned that they see that recovery isn't just Dr. Yonit Arthur, AuD (11:47.374) It is completely doable and it's in someone's hands. It's in your own hands to accomplish that recovery. But before I had the reach that I have now, I think I spent, when I was working with new clients, I think I would spend months, sometimes years just undoing the damage that had been done to them by medical providers and other people in their lives saying things to them like, what we've just been describing. It's incalculable. And goodness only knows how many people out there are wandering around thinking that they're permanently damaged and they simply haven't found resources like mine that tell them otherwise. I can't even estimate the number of people out there. All I can tell you is these conditions are actually quite prevalent, although chronic dizziness may be less so than chronic pain or chronic migraine. There are literally millions of people in the United States and millions of people else who suffering from them. And many of them walk around every day believing that there's no way out of these conditions and that all that can be done is to take the pills that they've been given and to live a dramatically reduced or dramatically limited life based on what they've been told. Roger K. McFillin, Psy.D, ABPP (13:11.799) In the book that I was reading with Dr. Lisa Rankin, she made some suggestions to professionals, including conditions like stage four cancer, for example. So even in situations where potentially the recovery is statistically quite low, the conventional medical doctor will like, inform them that it's statistically unlikely they're going to recover and that they should get their affairs in order. And her... belief given the fact that there are people that do recover is that we should communicate to patients in a way of that type of optimism and hopeful hopefulness such as I believe in your ability to heal. There are people that overcome this and recover fully. I am fully committed to you and helping you find that way with all the emphasis is on them and how that would change the outcomes. You said something just I think was fascinating, which I really align with is this idea that we have to undo some of the conditioning that takes place in the medical system. For example, people come into my practice and they attach to a psychiatric diagnosis. They're told they have a mental illness, they have it for life, and they just have to manage their symptoms. which is a complete lie. There's no truth to that at all. DSM psychiatric diagnosis aren't even discrete, legitimate medical conditions. just a label, but it does drive an entire industry. And it certainly creates a reality for the individual about their potential and who they are in their life that has such, I think, overwhelming negative consequences when you attach to it. So I'm curious because you're working somewhat outside the system. and so you're presenting an alternative. How do you communicate? How do you undo the conditioning for them that can set them up for a positive outcome? Dr. Yonit Arthur, AuD (15:23.009) I think this is something that I'm uniquely positioned to do and I do pretty well because I like to meet people where they're at first. So I will often meet people in that diagnosis that they've been given. I'm aware that the diagnosis that they've been given, similar to many psychiatric diagnoses, is just based on a description of symptoms. It's a checklist of symptoms. And I recognize that having a name to what you're suffering from can actually be reassuring and helpful in some cases because it lets you Google it or go on YouTube and find videos about it. I get that there's some value to it, but the value of it stops there once we know that there's no tissue damage or that there is no medical answer to the condition that you have. So I meet people there and I break it down mechanically first. I explain to people, What's happening here from a neuroscience perspective makes total sense. All the symptoms that you're experiencing make complete sense. You're not going crazy. It's not a mystery. Here's what it is. Your brain is simply misinterpreting sensory information. And our brains actually do this all the time. This is how sensory perception works. Your brain doesn't just passively take in information. It actively predicts what information is going to come in. And then it just makes comparisons to the sensory information that it's getting from your various sense systems. So it's very normal for brains to make errors here, to make mispredictions. I have a million examples. The other day out of the corner of my eye, I saw something small and black and I was sure it was my dog. It was the trash can, okay? My brain predicted dog, because it was about the right size and height. It was about the right position, but... it was not the dog, it was just my brain's best prediction based on the particular conditions that I was in. And it quickly had to update that when the sensory information came in and it didn't align with the prediction of dog. So that process similarly can lead to symptoms like dizziness, like visual symptoms, like tinnitus, like hyperacusis that are based in Dr. Yonit Arthur, AuD (17:48.497) some sensory reality, meaning your senses are giving your brain some information that's real, but your brain is grossly misinterpreting it or not using the information the way that it should to help you balance or see clearly or what have you. And then once people understand that, I explain that these, ultimately your brain's purpose, in your life is to keep you alive. It's a lot less interested in your comfort than it is in your survival. So it will always err on the side of keeping you safe. And if your brain is interpreting some situation as dangerous