Latest / Lucid Interval Podcast / Neuropsychiatry, Brain Health, and The Art of Therapy - Dr. Craig Clark, MD (4K) Part I

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Neuropsychiatry, Brain Health, and The Art of Therapy - Dr. Craig Clark, MD (4K) Part I · Lucid Interval Podcast

• Speaker 1: Yeah, amphetamine was originally marketed actually Adderall was originally marketed in the seventies, I think, as Obitrol. And it got pulled not because of safety, but because of efficacy, because most people acclimate. Speaker 2: Okay. It was as a weight loss drug. As a weight loss, right, right, right, right. So now it's a side effect. Now it's a side effect. Even though you won't lose weight. Speaker 1: But you know, one of the things that's I mean, tr a tragedy and we're setting ourselves up for all manner of problems as a nation is the obesity epidemic in kids. Like I I see so many kids in my practice who are who are obese, obese. I'm not talking about, you know, growing up we all had Well Yeah. I was I was a chunky kid in middle school, you know, and and then I sort of grew as my grandmother used to tell me, you'll grow under your weight, don't worry, you know, that kind of Speaker 2: Well maybe fat or whatever you Speaker 1: me. But I mean I see people who are morbidly obese as kids. ⁓ yeah. But Patty actually Amy and I were gonna do a podcast and Amy sort of like I just for a variety of reasons, including two teenage sons, she's like, I don't really want to do this. And so ⁓ we talked about Patty and I doing it. I think so I think like having the three of us, I I love Patty and Patty as you saw, Patty is Speaker 2: It's wonderful. She's wonderful you to do. Yeah. I've talked to her. We good? Yeah. Okay. So we're ⁓ good. ⁓ so I figured this in the beginning we'll talk kind of about your career, what you know, your back intellectual background, things like that, and what neuropsychiatry is. Yeah. I definitely want to get to TMS. Sure. Because like I feel like you there's ⁓ you're a wealth of knowledge on that, try neurofeedback, some other things, and then ⁓ I think we'll take a break about two hours, Taylor. Sounds good. ⁓ Ish. If you need to take a bathroom break, this can be edited. Sure. And ⁓ and then in the second half we can talk, I guess, a little bit more personal things. Sure. Sound good? Yeah, so cool. You ready? Do we need to do that? Are we doing our own thing? Okay, great. I just did it. All right. Doctor Clark, thank you so much for joining me. Speaker 1: I'm ⁓ truly ⁓ excited to be here and flattered to be to be asked to join you. Speaker 2: Thank you very much. ⁓ so when you're at a cocktail party or at a networking event and someone turns to you and says, So Craig, what do you do? What's your answer for that? Speaker 1: Well, okay, so when I was younger, you know, I started my career ⁓ really as a as a child psychiatrist. ⁓ I'd come to Vanderbilt and the combined program in neurology and psychiatry, but I quickly learned most of the people going down that path were going to be academics and I didn't really want to be an academic, I wanted to be a clinician. And so early in my career, probably eighty percent of my patients were under the age of twenty five, let's say. And so people would ask me that question, I would say I'm a professional checkers player. ⁓ because I I played checkers all day with little kids. Okay. And ⁓ Old made and you know, things like that. And they sort of look at me like ⁓ and then as time went by and you know, those kids that I started with all those years ago, some of whom I now treat their children. Okay. Wow. Some of the adults I treat their grandchildren. All right. You can guess my age based on that. But you know, I now say when asked that question, I say I'm a professional difficult conversation haver. ⁓ I love that. I like that. Yeah, yeah. Speaker 2: So is this that conversation? Is this an intervention? Is that what we're here for? ⁓ so well but but before let's back up a little bit. I mean, ⁓ how did you how did you decide on a career in medicine and and how did you decide on psychiatry? Speaker 1: Yeah, well, I I grew up in a small town in West Virginia, and my best friend's father was a a true ⁓ famil ⁓ family physician. Like he was an old old-time family doctor. I mean, he's a very interesting guy. He was a ⁓ a very strong patriot as a kid. He volunteered immediately out of his internship to go to Vietnam as a medic. He was a medical doctor, but he worked as a medic. There are tapes of him corresponding back home with his family where you hear mortar shells in the background and all these things. He won the ⁓ Bronze Star. ⁓ for his service in Vietnam and he was ⁓ very much like a role model to me. I thought that's the path I wanted to go down. I thought I wanted to be a family doctor. And I read the writing on the wall at that point that the changes in medicine that were coming, I wouldn't be doing what he had done, which was soap one fingers and birth babies and do you know cradle to grave medicine, that it would be more like I'd be a gatekeeper at a portal. I didn't really want that. And I always had an interest in the intersection of science and the arts. And so my undergraduate major was chemistry, biochemistry. I think you heard my story about why I don't have a double major, which if we have time, we can delve into that. But the other was psychology. And so I'm one of those rare people that actually uses what I studied in college. Yeah. ⁓ and that that sort of set the stage for me to ⁓ become a doctor. I so admired ⁓ Dr. Kleinstever is his name, and I so admired him and looked up to him and sort of set me down that path. And then the the fork in the road came with ⁓ first Neuropsychiatry and then and then ultimately child psychiatry, which are one and the same ⁓ yeah for me. Speaker 2: For you. Yeah. Wow practice. ⁓ so in a in the traditional path, I guess, in medicine, you'll go to medical school and you'll just study the same thing every doctor does, right? So you get four years of and then you'll have a residency and yours ended up being with your psychiatry. Yeah. Speaker 1: That's right. Four years of that, yes. Yeah, so mine was I had a ⁓ internship at Vanderbilt and mine was a little bit different than most psych ⁓ internships because I didn't do anything other than medicine and neurology because it was I had set down that path. But once I figured out that that ⁓ the dual path wasn't what I really wanted to do, ⁓ then I had three years of psych, ⁓ adult psych. ⁓ a running joke with me is that, you know, to be boarded in child you have to be boarded in adult first and always say it should go the other way because then you would understand Speaker 2: Developmentally right. Yeah, that would make a lot more sense. Speaker 1: Right. Create the context, right? ⁓ so so ⁓ did the ch the adult and then I really fell in love with child. When I did my child rotation, honestly I went into that thinking, you know, I'm I'm gonna kinda grin and bear this. I don't really wanna do it. But and then once I was in it, I just have always been interested in people and human development and and here it was sort of unfolding in front of me. And that that was the first time that that thought occurred to me that if I'm gonna be an adult psychiatrist, I will be so much better at it if I understand that this didn't just materialize out of thin air, right, that it came from somewhere. Speaker 2: Yeah, you have context, like the whole picture. That's right. there's I I think there's so much I could say about that. I mean, where the thing you mentioned first is that you see you were seeing that medicine was changing. Yes. And ⁓ it's interesting that you would describe family medicine, internal medicine as gatekeeping. Yeah. Which it does seem like you can't see a specialist unless that's right. You get a referral and it's almost like what those people are are there for. That's right. ⁓ which seems to be like a waste of resources, ⁓ honestly. Well Speaker 1: And and it's a waste of a s of a opportunity where someone and I I I pride myself on this in our own practice and what we do. It's like, you know, medicine is about first and foremost relationships with people and developing that relationship over time. And again, your understanding of someone matures and and and equally importantly in my humble opinion, their understanding of you matures. Okay. Trust. Because it is an interaction. Right. It's not speak to the Oracle and they tell you what to do. Right. Right. Okay. So it's just it Speaker 2: Like was that Johnny Carson would get the thing and it'd be like, ⁓ it's it's borderline personality. What would you know? Yeah. Speaker 1: Exactly. Exactly. Like you have to arrive at these things together. ⁓ we can we can talk more about that later too because it's a it's a funny question about the best treatment plans. You know, it stems from that. But that it's an interaction and that that trust is the foundation of that and that's built over time. And so one of the things I hear from patients every day of my life, and ⁓ you know, I've lived it a little bit of my own life on occasions when I've needed access to the healthcare system, or recently when my wife needed access to the healthcare system, that you get these discreet. discrete sort of packets of interaction and and it's like literally ten to twenty minutes and then you're just kind of on your merry way and it's like, well wait, what? And I mean I am a doctor. And I would walk out going what just happened there. Yeah. Right. Yeah. So there's no continuity. And I think that's what the the old school approach, the primary care doctor who knew you, followed you, treated you. And yes, if there was something really outside of their expertise, they would be they would have a fiduciary responsible responsibility and they would be, you know, negligent if they didn't send you for consultation, but it was consultation. It wasn't farming you out to three dozen different doctors. Speaker 2: Right. That's right. Necessarily. I mean, and because we have HIPAA is one of these weird things in this country. We have HIPAA. We have these great protections, but they balkanize information for the people that actually need it. You know, and and ⁓ there I mean I'm will be the first to say that like being discriminated for a medical diagnosis is a real problem. ⁓ sure. But ⁓ you know, we do now because of the opioid crisis, at least you know what other people what what their prescriptions are, you know, what prescriptions are being filled. Right. and so there's at least that from a safety perspective, but you you don't know the rationale behind that. I mean you in and so ⁓ I I can see what you mean about I've had this issue with myself. Navigating the healthcare system is so complicated because I really just wish I could have one person to manage all of my things. And i I ⁓ do you think the pediatrics still works that way? That was my experience growing up in the eighties and nineties, that I had one pediatrician, he had a partner who knew, you know, who I was, but like, you know, that that man was in my high school graduation and and like Yes. Yeah, does it still work that way, do you think? Speaker 1: I think it largely does. ⁓ you know, that it's interesting you bring that up, the same pediatrician, and I'll I'll give him proper kudos here and and ⁓ a man by the I start to say a young man, he's my age no longer qualifies as young. Sorry, Paul, but a guy by the name of Paul Hyle, who I knew from training, you know, you know, contemporary colleagues. ⁓ I have a son who's 33 and then two younger sons who are who are just turned 16 and soon to be fifteen. Dr. Hyle has followed them the in the entirety of their lives. In the case obviously my older. Speaker 2: Okay. Speaker 1: son, you aged out of the pediatric practice. ⁓ but we recently just got his retirement announcement. And I tell you, I mean, that was like, ouch, you know, like, and I'm sure the person who's taken over will be great and we'll get to know him and all that good stuff. Paul wouldn't hand off to someone that wasn't great. But it it's a it's a vestige of the old system. It really is. Yeah, I think that that's probably the one place and maybe arguably OBGYNs who pick up ladies when they begin to menstruate and you know need this kind of that kind of care may follow them through, you know, pre-peri and postmenopausal years and freedom. Speaker 2: They're both very personal decisions. Generally gonna be made by mothers, I think, for their children's care. And like that's a really personal decision. And hell hath no fury. Like you know, like you know, I mean I I just feel like our our the mothers in our society wouldn't accept anything less. They wouldn't accept being treated like a number. Speaker 1: No, absolutely. And and and and one of the truths, I mean, as as a child psychiatrist, I can tell you this is if with absolute certainty, the instinct to protect the young is more powerful in human beings than the instinct for self-preservation. And that's true in both fathers and mothers, but mothers in particular. Like don't mess with that kid. You know. You know, that's that's that's the big mistake. Speaker 2: So ⁓ there's a few things I've always wanted to ask a physician. ⁓ mainly about what is medical school like? ⁓ what do people learn there? ⁓ what's the style of learning? You were you were a faculty member at Vanderbilt, were you not? Speaker 1: Yes, I was on the clinical faculty for years. I actually ⁓ supervised people who were in their fifth year of fellowship and that meant that they were somewhere between zero and twelve months from hanging up the independent shingle. So I c I was catching them at the absolute tail end of the process. ⁓ but in the case of child psychiatry, that comes five years after med school. Speaker 2: Okay. So there's a long that's it yeah. I th I think there's a lot of just confusion around there's a series of tests that you take. You're out of medical school, you're still taking tests. Right. Can you just kinda walk us through the developmental yeah trajectory of a doctor? Yeah. Speaker 1: Sure, sure. Well, so ⁓ so med school itself is typically four years, and there's there are three different tests that you take. Well, two while you're in med school and one immediately after being in med school. ⁓ and the curriculum, the first two years of curriculum historically was in the classroom. I like to say I still have splinters in my behind from sitting, you know, eight hours a day in the in the classroom for two solid years. And it's very much a didactic thing, at least in those days it was. ⁓ and so, you know, it's it's biochemistry, it's histology, it's gross anatomy, you know, you dissect the cadaver under the watchful eye of your supervisor or whatever. ⁓ yeah, you study physiology, there's there's psych. Psych is introduced in your in your first year. Okay. And so for two years that's kind of the curriculum. And then you're released into the clinical realm. as a third year med student, and you start to actually see patients and the premises, you've sort of developed this basic understanding of pathology in various forms, what underlies pathology in the human body. Yeah. ⁓ anything that would be abnormal, you know, outside of the typical thing. So if someone has difficulty with digestion and they have a form of gastrointestinal pathology, or so goes the theory. Speaker 2: What do you mean by pathology? Disease essentially. Speaker 1: Right, disease, right. Yeah. And so you're gonna encounter real living human beings that have those conditions or diseases and you're gonna you're gonna start to interact with them like you and I are interacting right now, and we'll try to, you know, engage you, learn something from you, put that through the filter of my experience and and and fundamental at that point, just basic fundamental learning or knowledge. Eventually it'll be through the filter of your experience and say, Okay, so you have discomfort after you eat, you know, it's sort of a burning sensation. You feel it kind of come up into your chest. You went to the ER once 'cause you thought you were having a heart attack, but you're a super healthy 30 something. Sounds like gastroesophageal reflux disease. And your attending will either say, Brilliant, or what are you thinking? Right. And you'll and you'll sort of get shaped down or well, what else could it be? Maybe it's GERDS, but it could be something else. And, you know, are you going to send him out with getting an EKG because he did go to the ER and he did say he had chest pain. How do you make that decision? That kind of stuff. That's in the third and fourth years. Right. ⁓ now Since I left med school when dinosaurs roamed the earth, they've started doing more and more clinical things earlier on, which I think is a good move. I I think that the sooner you would get people actually learning the skills of interaction, the better. And I think that the again, from patients that I work with, you know, it's it's been a challenge for me to curate the right doctors to refer people to as neurologists or gastroenterologists or whatever, because so often The hard science part of it does not nicely meld with the psychosocial science part of medicine, right? Medicine is really an art. Yeah. And and so a lot of people who would excel academically in ways that would gain them admission to med school, they're not temperamentally suited to be clinical doctors. You can see how that Speaker 2: Okay. Yeah. Yeah. Well, I think there's you said something that I'm still noodling over at the beginning of this conversation, which is that you've always been interested in the intersection of science and art. And then as a as an explication of that, you told me you studied biochemistry and psychology. Right. Which is a fascinating parallel that you would draw between psychology and art. Yeah. And I'm I made a post I've started I'm starting learning social media. I'm trying. I'm on social media. ⁓ threads, this thing, 'cause I have some just quotes and things that I say and ⁓ Threads apparently seems to be the thing that I do if I don't want to do Twitter. And I ⁓ and I wrote about it. It came to me a while ago that ⁓ if art is a form of therapy, then therapy is also very much an art form. And ⁓ there is the the it's almost like an alchemy. It it's it one of the problems is ⁓ with I know that recently ⁓ MDMA has gone through its third round of trials and they were they were denied approval. And I think that From my best understanding of this, I'd actually love to talk to people who are closer to it, or maybe get your opinion, but ⁓ the FDA doesn't know how therapy works. Mm-hmm. That that I think is the real problem. You can't s you can't reduce it ⁓ to a single variable. And so a lot of the feedback they're giving was, well, this depends on individuals the therapeutic alliance between these people and we can't mass produce that. And so therefore this drug doesn't work. And and Sure. Right. And well Speaker 1: It's it's it's an interesting, there's a corollary here with the placebo effect too. Right. And you know, one of the challenges I I tell parents who are anxious about their child taking a psychotropic medicine, I'll t I'll tell them I'll say, well, you if this medicine's separated from placebo in a trial with with kids, then you can know with great certainty that it it probably is an effective medicine because the placebo effect is so powerful in younger people. And what's the placebo effect? Like that that's another fun topic. Speaker 2: Let's tell let's talk about that. I I I have a feeling that most people in the audience will at least think they know what the placebo effect is. Speaker 1: Well, it it's there are a lot of ideas about what it is. Yeah. But you know, one idea that just appeals to me and I think it it just on a intuitive basis, just as a human being myself and thinking about all the things that I've seen in front of me, is how important historically in our our development as a species, being part of the group was and staying with the group and receiving the protection and comfort of the group. And so if without that we would literally not survive. Right? Yeah. We're we're social animals. We need that psychologically, emotionally, but we also needed it historically for very practical reasons, right? Mm-hmm. So if one was left behind and ignored when injured, this was bad. This was very bad news. Okay. I I I think most things in life that you need to know are summarized in Forrest Gump. So authors Speaker 2: Excellent. Yes. Go ahead. Speaker 1: So you may remember when Jenny tells him, you know, Jenny says, Forrest, if you're ever in the battle, don't