Hi. Good evening. My name is Gina Vild. I recognize so many of
you from past years. I'm the Associate Dean for
Communications and External Relations at Harvard
Medical School. And it is my great
pleasure to welcome you to our second Longwood
Seminar of 2017. This is the ninth year in which
I've introduced the Longwood seminars. And as you know, we
asked past participants to choose the topics each year. And I can't remember
in nine years having had a topic
received this many votes and this many registrants. So I think we're
all very excited about tonight's speakers
and about the topic. 16 years ago, we introduced
the Longwood seminars, or Mini-Med school,
as a way to give back to our local community,
to our neighborhoods. And we wanted to share our
research, accomplishments, and our medical advances
with our neighbors. We've changed our form over the
years and now we live stream. Last year, the Longwood
seminars were viewed live in 36 different countries. So, to all of you
who are watching us from those 36 countries
or more, and all of you in the auditorium
tonight, welcome. Is there anyone here who
has never before attended a Longwood seminar? Oh, a few. Well, I hope you're
in for a treat. And we hope you'll become part
of our Longwood Seminar family. On the screen in a minute,
you will see some information. If you would like to receive
a certificate of completion, or if you're a
teacher and would like to receive professional
development points, we have information on
how you can do that. If you'd like to view any of
our past Longwood seminars, or would like background
reading material on this seminar
or past seminars, please view our website. And I want to ask you to
please turn down your phone but don't turn it off
because we are hoping you will join the
conversation on Twitter, and we encourage you to
tweet on hashtag Mini-med. Mad And now, for our program. Fear is a feeling induced by
a perceived danger or threat. It causes changes in our brain
and organ function, as well as our behavior. Fear is a catalyst
for fight or flight. It sparks a primordial
response that has safeguarded the survival of our species. But this healthy
defense system also can be a catalyst for anxiety
and for anxiety disorders. As the author Jodi
Picoult said, anxiety is like a rocking chair,
it gives you something to do but it doesn't
get you very far. So, what can we do about it? Tonight, our expert Harvard
Medical School faculty will explore the roots
and origins of anxiety and importantly, they will tell
us how it could be managed. Our moderator is Dr.
Isabelle Rosso, Director of the Anxiety and Traumatic
Stress Disorders Laboratory, at our HMS McLean Hospital. Her laboratory was founded in
2014 and as part of the Center for Depression Anxiety
and Stress Research. Dr. Greg Fricchione is the
Mind Body Medical Institute Professor of Psychiatry at HMS. He is the founding director of
the Chester M. Pierce Division of Global Psychiatry at
Mass General Hospital. In 2006, he became Director
of the Benson Henry institute for Mind-body Medicine
at Mass General. Succeeding Dr.
Herbert Benson, who was once a speaker at
our Longwood seminar. Dr. Courtney Beard is
a clinical psychologist with expertise in anxiety
disorders, cognitive biases, cognitive behavior therapy,
and treatment outcome research. She is an Assistant Director
of the Clinical Research Program at McLean Hospital's
Behavioral Health Partial Hospital Program, and Assistant
Professor of Psychology here at HMS. She is internationally known
for her work on cognitive bias modification. Please join me in welcoming
our esteemed panel. [AUDIENCE CLAPS] All right. Thank you very much. Is my microphone on? Yes? I hear it now. So, thank you so much for
that great introduction and thank you for inviting me
here today, and to all of you. Those of us who are
in Boston inside here today, instead of being outside
in the first 80 degree day we get this spring. Thank you for joining us. So I'm going to talk
today about fear and how we learn to fear,
how we learn not to fear. A little bit about where and
how that happens in the brain. And then transition
to explaining a little bit about how,
in psychology, we've applied some of what we know
about fear-learning principles to how we do psychotherapy,
to one of our psychotherapies. So there we go. So as was mentioned
just now, fear is really an emotional response. And it's triggered when
we perceive a danger or a threat in our environment. It causes a change in
our brain functioning, in our body functioning,
and in our behavior. And of course, most,
if not all of us, are familiar with the
idiom fight or flight response, or fight or flight
or freeze response, which is really the behavior
part of fear, right? Fear can cause us to
confront a danger, it could cause us to
run away from a danger, and it can cause us sometimes
to freeze on our tracks. Types of things that we fear. There's a few that
are the innate. And the fear of
heights are really the fear of falling