or some sensory information as dangerous, it will potentially overreact or over-respond to that sense information. So when someone has a good deal of stress in their lives or the brain has accidentally labeled a particular sensation or situation as dangerous. And then someone has an anxiety or threat response to that particular thing. It becomes a vicious cycle very quickly. You have a sensation or you're in a threatening situation. And at the same time, you encounter something that's not actually dangerous. Your brain associates those things. You have a reaction. fear reaction. That ramps up your alertness and then you start to feel the sensations more. Then you start to engage in all sorts of behaviors to try to avoid it because it's really scary and that tells your brain that it's actually quite just as dangerous as it originally predicted and people get stuck in this loop. So this happens with all sorts of physical sensations, most commonly with chronic pain, but these multi-sensory symptoms I'm describing are particularly scary. So people end up pretty vulnerable to that particular loop of threat and symptoms when they experience dizziness or one of these other symptoms. So to answer your question, I just gave you a very long-winded response, but basically demystification. explained everything I just said, and I said, this is just your brain operating normally. There's nothing wrong with you. This is normal brain function. Roger K. McFillin, Psy.D, ABPP (20:07.02) Hmm. Dr. Yonit Arthur, AuD (20:10.252) congratulations, you're not broken. Your brain is doing what it was adaptively designed to do. And so we can break that cycle by doing other things that your brain is designed adaptively to do, which is to rewire from birth till death. Your brain can adapt and rewire. is constantly engaging in that process. And by pulling a few levers strategically, we can help it adapt in the direction we want. Roger K. McFillin, Psy.D, ABPP (20:38.914) Well said. So let's talk about the various root cause aspects of this. think if I'm hearing you correctly, context matters. So there's an initial event that that's important, a response to that event. And then there's a multitude of reasons why these conditions may be maintained due to the way that they respond, the complexity to this. But from your understanding of the various kinds of root causes to developing these symptoms that we label. What have you seen in clinical practice? Dr. Yonit Arthur, AuD (21:11.476) Hmm. So it's wonderful that you're asking this now, because I just prepared a talk for a conference. I've been thinking about this in terms of stages. So I'm going to probably be drawing from this talk as I'm answering this question. For the majority of people, the simplest case is simply that someone developed a fear response to the symptoms themselves. Maybe they had a cold and they, okay. Simple, simple, simple example. When I have a bad day and I come home and I'm really stressed out and someone slams a door, I'm going to jump really high. I'm going jump. I'm to be much more reactive than if I had a great day and someone slams a door. My system's already on edge. So when someone's system is already on edge because of just random life circumstances or just a little anxiety or we... had some losses or financial stress, whatever it is. And then they end up with a symptom that's scary for whatever reason. In the backdrop of that, the brain can misinterpret the symptom as related to that backdrop of stress. And we end up looping in this cycle. So the remedy for many people is just calling its bluff and seeing that actually sensation isn't dangerous. It's just the brain overreacting to normal sensory information or to a misunderstanding of sensory information. So essentially what I teach people in this stage is just approaching the symptom rather than trying to avoid the symptom. So rather than trying desperately to stop the symptom, Google the symptom, to go to doctors to fix the symptom, to mitigate the symptom by avoiding or or complaining or lying down or hiding from it, which again is the most natural thing in the world. say this with zero blame. The things that I've seen, the sensations people have, Roger, any person would be cowering in terror from these symptoms. But once people realize this is all of that is feeding into this fear cycle, when they stop doing that and they just let the symptom be, and they understand what I've already said about Dr. Yonit Arthur, AuD (23:32.799) your brain can rewire, your brain's always plastic, that's enough to undo the cycle. That breaks the cycle and the brain can rewire itself so that it doesn't have this sensory distortion anymore. So that's kind of the simplest case. But the types of stressors people have, so I described simple stressors just now, financial stressors, what have you, the types of stressor someone has in the backdrop of these symptoms developing can vary quite a bit, let's put it that way. So some people just have life circumstances that are a little difficult. Some people have long standing habits and patterns of responding to things in ways that make stress a lot worse. anxiety and anxiety type patterns, obsessive compulsive thinking patterns that can really ramp things up. But also habitual... patterns of behavior that people will often think of as personality traits, but I don't. think of a strategic, like people pleasing and perfectionism and being super conscientious and like the go-to person. Those things also tend to not just amplify new stress, and I can give examples if that's helpful, but also create their own stress. So this person ends up with an inordinate, outsize load of stress. So when the symptoms show up, The system is so sensitized that it massively overreacts to the symptoms. And