don't play hero, just run. Yeah. Just keep running. And so Forrest gets in his first firefight and he just takes off running and running. He says, Well, I ran and ran until I was alone. And that was a bad thing. Okay. And so then of course he goes back and does the hero heroic acts of saving his his fallen brothers or whatever. But the idea that when someone approaches you and says, I'm gonna do something that's gonna be helpful to you, I see you're hurting, I see your suffering, I see there's some malady that's come over you and that person approaches you and says, Let me let me take you underwing, let me let me give you this vitamin, let me introduce you to this therapy, let me teach you that exercise helps, whatever they do, it doesn't matter, then you have received something innerpersonally. And again, we can get into the the super deep rabbit hole conversations of the energy transfer. I know you had the neuroshaman on. We're gonna have the neurosham. Speaker 2: Yes. Shout out to Laura Martinez. Yeah. Yeah. No, the energy transfer. Yeah. Speaker 1: Love that episode. And so, you know there's a way in which you could formulate or think about human beings as biological energy processing units, right? So we process energy and you and I right now are having an exchange of energy. Right. And we can't see that. That isn't observable. It certainly isn't measurable with currently available tools. Right. But anyone knows that it's true. Anyone that's ever had a great friend or a trusted doctor or a spouse that they really love and value their, you know, their time knows it's true. Right. Yeah. Speaker 2: Yeah, I think actually there they're we are breaking a a science of observation with that. It's functional near infrared spectroscopy. Have you heard this? Yeah. Tell me more because Speaker 1: I I don't know much about it. Tell me Speaker 2: Imagine if we both had EEGs on and we were talking to each other and there was a way to measure the coherence between the waves. At some point I'm wait I'm supposed to ask you what EEG is. That is possible. But yes, right. Well so imagine that but with spectroscopy where you can actually you know essentially read c carbohydrate metabolism in the brain. And ⁓ we're learning a lot more about what mirror neurons do. Because I mean there's a physical mirroring that that does that they involve. I mean you can kind of monkey see monkey do, and that's what those mirrons are for. But ⁓ I I don't I mean it's so new and the trials are very, very small. Right now that I think we're at a proof of concept for the technology to show that that there's a there there. and I think a lot of the research is being done in Columbia, if I recall correctly. I need to go back and see the World Science Foundation had a really cool talk on it. But there's a saying that this neuroscientist used, this term and I love. She calls it the social synapse, which is the space between us right now. Absolutely. It's you synapse is the space between, but there's information flowing. Literally. I mean use words and sound and these vibrations and we create meaning. Yes. But so it doesn't have to be a neurotransmitter, but there's neurotransmitters working here and over there. And ⁓ there is something being exchanged across distance which is ⁓ spooky almost. Yeah. Speaker 1: Absolutely completely by that idea. Yeah. ⁓ I think I've seen it. I mean. Yeah. Well, one of the one of the to me, like one of the least scientific things that can happen is when there's something that's observed that isn't consistent with or explainable by known means and people go, right. Neuroshaman. Right. You know, it's like, and th there's this dismissive quality to it. And that's the antithesis of science. Science goes, hmm. So you can another way of saying it is science happens at the edge of our understanding. Right? Like, I don't I don't understand this. I observe it, other people observe it, other people have experienced it, but we don't have a ready explanation for it. So does that mean it doesn't exist or does that mean that we just don't have a means to measure or quantify? And science loves to measure and quantify, which again, I'm not saying that's bad. I'm just saying like if there's anything history has taught us, right, is that there are things we don't know about and that we'll eventually know and then it'll seem like common sense, common knowledge, but at the time, so you know, in in in Speaker 2: If you look at the history of any field of science, it's mainly characterized by a bunch of scientists being later proven wrong. Right. I mean, essentially that's what's what it is. Like that's kind of and there I I talked with ⁓ I don't know if you heard my episode with Jonathan Rosenthal, who's a neurologist at ⁓ yes neuroscience of yoga conference. Yes. We talked a little about just what is science and and this this component of falsifiability. And then he said he had a professor that would say, like, your job as a scientist is to build a model to explain the world. And then try to break it, try to destroy it. Exactly. You're trying to prove yourself wrong. ⁓ how does that apply to how how does that relate to a clinical practice of medicine? I mean, are you trying to prove yourself wrong as a clinician or are you hoping that the information you're using was by people who try to prove themselves wrong? Speaker 1: I think it's probably both, you know, if if you sort of formulate it that way. I I think that you have to be ⁓ I think good clinical practice calls for extreme levels of humility. Okay. And, you know, d as you know, I love quoting my grandmother. One of my grandmother's favorites was the smartest people know what they don't know. And be the there's another quote from my grandmother, be be the eternal sophomore. So sophomore, the knowledgeable fool in Greek, right? So you can know things and you you know, not n not being immodest. I mean, I think I know quite a bit about human development and psychiatry, psychology, neuromodulation, whatever. I've learned a lot. But at the same time it under under no circumstances would I labor under the misconception that I know everything I'm gonna need to know. And I also think a huge part of it in in clinical medicine is gaining the trust, building the relationship where people will then share with you the critical information that you need. And there's this very and I talk about false assumptions. I mean, I one of the huge false assumptions in clinical medicine, and especially in psychiatry, and I used to see this all the time when I'd supervise fellows, is that they'll meet with someone and have a again, the the modern model is very brief intervention. Have a brief conversation with that person, and they just assume that now they've, you know, they've sort of filled out the form that the insurance wants to see. And so I've got all the information I would ever need to know in order to effectively treat this person. It's like, well, chances are good. I don't care how skilled you are, I don't care how interpersonally adept and warm you are. Chances are good that you're not going to know the whole story for a long time. The whole story is complicated, it's nuanced, and guess what? Bad news, it changes in real time. Right. So you have to constantly be collecting and I think in that sense also forming and testing hypotheses, but be being willing and even welcoming of when the hypothesis doesn't hold. Okay, here's again, this is almost better than what it does, right? Yeah. It's it's a new opening. Speaker 2: Exactly. Well, I mean, there's this saying in like it in among scientists I've heard that like it's a sick burn to tell someone they're not even wrong. You know, 'cause it's like if this is an unfalsifiable thing, like it would be better if you were wrong because you might learn something. You know, like I think to be not even wrong is just to be stuck in like an epistemic cul de sac and you just never get out. Right. Yeah. It's a blind loop. Yeah, and and ⁓ yeah, it's it frustrates me because that's I I think a lot of cases that's how psychiatric diagnoses work. Speaker 1: No, that's exactly right. Speaker 2: 'Cause it's just i if they if there even is a you know a a physiological component to them, ⁓ we don't know what that would be in a lot of cases and we don't have any diagnostics for that. And so that can be very frustrating, especially because of the way medicine's balkanized now. Yeah. I you know, you're you're speaking about I think your philosophy of of being a physician, being a clinician. ⁓ and it I think it relates to one of the things about you that is quite unusual, which is that part of your practices involves what we would call therapy now. You know, sitting or I would call talking to your patients for you know a protracted period of time getting to know them over time, right? Which is, you know, it's it's strange to say that a psychiatrist that does therapy is is a really remarkable thing. It's but it is. It's almost like I think we are r nearing a place now in the culture where that doesn't even seem remarkable probably to s a younger generation because we don't really have the cultural representations of these Freudians or whatever of the, you know, the doctor with their couch. Speaker 1: It's an anachronism. Speaker 2: Yeah, yeah. ⁓ so what was your what was your training like, you know, as becoming a psychiatrist? Was that part of the training then? and and what was that like for you? Speaker 1: It it was, you know, which which again it's really interesting 'cause I I I think one of the things as you get older is you lose things. Like you know, you lose your hair or you you lose muscle mass. Or you you you've for friends, you know, I've had friends who pass away, you know, those sorts of things. You lose a lot of things. ⁓ and one of the things that Amy and I talk about, my wife Amy and I talk about is the loss of this like sort of idea or model that we were given and that we hold dear of how this how this should be approached. And the idea that like for example that a medicine or even that psychiatric nosology is precise enough to inform on an individual basis all the details of a plan that you would need. Yeah, naming. Like how do you rise faggots? And again, it's not there's a place for it. Speaker 2: Can you clarify what nosology means? Yeah. Speaker 1: ⁓ it can definitely be helpful, ⁓ in the broadest sense. But one of the most important things is understanding the limitations. Like any tool that you use, it doesn't matter what that tool is. You have to understand its limitations to implement it to the best possible use. And I think like there is this over investment in giving it a name. ⁓ historically I've said to patients, ⁓ You know, we can call it what do you want to call it? We can call it Charlie Brown. We can call it I don't care. Call it whatever you want to call it. Here here are the things that are obstacles to you growing and healing and being your the best version of you. What are the tools that we have available to kind of try to intervene on your behalf in in that way? And then how are we going to implement those tools? And a huge part of that is which tools are you comfortable using? Right. In other words, it's again it's not speak to the Oracle and walk away with, you know, whatever some prescriptions and a follow-up in six months. It's like It's a dynamic interchange between human beings and people have different feelings about that. Yeah. ⁓ but to your original question about about how I was transferred. So I've I I call it I referenced Forrest Scump earlier, I call it my Forrest Gump life. ⁓ when I came to you know, 'cause I I did I I've had a cool life and I showed up at Vanderbilt at a very unique time. The outgoing chairman had been the ⁓ had been the ⁓ Speaker 2: Yeah. That's cool. He had a cool life, yeah. Speaker 1: President of the American Psychoanalytic Association. Okay. And ⁓ Dr. Hollander, I had him briefly as a supervisor, Mark Hollander. And ⁓ at that time the incoming chairman, Mike Ebert, was literally like interested in fractioning monkey brains. Okay. Okay. So you could not have Speaker 2: That's an interesting changing of the guard. Speaker 1: Very interesting changing of the guard. And Vanderbilt was a psychiatric, ⁓ pardon me, a psychoanalytic institute, I believe, in those days. So you could go there and train to be an analyst, you could receive your analysis there. And so, you know, the traditional Freudian psychotherapy was, you know, it was a stronghold, right? Yeah. And so I had Dr. Ebert was my advisor. Dr. Hollander was one of my supervisors as a young psychiatrist. I love telling the story about Dr. Hollander. I went to Dr. Hollander's for my first meeting of supervision, and he had a photo hanging on the wall and he was standing in a bar with his arm around Kurt Vonnegut. Okay. Okay. And ⁓ and I and I recognized Kurt Vonnegut of course in the picture and I was like, ⁓ that that's him. And so he came in and he greeted me or whatever. And I said, ⁓ Dr. Hollander, who's that in the in the in the photograph there? I knew who it was. And he looks at me and he kind of steps back and he goes, Well it's me. Which is Speaker 2: Excellent. Speaker 1: Excellent response. Yeah, never mind the Vonnegut guy who cares about him. ⁓ but so when I went through ⁓ training, there was a very significant emphasis on ⁓ psychotherapy. A lot of that was analytically tinged, but we were taught that, you know, the best care, which I still believe, the best care really integrated because they're different things and they they complement one another. They're not Speaker 2: What are you talking about? Speaker 1: They're not in competition with one another. They complement one another. And so I was taught that, you know, psychotherapy should be a part of every patient's treatment plan. And that we were the people who had the best training to do the psychotherapy, the psychiatrist. Now, nothing against psychologists. I don't have to say I like it so much I married one, right? Right. But and I and I deeply believe that psychologists can be tremendously helpful. We have them on our team in our practice now, you know. But but we were taught that like, look, you have the highest level of training. You're gonna have that. that broadest understanding because you have the medical, biological, developmental, as well as psychological, emotional, social understanding. Right. And so your job is to kind of lead that team. And maybe you don't see every individual patient for psychotherapy, but you understand what psychotherapy is, what its role is, how it complements other medical treatments. That's just part of what you do. ⁓ and at the same time, David Baer was my mentor who was a neuropsychiatrist. David Baer, very interesting guy. he one of the things he did that was kind of cool was when Hinckley attempted to assassinate Reagan, he did the neuropsychiatric evaluation on Hinckley. He's kind of well known for that. But he was definitely the brain is the organ of the mind. He he was very interested in the intersection of epilepsy and clinical psychiatry. And so Dr. Baer was very much a neuropsychiatrist, and that's how I came to be under his supervision. And he he mentored me in the early part of my career. So this very interesting, like You know, again, the monkey brain, the neurologist, the and and then the ⁓ you know the Speaker 2: The the analysts. Yeah, yeah. I mean it seems like it's kind of almost like you know, the collision of like counterculture with Reaganomics and happening at that. You know, basically when those two things came together, there was a little bit of both involved. You know, went from like very woo woo to very materialistic. ⁓ yeah. ⁓ so it in your training did you have to submit to psychotherapy? I hate to use the word submit, but like were you were you analyzed and like did you do analysis? Speaker 1: did not do analysis. You weren't required to do that. I had colleagues in in the training program who did ⁓ participate in an analysis. ⁓ and that was available to you. I think it it wasn't free, but it was some sort of discounted rate or something if you wanted to go down that path you could. ⁓ but I I one of the most positive experiences in my life was ⁓ we were were required to attend this ⁓ it w it was weekly ninety minute group and it was populated exclusively by psychiatrists in training and psychologists in training. It was led by a psychiatrist and his psychologist wife. Okay. ⁓ about this experience I like to say nowhere to run, nowhere to hide. Speaker 2: Yeah, yeah. Speaker 1: Okay. And I learned, you know, I my first few visits there, I was like, Why am I here? I'm the happiest guy I know. This is ridiculous. I don't need to do this. And then I'll never forget I could tell you the room, tell you who was sitting there, the coffee cup I had, what I was wearing. It's burned into my memories. I had this autonomic discharge and I wasn't even talking. Someone else was talking about their development. And ⁓ and all of a sudden I was like, ⁓ my God, I have issues. You know right? Let's see, I was that would Speaker 2: How old were you when this when you had this realization? Mid twenties like Speaker 1: Twenty yeah, twenty seven? Yeah. Something like that. Speaker 2: That's the time. That's I think that's a time developmentally where people just at that time start to realize, ⁓ wait a minute. I don't have it all figured out and maybe some things in the past were like not normal and maybe need some further further investigation. Speaker 1: Wait a minute. She's exactly right here, Drew. Speaker 2: It really is. Yeah. There's I mean, there's ⁓ they're saying ⁓ someone told the other day that they were they were glad they escaped the twenty-seven club 'cause there's a number of artists who have died at the age of twenty seven. ⁓ Jimi Hendrix, I think, was twenty-seven, Janice Joplin, Chris Farley. I mean, there's a bunch of people that were that right at that age. Drug overdose. There was they had succeeded enough to be wealthy enough to be able to afford a real real drug habit, and that's that's generally how they died. Amy Winehouse. My generation. Speaker 1: ⁓ Amy Wine. Right. They told me to get a rehab. I said, no, no, no. Right. Yeah. No. So so I think it's very interesting too about the twenty seven club because in typical, you know, assuming everything is going swimmingly right on plan, especially for we men, our brains aren't gonna be done growing until mid twenties. And I think that that growth, particularly the frontal cortical networks, ⁓ allows a kind of self awareness. that opens the door for those kind of, you know, positive revelations, self understanding, but also probably causes you to go, ⁓ this I this is real. Yeah. Time to adult. You know, all those kind of Speaker 2: Yeah, there's and that the so and this is relatively recent knowledge that we have that the the male brain is I think we're still we're continuing to push that age back of maturity, right? ⁓ how do we know about that? Speaker 1: Yeah, we had it through neuroimaging studies that have been done. It suggests that the the full maturation of the nervous system and the last thing in human beings to be done growing typically is the right prefrontal cortical area. It's the seat of inhibition. It's where a lot of action in ADD, you know, the ADD world, a lot of people talk about there's, you know, underactivity. We see that. I mean that's demonstrable in various types of imaging. We see it on quantitative EGs. We do it in our practice. You know, it's just sort of an underactive right prefrontal. Speaker 2: So you're looking at and just I guess at a population level you can look at men and versus women at a certain age. So it's activity is it also seen in like cortical like volume or is it really just activity? Speaker 1: You know, I think it's both. I think it's ⁓ you know, that I'm not absolutely a hundred percent sure of, but I think it's both. Yeah. And I can tell you for as a clinician that it's like people pass that age and things can really start to get better. I was sitting this morning with the parents of a sixteen year old and part of it, you know, at my age and stage of this game is like, you know The dad is saying, ⁓ yeah, he's disrespectful and he's challenging me on everything. And I was like, welcome to the club, buddy. I have I have three sons, you know, welcome to the club. But ⁓ we were talking about like, you know, these years for people with neurodivergence, neurodevelopmental differences or atypicalities are so important because if you can just kind of shepherd them to that twenty-six, twenty-seven, twenty-eight. In the world of ADD, we think a lot of people's again, their brain is just