is an example of that. You see this in little
babies and kids. We have this hardwired. But really most of
our fears or learned. And you see here on the
bottom of the slide, a little boy who's reaching
towards a hot stovetop. There is no innate
reason for him to be afraid of this
stimulus, of this situation. But if he touches
that hot handle and in that moment
gets burnt, he will learn very likely that
this is a dangerous stimulus. And he will learn to fear
and avoid that stimulus. And this is adaptive, of course. This is an example of
adaptive fear learning. Which is a very important
thing to remember, is that fear is really
hardwired in our brain because it allows us to survive
or escape dangerous situations. So this is a very
well-known schematic from Joe LeDoux, one of
Joe LeDoux's publications. Dr. LeDoux is an
internationally-renowned, and really pioneer, researcher
in the field of fear. And he shows the idea that
if you're walking around in the woods and you see a
snake, your body and your brain will mobilize a fear response
very rapidly and outside of your conscious awareness. And essentially,
what happens is that, of course your eyes
initially see the snake, and very quickly there
is a very rapid pathway by which this
information gets taken to an area of the brain
called the thalamus, and then to the amygdala, which
is really a region that I'll be talking a bit about today
because it is centrally positioned to then mobilize
all your bodily systems and create a fear responses. So this is an example
of adaptive fear, right? You escape the snake,
you don't get bitten. There are also times when
fear becomes maladaptive. So now, you're having
fear responses, for example, when
there's not a real danger or they are excessive
in some way. And that's when we start
to talk about anxiety disorders or fear-related
disorders, like PTSD. People with PTSD
have experienced a very traumatic event,
something that really induced fear at the time, and that was
probably adaptive at the time. But then they go want to
continue to experience anxiety and hypervigilance,
memory alteration, like reliving the trauma through
flashbacks and nightmares. All manifestations
of continued fear despite the trauma or fearful
event now having passed. And this becomes maladaptive. So that is one example by which
fear can become maladaptive. I wanted to briefly
mention panic because panic attacks are
also commonly talked about. And, really, panic is fear. This is a description. Somebody describing what it
is like to experience a panic attack. And you could see, it says
"All of a sudden I feel dizzy. My legs gave out on me and
I couldn't catch my breath. It felt like someone
was choking me. I could feel my heart
was beating too fast, I was terrified, I
was dying, I knew I had to get away
before I lost it". This description
of a panic attack really encompasses a lot
of the symptoms of fear. And really, when we talk about
panic attacks and anxiety disorders, we're talking
about fear attacks. And fear attacks
or panic attacks really occur in all
the anxiety disorders, and in a lot of
psychiatric disorders, it is sort of a
common denominator. And they all have this
physiological fear response component to them. So the amygdala. The amygdala is a small
structure in your brain and we know that the
amygdala drives fear. It's command central
for fear, in a way. It's located in the temporal
lobe of the brain, which is sort of on the side of
your head, behind your ear, behind your temporal
bone, deep in there. You have one on each
side of your brain. And to understand how the
amygdala works in fear, it's very useful to
know a little bit about how it's connected
to other parts of the brain because it's really
positioned to both receive sensory information. So information from
all of our senses converges on the amygdala,
on the input area called the lateral
nucleus of the amygdala. What we see, what we
hear, what we touch, pain. All that information gets
conveyed to the amygdala. All very relevant information
for threat processing. And then, the output
of the amygdala through this central
medial nucleus, that is connected to a bunch of other
hard to pronounce brain areas, brain stem areas. The point being that
these are all areas that control bodily functions
that are involved in emotional responses. So when the amygdala
connects and talks to the lateral
hypothalamus, it can control how fast your heart is beating. When it talks to the
parabrachial nucleus, it can control your
breathing rate. And it could really modulate
your emotional response. So it takes some
sensory information and it also controls your bodily
response, and can trigger fear. The amygdala is also very
involved in learning to fear. Conditioning is a fancy
word for a type of learning. Fear conditioning, simply
put, is how an animal learns to fear a stimulus. And this is an experimental
paradigm in psychology that's extensively studied. So you can go into
the literature and find all these studies of