it's not enough in those cases to just react differently to symptoms. We also have to undo some of the stress that's feeding them. So we have to look at someone's habits. We have to look at how someone deals with anxiety and intrusive thoughts. We have to look how someone deals with really their relationship to themselves and other people. because all of those things are making the system so much more sensitive. And then I would say there are also people who are also suffering from post-traumatic stress disorder or severe effects of trauma, whose systems are even more sensitized and rigid. And so for them, behavioral changes aren't enough. We have to get to some of the fundamental Dr. Yonit Arthur, AuD (25:55.433) worldview that they have, the fundamental beliefs they have about how the world works. And that's what helps undo some of that stress backdrop. Roger K. McFillin, Psy.D, ABPP (26:05.677) I'm struck by the overlap here in how I, as a clinical psychologist, approach emotional disorders and emotion regulation. There's this paradoxical effect. The more you try to control and avoid emotional states, the more debilitating and overwhelming they become. And we see this in no other condition, a ton of conditions, but obviously one that comes to mind is our panic attacks. which I'm sure there's an overlap in the symptoms that you are working with and these types of conditions that we actually use exposure work that the person's panic attacks are often related to a misinterpretation about the symptoms and their danger associated with them, which creates a stress response. And then there's a fear of that internal state and attempts to try to control or avoid it, which leads to a panic attack. So very similar kind of interventions Dr. Yonit Arthur, AuD (27:01.44) theory. Roger K. McFillin, Psy.D, ABPP (27:03.447) with this way that we relate to our inner experience, the more attention and focus we give them, the worse we begin to feel. Dr. Yonit Arthur, AuD (27:12.512) That's exactly right. There's a tremendous overlap and probably about to say a few somewhat controversial things, which I know is welcome on this podcast. So first of all, I want to say that these symptoms themselves quickly layer in. psychiatric symptoms because of the disorientation they produce. even in the absence of some kind of psychological root cause, someone who has multisensory distortion related symptoms will often end up with panic attacks, with intrusive thoughts, with OCD, thought patterns. because the brain is in such a state of fear and disorientation from the symptoms themselves. So that becomes layered on top of just pure fear of symptoms. And so we have to use actually the same methods that you just described to help undo some of that so that the system can calm down. But I think that may not have been controversial. This is what may be controversial. Okay, I want to be careful about how I say this. I want to be accurate. on a larger level, some people's dysregulation or stress manifests in psychiatric symptoms and other people's dysregulation or stress manifests in physical symptoms. And I don't differentiate between the two. I certainly differentiate on a... Dr. Yonit Arthur, AuD (28:46.508) practical level because I want people to understand I'm not saying they have a psychiatric problem when they have PPPD or MDDS because it's different. But the kind of circuitry that leads to chronic physical symptoms is the same kind of circuitry that leads to chronic anxiety and depression. It reflects a similar process of conditioning, of threat appraisal, and of maladaptive loops that keep someone stuck in a rigid state. and similar interventions undo those stuck circuits. Roger K. McFillin, Psy.D, ABPP (29:25.156) So I'm thinking of some challenges here. I'm sure there's professionals who are listening and we all face some difficult things because the concern here is coming across as if we're invalidating the seriousness of the condition. I think a lot of people come in to see us, myself as a clinical psychologist, yourself and your work is that they've already been invalidated by the medical system. Some will say, well, it's all in your head. They might not be taking it seriously enough. Dr. Yonit Arthur, AuD (29:31.808) Yes. Dr. Yonit Arthur, AuD (29:53.644) Yes. Roger K. McFillin, Psy.D, ABPP (29:56.281) And then we were talking about this approach where we're saying, well, it's complicated and your internal appraisal of the event, how you view it, how you think about it, your response to it is critical here, as well as looking at other aspects of your life and how you respond to them. But they're not wired to view it that way. Generally, they view it as a medical condition separate from them, right? It's like something that the... Dr. Yonit Arthur, AuD (30:25.878) happen to them. Roger K. McFillin, Psy.D, ABPP (30:26.966) It happened to them, the doctors reinforce that many view it's genetic in some way, which communicates it's outside your control. How do you find this balance between validating the suffering, but also trying to inspire and motivate to change your way that you respond to it? Dr. Yonit Arthur, AuD (30:47.68) Yes, that's an excellent question. I have a few answers to this. And one of them is by the time people find me, they're desperate and nothing else has helped them. Because unlike psychiatric conditions or alleged psychiatric conditions, there isn't treatment that supposedly works. There is no pill they can take. There is no rehab that will help them manage their condition. They are told there is nothing that can be done for you. Good luck. And as horrific as that is and as much as that as I'm even just saying the words to you I can feel my heart just sinking into my stomach. It fills me with this rage of injustice. At