more slow to mature. That's why it's been referred to as the classic neurodevelopmental disorder. ⁓ and then their maturation may come along late twenties, even early thirties. And I see that in my clinical work. Like all of a sudden they're different. Speaker 2: Okay. Speaker 1: I say all of sudden. It happened gradually, but it feels Speaker 2: Are you seeing it in terms of like conscientiousness or like outward signs of absolutely being able to adult? Reverse planning is also really hard for me. Like, you know, it's like I need to be there by noon. What do I have to do? Yeah. What do I need to eat? Yeah. Yeah. I mean, I'm I'm thirty nine and I'm still working on it. But like, yeah, no, I get I get but there was a noticeable shift for me too. Yeah. You know, around thirty where it's like, ⁓ wait, I can I can somewhat manage an adult life now. Yeah. Speaker 1: Think ahead. ⁓ Speaker 2: So I we were asking about your training. Yes. You also I I think you told me once that you ⁓ you perform a role involving current child psychiatry. I think the boards. Speaker 1: Many years ago, ⁓ this has been many years ago, I I went one time and and helped ⁓ administer the board. Speaker 2: Yeah. ⁓ but you're you're talking to people coming out of their residencies now. Yes, that's right. How are things different now versus when you did your training? Yes. Speaker 1: I s I stopped supervising residents a few years back. There was a change in the guard at Vanderbilt and there were some internal changes in terms of how that works. So I haven't been doing that in the last number of years. But I I think that in the in terms of like our practice, we've been at various points interested in possibly recruiting someone. And again, maybe this is ⁓ you know, my grandiosity, but I sort of thought like, hey, this is a pretty nice place to work and it's a sort of a unique situation, you know, you do a lot of things that make doctors miserable that you won't have to deal with if you're you're here. And what I learned is that, and this is this is a loss and this is a sadness, is that ⁓ what happened was is that we were interviewing these people and these child docs. And they were like, well, but I can get this job remotely supervising nurse practitioners and they're gonna pay me four hundred, five hundred thousand dollars a year and I won't ever really have to see anyone. maybe push them to shove a few patients a week, but I'm really going to be in a remote supervisory role. And you know, I've got yep little kids and I just I can stay home and help my wife and and just basically have a couple of Zoom calls a day and I make an enormous amount of money. Right. And so I think that the especially for the people who are at that penultimate level of training, the child doctors, you know, go a few years past with even the adult doctors. So they're highly qualified. And the way the Speaker 2: Okay. Speaker 1: corporate medicine machine sees them is they're going to play this supervisory role. They're not going to actually conduct the treatment themselves. That's going to be farmed out to nurse practitioners, licensed professional counselor, whomever. And they're in theory, you know, they're providing the supervision, but if you don't ever really see the patient, you only see them very infrequently. Speaker 2: Basically renting their license out, essentially, for the nurse practitioners to be able to say by that. I mean, there's a lot of that going on. I mean, a lot of like ⁓ TRT clinics work that way too. ⁓ yeah. There's gotta be a there's gonna be a licensed physician, but none of the none of the patients there will ever see that person. You know. ⁓ but there's you know, the the law requires there to be a license. That's right. Yeah, but I can see how if I'm an insurance company, ⁓ I would or you know, ⁓ who's you know, I'm deciding or the I'm the payer. Speaker 1: That's right. Speaker 2: I'd rather have 15 nurse practitioners, one psychiatrist, because they're all gonna dispense mostly generic drugs. And I'm gonna, you I'm not gonna have to build a psychiatrist out for eighteen people's worth of caseload. Right. You know, I mean that's just that's just saving a lot of money and ⁓ the outcomes are so hard to measure if they're not materially any better because of that model or worse. Like it's that's one of the challenges is like, ⁓ how do you prove that you're compromising care? That that would that's my concern. Like as a patient who's trying to advocate for this, it's it's hard to prove it when it's being done right. Like that that's a real challenge. Speaker 1: ⁓ that's exactly right. Yeah. Well, and w I think again, like knowing the l I said earlier, like knowing the limitations of any tool. The same as like knowing the limitations, like a what well one theory would be, okay, so so the you know, one of my favorite topics, which you know, I'm trying not to get salty on your podcast, but like the the ⁓ one of my favorite topics is the concept of evidence base. And Speaker 2: Let's do it. Let's do it. That's what we're here for. Yeah, Dr. Patty and I talked about this last week. Tell me, yes, it came up. She I I could I could smell the ambivalence in the air. Yeah. So tell me about evidence-based. What does that mean? Well what does it really mean and what do people think of these? Speaker 1: Yeah, I mean s so ⁓ I I'll I'll I'll tell you a a a a comical thing and then I'll be serious for a minute. Okay. So you know how I like I think people remember the comical things better. So patients will approach me and they'll say, Doctor Clark Speaker 2: Yeah, sure. Speaker 1: You know, I d I don't I'd I'm this is awkward because I really like you and I know you're trying to help me, but you know, you haven't really mentioned behavioral activation. And I was talking to Chat GPT and Chat GPT said, What I really need is behavioral activation and you just haven't mentioned that. And so I just I just need to know, you know, before we press on any further, ⁓ are you certified in in behavioral activation? Now, I'm not picking on behavioral activation because frankly I think it's a great concept. Yeah. But one way to think about this is every twenty five years or so, someone takes a Old concept, renames it, writes a book about it. From this, we create a whole series of seminars. You can go to Opry Land on the weekend, get a certificate, hang it on your wall. You can put a little s you know, like behavioral activation thing on your website, your Instagram profile. I'm certified in this. And my response to that at the time, and again, this is someone I know well. I wouldn't say this to a new patient necessarily, but I said I said to this particular person, I said, if only I'd thought to tell people to do things that make ⁓ feel better. I don't know where th such a profound idea. Yes, it's like such a deeply profound idea. And so so things like this come along and they kind of catch on. Another youngster a few years ago told me, ever since Dr. Siegel invented mindfulness, you know, the famous Speaker 2: All these years. Right. Dan Siegel? Yeah, yeah, okay. Yeah, all right, got it, got it. Speaker 1: And I was like, Well, please don't tell the ancient Chinese They they think someone else invented Speaker 2: Yeah, don't tell the ogres. Yeah. ⁓ my gosh. Or yeah the It's funny you said like every twenty five years they'll reinvent the thing and I was thinking, man, they shouldn't they should develop psychotropics so they could get it out of every seven years. Repackage the same thing. ⁓ call it call it new. Yeah. Yeah, of they are. Yeah. I think Zoloft is basically kind of like that with with Prozan. Essentially. Speaker 1: thinks they aren't doing that. Well, and do you know how many different names there are for methylfinidate? Like, you know. Speaker 2: I've probably I've taken a good bit of ⁓ I mean I I've I've had Ritalin Concerta, my dais no, no, my dais is amphetamine. I've had ⁓ what is it ⁓ metadate C D. Those are new. Those are new Speaker 1: Meditate CD, Cotempla, Trana. Yeah. There's a long list. Yeah. They're they're basically like 30 some odd. I think at last count it was more than three dozen months. Right. And they're all it's it's delivery mechanism. And arguably the delivery mechanism can matter on an individual basis. I'm not saying that isn't true. It is true. Speaker 2: Brand new. Speaker 1: But on a the they're all methylphenidate or amphetamine. And so it it really is. I mean, it's a strange place in America where, you know, science and clinical medicine intersect with commerce. Speaker 2: Right. Right. When I I've talked to a lot of people and ⁓ there's a I think a movement I would call it ⁓ c ⁓ called critical psychiatry. ⁓ which is and I think this shouldn't there shouldn't that I think that name should not be re as redundant as it is, but it's basically just taking a critical or skeptical eye to the evidentiary basis for What we see as modern psychiatric medicine would be critical of things like that. The intersection of in the United States, forty percent of the pharmaceutical industry's profits come from psychiatric drugs. It's an amazing product because it will never cure anybody. Usually it needs to them lead to them needing more of the drugs that you know to manage the symptoms. And you take it every day for the rest of your life. And if you try to stop, you get sicker than hell and we call that a relapse and it's your fault. So it's it's a great business model. and ⁓ And people in other kind of talk to some people in the Anglo Sphere, I've talked to people in the UK and and in Australia. Right. I'm I'm hoping to have actually a couple of them on soon eventually. But yeah, they're just kind of looking at the at the research basis and just saying, you know, like there's kind of a creep between you'll you'll have something very narrow with the FDA approval, then you get all these off label applications. Then you're and we're basically trying to wholesale out antipsychotics as being less like, ⁓ you a little back pain, just give you some antipsychotics for it or whatever. You know, let's just sell more of it while we got the patent. And Speaker 1: Expanding the indication. Speaker 2: Right. Well, I wouldn't say growing new growing the market is really what they're doing. And ⁓ people in, you know, they think that we have drug commercials is just more welly. Yes, we just got it. Expanding the market. Yeah. Yeah. ⁓ well that's another thing we ⁓ you know we could talk about too is just like the diagnostic creep, you know, that's happened over time. I mean, when you became a psychiatrist, which DSM were we on? Was it three or four? Three. DSM So you've been through three DSMs now. Speaker 1: The aircraft. Three. Well, then I c almost caught the tail end of two. I think two when I was in med school, maybe three there. Something. Speaker 2: That was a big change between two and three. Three was nineteen eighty. Yeah, yeah. That's a big change. I've read a lot about that time, is where we went from almost entirely analysis, I think, in the second right. And then the third one was when we we kind of started adopting the the medical model. Speaker 1: Nighteen. Yes. Yeah. But the I wanna I wanna circle back to the evidence base a little bit before 'cause I I'd I'd really 'cause I left it hanging with what I thought was the humorous story. Yeah. But the evidence base, like everything, so these studies, I mean, when I taught and I to this day I try to teach my team, you know, younger people in the team who I think are really sharp and really do care. I mean, we've we've curated this team of people who are amazing. And a huge part of being amazing in what we do is caring. Yeah. And you have to care. Yeah. And you also have to be able to think and to think critically and to not just take everything hook on and sinker that's given you, right? And so like the the the evidence-based thing, most of these studies are done short term. They use by necessity, and again, I'm not I think Dr. Patty would probably say something similar. By necessity they use things like rating scales, right? How are you going to quantify the change? You have to have some sort of a rating scale. Sometimes they make up their own rating scale. Speaker 2: That means you ask someone on a scale of one to ten how do you feel. Yeah. Right. And or scale of one to seven. And then, you know, so there's there's some obvious issues there with subjectivity changing even within one person over time. But like yeah. Speaker 1: And and in their own ability to stand back and observe themselves. Speaker 2: But you gotta you've gotta you you've gotta you've gotta have some sort of data, right? Some sort of measurement. So that's the best we can do right now. Speaker 1: Right. And the placebo effect. Right. You know, I mean it's I mean, there's just so many different things. But like, you so depression study uses the PHQ nine nine questions about how you feel, all of which are felt to be in some way germane to mood and progress towards relief from melancholic depression, you know. And so you you so you you you do some type of an intervention and you periodically administer this and then it's creates a beautiful PowerPoint graph with the line going down or not. And you know, the placebo or control group that didn't receive, you know, the treatment. How did they separate you know some of the limitations of the math that's applied there, like you know, everyone the mighty P of less than 0.05, which is you know less than a five and one hundred chance it happened by chance alone, which sounds like that's that's pretty good. But then if you really look at individual predictability, it's like 5149. Speaker 2: ⁓ randomness. Yeah. So yeah, so it's like retroactively you can go, well, there's less than a five percent chance this was random. But but with that, when you look at that test's ability to predict future results, which is kind of the point of science. The point is to be able to predict what's gonna happen right reliably. ⁓ that and that's what I would say like the diagnostic utility, ⁓ the utility of like these diagnoses is very low. Or or of an intervention is what we're kinda talking about now, the evidence base. Speaker 1: Yeah, the evidence-based so so the evidence-based someone comes out with a study that says a dozen sessions of C B T or you know, some particular type of therapy, C B T is the darling of the evidence-based crowd. So a dozen C B T sessions, you know, produce an effect size of, you know, 0.34. And, you know, patients, you know, reported this much improvement and clinicians said their global assessment of functioning, the GAF score went up. And so like we're okay, well that's great. So what we now know is that in a 12 week epoch with these particular patients and in the med trials, all of whom are cherry picked. Speaker 2: Right. Speaker 1: Select and the pre-selection process in the medtrals excludes pretty much everyone that would ever walk into my office. Speaker 2: Right, right. Anybody who ⁓ is mentally ill. Yeah, you're right. Right. Well Speaker 1: And yes, or or you know, like and and again some of this is selection bias. So again to be to be balanced and what I want to say. Some of this selection bias because now my role is only to see people I like to say they've been kicked out of every decent practice and they you know they have to come find us, right? And they come find us because we do things differently, because we do ⁓ shockingly we talk to people. Yeah. ⁓ we offer therapy of various sorts, we offer neuromodulation, all these different things. Okay. Let's talk to people about lifestyle things, right? But in those drug studies, like if a drug is being assessed for its efficacy and depression, then they will exclude people with OCD, people with bipolar disorder, people with various forms of anxiety, people with substance use. Pretty much everybody that comes to see me who has refractory depression has one or more of those things, oftentimes more than one of those things. And so again, applicability, how does that extrapolate from the the study to the actual clinic? where you meet people who didn't play by those rules. Yeah. And again, the drug trials, I mean the are they Speaker 2: It's not about playing by the rules necessarily. Like they're they're they're presumably they're inheriting what you're asking to do, but they just don't fit in the box. Yes. You know, they don't because the this all assumes that these di d disorders, these diagnoses are discrete. Yes. Pathologies. But if everybody's got five of them that, you know, obviously they're not. It's ⁓ the probability you'd have five independent neuropathologies is is you know almost winning the lottery. And so but that's kind of what science, you know, that what we are doing assumes that. Right. So it's you only have to only have depression but not any other problems. Which I you know, I imagine ⁓ i if you probably are not seeing very many of those people like you said because you're seeing the hard cases. Yeah. But I bet that for people that just have a little depression and no other issues, maybe these antidepressants probably are fairly Speaker 1: That's what my my good friend, I have a well, I mentioned Dr. Kleinstiver earlier, the other younger Dr. Kleinstiver, my good friend, who has been one of my best friends since we were seven years old and who I talk to on a regular basis still, who's an internist in Pittsburgh. And that's what he would tell you. He would tell you that he is in the role, you know, mo nine out of ten prescriptions for psychotropics come from primary care doctors, not psychiatrists. That's another whole Can of worms. So they'll require another two hour podcast. But but at the end of the day, he'll say just that, Andrew. He'll say that ⁓ you know, he meets these people and they have, you know, mild, it's just it's depressionism. It's it's not just an adjustment disorder or whatever. They have mildly to moderately severe melancholic symptoms and he'll give them these meds and they come back and say, Doc, that was great. Thank you for doing that. They take it for maybe several months or a year, they stop, they're on their merry way. But None of those type of people come see me anymore. I mean, maybe way back at when, yeah, but none. Speaker 2: Because they've been they've been screened probably. They've gotten someone else has gotten to them with correct. So how did that I and I've that's really what I've been wanting to get to. I think I don't I didn't bring my watch. I think we've got probably in in the second hour now. ⁓ fifteen minutes in. Okay. So ⁓ you know you have a really just a fascinating like bundle of arrows in your quiver. As a doctor. I mean like your office is a cool place for a brain nerd. and I'm curious, I'd love to talk about s those specific interventions, but I'm really curious how did you find yourself in this position of being the psychiatrist that people go to when they've when psychiatry has failed them? Yeah. Like when when they've tried psychiatry as it's conventionally practiced, didn't work, they find their way to your office. Right. You know, how how did you find yourself in that position? Speaker 1: Yeah. I so I think that yeah I'm that's a good that's a really I like that question. How did I find myself in that position? Speaker 2: Like in the forest gump, it's in tradition that we have. Speaker 1: Exactly. It feels like that. I think ⁓ if Amy were sitting here with us, she would say you can always count on the fact that Craig is the biggest nerd in the room, which is probably true. ⁓ statistically speaking, I mean maybe I put myself in the right position, I might be the second or third Speaker 2: You're Depends on the room. Yeah, yeah, yeah. If you're fortunate it's you're not. Yeah, yeah. Speaker 1: And I have friends who would ⁓ challenge me for that spot for sure. ⁓ but I I think that I just was always curious. I like to learn. ⁓ again, I hear my grandmother saying, Be the eternal sophomore. And so I like to learn. And the other thing that happened was is shocking, but you meet all these people who don't respond to the standard treatments. Like it it even y you know, even if you aren't necessarily there isn't that referral selection bias that eventually evolved, in part because of people's needs, but also in part because of the managed care thing. That now funnels a lot of those people. Both of those factors funnel people are Speaker 2: What are those two selection buys and managed care? Speaker 1: Managed care meaning the sense that a lot of people are gonna go to whoever their insurance company will pay for. Right. And, you know, and they're gonna get the the shocking truth is that the ⁓ average visit I don't know if the listenership knows this, but the average visit time with the psychiatrist is fifteen minutes. In primary care it's eight minutes. Now, I I always say I'd I find it hard to greet someone and sit down and initiate in fifteen minutes. That's that's a real challenge and I've been doing it long time. I know a lot about Psycho Farm. I honestly don't believe I could give someone proper care in fifteen minutes. Speaker 2: How often is that like fifteen minutes per what period? The min minimum ninety days? Quarterly usually. Quarterly. Yeah, because that's what the law requires you to sell it every 90 days for a controlled Okay. Yeah. And fifteen minutes is the probably bare minimum required by law to to write a controlled. Speaker 1: That's right. And so you get an hour a year is another way of saying that. ⁓ so you know, people say, ⁓ we're gonna ration care or whatever. We're already rationing care. This is like, I mean, this is a form of of of of rationing care. So I think that I saw the need in front of me. I encountered these people who didn't get better with standard, you know, medical interventions, with psychotherapy. We were doing psychotherapy from the beginning. Probably the first thing that grew out of my perception of need in the patient population was group. I was reading about group and how group was preferentially effective for younger people. No shock since they do everything in small groups. Yeah. One of my best teachers, he was a psychologist, used to say, ⁓ young people who go to traditional individual therapy learn how to relate well to middle-aged men and women. ⁓ Speaker 2: I mean that's an important skill to getting ahead. That's who decides if you get to go to the school or have that job. Or I mean like that, you know, I imagine there are probably a lot of people that Dr. Patty works with that just don't have that skill and that's how they end up ensnared by whatever. So I like I think that's there's some there's some profound truth to that. Yeah. Yeah. But it's also like, yeah, yeah, you're learning how to have, you know, 40-year-old relational skills and practice nonviolent communication as a fourth grader. And you ⁓ know. ⁓ Speaker 1: Exactly. Not to diminish that. And then then but then then you know everything you do is a cohort based, right? As as you grow and mature and so and so group makes sense. And and I've always found that group I mean with a handful of important exceptions. I've seen some little children for group and I've seen, you know, some teenagers who I think really did do well in individual therapy. But they usually will definitely return on investment wise, you know. It's it's it's ⁓ group is is the ⁓ thing. And then and then Along came the the there were these ideas about neuromodulation and you know TMS, you know, in particular. ⁓ neurofeedback has been there for forever. ⁓ it's not n neither of those things are really new, but their application in clinical medicine is relatively recent. And ⁓ I you know, people would ask me for years about neurofeedback. They wanted their children to receive neurofeedback, and I always said interesting but unproven, and one of the challenges was there was no There was no ability to to take a a quantitative EEG and have a fully human database. I mean, I know this sounds ridiculous, but some of the early databases had rat and monkey brain data in them. Right. And so the this guy, Bob Thatcher in Florida, was the first person to really get through the FDA a comparative database that was appropriate and applicable. And that happened in 2012 and Speaker 2: When you say comparative database, you're meaning among different patients, not the same patient over different times. Yep. Speaker 1: Yeah, got together I think a I f I forget the exact number, it's like a thousand patients and and did these quantitative EGs and established, you know, a very there's a very broad range of what's typical, right? And so that you don't you know, ⁓ conflate a typical variation with something that truly is outside the norm, maybe normal. That's by statistical means again, they're they're shortcomings and all that too. Yeah. Speaker 2: Yeah, but yeah. Speaker 1: It it allowed neurofeedback in my mind to have validity because you could say, well, that isn't just, hey, Andrew has studied yoga and so he's got a particular his alpha frequency is more prominent than Craig's who didn't or whatever. ⁓ a fun story about that with a songwriter, but we'll get to that another time. But ⁓ but anyway, so n Neurofeedback in 2012 when that database was approved, we started our neurofeedback program. And then ⁓ a few years before that, one of my partners was the first person in Middle Tennessee to have a TMS machine. And it was approved in 2008 and 2009 I started using transcranial magnetic stimulation. Yeah modulating the neural network with a magnet. Speaker 2: Mm-hmm. Yeah. Okay. Cool. And you had a friend that had one and you had to check it out. Yeah. And back there like Yeah. It's like ⁓ yeah. And I mean I'm hearing you talk about this and you started off by saying you're a nerd and I'm like, yeah, this stuff's all really cool. Like I mean it's really cool stuff. Like you got you got some cool equipment, you know. Speaker 1: Yeah my partner. Just a fellow nerd injuries. Right. Speaker 2: Get it. I'm like, of course, it makes sense. They lay you basically were like I that's how I am with cameras. Like in technology, I'm just like, I wonder what this thing does. I want to get this toy to play with. And eventually people are like, Hey, will you photograph my whatever? And I'm like, ⁓ I'm not qualified to do that, but I really like I'm just gonna nerd out about it anyway. So like I might as well get paid for it and Yeah. Yeah, it's kind of like you've you know I wouldn't say that's a forest gump way of finding a way into it. Yeah. But like, yeah, it's it's a good way, you know. So you've had neurofeedback and TMS were about the same time that they became clinical Speaker 1: I'm trying think about the timing of that. I think we started our ⁓ I started using TMS with my patients about 2009-ish, somewhere in there, late 2008 or late. It was approved in March of 2008. Okay. And that's round about that time a little later, I started using it. And then neurofeedback in 2012. And that was really tied into there's a really convergence of things with neurofeedback. One was the availability of the computing power to crunch the numbers outside of a mainframe. Okay. And that we had I'd never forget we we went into Best buy to get our first neurofeedback computer and I'm asking this guy ⁓ about ⁓ these gaming computers. And he's he's looking at me, he's like, Dude, you're into gaming. I'm like, Well no, not really. I got a crunch Speaker 2: Right. Yeah, you know, I gotta crunch brain data. So let's let's let's dive into each of these because I'm deeply fascinated by them. Let's start with neurofeedback. Sure. What is that? Speaker 1: Yeah, so neurofeedback is a specialized form of biofeedback where basically we ⁓ at at baseline we take a sample of your of your brainwave activity, ⁓ using a you know traditional EEG, but we quantify that data. That's the name quantitative EEG. Speaker 2: Yeah. Speaker 1: Electroencephalography. So you know, taking a taking a tracing of the brain's electrical activity. And it's usually done with these twenty one lead devices. And what we're really looking for when we when we do that, well, and I should also clarify quantitative versus qualitative. I'm old enough that I remember when I was starting down that combined path, we would go in the morning and there would be I don't you guys are too young to remember the bifold computer paper with the edges that you turn. Yeah. Tear the edges off. Yeah. So there would be these bifold computer things where the tracing had been done. And then the tech, who they were usually pretty astute because they'd seen hundreds and hundreds of these and they knew what it should look like and what it shouldn't, would put sticky tabs, like little yellow sticky tabs, and then you'd flip through and go, ⁓ well no, that was that was limb movement or that was horrible. That's that's actually some sort of epileptiform activity or or geez, there's some global slowing here. There's the person has a metabolic disorder or whatever. So you were qualitatively assessing the tracing. Quantitization is really primarily ⁓ phase frequency, amplitude, and coherence, but you can use ⁓ other mathematical methods to derive additional data about brain connectivity and function from those primary indices, right? And you can compare this to a normed database and say, not are there differences between our EEGs, because you know we have different genetics, we have different experiences that sculpted our brain connectivity, and so of course they're going to be different. But the question is, are they different in ways that would truly be statistical outliers? And if so, is that statistical outlying activity or connectivity or lack thereof? The you mentioned like synchronization of brain activity, brain networks synchronized in certain ways for certain functions. Is that something that would lie outside the developmental norm defined as plus or minus two standard deviations from the mean? And if so, is it in a part of the brain that we would expect to correlate with this person's particular profile? huge thing and again ⁓ not to be too self-serving but a word of caution I think because this is unregulated ⁓ you can just kind of do this. You can right by the machine and set up a clinic and go to a little weekend seminar at Opry Land. Yeah. Right. Speaker 2: Yeah, properly. All right. Yeah. Go to Dollywood or whatever you gotta do, you see the Wax Museum and get certified in Brainerd and you're a female. Speaker 1: Exactly. Okay. And and so you know, this is where being a good clinician comes in because it's not just is the activity abnormal, it's is the activity abnormal i in a way that's salient to what the person needs help with. And also understanding some people may have activity that's abnormal that's a result of their life experience or their path. This is the songwriter I was telling you about songwriter who came to me and was doing neurofeedback with the different practice and he said, is it possible that it's making me worse? And I said, Well if it works, it's w there's gotta be a possibility it can make you worse. What do you what's going on? He's like, Well I have writer's block. Speaker 2: Interesting. Speaker 1: Interesting. And ⁓ I was like, well, bring me your stuff. And so he brings me his quantitative EG and I look at it and it's like, there it is, back here in the association cortex on the left. He's got all this high beta activity. Well, of course he does. This you know, this this is where you would expect high activity in a right-handed person who's, you know, developed this particular skill. ⁓ and and so he had lost his ability to write songs. As a result of downtraining there. And he'd been told, like, ⁓ you've been misdiagnosed with ADHD, you actually have anxiety. And if we downtrain this, you'll have less anxiety and you'll feel better. Well, it didn't do anything for his ADHD, but it did shut down his ability to write songs. Right. Which is a fascinating thing, sort of a talk about a proof of principle. Right. Yeah. Yeah. And and also to ⁓ one of my pet peeves is neurofeedback clinics that say there are no side effects. That's foolishness. If it if you're manipulating someone's neural connectivity, there must be the risk of Yeah. Speaker 2: But well, I think side effects is kind of a contrivance. Yes. It's the it's just it's an effect. It's an effect. It's just the one you're not paying for. Exactly. That's the only right. Yeah. I mean, that's it. It's an effect. ⁓ exactly. Yeah. I mean, I've taken amphetamines for so many years. I know that there's like the side effects. I'm like, it's it's a central effect of amphetamine that it's gonna make you a little jittery and like you know, it will suppress appetite, which may be an effect or a side effect depending on how the drug is packaged. Speaker 1: And design. Speaker 2: R right? I mean it's like if it's a if it's a weight loss drug and its mom is a little helper, right. It's a great deal if it'd help you lose weight, right? Is that what the original was? Yeah. Speaker 1: Yeah, amphetamine was originally marketed actually Adderall was originally marketed in the seventies, I think, as Obitrol. Okay. And it got pulled not because of safety, but because of efficacy because most people acl Speaker 2: It was as a weight loss drug. As a weight loss weight. Right, right, right. Right. So now it's a side effect. That that it will suppress your appetite, even though you won't lose weight. So ⁓ i with neurofeedback, I mean, as I understand it, so you've got these leads on your scalp and they're measuring brainwave activity through the scalp. I talked with Dr. Rosenthal about this because he does ⁓ he does interoperative ⁓ monitoring. He was he was actually monitoring a brain surgery on a monitor while I did my interview with him, ⁓ which is fascinating. And he's looking at E G data and just, you know, different parts of the brain and ⁓ Speaker 1: Yeah. Speaker 2: And so he's obviously got the benefit of doing that from inside the scalp. Inside the skull. Right. I think, which is, you know, you're not gonna cut up in someone's skull for ADD. Deeper. Right. Yeah, yeah. But ⁓ so you've got these different brainwave frequencies you're you're reading. I think I remember they're ⁓ alpha, beta, delta, and theta. That's right. And ⁓ they have different associations for different kind of activity. Right. Hi it was you said it was high beta in his Yeah. And that would be ⁓ associated with anxiety, right? Like when you think high beta, but it yeah, in this character, in this person, it was a skill, you think. It was a result of like a deep focus kind of almost. Speaker 1: It was a trained skill. Yeah, it's like saying maybe Roger Feder has an extraordinary motor ⁓ cortex. Speaker 2: Interesting. It probably does. And it probably was born with that and then has developed it from an early age. And yeah. So that's exactly right. But I was thinking, you know, interesting of having high beta associated with ⁓ creative expression. For me, what I've noticed is I've ⁓ really the recognition that I I'm an artist, I'm a creative person, and like, ⁓ that was what was missing. I've always known something was missing. I thought it was something wrong with me. And really it was just that I wasn't I wasn't around creative people and I wasn't creating. Yes. There is a sense of Pressure to get it out. That's how it feels like. It's like there's something in my head and I need to I have to get it out. Yes. And it almost is kind of an anxious feeling. Yes. ⁓ almost like an acathesic feeling. Like if I don't move on it, I'll go crazy. You know, I'll go nuts. And it's interesting that that it like it would be probably a high beta, like that push of like I have to do something right now or I'll and I'll feel better if I can show the world what I see through this the lens of this camera. Speaker 1: Yeah. And you know, you said earlier if if ⁓ therapy is art, artist therapy, and you know, it's like ⁓ this interchangeable it's ⁓ as someone who's who's married to an artist, my wife describes this. Like she literally will get pent up energy to the point like she has to do something creative. She feels like she has to release it. Yep. And you know, I would argue after all these years that that's therapeutic. Of course. And, you know, like one of the I mean course in the in the corporate world in an early season of my life I directed an in patience, right? Okay and I worked for ⁓ H C A briefly. And again, HCA's done a lot of good in the world. So it's not this is not like throw shade on HCA. But the the dynamics between the administration and the clinical leadership about what should go on. And one of the first things they wanted to do when managed care came along and they started to, you know, cut payments and I think says, Can we get rid of the music therapist? Can we get rid of the art therapist? Right. And my response at the time was, no, because because there are people for whom and this is even more common in younger people. They don't have the full ⁓ the that's the word I'm looking for, the facility with language to really process what's going on with them. But you put them in front of an easel or you give ⁓ some clay, or you teach ⁓ to play a few chords on the guitar and all of a sudden these amazing things come out. Yeah. Okay. And it it's it's it's so so this release is therapeutic, right? Speaker 2: Yeah. Well, I'm I mean, I would say the absence of that release is the whole reason for the needing the therapy. You know, really it's just that like the there's the something is wrongness feeling. I've noticed it's gone away. You know, I started a little film program here. And just having other people to talk about movies with, I mean, my level of neuroticism plummeted. Just the sense in my body that there was I was sick, I was something was injured, whatever, like I had all this bodily ⁓ issue, not dysmorphia, but it was just like a It's sense of dread about being sick all the time. And it went away in the f within a week, a week of just of you know, film studies. And it was you know it's just like this is what I'm supposed to do and the idea that I might be able to actually make something. Film takes a long time to make and I still want to ⁓ to make at least a movie, some movies, but and working on a photography is a a much faster turnaround, you know. ⁓ and it's a it's a simpler setup and there's sometimes it can be more profound. But I've got multiple art forms now that I can get out and Speaker 1: And you've got a great eye, yeah. Speaker 2: Yeah, my sense, you know, it's really a ⁓ it's because of neurofeedback. ⁓ I like w neurofeedback changed my life because ⁓ the feedback I got was ⁓ a a movie. Yes and and there's a screen and it will shrink at the edges and it's not a crop. So like it the whole screen would shrink, which is weird because the image gets smaller. And it becomes like a game. I understand neurofeedback for children a lot is like a game and there's a frog or something gotta eat. You can do it that way. Yeah. There's it's it's goal, it's goal oriented almost. So there's a little reward. Like there's this dopamine when you when you do the thing. And yes. For me, I'm just trying to get the screen to go out. So like that was my neurofeedback. And it I I think as a result of I think I did 30 sessions. ⁓ I think it is ⁓ objectively true that I can pay better attention to a movie than anything else. Like I'm I am more mindful and in the moment because I've trained my brain when I'm looking at a screen. And I and another thing that changed is most people when they watch a movie or television, they just kind of zone out, but they're like they're listening, they're engaged in the story, but they're not visually engaged. And a lot of like Netflix, ⁓ for example, i is actually pushing creators to make this what's ever on the screen not important. And to restate the plot because they because they expect people to be here. ⁓ my goodness. So they want their screen, they say it's not second screen enough is what it's called. Well am I supposed to They want they want their screen to be the second screen and they want it to just be playing. So ⁓ that's not ever how cinema was ever designed. It's a photographic art and the meaning really should start with the image. And there's this ethic of every frame of painting. You know, a a movie is a series of individual still photographs, frames, played back at twenty four frames per second, and that gives this illusion of motion. And when you add sound, it's it's very immersive. But you should be able to pause a movie at any point randomly and whatever frame you see should be like a painting. That is for me the standard that that I would want to go for as a filmmaker because when we lost that, there were people said that when talkies came out, it ruined cinema. That was the doomers were saying. And I think they were kind of right. It as it as it existed, cinema was an international language because Or isn't it was an international art form because there was no language barriers. Sure. You would see text or whatever, but it wouldn't be coming out. It would be like and then it would be the the thing what this guy said after you see the action. So everybody in the world who saw it had the exact same experience. And now, as you pr you probably understand from working with things like language disorders, there's a difference