the same time, in some ways, that's the saving grace because the biomedical paradigm does not have anything to offer these patients other than pills that sort of manage their conditions sometimes, but don't really. If they worked or if people thought they worked, they wouldn't be looking for information on the internet about it. So that's part of it. So to sum that up, it's... the time people find me they're miserable. They've tried everything else. I'm like, well, what the heck? guess I may as well try what she's saying. might be like, maybe I'll be nice to myself and I'll do this 10 minute meditation and see what happens. That's also why, Roger, I do so much of what I do for free. So I do a lot. I mean, I put out weekly YouTube videos for years now. I have a free course that's very comprehensive. All of that is because I think it speaks for itself and people need to People have very good reasons not to trust me once they've been gaslighted to the ends of the earth by a whole bunch of people, medical providers and others. So I say, you don't have anything to lose by trying this. I give them the evidence. I say, this neuroscience makes sense. What I'm saying makes like complete sense. Dr. Yonit Arthur, AuD (33:04.384) But you don't even have to just trust me on that. I want you to try this. Just try this and see how it goes. And if it works for you, then let's keep talking. And if it doesn't work for you, here's some other things you can try. think presenting the information and having people be able to access that information without needing to invest monetarily is a very big part of that. It earns people's trust. And I think It also demonstrates to people that I really believe in what I'm talking about. So they know I'm not asking for anything in return other than their attention for 15 minutes while they watch a YouTube video. So again, for people who often have very good reasons not to trust people both because of their experience within the medical system, but also often as we talked about, as the result of experiences that occurred long before symptoms ever started, they can see that I might be someone who has good intentions and is trying to help. So I think those are the main components of how I reach people. The other thing is the provision of absolute proof that it works. Just as you said, I don't frame things in terms of guarantees, but I give people success stories and I share constantly, I share anecdotes. mean, the success stories represent the tiniest fraction. My YouTube channel is full of comments from people who've gotten better and who've seen improvements. It's overwhelming proof to people that there's something to what I'm saying and that there's hope. And once the door is cracked open, once there's a little bit of hope and people are willing to try, then they can be helped. Roger K. McFillin, Psy.D, ABPP (34:59.579) I want to get into those specifics, those stories of people who've fully recovered, those matter. I want to understand what all those components are and what you've seen in practice. But I did watch one of your videos where you were kind of rating them, right? You were rating the various interventions. Dr. Yonit Arthur, AuD (35:15.156) that was a fun YouTube thing. Yes. Roger K. McFillin, Psy.D, ABPP (35:18.683) And you talked about SSRIs and SNRIs, right? And it's very interesting because I think you spoke about them in the way that most medical professionals, psychological professionals discuss it. They say, well, I found some people where like it's been life changing for them. Dr. Yonit Arthur, AuD (35:23.851) goodness. Yes. Yep. Yep. Roger K. McFillin, Psy.D, ABPP (35:47.239) plenty of people where nothing's noticed, and then a ton of people harmed. And I've kind of dedicated my career to answering that question, like looking into the research itself. And you said something that I thought was important that I want to address, that we both can address. You said that many medical professionals are gonna prescribe that drug because they believe it's of like low harm, right? There's not really any risk to it. Potentially even believing that it has a powerful psychological effect. But the risks I have come to learn as many of others are very, serious. In fact, I just had a professional that who described it as a mitochondrial poison. We have conditions called post SSRI sexual dysfunction, which is permanent, permanent sexual dysfunction from taking the drug. Dr. Yonit Arthur, AuD (36:33.493) Yes. Roger K. McFillin, Psy.D, ABPP (36:47.574) There's a range of metabolic illnesses that are related to the drug. Then there's the mania, there's the suicide, there's the violence. So these drugs certainly do have severe consequences. But I look into the placebo-controlled trials and works with placebo. There's not really a measurable difference between taking a placebo and an SSRI. Although SSRIs are not a placebo, they are an active substance and they do induce emotional numbing. What we talked about today, the inducing of an emotional numbing, control avoidance, repression doesn't lead to positive outcomes. In fact, that's the opposite. So what do you think is happening for those who say, this has made all the difference. I started taking this pill and I just feel much better. Dr. Yonit Arthur, AuD (37:34.815) Yeah, really excellent question. I try really hard to give agency to my viewers and my clients. I want them to learn to take responsibility for their health rather than thinking that I'm some kind of expert on them. But. Here's what I've seen. What I've seen is that the majority of people who are prescribed these things for their symptoms do not have any benefit from them. There are some limited studies suggesting they provide some benefit. They are very poorly controlled and