between the words and the meaning we make of those words, and that makes translation an art, but there's a little bit of a drift semantically with when you're translating from one language to another. If I watch a Japanese film, there's just cultural differences that are not gonna make it. and but yeah, the the image. So now like I I also a lot of people kind of dead eye in the center of the screen or they're looking at you don't realize there's fascinating studies on eye movement tracing that neuro neuroscientists can do. Well, it's fascinating what people do with their eyes when they're watching movies and there are autism studies I think involving this. One of them is was done on a movie called Who's Afraid of Virginia Wolf? Have you ever seen this film? Speaker 1: Absolutely. You know, I'm familiar w I I don't think I've seen it. I know the title Speaker 2: It it was one of the best films I've ever seen. I think it was Sydney Lumet and it was a play. It was very stagey. But it had Elizabeth Taylor probably the one of the best performances I've ever seen. And it's she's this wife and she's got this husband who's an academic, and then these two young academics that are there after a party, they're all drunk. They don't need to be drinking anymore. And this marriage is just th these people are all miserable. They're miserable to each other. They're drunk. So again, it's really amazing play. But there's a ⁓ there's a moment in it where he comes and opens he he pulls something out and you think it's a rifle. ⁓ in the middle of this fight or whatever, but it's an umbrella and there's this surprise. And apparently people with certain neurodevelopmental disorders don't register, they don't understand what's surprising about it because then you can tell their eyes are off somewhere else. Like and so it's that's a fascinating science of with cinema you can manipulate where people are looking. But ⁓ I started looking at the image from the outside in instead of from the inside out. And you kind of there's a zooming back, zooming out feeling. And that's really how meditation works for me. It's a Photography and cinema for me are a are a meditative practice. Absolutely. It's a practice in being present with how you feel and what you're noticing. And ⁓ it started with looking at the edges of the frame and then realizing, like, you know, there's black bars up here on some of them, but not all of them. And the black bars are different sizes. What the hell is that about? You know, why and there's a there's a technical answer to that and there's a creative answer to that. Right. But that's how it started for me was nerding out and like, why do I care that Oppenheimer's on film? You know, like why do I care that I see that what what difference does that make? And it it's kind of how I've got into it the way you did with Speaker 1: Absolutely. Speaker 2: The neurofeedback and the TMS of just being like this is cool stuff, but is it there yet? Like is it there for my practice? So yeah, that was my digression on on what neurofeedback has done for me. It's like yeah, I can pay attention now. Speaker 1: It's it's interesting too. And and that and that again, like that probably eventually that would extrapolate outside. But it initially for a lot of people, again, you you expect that the skill's gonna be most ⁓ accessible under the circumstances that most closely approximate the environment in which it happened, right? Yeah. And then over time it can it can extrapolate. But the but the underlying premise, you know, operant conditioning, people say, ⁓ you know, I don't know about operant conditioning. Is that really is this really, you know, it's just and and again I think it's like so many Back to humility and knowing the limitations and not being a salesman to someone about something that you're doing, but presenting it in a very balanced way. ⁓ and so neurofeedback, I mean, obviously it's not a panacea. It doesn't work for everyone. There are people who for whatever reason it's not highly effective or effective at all for that matter. But it's very reliably effective and it's very safe. I mean, as things go, especially if it's implemented by somebody who actually knows you, right, as opposed to looking at your checklist and then downtrending your beta that made you a Right. ⁓ Speaker 2: Per perhaps a maybe I mean that could be a very immensely profitable skill too for some people. And to lose that, like that's a big problem. I get it. Like especially if you if you're f of the p few people who are fortunate enough to make to earn any living from your art, which is a vanishingly small number of people. Well Speaker 1: We're here in Nashville, so we w ⁓ in the interest of privacy we won't go any further. Let's just say that this person wasn't doing it on an amateur level. Speaker 2: Sure, sure. Sure, yeah, yeah. I mean it's it's it here it is is one of the weird things where you meet people and you're like, Well shit, this person has Grammys and they're just this guy that I d but I mean i I can relate to that on a soul level though too to lose that ability like gosh, I mean there's that's a grief process you have to go through at that point. And so it is important, like that's why I wouldn't want just some person ramp messing with my brain. You know what I mean? Like the brain a brain is a terrible thing to let someone experiment with. Speaker 1: Yeah. And so the the operant conditioning model, you know, Eric Kendall won the Nobel back in two thousands, early two thousands, I think two thousand one, somewhere near two thousand three, for demonstrating in a very simple organism how ⁓ operant conditioning works. And basically environmental stimulation causes the neuron to bud and to grow new connectivity, which is the physical substrate of learning. And so there's ⁓ it's not surprising that younger people tend to get better results as a result of that. They're they they're the neuroplasticity of the human brain peaks between the ages of four and twelve. So that's your ideal neurofeedback candidate. But you know, we've we've trained people successfully, my own my own age and beyond. In fact, we had one lady who had a very unfortunate incident where she suffered a bifrontal head trauma and ⁓ was ⁓ Yeah, just severely impaired from that and that had a long course in neural feedback but did really, really well with it. But again, it doesn't work for everyone. And I think a huge part of it is is like, is the person doing it number one, are they qualified to understand the big picture? And number two, are they actually monitoring you? Are they seeing you? Are they asking? Is this because the protocol isn't set in stone. The protocol is my best guess with the consultation of someone who's been doing it for forty-five years based in Minnesota. It's my best guess about what's most likely to be helpful for you individually. But again, then on an individual basis, y y you know, it may or may not be. And sometimes we have people start down a path and they'll say, Hey, you I if I if anything, I think things are worse. Well well let's let's stop. Let's back off. Let's how's it worse? Because that's another thing. Like Speaker 2: Well that's information too that could be revealing, right? Yeah. That's just as obvious to me that I'd be curious to know. Well, like w yeah. Right. ⁓ I've had situations where I've been talking to physicians and I tell them I I took this drug and this thing happened, and I'll go, That can't be right. That's not that's not how that works. And I'm like, What what do you mean? I'm the data. You can't reject the data. You know what I mean? Like what do you it's just like you know, ⁓ but you know, it's like I'm blind now. I'm not making this up. I never got I've never went blind, but it was just like, No, that can't be that. You can't be right. Like it's hysterical. ⁓ and it it's just like I don't know why you would want To reject the data, but for some people I think that it's some people definitely seem to have a higher tolerance for complexity than others. Speaker 1: Yeah, it's it's I think it's ⁓ you know, and I we may have talked about this in the past, but I I I I really do think like that what between the fifteen minute visit and the pressure to see more people and the declining sort of like there was a time when I think doctors were held in very high esteem. And between all those factors kind of come into play and people feel defensive. And there's really nothing to feel defensive about. Like I mean any well, ⁓ One of my favorite memories from school was ⁓ for my first day of psychopharm, the professor said, You you know, the classic, if you only remember one thing, right? And that he said, Any drug can do anything to anyone at any time. And I remember I remember thinking, Well, that's helpful. Speaker 2: What a way to narrow it down. Yeah. Right. Right. Speaker 1: That's the most useless thing anybody's ever said. Right. And then of course, like so many things when you hear them when you're naive, and then 37 years of clinical experience later, I can say, that guy, he he had it going on. He understood. Because the truth of it is, is like the side effect that you experience may be an uncommon side effect. We may not readily have an explanation of why that drug would cause that side effect. But if we are observing it again, it's back to the anti-science. Here's something that, you know, and like, no, that's impossible. Speaker 2: Yeah, it's an it's and it's not even unscientific, it's anti scientific. Well the point of you know, I've made this this point before too, that like in a l a lot of things that I've seen with psychiatry, it seems almost anti scientific or I would say pseudoscientific, but ⁓ that the point of science is to try to prove yourself wrong. It's it's a technology to promote intellectual honesty. Yes. Right. To know that when you're wrong, right? And right. Speaker 1: to the Tower of Galilee. Speaker 2: ⁓ I I I've had many experiences where it seemed like it was almost designed to prevent that. ⁓ because because the diagnoses are are all subjective, there's no way you can really prove one wrong. And then when you had that lack of construct validity and the unfalsifiability. ⁓ and there's another number of other kind of factors there that make it that so. But it it really just kind of depends on you make a good point and something I haven't actually thought of is that I think that some people who are physicians, probably all people definitely, but people are insecure sometimes. Yeah. ⁓ and people can get defensive and that's a human that's a natural human response to being questioned and also because of things like the internet, Web ⁓ D, but now chat GBT I'm sure is an increasing problem. Speaking of I I need to ask, I've been hearing more and more about ⁓ AI psychosis. Are you informed about this? Are you hearing anything? Speaker 1: I don't think I really know a whole ton about it. The that the AI itself develops psychosis. Speaker 2: No, that it's inducing psychosis in humans who are using it. Speaker 1: Well, I I know for sure ⁓ that it'll do fun things like ⁓ tell meth addicts like, Well, given what you've told me today, I mean maybe a little meth wouldn't be the world's worst idea. Right. And I think Speaker 2: Because math addicts have notoriously good judgment. Just do a little math. That's like shit, how why didn't I that didn't that why didn't that occur to me? Yeah, right. Yeah, exactly. Right, right. That's funny. Yeah, that's scary, but it's it shouldn't be funny, but it is. Speaker 1: Yeah. Don't do a Yeah. quarter there's right ⁓ is that is that a little Well, i in and and again like back to the the the technology and the the strange medicine and medicine and ⁓ commerce business were strange bedfellas. And I love telling the story of one of my colleagues who's lovely guy, a very bright guy. ⁓ straight out of fellowship he went to a a to say a rural area. Yeah. ⁓ wouldn't want anybody to be able to do Speaker 2: Do you see this the same yeah? Speaker 1: But he went to a rural area and set up practice and he was the only child doctor within literally hundreds of miles. And of course, immediately there's an enormous need for child. Okay. And so I mean, he was, you know, full to the gills and beyond and was working a tremendous amount of money or a tremendous amount of time, making a tremendous amount of money. He's from a modest background as well. His parents were not well to do. He bought his mom a house. He did all these things, you know, lovely, lovely things to do, but he neglected to pay his federal taxes. ⁓ okay. And when he told me this story, I said, What do you mean you didn't pay your taxes? What are you talking about? And he's like, Well, I thought they were taking it out. And I was like, Dude, you're self employed. Right. Yeah. And so, you know, luckily he was able to, you know, work with the IRS and you know, get get get right with the Lord and all that good stuff. But the reason I tell that story is because that's how little Speaker 2: Who's there? Yeah, who's there? Yeah, yeah, yeah. Right. Speaker 1: business education most doctors have. Right. Like he literally didn't understand that taxes were going to come due after his first year. Right. And he was doing it wasn't like he was out spin thrifting these things. He bought his mom a house. Right. Nice thing to do. But he had been so irresponsible from a business standpoint that he put himself in this tremendous hole with the with the tax man. Right. And so again, I think unfortunately these things have have come together in a in a way that that's that's really problematic. And that what's things are being sold, if that makes sense. Speaker 2: Yes. yeah, it's like almost a consulting model where a consultant has a series of products they can sell you and they want to upsell you and that's where the profit is coming from. It's like what can I, you know, can I sell you on this thing? Because this one treatment I have may have very high margins. You know what I mean? ⁓ like like that's the decisions that's I know that at a corporate level, that is what's going into it. No, no, I'm gotta be Speaker 1: People I mean, so so people ask me and I I I try not to be because I know they're not asking it with malice, but people will say, Are you a TMS clinic? And I'll say, No, we're a clinic that can offer you TMS if you need it. Right. And you know, that a a friend, you know, we won't we won't just a friend has a son who's in this world. And so I've had very candid conversations with him. I mean, TMS clinics, if it says TMS clinic, as my grandmother used to tell me, if you go to the barber shop you get your haircut. Right. And so they're trying to get as many butts in TMS seats as they possibly can. And I'm not saying that they don't do great things. I'm sure lots of people have had effective TMS is a highly effective treatment. So probably a lot of people have had, you know, life-changing experiences at TMS clinics. But I'm also willing to bet you that a disproportionate number of people were put under the TMS helmet, who probably that wasn't necessarily the best right choice, but it was more of a commercial decision. Speaker 2: To put that patient in there because it's difficult. And so these things were extant before you adopted them. Right. You were waiting for an evidentiary basis. Now, and that's also happened with a new treatment recently, too, also with spravato, right? Eschetamine or spravato, yeah. So I'd like to ⁓ let's go there then and I'd also like to talk about what TMS is, because that's the that's the transcranial neuromod. ⁓ but ⁓ so spravato's come out, and that's the brand name for eschetamine, right? And people have been do Speaker 1: Yeah, that I mean. Speaker 2: Going to ketamine clinics for years now, right? Yeah, yeah. Yeah, I've heard of it as kind of it's being kind of branded somewhat with psychedelic medicine, even though it's not. I mean, it's not a psychedelic medicine. But ⁓ they're they're I guess they're biologically completely different. ⁓ but I just think there's a demand for psychedelic medicine. So it's advantageous if you're in the business of running a ketamine clinic. But the interesting thing is if they're j if you're only just adopting it now as a psychiatrist, what if people Speaker 1: Ever, never. Speaker 2: Why have people been allowed to do it for twenty or thirty years? How did that Speaker 1: Transpired. Expansion the indication. You said expansion of the Yeah. Yeah. Yeah. Well and okay, and again I one of my things in life is be balanced and approach with ⁓ with grace and the compassion and like the idea that like, you know, I think Speaker 2: Market. Yeah. Speaker 1: Doctors are oftentimes presented with very difficult circumstances and pa patients who literally in the case of eschetamine and ketamine therapy historically, the population that was most likely to receive that kind of treatment was a population of people who were acutely suicidal. Okay. And the the reason that that particular population was targeted was treat treatment refractory, defined as have failed to respond to ordinary treatments. And then people who were acutely suicidal. And the acutely suicidal person poses an especially problematic risk, right? Because we we do deal with people who are absolutely convinced that the best thing they can do is kill themselves. Okay. And a lot of them have plans to kill themselves at some level or another, and they have means. And it's not comforting to hear as a family member, but there's really not a lot the doctor can do about it. If someone decides that they're going to kill themselves. You know, people have killed themselves in padded rooms in state hospitals that run their head into the wall and broken their neck. And so you can see if someone's really dedicated to that. So you you have this like, you know, sense of urgency obviously for these people. If someone's sharing this, then you you want to intervene. And at the time there were very f still really, there are very few things that work quickly. In the quickly working category, we have misketamine or ketamine, we have ⁓ ECT, electroconvulsive ⁓ therapy, and there's a newer ⁓ drug called Avelti that's ⁓ relatively new to the market that seems to work a little bit more quickly, but there just aren't really that that Speaker 2: What c what class of drug is a built? Do we know what it is? Speaker 1: You know, let's see, I Velty, I'm blocking right now, my friend. Speaker 2: But is it something that would be administered like an EMT? Speaker 1: ⁓ no, no, no, no. It's a it's a oral antidepressant ⁓ medication. And I I'm blocking about the particular ⁓ receptor subcomplex that it works on. It'll come to me if I don't try to think of it. You can edit the we can fix this. ⁓ but it it it works on this in the in a unique way. So even if you failed multiple other SSRIs, S N R I, ⁓ Speaker 2: We'll think of it two hours from now. Speaker 1: y you know, you've you've had TMS for that matter, ⁓ because all those are mechanistically different from the the mechanism of action of IBLT. And likewise eschetamine, it works differently in the body and in the brain. So for that reason, it's ⁓ it's you know, it's it's thought of as a novel trial, an independent trial, apart from other things that you've done, right? So that's that's eschetamine. again, it it doesn't work for everyone. The results are generally pretty good. It does require ongoing maintenance treatment for most people. So if you respond, the the F the effect of the drug is not durable over a long period of time. So you were saying like the some of the psychotropics, you have this perfect business model of like Speaker 2: Like you stop. A drug that never cures anybody. Yeah, it makes you sick and you stop. Yeah. Speaker 1: Yeah, yeah. And and and again, to be balanced about that, I would say that's the case with hypertension and cardiovascular disease, statin. Cholesterol, statins, all the all the all the above. ⁓ and so so I think that that is its role. We so you said if it's been around forever, why did it take Craig Clark? Speaker 2: You're telling me a lot about the psychiatry of it, but we've been using ketamine for a long time before it was used for mental health. Yeah, anesthesia. Yeah. Child like child dental surgery, I think, right? Like children. It's considered mild enough for children. Yeah. And why is it effective for a like a child dental surgery? Why would you what are the benefits of it as an anesthetic? Speaker 1: Yeah. That's right. Yeah, it induces this sort of relaxed, disassociated kind of ⁓ feeling. Just you people will say they feel floaty or you know, they're kind of like there but nothing's really troubling them too much and Speaker 2: This is in a conscious waking state. That's right. Too, right? So I there's some surgeries where people need to be awake as well. That's right. I imagine ketamine would I suppose be helpful. Brain surgeries like that. Speaker 1: Right. That's right. They use it in certain types of surgery like the Speaker 2: Have you ever been in the room for brain surgeries? I training on Speaker 1: Yeah, yeah. I've been in in the neuro in the neuro suite back in in training. It's a crazy thing to see, you know. Yeah, the the the context that I saw that was ⁓ surgery for intractable epilepsy. Right. And so they're mapping out where they're going to cut. ⁓ Speaker 2: Yeah. Yeah. Movements and yeah. That's what I I talked with Dr. Rosenthal about a couple of weeks ago. Cause ⁓ we talked it's so interesting. Epilepsy is an interesting thing because there's the that connection. I think it was David Baer that is interested in the study, the yes intersection of yes of epilepsy and yes psychiatry. I mean, it's s it was s very surprising when I learned that ⁓ one of the main classes of drugs you would use for bipolar disorder would be anticonvulsants. That's right. Well, what the hell is the connection? And You know, nobody knows. But but and then there's this ketogenic diet that comes in that's definitely anticonvulsant and that may have applications. But ⁓ temporal lobe epilepsy, really fascinating thing. And we talked about the split brain phenomenon, which is the people who've had like a radical cholestectomy that you they sever the left and right parts of the brain. and that's you know, it's just a fascinating thing. Do you do you see do you have patients that were like have a co occurring epilepsy with psychiatric disorders? Speaker 1: Very commonly. Yeah. Go that that flows both ⁓ that flows both directions. Really. So if you have ⁓ epilepsy, you're way more likely to have some variety of psychiatric challenge. And likewise, if you are someone who's affected by depression, anxiety, ADD, whatever, ⁓ both directly and indirectly, a lot of the ADD crowd has abnormal have abnormal EGs because of trauma. They ⁓ are more likely to do impulsive things and take a blow to the head. Speaker 2: Okay. 