very small studies. And a Cochrane review found that there was not enough evidence to support their use, just so we're clear. the evidence is not great. anecdotally, physicians will often tell their patients, yes, I've seen people be helped by this. For some minority, there seems to be some kind of effect. And I cannot tell you if that's placebo or not. This is outside of my area of expertise. So I feel uncomfortable weighing in on whether it is placebo or not. But what I can tell you is the way that I will frame this for people is This, if you're going to use this, this needs to be very short term and it needs to be used with full informed consent. And you have to have a tapering plan to get off of it when you start that that to me is the responsible way to try something like this. That's not how it's typically used and that's the problem to me. If it is a powerful psychiatric drug that does induce emotional suppression, when someone is in horrific levels of distress because of a deluge of both this physiologic terror that results from symptoms and physical symptoms themselves and they're completely stuck in this catastrophic loop, then Dr. Yonit Arthur, AuD (39:47.675) Using a medication to break the loop to me makes sense, but it should be used as a loop breaking device, not as a maintenance device. Roger K. McFillin, Psy.D, ABPP (39:55.771) Yeah, so my question with that is why when I, if that was going to be the approach and it's not my approach, don't any way recommend it. Why not just use a benzodiazepine? Dr. Yonit Arthur, AuD (40:01.429) Sure. Yeah. Right, right. Yeah, that's, that's a great question. And to me, I think there's concern or at least a belief among doctors that benzodiazepines are more, obviously, they are more addictive than SSRIs. But when used to short circuit a loop, like what we just talked about, that that's actually what they are intended for. And when they short circuit the loop. If the person doesn't keep taking them, then we don't need to worry so much about them getting addicted and having to go through withdrawal. think that's, that's my thinking on it. I don't think providers see it the same way. I think they see it them as potentially more dangerous. Really, you know, Roger, I think what it comes down to as I'm running through this in my mind is they don't trust their patients. I think that's what it is. They don't trust people to be able to make good decisions for themselves. They think of SSRIs as easy like band-aids that, everyone takes these, so many people are on them, they're really safe. I'd rather give you that than that big scary benzodiazepine thing. People get addicted to those things. I don't want you on those. Understandably, because they're not going to be there to support the person through proper use either. If they're going to just give them a five-minute appointment and then prescribe them and then send them on their way. right. I have seen people, countless people end up addicted to benzodiazepines because they were just given full bottles of them. Like you just need to take this when you're dizzy and they're dizzy 24 seven. So they just take them every day and then they end up addicted to them. ideally, ideally, actually, again, I'm saying this with as an informed lay person, not as a medical professional, because prescribing medications is outside of my scope of practice, but Dr. Yonit Arthur, AuD (41:56.38) Ideally, people would not be given SSRIs. They would be given some kind of medication that would break the cycle, and then they would be given intensive help that would teach them how to keep the cycle broken non-medically. Roger K. McFillin, Psy.D, ABPP (42:11.825) Here is my belief system on who responds to SSRIs. Now, if somebody received full informed consent on SSRIs, it would further decrease the effectiveness of them. So what I mean by that, if people are really told of all these risks and the limited evidence, then you decrease their response to it. It acts, it'll be more of a nocebo kind of effect. So doctors don't provide informed consent and most doctors aren't informed. Dr. Yonit Arthur, AuD (42:23.915) That's true. Yeah. Roger K. McFillin, Psy.D, ABPP (42:42.203) So, but those who do respond generally are the ones who have these strong beliefs that there's something broken about them physically, something genetic, and the drug is going to correct that. And in that belief system, that is powerful because what you do get to see in the studies that we're able to create this portion of the evaluative process in the study is like when you get a person to guess whether they took the drug or the placebo, it is the guess that leads to the outcome. So if you had the placebo but you believed you got a drug, an agent, you have a more robust response. That tells me the power of the mind and our expectations in our physiological responses to that. Dr. Yonit Arthur, AuD (43:22.377) Yep. Yep. Dr. Yonit Arthur, AuD (43:41.546) Yep. And this may be something you don't agree with. And this may reflect some of my own discomfort with seeing people suffer rather than good clinical judgment. But I kind of feel like, all right, when someone's in that level of distress, let's leverage what we have to leverage as long as we're not taking too big of a risk. And we can... We can argue about how much of a risk it is to take an SSRI for a limited period of time. I don't know that I have good data about that. I don't know that I know enough about that particular use case. But I think that rationale makes sense to me. If when someone is in a state of so much dysregulation that they, nothing that I can do behaviorally or cognitively or emotionally with them can take root because they're just they're just not even here, then whatever I need to leverage just to pattern interrupt whatever's going on, let's do that. And then we'll figure things out afterwards because these are, these are, I cannot even begin to emphasize. These are not just like, I'm kind of feeling like lightheaded. These people, the, the level of suffering is incomprehensible what they're going through. they are so, in some cases, so completely hijacked by this abject terror and existential dread and doom that they are incapable of doing anything to help themselves initially. And so to me, it makes sense at that point to strategically apply whatever I need to apply to leverage whatever placebo effect I need to leverage just to get them out of that state. there's just like... the door is just a sliver open and then we can start doing anything else. Cause I don't think that these are long-term solutions. So again, I can't tell you that that reflects good clinical judgment or just the empathy that I have for my clients. And I will say that I have unfortunately seen people harmed by medications their doctors gave them, even when they took them for a short time. given what they're going through, at least at that stage, I can... Dr. Yonit Arthur, AuD (46:06.131) at least make a case for why we would do that. Roger K. McFillin, Psy.D, ABPP (46:08.785) Yeah. No, I completely understand your perspective. This is ultimately an ethical and a scientific question. We actually should be comparing pharmaceuticals, the ones that are chemicals made in a factory with other more natural interventions and naturopathic work, supplements, different things found in nature. The reason why that's rarely ever used as a control group is because the pharmaceutical companies know that they that may have a more robust response than their drug. And that's not, you know, there's no patent on it. um, we couldn't, we could be able to provide something that is natural and safe, that shifts physiology, at least temporarily. And then what you would also do is you would employ that placebo. kind of response. even the doctor says, I really believe this can help you in a really difficult moment. Use it sparingly, but this is going to help. That in itself is going to help a large number of people in exactly what you're saying is kind of breaking that loop, decreasing the suffering, and then we're going to help them, which is my next question. Let's start getting into what actually does work. You've seen the success stories, both in your own practice, but from people who've just come on your, your channel and they've talked about, you know, how they overcame this. What do, what do we know? How do we communicate it to the listeners? Dr. Yonit Arthur, AuD (47:48.384) Yeah, yeah. So thank you for touching on the perverse incentives, by the way, because I think as individuals, the medical providers are really generally trying to do best by their patients. And they're often just misinformed and don't have alternatives to give them. I believe that anyway. But on a systemic level, there are perverse incentives that do prevent us from offering these. patients potentially a wider range of options, some of which are non-pharmaceutical or more natural or potentially less harmful that right now we just don't even know about because they haven't been studied. So just want to agree with you there. So what does help people? So sort of going back to that framework I presented a while back in our conversation about I kind of give you three groups, you the people where it's just dominated by fear, people where it's dominated by habits, and people in which we're dealing with much deeper rooted trauma and beliefs. So I think it looks a little bit different for these three groups. But where it really starts with is with the education, as I mentioned before, really understanding everything I explained and I have just... immense amount of information on my YouTube channel. For someone who is suffering from this, just go watch some of my videos. It'll explain this ad nauseum in 50 million different ways. But people really have to, I guess what it really comes down to, Roger, is that people have to have some hope. They have to have some hope in order to have any kind of momentum to do anything else. So I think that the point of all the education and the hey, this is the mechanism and this is what you do and this is how you get better and these are the success stories. The point of all of that is undoing the nocebo, providing maybe a little bit of placebo, but also opening the door to some hope so people have some motivation to do something because then they have to do stuff. So I'm asking them to do stuff after that. the doing stuff starts with Dr. Yonit Arthur, AuD (50:01.395) reacting to symptoms differently, and we alluded to this earlier. There's a meditative practice we call somatic tracking, and that essentially means deliberately spending time with the sensation to not change it, to form a little bit more neutrality with it. You were talking about panic disorder. It's a lot like that. So people are fearing this state and applying all sorts of meaning and stories to it. And I asked them to get out of that and stop trying to avoid it and just let their system become acquainted with this state as unpleasant as it might feel from a sensation perspective so that the brain can learn, this state actually isn't the source of threat that I thought it was. So that's foundational, responding differently to symptoms. From there, that actually most people with the education and responding differently to symptoms and just learning to be just more indifferent or apathetic or more neutral towards sensations, that does it. That alone will often get people out of chronic symptoms. But I think many people, with these multisensory systems because symptoms, because they tend to be stickier, they