'Cause of head trauma, brain trauma. Right physical training. Can see that on an EEG? It's just by there's a specific area where activity would be low or Speaker 1: Yeah. Right. Abnormal. Yeah. Like slowing in that part of the brain or certain patterns of connectivity disturbance that are that are known. There's a there's a Department of Defense database that actually compares the patient that you're you submit a sample of Craig's brainwave and it compares it to the database and says, how closely does it approximate those things? Speaker 2: You earlier we were talking about hi I mentioned HIPAA. Yes. Right. You I HIPAA balkanizes your information. So there's no way to map this is one advantage I think China has over the United States on because there's there's no privacy there. You know, I mean like they definitely don't have HIPAA, that's hysterical. Right. But you they can study the whole population, you know, with their quantum computing and things like that of big data. ⁓ and I assume that the you know the the reason you're going to the Department of Defense, they have a lot of head trauma, but they're also probably not subject to HIPAA. Like they c they can anonymize and aggregate their data without getting individual sign off. 'Cause it's by joining the military you probably sign away your right your privacy rights to in medicine or it's get your benefits from the VA. Speaker 1: It's interesting, like you yeah I hadn't thought about that, but that's I'm sure that's true. And I I mean I know like you can you can buy into using that or not. Right. You don't have to. Speaker 2: But you c to use the some MBA probably from Vanderbilt got ⁓ to license that data out, which is good business. But it's I think that's a challenge. You know, we were talking about EEGs with brain injuries. I is EEG effective as a diagnostic tool? Speaker 1: Well, there are limitations to it. Again, see, I think this is the other thing. It's like people will say to me, like, ⁓ well, Chat GPT told me that this doesn't diagnose anything. Well, yeah, we could throw you so ⁓ and I I I left a hanging chat on that. Let's just very quickly do that and we'll talk about does it diagnose brain trauma or A D D or whatever? And the answer is it doesn't. But but the short answer. But ⁓ you know, what chat GPT told me. One of my patients who is ⁓ a very high level computer dude. I mean he he is he's in cybersecurity at a level like where let's keep the terrorists from flooding the Tennessee Valley, you know, that kind of stuff. Yeah. But that isn't what he does, just to be clear, dear listeners. I'm not giving away identity, but it's that kind of stuff. Okay. And so he told me that he said Chat GPT, again, the the blend of commercialism and medicine and all these things, ChatGPT will tell you what you want to hear as it perceives it. So depending on what you've said to it in the past, what you've asked it about, what you've tapped on and searched, there's an algorithm there. We were joking about the algorithm as we walked in here today, right? And so ⁓ there's an algorithm there and it will direct its answers in a particular way. So he said, if you really want anything helpful from Chat GPT, you have to say, please don't fluff me here. Like Speaker 2: I've I've had to tell that many times and I've gotten where I only use it as my assistant cinematographer. Like I only ask it for technical now I do use Claude, which is anthropics AI, because its verbal reasoning skills are noticeably better. It's the best. And if you think about which component of intelligence is most relevant to to EQ, you know, it's gonna be that. Absolutely. And but I also have instructed it and from the beginning, I was like, look, I'm gonna use you for this purpose. If you tell it what role to play and say, don't kiss my ass. Like, you I'd like you to play the role of a play the role of a of a forensic psychologist. Tell me to figure out why this did, or play the role of a career coach, or play the role of a a friend who's here to keep me accountable. Right. There are ways to do it. You have to prompt it, but you also have to be interested in intellectual honesty. You know, which is like that's a radical selection there, right? I mean, most a lot of people maybe are just using it as a friend or someone to make them feel better, which is also specifically not what therapy is either. And it that's a whole problem, right? Like they're using it as their therapist, but just use a little meth. Right. It's a sycophant. Speaker 1: It's a bad thing Yeah, it's a sycophant. That's a great way of saying it. And the what I mean, again, you asked me how I introduced myself at parties and I said in my, you know, later parts of my career I introduced myself as a professional difficult conversation haver. Like, I mean, if I'm doing my role well, I'm gonna have difficult conversations with people. But that doesn't mean that they're unpleasant or unkind. It just means they're difficult. Right? If you if you really care about someone's development as a human being, you're invested in them, then you will say the hard thing. It's like I I I joke all the time, my wife Amy taught me none of us are perfect observers of ourselves, you know, and someone that really cares about you and who's willing to reflect back to you things that you need to see, that in my opinion is one of the deepest, truest forms of love. It's like I'm invested in you in a way that I'll do the hard things with and for you. Speaker 2: Yeah, that's profound. I'm ⁓ in my own like my personal growth practice now, ⁓ I'm working with Laura, the neuroshaman, neuroshamonic healer, and ⁓ she's got this ⁓ new ⁓ curriculum that she's put together called the neuroshamonic path. And ⁓ it's to train people in some of her practices. and really just the intersection of neuroscience and shamanism and a lot of it just involves brainwave activity and and the way drumming we respond to drumming and that induces data states and absolutely and Speaker 1: That vagus nerve is activated. Chanting Speaker 2: Chanting, yeah. So you mentioned brainwave entrainment between people and I think harmonies like that's literally what you're kind of trainment of sound and of brainwave. And I also think that's probably related to what spirituality is. That you mentioned the placebo effect and like we have this desire to be to be cared for and to be part of a tribe, to be part of something bigger. Absolutely. There's a dark side to that too, which is tribal violence and and hatred. But I think when the ego becomes a super ego, when the ego dissolves and merges into something bigger, greater than ourselves. That's I think the definition of that's what transcends all religious and I I ⁓ there's some pressing for that. I've got some people I want to talk to about that, but I would also love to do my undergraduate study on it. But you know, Laura was I'm doing some mentoring with her 'cause she's, you know, told me like, you I see you as being a healer, someone who can who can implement these practices and help people. And I don't see myself that way, but I also for a long haven't really seen myself as particularly masculine, which I tell people then they're like you, like, you know, because I am like I do have a beard, but like, you know, whatever. I mean, you know, and just there's a lot of things that I don't see myself as. And I've said for many years, I d I think I first said this to myself ten years ago or more, if I could give one gift to the world, it would be for everyone to see themselves through everyone else's eyes. Sure. Because warped sense of self is just the cause of so many problems. Low self esteem, I think it's very common, unduly high self esteem. is also an a you know another problem. We call that narcissism or other things of you know, I think in some cases psychotic disorders are are like where you have a lot of ⁓ delusions of reference. It's just like their sense of self is like super inflated where you think that these people on this park bench are out to get you. And right, ⁓ why do they care? And it's just that the the inability to reality test. Right. Because you can't see yourself clearly. And ⁓ but what she reflected to me was that I see people. And I think that a lot of what I've been moving towards with my photography is To I just worked with a model for the first time last week, two weeks ago, and ⁓ it was she's a trained model, she's a really talented woman and but I was like, man, this is what I'm born to do because what I what I produced was exactly what was in my head. And I do have this benefit I've looked at enough images now and it's ⁓ I have a feeling, that's what I notice and and that's when I know that the moment is right. And ⁓ but ⁓ to help people be seen, I think especially for me, I'm gravitating towards helping women be seen as an embodiment of the divine feminine. ⁓ and not in a sexualized way, just as as just being, you know. And ⁓ there is that sense of like wanting to be able to see and to be seen that we have like this desire. And it is hard. Like we need good mirrors. That's what I've been saying is like I don't know how to see myself clearly. Like I haven't figured that out. And I do guided meditations and can't see anything. I'll go in a room and then I'm seeing everything and then I look in a mirror and there's nothing in it. It's a very strange phenomenon. I'm sure there's a a ⁓ deep Jungian explanation for it. I just haven't I haven't I haven't discovered that yet. But my my kind of my substitute for now is just to have a lot of great mirrors. You know, and some people I think developmentally their their life they're surrounded by people that are like fun house mirrors. They just what they're reflecting back to them is very warped. You know, or society will do that as well. Yes. And so then you're just like you have a very false sense of self and you're just you don't know. That's called toxic shame or or whatever you want to say. And so one of the things I've learned is that like my success in life, and success is not how I want to think of it, my happiness and my well being has directly correlated with me finding a bunch of better mirrors. You know, just have choosing better people to who can honestly reflect back to me and also have the capacity. Speaker 1: Yeah, you become the five people that you spend the most time. It is true. And and I d I love that ⁓ funhouse mirror because that what's I think what's happening, you know, and I I joke around with patients every day and say, you know, as a father and a son myself I have, you know, ⁓ compassion flowing in both directions. But Speaker 2: It really is so true. Yeah. Yeah, yeah, that's true. That's true. Yeah, yeah. Speaker 1: It's it's it's really it's really interesting because I think that w unwittingly and again another one of my best teachers used to hit one of his favorite sayings was there are two types of people. You ask if we did therapy and training and you know, I did ⁓ ninety minutes a week in that context for six years. Speaker 2: ⁓ as a as a patient, as a subject. You were receiving the therapy, not giving ninety minutes a week for six years. Speaker 1: Yeah, you know. Nine minutes a week for six years, a lot of therapy. And it's also a lot of therapy in that context where you're with other very sophisticated psychologically minded people who are, you know, they're they're interested in this. And and Speaker 2: Yeah. And you what a fascinating population to work with too. Psychiatric residents. Speaker 1: Yeah. Yeah, it was a cool it was a very cool, very cool ⁓ experience. I drive by there to this day and on the way over to the to the office on Dorothy. And ⁓ I still to this day have a little heart tug when I go by because it was such a such a a brilliantly, you know, ⁓ a positive ⁓ ex experience. But I think ⁓ I'm sorry, I lost my train of thought from what we were talking about. Yeah. And so I think that compassion flowing both directions as a father and a son. Speaker 2: We were talking the mirrors and ⁓ Speaker 1: And I think what happens is that if you're if you're not in therapy or you haven't been, my teacher would say there's two types people people who are in therapy and people who should be. And if you're if you haven't been through a therapy experience, and and therapy doesn't necessarily mean you lie on the couch and receive 12 sessions of CBT or whatever, I think lots of things can be therapeutic. But you are involved in some therapeutic practice where you elevate your understanding of yourself and the world and You start to see things more clearly through your adult eyes. Because we all learn about ourselves through our child eyes, which has inherent shortcomings. Right. Yeah. Yeah. Okay. Right. So if you aren't in that practice, then you're subject to the fun house mirror. And then when you become a parent, you use your fun house mirror. Again, not with malice, but you use it because it's the mirror that you have. Right. It's how you see things. And all of the the like the one of the truths of fatherhood is that. All the things that are both like, ⁓ look at that, he does that just like me, and ⁓ my God, he does it just like me. Both happen. You know? Yeah. And and so depending on your own internal ability to navigate that, right? Your response can be very different. Right. And if if it's something that's off-putting to you about yourself, that's an especially volatile, you know, moment in that child's development, right? And you see the thing that you dislike most in yourself in that child. And you respond to it with aggression or hostility or trying to control it or whatever. And of course, inevitably that has the opposite of the intended outcome. Speaker 2: Of course. Yeah. Yeah. Of course. Like, yeah, shame is a very short term tool. Like I mean, in the short term you can, you know, it it will it will modify behavior. Yes. But you know, there's a saying I've sor I've said, like, you know, you can like if your dog keeps crapping on the rug, like you can if you can terrorize him, you can get him to stop. But if you do it bad enough, eventually he won't crap anywhere. Like you'll just won't go. You know, I mean that that's like that's the end stage result of shaming something for having a body. That's right. You know what I mean? And ⁓ Speaker 1: You create the freeze response. Speaker 2: Right, right. You just just like I learned helplessness. Yeah, right. Like I don't know what to do. Yeah. ⁓ Speaker 1: And y and that concept applies in clinical psychiatry a lot. Learned helplessness applies a lot. Well, just a lot of people have for various reasons, some of which may have to do with environmental factors like how parents are approaching things or teachers coaches app approaching things, but also because they just may have differences in their neural development that they're not able to solve the problems that they're expected to solve. Speaker 2: How so? Speaker 1: And a subpopulation that's especially prone to that are people who are really bright and capable, but who have some niggly thing that's in the way. Yeah. And so they are told and then eventually they start to think themselves, Well, why can't I do this? And then they just come to this this point of their resigned to failure. They just will sit down and quit. Yeah. I see it all the time. And it's really sad because you know, that's the greatest resource. One of my patients who was Head of human resources for a big company for a long time. He's in his eighties now. He always says the greatest resource we have as a country is human resources. Yeah. And so there's nothing worse than wasting human capital. Wasting someone who really has amazing potential. Right. ⁓ and all because they were looking in a funhouse mirror. Speaker 2: Yeah. It's just like there or or like life is just a series of funhouse mirrors. And it's it's ⁓ I've you know, for me it's just it's hard to tell. Like now I'm on guard for Speaker 1: Yes. Speaker 2: ⁓ flattery. Like I'm very I'm very I don't I don't encounter a lot of flattery, but it I have a bias, which is kind of like a cognitive thumb on the scale against it. It's much easier if we all have a negativity bias, but for me it's much easier to accept criticism than it is sincere compliments. And then flattery it's like, man, I don't want someone to puff on my ego. Because it's almost like someone's trying to turn me into something useful to them. Right. Sure. ⁓ but ⁓ yeah like that's why you you know What we started this kind of line of conversation when you're talking about difficult conversations. And I've gotten to the point where when people I I the one of the things that flatters me the most is when people can tell me something, can give me real feedback, like criticism, constructive criticism, and say, Hey, you could have handled that better. I would have expected more of you, whatever. Because I'm flattered that they would respect me enough to tell me the truth and ex and know that I'm not gonna be a jerk about it. Speaker 1: No implies Speaker 2: And they care, you know, they care enough 'cause like I encounter people who I could give feedback to. You know what I mean? Like we all do. Right. But it's just like A, this person's not gonna take the feedback most likely. There's some kinds of personalities where they're just they're gonna teach tree as a personal attack. Speaker 1: Amy would say the development of their soul was not ready. ⁓ Speaker 2: You know what it is. That's that's it. You know, I guess that's for people who believe in reincarnation, that's that's probably some reassurance. ⁓ yeah, but it it is it is a cool thing to be able to have that capacity, but it's taking years of work and like calming my nervous system to be able to say and I'm I think just ⁓ there's something maybe it ⁓ it's just a personality thing, but I'm very interested in personal growth. Now maybe that I'm I'm wondering now, does that come from a fundamental assumption of i inadequacy? Maybe. I mean ⁓ that like if I'm just always, you know, wanting to wanting to grow, wanting to learn. I mean, I'm do with photography now. I did this one thing that's really cool and I'm like, all right, now I need to learn how to use the speed light. I've never used that. What can I do with that? And like I wanna you know, a lot of filmmakers are like that. Francis Fort Coppola is just like, I don't want to make another godfather. I did that once, I learned how to do that and didn't want to make a second one. True really didn't