tend to produce so many other physiologic effects, there is often some kind of, hey, there was a backdrop in which all this happened. There was context in which all this happened. And maybe that context is suggesting that the way I was living my life before was not working well for me. There was some distortion. There was some, There was some way in which I was relating to myself, my stressors, my environment, other people in my life that was not serving me. And that's why my system became so sensitized so easily. always ask, I always tell people what started the symptoms isn't what keeps them going. And it's worth knowing what did keep them going. Why did you get set up for chronic dizziness and other symptoms? Dr. Yonit Arthur, AuD (52:16.4) before the symptoms even started. Your system was receptive in some way to chronic symptoms. Why did your system respond with chronic symptoms? Whereas a lot of people, I have an example, whereas a lot of people, they end up with dizziness from what, for whatever reason, they don't end up with chronic symptoms. That's not just a, fatalistic genetic question. There is, there is a body mind answer to that question or a mind-body answer to that question. So one of the most common causes of dizziness or the most common cause of dizziness is BPPV or benign paroxysmal positional vertigo. Your viewers will know this as the ear crystals. So it's positional vertigo when you turn your head or you lie down, it creates spinning vertigo. It's a very unpleasant condition. It's caused by calcium crystals in the inner ear. It's very easily rectified with physical therapy, you usually go and do one exercise and you're done. You just get the crystals out of their position back to where they belong. Most people, I worked in conventional audiology practice for years before I started doing what I'm doing now. Most people hop off that table and they say, well, that was terrible. And they go on their merry way and that's it. So they have this terrifying experience of vertigo and their system says, well, that was bad. Roger K. McFillin, Psy.D, ABPP (53:33.183) Mm. Dr. Yonit Arthur, AuD (53:39.155) and it just kind of absorbs the shock. It deflects the stories and they move on with their lives. Other people have BPPV and it sets off chronic symptoms. what basically the whole premise of everything that I do is to answer the question, why did your system decide that BPPV needed to lead to chronic symptoms? And the answer is usually in what I was saying earlier that something about the way that you were living your life was creating more stress or was not aligned with the way that you should be living your life. And rectifying that is what needs to happen for people to fully recover. And I can get into more specifics if you want. Roger K. McFillin, Psy.D, ABPP (54:27.633) One of the questions I have are the, some of these emotional factors that maybe they haven't been dealing with in bad relationships, trauma history, they're in spaces in their life where they feel like there's no way out or they're afraid to make a big change. What have you noticed about the role of emotional factors and things that they have to face in their life and these symptoms? Dr. Yonit Arthur, AuD (54:33.246) Yes. Dr. Yonit Arthur, AuD (54:52.554) the huge role, huge role. I do want to say that because so many of my cohort have obsessive compulsive tendencies, I always exercise some caution when deciding, this means you have to change something in your life because they'll obsessively try to find the thing that needs to be changed in their lives, right, to rectify the whole problem. So I... I try to go a level deeper and say there's something about the fabric of self-relating that's the problem. And it all kind of, it all kind of derives from that. So there's, there's something in the way that you're treating your own internal experiences and there's some lack of alignment between authentic, authentic you and the way that you're presenting yourself to the world that's leading you to make decisions that don't meet your needs. and that require you to suppress who you are and your emotions. again, I exercise some caution with many of my people, but it sort of comes to that. So what I will often see is, this is the funniest thing. I have a saying that jerks don't get dizzy, okay? And obviously jerks get dizzy, they just don't stay dizzy. It's a thing. It's a thing, Roger. When I started working with people, I was like, my gosh, why are all these people so wonderful? They're just the kindest, most conscientious, most caring people. And they really are. They are just, they're just the best people I've met. I mean, they're just the most, the kindest souls. And I think that's part of the issue. I think that's part of what leads them to end up with these conditions. And I've seen, I've observed this across multiple conditions. They have certain commonalities. I'm not, again, if you're a jerk out there and you have chronic dizziness, you are welcome to join the cohort anyway. But chances are you are an overly responsible, conscientious person who may be very empathetic, may be highly sensitive and have a tendency to take on other people's crap and not necessarily prioritize what you need. So Dr. Yonit Arthur, AuD (57:19.322) it often comes down to patterns like that. It often comes down to not necessarily major life decisions that people need to make. Like I need to quit my job and move to another country or I need to end this relationship. Although certainly I've seen people in abusive relationships. I've seen people in jobs that they hated. I've seen people, you know, in all sorts of other life circumstances that just needed to be changed. But more often than not with my people, it's It's in the how, not the what. It's in the how they're living their lives every day with a sense of urgency and forced selflessness and lack of regard for the sacredness of their own experiences. And I say that recognizing, Roger, I think you and I share this view that culturally we're seeing a disturbing trend toward narcissism. and individuality being placed on some magical podium as the ultimate goal. that's not what I'm talking about. I'm not talking about, need to just be who you are and to heck with everyone else. I'm talking about extreme ownership of your stuff. I'm talking about extreme honesty with yourself about what you're actually feeling, what your needs are. realistically, the importance of connection with other people, and how you're avoiding some of your needs and feelings by navigating the life the way that you're navigating it right now. And that's not narcissism, that's actually humbleness. It's the opposite of narcissism. It's humble enough to realize that you are the source of a lot of your own suffering. So I think that about sums it up. Roger K. McFillin, Psy.D, ABPP (59:15.592) I think that's worth repeating. What's that last statement you just said about about your own suffering? Dr. Yonit Arthur, AuD (59:19.422) Yeah. Yeah. You're the source of a lot of your own suffering. Yeah. Yeah. Roger K. McFillin, Psy.D, ABPP (59:29.918) Yeah, that's both empowering and frightening. And I just wrote, I just wrote an article on my sub stack around the victim perpetrator narrative that exists in our culture and how that can get played out in therapy and how that can serve a person, at least in the short term, but keeps people stuck. And that narrative is pushed on us a lot more frequently and intently than I think people recognize. It's pushed in our Dr. Yonit Arthur, AuD (59:57.31) Yes. Roger K. McFillin, Psy.D, ABPP (59:59.5) culture through social media, through politics. There's a kind of a cultural war that pushes left versus right, identity politics, genders. I mean, it's just, it's rather consistent. And when you talk about becoming more narcissistic in our culture, more self-centered, this desire to be an influencer or to obtain fame and fortune and those things, which Obviously most people are not ever going to obtain and even if you do, it can become more of a curse than anything. But what we see is that people create this reality for themselves in which they are perpetually victimized by others. And that can include the medical system, a doctor, a spouse, a friend, a parent. And that mindset in itself can be so toxic and poisonous because it really does outsource your agency. Dr. Yonit Arthur, AuD (01:00:59.06) Exactly. Exactly. And that's why it's such a tough task to communicate to people this nuance. Because ultimately, darling, conscientious, loving, caring, selfless folks, on the surface, it looks like I'm telling them to focus on their own experiences more. Roger K. McFillin, Psy.D, ABPP (01:00:59.349) And yeah. Dr. Yonit Arthur, AuD (01:01:23.17) And a lot of them will go to therapy and they'll start doing that and inadvertently end up doing just what you just said, giving their agency away to everyone else. to me, this is another maybe controversial statement I'm about to make. Selflessness is extremely selfish. When you're using selflessness or that's an example, as a way to meet your needs in a roundabout way and thus create internal resentment toward other people, you're hurting other people and yourself at the same time. this is what I'm talking about when I say extreme honesty or extreme ownership of this stuff. You have to respond with with acceptance, unconditional acceptance and self-compassion. when you see your own patterns in order to be able to see them clearly and realize how they're contributing to your own suffering. And that's what I'm trying to teach people not to be narcissistic, but to actually expand their lens. they're, they're not a system that's constantly trying to, to manage things that they're trying to avoid, not a system that's constantly self-absorbed, but a system that can engage fully with the world around them and appreciate how authentic connection with the world around them is the key to living well. Roger K. McFillin, Psy.D, ABPP (01:03:00.565) Well said. A lot of nuggets in here today. Dr. Yonit Arthur, AuD (01:03:04.698) Yeah, I hope so. Roger K. McFillin, Psy.D, ABPP (01:03:07.105) It's interesting they don't just apply to these conditions you treat. They are of universally applicable in healthcare and mental health care and to a life worth living, in my opinion. So I really do have a lot of gratitude for being able to meet you and being exposed to your work and so thankful for you coming on the podcast. How can people Dr. Yonit Arthur, AuD (01:03:11.402) No. Roger K. McFillin, Psy.D, ABPP (01:03:34.901) Find out more about you. Where can we direct them? Dr. Yonit Arthur, AuD (01:03:38.815) Best place is my YouTube channel, The Steady Coach. If they just search for it, they'll find it or it's youtube.com slash at The Steady Coach or my website, thesteadycoach.com. That's where they can find the free course if they are dealing with dizziness. And actually my dear colleague and I are about to put one out for tinnitus and hyperacusis as well. Newsflash based on everything that we talked about today, the principles are exactly the same. They just use language that relates specifically to those kinds of conditions. And just as you said, the principles are totally universal, but I do think it's important to meet people where they're at first, and I need to meet them in the physical condition that they have first. Roger K. McFillin, Psy.D, ABPP (01:04:25.899) Well said. Dr. Yonit Arthur, I want to thank you for a radically genuine conversation. Dr. Yonit Arthur, AuD (01:04:31.284) Thank you.