want to make a third one. Yeah. But they paid him, you know, a truckload of money and he was bankrupt, so he did it. You know, 'cause he wanted to learn how to do something, it didn't work out. And ⁓ and I get that, but like that's just something I'm very invested in. So I do take that, but it's like I've been in situations where the mirrors that were that were reflecting back to me were were not reflecting in good faith. You know, and that's that's a challenge. So and and we now have a society where you can have a thing in your pocket that will tell you whatever you want to hear. And it's hard, you know, I I guess how have how have you seen that change like as a as a as a physician, but also as a therapist? Yeah. With the age of the internet, Web and D, chat rooms, social media, I mean What's the change been like? Speaker 1: Yeah. So I I'm glad you asked that question because it's one of my favorite topics and it's become more and more germane over the years, right? I mean it's just been this interesting progression. Yeah. and I do think like a lot of times again, this the sort of the final stop on the journey. A lot of times people have got a lot of that out of their system by the time they find us, so we'll probably not get it quite as much. But the way I the way I try to explain this to people is there's intellect, right? The native ability to learn, right? You you some people Speaker 2: Okay. Speaker 1: just have better intellectual capability. And that's n neither good nor bad, right nor wrong. It just is. Okay. Then there's knowledge, which you accrue through experience or study of one type or another. You can have a database in your in your brain. And then there's wisdom. And clinical wisdom is a is a peculiar thing because you can't get it in the short term. It's impossible. Like no one can have it. There is no such thing in my in my opinion that there can be brilliant young surgeons Because they can go in and they're doing some procedure that is a mechanical thing and they're especially adept at that. And they could be brilliant in that sense, but maybe your their colleagues would argue, but they're not brilliant in the post op, or they didn't really always select the right patient for it. But they could be brilliant in that sense. They have this, again, this ⁓ fluency with a procedure or some technical thing. But there are no such things as as brilliant young psychiatrists. They just don't exist. Because so much of it is walking the path over a long period of time, appreciating the developmental context, watching how things unfold. No one can no one can tell you that. And even if they could, they'd have to tell you seven billion different. You know, versions of it, right? So each time people say to me, Don't you get tired of talking to depressed people? And I'm I'm like, no, I don't. Yeah. And the reason I don't is because ⁓ I've never I've never encountered two people with depression who were exactly the same. Everyone's story is different. The ⁓ the famous story about the tennis star Billy Jean King, she I've never seen the ball cross the net twice in the same way. So she had this keen ⁓ observational ability of the ball. She was attuned with the ball. So she recognized that there were four in cross courts and down the line or volleys or whatever you might be, but no two were exactly the ⁓ exactly the same. Speaker 2: Yeah, yeah, that's interesting. And there's there's a ⁓ what caught my attention was the attentional component of what you said. Yeah. She sees the ball. Like she can follow the ball and she remembers. That's kind of how it's gotten with me with photography. And I'll tell people like, well, or movies where I'm like, no, but in that shot in the beginning of the second act when you did the thing and it was using a zoom on that, and it was that people are like, What are you talking about? Like, what shot? You know? And ⁓ but when you just you train the brain, you can do that. And I bet that there probably are some things where you have some cognitive shortcuts. you can employ where you just you know. It's like you said, like, okay, well, you've got this thing, you're thirty years old, you probably didn't have a heart attack. So this might be, you know, I just know from experience that ⁓ right. What are some of those things that are like the no brainers kind of if if w if there were such a thing in psychiatry that where it's ⁓ if it's when it's present, it's a pretty reliable indicator of like a bad mood or Speaker 1: Well, th that sure. I mean I think like one of the things that's lost and it's a it's a shortcoming of certain ways that that clinical psychiatric medicine is delivered and psych psychological medicine is delivered, is that if you're not in the room with the person and again I'm look, I do telehealth, I'm a proponent of telehealth. I think the fact of it is is that, you know People like me are in very short supply and like lots of people need it. They a lot of people who need it can't get in the car and drive to Nashville right four hours one way or whatever. It's like ⁓ or they can't do it with any regularity. So so, you know, it is what it is. It it's like everything, right? It's a mixture of positives and negatives, you know. ⁓ Things that make it good and things that make it maybe not so good. But one of the things that's that's missing is the ⁓ observation of the person in the room and like their psychomotor activity. Like ⁓ you said, what's an indicator of depression? ⁓ because it true melancholy is such a physical experience, people who have had it will tell you it's a whole body experience, you know. It's not just feeling sad or having a low mood. And one of the things is the the psychomotor retardation or agitation and atypical depression. ⁓ the rhythm and tone of voice. ⁓ I always ask people ⁓ something to start with like, Hey, what's been going on? Or you know, what are you what are you up to? You know, and and I do that with intent. You know, part of it is I think just like developing rapport is super important and like getting to know people is important. Like what's up in their life, what's going on with their family, their friends, their interests or whatever is important. But another part of that is just where does the mind go spontaneously? And again, sticking with the example of depression, people's minds will go to the negative. Like, well, I thought I had this opportunity, but Speaker 2: media. Speaker 1: This happened and I guess I guess I just am never gonna have an opportunity. That happened, that's disappointing, but like maybe maybe you could work around that, but that's not occurring to them. Yeah. But back to the whole advent of the internet, chat GPT, intellect, knowledge and wisdom. I try to tell people people will bring me stuff from Chat GPT or you know, other AI models. They'll they'll bring me things that they've searched on the internet and I'll say, Okay, like this isn't necessarily wrong. It's just not right about you. Yeah. One of the great paradoxes of clinical medicine is you know if you think about the bell curve, right? You know, the famous, you know, all right. And so in the bell curve model says To practice safely and effectively, you really need to know about plus or minus two standard deviations from the mean, what constitutes the developmental norm and distribution of characteristics, all biological characteristics seem to follow that if you collect a large enough sample that exists on a bell curve. But the the clinical conundrum. And again, back to I've got some six or eight or twelve week or even a one-year study, which is a short time in the development of a human being. And then it said that this particular intervention yielded this particular result. It's it's like the study tells you about a trend in a population, right? Which is great. It's helpful. You gotta have that. And in fact, I would again, to be fair, you can't practice safely without that. You need that knowledge base. However Then we have the paradox that we're sitting with a group of one and we don't know where they are on that bell curve. Right. And so your job is to discover where this person is. Right. And guess what? Again, they're not always where you think they're gonna be. Right. And they don't always tell you right away either. Speaker 2: Yeah, they may not know what to tell you. That's another thing you've thought of el elsewhere. It's like why fifteen minutes is not enough time. Because they there may be something super relevant and you're like, there's a because we have blind spots. We all have blind spots. That's one of the ways that like the mind works to protect us is spot on. Yeah. Speaker 1: You're absolutely spot on. And one of things that good doctors in my world, this type of medicine, do is they teach people how and what to tell them. Like by asking questions Does that make sense? Speaker 2: Interesting. It's almost like a leading question. Yeah. But one that's not it's not necessarily leading to a result, but it ⁓ does presuppose maybe two options. I so I ⁓ people Speaker 1: People, Andrew, people ask me, or people will say to me all the time, no one has ever asked me this. And they'll have been through, they'll have been to a half dozen different. Speaker 2: Can you give me an example of a question that people say without kind of Speaker 1: Some of them are basic things. I mean like just very basic things, things that I would consider like just, you know, people that have had chronic treatment, refractory, ⁓ you know, ⁓ let's say, you know, depression or anxiety, and no one's ever asked them about the possibility of hypomania or mania, which would, you know, change the course of their treatment. No head injury. People say, no one's ever why are you asking me about head injury? I'm like, You know, and and and again Speaker 2: It's almost like the brain isn't relevant to psychiatry. Speaker 1: Yeah. Well, you know, the the historical criticism, the only specialty that doesn't examine the organ it treats. Yeah. Yeah. ⁓ and that's changing. You know, imaging technologies come along, quantitative EEGs, functional MRI, pet spec, Dan Amonds made a whole career out of spec. I mean, it's like, yeah, there's there are ways, there are ways to kind of look at it. and in and to explore what's under the hood now that didn't exist. But I'm I'm when I say people say, ⁓ gosh, no one's ever asked me that, I'm talking about things that I would think of as basic things. Like not asking me, ⁓ for example, about you know, i if you've traveled, I can ask people that, have you traveled? Because, you know, people get exposed to things. Right. Right. Yeah. Traveling. And we've got a patient right now who had a abrupt onset of some particular symptoms that could be construed as pandas and this person has had ⁓ exposure to a parasite. And sure enough, although it's traditionally associated with strep, there are reported cases of parasitic infections producing the antibody that attacks the basal ganglia and produces a, you know, abrupt onset of ⁓ Speaker 2: Pendant what is pandas against a neurological Speaker 1: Pediatric autoimmune neurological disorders associated with strep. It's quite a it's an acronym. Pandas. Yes, pandas, of course. Of course, PANDAS. They're the jolly bear. Speaker 2: Got it, got it, got yes, I remember. I remember the one that everybody's really fascinated with their sex life. Yeah. Yes. Yeah. ⁓ yeah, so ⁓ yeah, what are like I've what are the role of things like ⁓ in your practice, diet, exercise, sleep, lifestyle? I mean ⁓ how much of your time do you spend on those factors relative to everything else? Speaker 1: Okay. So I call it getting the biological trains running on time. All right. And this this is another thing like the whole effect size and predictability on an individual basis. Another this is another one of those areas. So let's say that you have a novel antidepressant. And let's say that it produces a you know, has an effect size of point four, which you know on the on the standardized inventories we're applying, you know, it's good. It's really good. It's great. Yeah. Yeah. So forty percent reduction. That's awesome. Yeah. What about the other sixty percent? Speaker 2: Yeah. Speaker 1: This is like in the in the in the opiate crisis world, like you know, opiates like a ⁓ an opiate drug will on average reduce pain by about 30 percent. Where's the other 70 percent? Right. So so the we've known for forever, I mean again, this isn't anything new, we've known forever that physical exercise is enhances brain function on all levels, but especially cognition and attention, executive function. We've known that diet, like I mean, you know, here in the United States, I mean my my joke that I I say to I I I t I tell kids things like McDonalds, I tried to think of the least appetizing name I could come up with and I I came up. I came up with non nutritive gruel. I said Speaker 2: Yeah, that's a great way of putting it, yeah. Speaker 1: No. ⁓ but my my nickname for the ⁓ the the American diet, this if you think about it, the standard American diet, what's that an acronym for? Speaker 2: ⁓ That's so true. It's a sad diet. Sad diet. It really is. Yeah. Yeah. That's just yeah. So seasonal affective disorder too is also sad, but yeah, like it's you don't get enough sunshine. You have sad yeah. Like I mean basically that's it. Like you're not getting enough vitamin D from your skin and like you're sad. Speaker 1: It's the And it's like, you know, all the things that your mom or grandmother told you growing up turn out to be true. It's like you are what you eat that's literally true. Speaker 2: Yeah, yeah. Speaker 1: Yeah. And it's being supported by something. Yeah. And and so like we've known for forever the Mediterranean diet. There was a tongue in cheek article on Medscape a few years ago saying should the Mediterranean diet be approved by the FDA for the treatment of depression? And basically the premise was, you know, for a drug to get approved, it has to have two studies well done where it, you know, exceeds or eclipses placebo and shows a favorable safety profile. And at that point there were three studies showing Mediterranean diet, accomplish those things. And it's also cardiovascularly probably the best diet. ⁓ what kills Americans cardiovascular disease at this point, right? So Speaker 2: Or stroke. Yeah. Speaker 1: Yeah, I mean, yeah. Exactly. Exactly. So so the ⁓ the Mediterranean diet, again, which is easily accessible for most people, fresh fruit, fresh veggie, nuts, legumes, right? Olive oil, fish, olive. So if you eat that, ⁓ there was a was there have been a number of these, but there was a recent study that said for mild to moderate depression, exercise is as good as Prozac. This again, this is a repetition of an old study. That's not even good Speaker 2: That was a Duke study, it the original one, right? And then somehow nobody wanted to find out more. Yeah. Right. Right. Somehow there's not much of an incentive to find out that like something you can do for free works as as good or better. Absolutely. Speaker 1: Yeah. Absolutely. And and that is good for you, period. And there really isn't like what's the downside? I mean, I guess maybe you get a repetitive motion injury or something. You could argue if you That's true, you know, long enough. You run it. But but when you think about the risk benefit the risk benefit analysis of antidepressants, for example, versus exercising. And and I think most patients when I say exercise, they think I have in mind they're gonna train for the Music City Marathon or something. I'm talking about taking a brisk walk. Speaker 2: Yeah. Yeah. Well it's for some people that's enough stimulus to be exercise. Yeah. If you're sedentary. Well going up the stairs instead of the elevator, just getting slightly out of breath on purpose several times a week. Like that's really what you I mean ⁓ Matthew McConaughey's got a witticism which he's good for is like just try to break a sweat every day. Yeah. I mean, like it's just like you don't have to remember this many beats a minute of whatever and like thirty minutes of zone two and whatever it's just like just break a sweat every day. Like and not from going to the fridge. Like just do it like you know on purpose. Speaker 1: Not from going to the fridge. Speaker 2: Yeah, yeah, you know, it's like I've got this tub of of ice cream that I'm bringing back and it's like a load. Speaker 1: You know, the so the Mediterranean diet is famously anti-inflammatory, right? And so, you know, one of the things we know is that inflammation in the deep limbic system is associated with depression and anxiety and bipolar syndrome. I mean, all these things. And and so anything that will calm inflammation, you know, omega-three supplementation. But you mentioned so we kind of hit diet pretty hard. Exercise. I mean, it's a no-brainer, no pun intended. There's pretty good evidence that if you vigorously exercise, it releases in the frontal ⁓ cortiquaries about the same amount of dopamine from taking five milligrams of methylfinidate. I believe that. ⁓ yeah. Speaker 2: It's very and ⁓ I found that ⁓ What I I was fascinated with at one point I was, you know, I've talked to you about doing PhD and ⁓ and I was interested in neuroscience for a while and I'm glad I haven't gone down that road because I realize I'm more interested in then in people than data. I don't want to be in a lab looking at data the rest of my life, but ⁓ the neuroscience of exercise. Why does it make me feel so good? Like that's really just it's a and there's a kind of a profound thing because exercise or physical exhaustion, physical activity is kind of a component in a lot of spiritual practices. Speaker 1: Absolutely awesome. I was thinking the same thing. Speaker 2: Runners high flow states. Like they're these non-ordinary states of consciousness. Yes. ⁓ Courtney Do Walter is is a ⁓ one of the best ultra runners in the world. I think she I don't know if she's still in the still in the sport, but she won the Moab two forty, I think like three years in a row. And she's this, you know, little woman. She's just a beast. And she's she talks about going into the pain cave. And she'll hallucinate famously. And these critters will come visit her. She'll get two minutes of sleep in a in a two hundred and forty mile race in the desert. But she goes in the pain cave and it's like it's like a womb or something. And there's a Speaker 1: Yes. Speaker 2: ⁓ dissociative element probably it's almost like people describe ketamine being a khole and ⁓ yeah but there's this non ordinary flow to it with rip the repetitive movement and ⁓ i was always fascinated by that and and and for me there are different kinds of exercise I think the thing that's ⁓ I ⁓ met with ⁓ psychophysiologist Ryan Olson who's I was at UNT he's part of this kind of movement now of people trying to figure out a way to to give prescribing guidelines to physicians. For exercise, because it's clear that there are different interventions are good for different things. Strength training is different from high intensity cardio versus low intensity cardio. And for me, low intensity, what I you know, before here, I came and was like, I need to not be sleepy in the afternoon. If I get on a bike, an exercise bike, and ride for 50, 60 minutes at a low heart rate under 130 beats a minute, it's so stimulating. I've got to be careful about how late in the day I do it. ⁓ and whereas if I go run or I do something high intensity, I'll fall right asleep. Like it's like a sedative. And I can use them that way. Speaker 1: It modulates different networks and different ⁓ neurotransmitters. Speaker 2: But you five milligrams of methylfinidate and I'm like, Yeah, that checks out. That's about right. That's about right. But it but there's no downsides to it really. There's no downside. Other than you gotta eat some more food, you know, which some people would see that as a benefit. And like hopefully Mediterranean, yeah. Speaker 1: It's better. Yeah. Hopefully Mediterranean. But no, there there was something recently, you know, because I have an eye on the I mean, on any given day, I might have a seven year old, a twenty-five year old, a forty year old, and an eighty year old. And so I'm sort of like, hmm, so what what's going on in these on these, you know, the extremes of lifespan? But you know, one of the things that's I mean, tr a tragedy and we're setting ourselves up for all manner of problems as a nation is the obesity epidemic in kids. Like I I see so many kids in my practice who are who are obese, obese. I'm not talking about know, growing up we all had Yeah, yeah. I was I was a chunky kid in middle school, you know. and and then I sort of grew as my grandmother used to tell me, you'll grow into your weight, don't worry, you know, that kind of happened for me. But I mean I see people who are morbidly obese as kids. Speaker 2: Well well maybe fat or whatever. Speaker 1: Right. And so there was this this article again talking about how HIT training, high intensity training, was preferentially effective for these kids and helping them get their weight down the ball. And it's like you know, you need to and it's it's very it's very like scientifically, you know, presented like, you should get your heart rate up and you should do it X many times in this interval and then you should you should do it this many times a week. And it's better if you do it for a longer period of time than meaning like over a longer period like of weeks and months, right? So and I mean again the I one of my aspirations in life is not to become an old man sitting on the front porch complaining about the government. This is one of my central life. ⁓ Speaker 2: Stick to it. Yeah, okay, good. ⁓ Speaker 1: Somebody throws the ball, you take off run running after I'm gonna play quarterback, you know, like okay, well, I'll be the tight end, you know, whatever. You're running around and you're doing these bursts of activity and you do it every day. And it was built into your life, right? That was just something that you did. I even at 39, you probably did that. Yeah, my son and I talk about my oldest son is 33. We talk about this. He just missed some of this craziness. Like, let's don't have recess in school. Speaker 2: There's no recessing Really. Speaker 1: Anymore. There's no well, or very little. Really? Yeah. Recess. Well, because Andrew, after all, the most important thing is the number you get on that test, you know. Speaker 2: That makes sense. That makes perfect sense. Right. And of course the best thing you can do is l give them recess right before they do the test because the neuroplasticity will be higher. Yes. Speaker 1: Yeah. Well right. I'm so glad you said that. You know, the the vigorous exercise enhances cognitive function by virtue of release of B DNF, brain drived neurotrophic factor, but known in in neuroscience circles as miracle growth. You so you literally fertilize the neural soil with exercise. Yeah. ⁓ and yet we we just decide like we should we should take that away so we can have, you know, twenty more minutes to study for I don't know, whatever. Speaker 2: Yeah, yeah, yeah. Whatever kind of math they're teaching, it ain't sinking in. Like it's n twenty more minutes isn't gonna matter. You know, but I guess that you know, you could probably pay teachers for a few extra days because there's probably a number of hours per year the students have to be in school. So like that means that you can chop off days of pay. Yeah. At the end if that makes sense. So it's a probably a cost saving measure too. Speaker 1: Well, I'll I'll throw a shout out here to my good friend ⁓ David Steiner, who is ⁓ heads up ⁓ think tank at Hopkins on education. And ⁓ so David, you know, he travels the country trying to understand what's going wrong and how to remedy it. He wrote a lovely book about this if anyone's interested. But anyway, the the ⁓ the the fact is is that for the first time I measured IQ and performance and all these different cognitive parameters are going down in the population. They've historically gone up, up, up. Mm-hmm. Right. And I think it's the most recent generation that they are now distinct. Speaker 2: A lot right probably right on life expectancy. Speaker 1: Yeah. And so so they're not learning and like again, is it by complete chance that we took things like exercise out of the school? Is that is that maybe that had something I'm not saying it caused it. I mean I know that it's multifactorial obviously. But ⁓ it it didn't help. Speaker 2: Yeah, that's interesting. I wonder I've remember that because there's this thing called the Flint effect where IQ goes up or you have actually doesn't go up. You have to keep resetting the norm by about three points a a decade, which is fascinating. I mean it shows that like there's a lot of theories about why that is. I think a lot of it is that there's some clearly some environmental factors that will definitely pull your IQ down. We don't put lead in our paint anymore or in our gasoline. Like that probably has a lot to do with it. ⁓ you know, people don't make a habit of handling mercury or or you know, I mean like that there's just there's things that we do. We wear helmets during football now. Right, yeah, yeah, yeah. ⁓ but ⁓ I wonder if those numbers like the IQ and those are going down, is that just in the United States or is it just in the industrialized world? Are we seeing it outside of the industrialized world? Speaker 1: Yeah. Data I've seen is in the US it may be true in a broader sense. I couldn't speak to that. Speaker 2: It's interesting. Yeah. Yeah. And do you think that ⁓ what else besides lack of exercise or her sedentary lifestyle gaming, you know, like what do you think could be contributing to that? Speaker 1: ⁓ I th I think that the the screen addiction is a real thing. And I think that it you know, it's being introduced at younger and younger ages and it it it's d definitely impairing one's attention. I c I call, you know, and again You know, my son's a professional gamer, so I'd have to be careful what I say. But ⁓ I think that ⁓ certain types of gaming. My son is engaged in a type of gaming that's ⁓ problem solving gaming. He calls it ⁓ poker meets chess, which is probably right. But a lot of the a lot of the gaming that goes on, it's I call it the anti neurofeedback because it trains your brain to have short attention ⁓ and to expect a reward immediately. Speaker 2: Right. One thing I've noticed and I don't game, but I you know I have in the past that's very insane is there are these things called loot boxes that are and I'm not you know I'm not a gamer. There's a whole psychiatrist that's dedicated to gaming, healthy gaming. I told you millions of people that's about five million followers. American Psychiatric Association just published something saying that they've looked at like Speaker 1: Yes. Healthy gamer. Which says something, doesn't it? Speaker 2: That ⁓ that about him and about his coaching program because they're saying people are getting more out of his guidance than their own at the American Psychiatry Association. That's shocking, yeah. That's interesting. But there's a thing like these loot boxes, I guess in like a in a in a game where it's just this big world, it's a sandbox game where you can just play, do whatever you want. There's whole side quests you can do, whatever, but it's you just you're there forever and it's a game that never ends. Like you never have to beat the game. So it's a good game to make. ⁓ There's a loot box and you find it and you'll get like equipment or money or gear or whatever, but there's always a little ching, like and some stars that'll go up. Yes. And these things that will prime, you know, dope a dopaminergic response of like a little reward of like, ⁓ there's a little bell that goes off every time I get a loot box. And don't of course it is. Speaker 1: Don't think that's bad. So so I I I mean, I was at a conference one time and I'm I'm a friendly type and my wife is a psychologist, I said earlier, and there was a nice lady seated beside me, and you know, we just kind of chatted a little bit as the conference was starting. So at the break, we're getting a coffee and a ⁓ croissant or whatever. And I said, ⁓ see, you're psychologist. What do you do? What kind of are you clinician? Researcher said, ⁓ I work for the gaming industry. And my my first response was Vegas. I said, ⁓ so you like you work for the casinos or you like a riverboat and you know, gaming? Yeah. She looks at me like I'm a total idiot. And she goes, No, no, no, gaming, you know, gaming. Much bigger industry. And I I said, ⁓ I'm still having a moment of being dense. And I said, ⁓ I don't know, what do you mean? She goes, you know, like EA sports. Yeah. That kind of thing. I was like, gaming. And then again, the naivete persisted. I Well, what do you do for them? And she looks at me, she goes, I design reinforcement protocols. This is a sophisticated way of saying I make it a day. Speaker 2: Make it addictive. Yeah. Well, and you know, algorithms kind of do that on their own. They evolve to be addictive and we're ⁓ we don't know why. It's just what gets people to use it more. Yeah. But yeah, that's there's it's almost like you know, a physician, a heart a cardiologist that works for this, you know, the tobacco industry. Like that's just like I mean, there's something like I not to throw any shade at the people that do that, but it is scary that you know the number one job in Silicon Valley are cognitive scientists. ⁓ like that's who's getting hired. Of course. You or computer scientists, but even them, the AI can do the computer science in a lot of cases. They need human computer inter you know, intervention. facing experts and that's scary. So it's like we have as a society a lot of things working against us. ⁓ I we're getting close to time to wrap up, but I want to ask you about one more thing since we're on the subject. Yeah. I think Australia has set a a minimum age for social media at 16. Right. And I I just saw this was on real time with Bill Mar this last week. Someone was talking about it that there's a site the the example was used Stephen Pinker is a great cognitive scientist in Harvard. He has this Speaker 1: ⁓ right. Speaker 2: wonderful book out now called ⁓ what happens when we all know that we all know something like that. And there's it's common knowledge. Like when it's it's the Abilene paradox, but no one really wants to go to Abilene but no one wants to say it. And then someone admits it and everybody's like, Well who wanted to go in the first place. ⁓ that now that one country has agreed to ban it, a bunch of other countries are sending this, you know, or go s following suit. Right. And there's an interesting thing and I'm not a parent, obviously maybe that's not obvious. I'm not a parent. ⁓ but I you know, I have lots of age peers now. My brother and sister both have have young children, and my sister's an educator. ⁓ the challenge of having a child and who's gonna say, All my friends have this, and you have as a parent, like there's that there's that cohort model of development. You don't wanna deny them that, but you know it's also not good for them to be on their phone at, you know, on the social media at 11 or 12. And it's almost like mutually assured destruction. Like th there's it's like the nuclear arms race where at some point we had to get together with the Soviets and start saying, let's just agree to like we'll draw down if you draw down. And that's kind of what it has to be at a societal level that everybody we have to ban it for everybody or else right nobody's gonna prevent their kids from doing it. ⁓ what do you think about that just as a I mean, as a child psychiatrist and as a parent, you know, about banning social media at at that age and Speaker 1: Yeah. Yeah. Yeah, and to some degree, I mean, my oldest son, ⁓ he'll he'll tell you if you were sitting here with us, you'd say I dodged a bullet with all that. And 'cause he's just old enough that it really wasn't on the phone. Yeah. And and and you know, he he's just for a variety of reasons, I think it wasn't his temperament to be into that sort of thing. But our younger boys, Amy and I fought the good fight, maybe a certain degree of naivete, without that experience necessarily with Mason, fought the good fight on ⁓ keeping the keeping those devices out of their hands. Hands until ⁓ they were 13 or 14. They've had them, they've had them now the last couple of years. We've truly tried to have parameters around it in various ways. ⁓ one of the parameters that I encourage parents to have is that at any point, if I say, hand me your phone, you hand me your phone. And at that point, I'm I'm sorry, I may be violating your privacy, but I'm gonna look at your text messages, I'm gonna look at where you've been on the internet. And maybe there are programs that do this. And I prefer the personal touch, which is instead of Instead of like, ⁓ you know, covenant eyes is gonna tell me you're looking at porn or whatever, ⁓ then I'm gonna see it and then we're gonna have a conversation. Speaker 2: It's a difficult conversation about it. Right, Jeff. Right. I bet. I think you as a father. My God. You haven't even asked about that. Okay, go ahead. Speaker 1: Yeah. But but you know, and I I think that again, those kinds of safeguards, ⁓ you know, our boys, neither one of them, it's never really been a problem with them, although I think that they're so from a personal level, we've I think we've navigated it reasonably well. That you alluded to the whole idea of the cohort effect and that is definitely an issue. I mean they were I my boys were from the time they were ten. They were like, everybody else has a phone. Why don't we have a phone? Y'all need a phone, blah blah. I'm like, you don't need a phone, right? I'll get you a flip phone. Well what if there was an emergency and I can't call you? Well I'll get you a flip phone. No, no, no, because then I've got you know it's Speaker 2: Like, leave this dork with a flip floam. But billionaires like them now. Yeah. They won't let their kids on. Yeah, Facebook, the people that work there won't let ⁓ kids on them. Yeah. Speaker 1: Right. Well all the rebelli dudes won't let their kids Yeah, so so I mean, I think I would encourage people to definitely put it off as long as you can to appreciate that there probably are benefits to having it and being being part of the group and you know, messaging one another and you know, they what one of the things I figured out they do is they do these FaceTime calls that last all night. You know, and they have all their friends on the FaceTime call and they're all talking to each other. Yeah. Or they're, you know, sometimes I come in and they're doing homework together, which is kind of cute and sweet. And you know, and that's that's fine. But ⁓ just also being really clear that, you know, when you're thirteen, fourteen, fifteen years old, as a neuros psychiatrist who thinks a lot about neural development, that child doesn't have the frontal control to exercise good judgment around those things. That's right. They need their parents to help ⁓ with that. And of course they're gonna resist because that's their job as a teenager. Speaker 2: Control load control inhibition and Yeah. Yeah, it's to be resistant. Yeah. To be individuating and later. Yeah. Speaker 1: Yes. Yeah. But then they're gonna love you for it later. Now the social media thing, there's that phenomenon in adolescence called the imaginary audience, right? So I imagine that I'm the focus of everyone's attention. A corollary of this is the 20, 40, 60 rule, right? When I was twenty, I said to myself, I have to date the right girl, wear the right clothes, drive the right car. When I turned 40, I said, I'll date who I want, wear what I want, drive what I want. And when I was 60, I realized no one ever cared anyway. Yeah. And and so you're delivered from that imaginary audience through your adult development. But as a teenager, it's very real. And so one one of my 20-something Vanderbilt kids said to me, my favorite comment ever on social media, she said, you don't meet the person, you meet the representative. Right. And it's hard as a kid to understand that, that this is curated. And I say to young patients, well, how many times have you seen like images on your feed, your Instagram feed where people picking their nose? Speaker 2: Yeah. Speaker 1: Have you seen any videos of people stumbling and spilling coffee all over the brand new suitor dress? What about a video clip of the knockdown drag out they had with their family last night? You see any of that? Right. Yet do people pick their nose, do they spill coffee, do they get in fights? Right. They do, don't they? So what are you seeing? Like you're seeing, you know, this is curated or selected. It's to put forth a particular impression about things that probably doesn't fully reflect reality. But if you buy into that You think, look how fabulous their life. What's wrong with mine? And that's part of that imaginary audience. And then when you put an image out there, you imagine that people are if they don't think I hear all the time, I posted and no one liked it. Well, I mean I tell my boys, like, well, maybe they were doing their homework or maybe their parents had good judgment. Maybe they were doing their homework. Yeah. Getting some tennis balls. Right, right. That's right. You know, maybe they weren't looking at their phone going, When is he gonna post? You know. ⁓ and so again, because there's that natural social anxiety at that age and that natural comparisons going on, it drives people to levels of anxiety that I again, I I d I don't think it's happen chance that the incidence in the clinical level of anxiety has gone up, up, up ever since the introduction of the iPhone and social media. Yeah. Speaker 2: Of anxiety. Yeah. Well there's Jonathan Heights book, The Anxious Anxious Generation. Yeah. You know, this is written a lot about this and it's ⁓ it's kind of scary. Speaker 1: It's spot on too, by the way. I mean I can tell you from a front row seat these Speaker 2: You're just seeing a rise in anxiety disorders in adolescence. Absolutely. Is that tracking is it or is that ⁓ being followed by a rise in like prescriptions for of course. It's gotta be, right? Of course. Benzo dizebins or Right. Yeah. Or or any other anxiety drug. Yeah. Speaker 1: Sure, anxiety medicines and you know, like, you know, ⁓ you know, the ⁓ SSRIs and these type of medicines, you know. And and again, it's not that those are medicines don't ever have a role, but like if you if you well, okay, fun fact. So if depending on the let's let's take ADD, because it's an especially good example. ADHD is a powerfully biologically determined condition. That's you know, the her heritability coefficient, which is a measure of how much of the phenotype that you ultimately see is biologically driven. It's about 0.8. ⁓ okay. Yeah. So 80% of the phenotype is driven by biological or genetic factors. It's highly heritable. And then people say, well, that means 20%'s environmental and and it's true. So you know, you can you can do environmental things and that can help. It's not to say that environmental things never help, but it's the bulk of it. If you look at depression or anxiety, it's about 0.55. Okay. That means almost half of what you see is environmentally driven. Right. So environmental decisions that you make, like do you exercise, do you sleep, do you eat a healthy, balanced diet? Do you stay away from toxic things like alcohol and drugs? Do you stay away from toxic relationships? Like do you curate friends in a way that they are going to affirm you and build you up and really love you and support you? Or do you have people that to your which mirror are you looking in? Right. Because in adolescence, your friends are your primary mirrors. And they all have underdeveloped brains themselves. Right? Right. Speaker 2: Right. Terrible judgment. Them and meth addicts are just like a group. Right. Never want to ask for advice, right? Because they're a meth addict, they thought it was a good idea to ask ChatGBT about how much meth to take and like there you go. And there's this is the some things, you know, kids, adolescents will say things you're like, what in the hell were you thinking? It's just so boneheaded, but it's just it's what they're like. Speaker 1: Just go ahead and tell ⁓ what you really think. Right. Yeah. I can't I can't I I I lose count of the number of times I've said to adolescent patients that I worked with, if you have to start it with, okay, I don't mean to offend you, but yeah. Just keep that thought to yourself until you can think of a way to deliver it in a more kind, compassionate way. Speaker 2: But I mean half of depression and anxiety come but ⁓ roughly half comes from the choices we make. You know, I don't I think there's probably no better way to wrap this episode up. So ⁓ thank you so much for joining us and I'd love to have you back. An episode break coming and got another we're gonna record soon, but that'll be out a little later. All right, thank you so much, Doctor Carter. My pleasure. We breaking? All right, great. We'll have enough time for yeah, maybe a little Speaker 1: Middle factor. Absolutely. I'd love to. ⁓ look forward to right. ⁓ good, okay. Yeah.