fear conditioning experiments in mice, in primates, in people. In a typical fear
conditioning experiment you will find that what
happens is you give what's called an unconditional
stimulus, in this case to a mouse, a mouse is
getting a painful foot shot, and this is an
unconditional stimulus because it's sort of a
universally aversive stimulus that's going to produce in
every mouse a fear response. The mouse is going
to probably freeze. In this case, it's running away,
but it's going to be afraid. Part of the experiment
is also going to have a neutral stimulus
presented, and this is a sound. A sound by itself is
not aversive, right? So if you present the sound
by itself, of the mouse is not afraid. This is how we model fear
learning, fear conditioning. The fear conditioning part
is, you pair the sound with the shocks. So the neutral
stimulus is presented. And then the shock is presented. Of course the shock
produces fear. And if you repeatedly do that,
sound, shock, sound, shock, sound, shock, sound, shock,
the mouse is going to learn, gee, these two things
are associated. The sound predicts
the shock, the sound predicts something
bad happening. And that learning is
fear conditioning. And the sound becomes
able by itself, now becomes able by
itself to produce fear. We now call it-- pardon
me, and I go back? A conditioned stimulus
because it's a learned fear and it produces a
conditioned response. We learn fear response. So you've now learned something
neutral has become aversive. Fear extinction is a
very related concept it's also a learning
form of learning. What you can do now is that
you can present your tone, your sound, which is fear. But what happens if you
continue to present it by itself, without
the shock, without any aversive consequence? The mouse now learns
something new. It now learns sound
predicts no shock. Sound predicts safety. However you want to put it, but
that the shock and the sound are no longer associated. And the fear response lessens. And we call this
extinction of fear. Until again, we've
done this repeatedly, showing the sound
over and over again, there is no fear
response anymore. And the reason we study
of this in the lab is because it translates to how
we learned fear in real life. So as I mentioned earlier,
a disorder like PTSD requires exposure to
a traumatic event. And here I've used the example
of a really bad car accident. It's an example that a lot
of us, especially in Boston, maybe can relate to
being in car accidents. This is a really bad one. You can see the car
is crushed, maybe it's happened on a highway,
there's trucks, maybe there was a crash
with a truck at high speed, it's a bad car accident. Most, if not all, of us
would react with fear. This is an
unconditioned stimulus that's going to elicit fear. And probably in that moment
that's really adaptive, right? Maybe that allows us to grip
the steering wheel harder, swerve out of the
way of the truck sufficiently to not get killed. In the hours and days, and maybe
even weeks after that happens, we might still be
a little on edge. Maybe we're thinking
about the accident a lot, maybe the sight of trucks
causes us to be anxious. Maybe going on the highway makes
us more nervous than usual. Maybe we don't
really want to drive. We avoided it a bit. And that is an example
of conditioning having happened, where stimuli
that were present at the event now elicit fear. And that's pretty
typical and normal. If we continue to go along
our daily lives driving and so forth, over time,
we're going to now extinguish this response, because
trucks, and cars, and highways are not
causing accidents most days would go out. And we experience less
fear until we're back to our everyday
experience of driving. Most of us, the
large majority of us. For some proportion
of people, they will continue to have fear
and these kinds of symptoms, and more, when they see
reminders of that accident. And they might then
meet criteria for PTSD because that fear does not
abate and does not extinguish. And so this is how we've
come about thinking of PTSD and phobias as disorders
that involve fear conditioning and extinction. And these are some of the
statistics that you can look up in the literature that show that
really most of us, up to 75% of us, experience trauma
at some point in our lives. And most of us, in the
days and weeks after that, will be experiencing
some symptoms of fear, and that's normal and adaptive. But then, most of us will
extinguish that, and only 7% of people go on to
develop PTSD after trauma. And we think that is in part
because of persistent fear and failure to extinguish fear. What happens in the amygdala? A lot of this happens
in the amygdala. So I told you earlier
that the amygdala receives sensory information. When you present
a shock, that is sensory information that
travels to the amygdala, and a strong input
that causes the neurons in that lateral nucleus to fire. And then, those neurons
are strong enough to cause the firing of
the central medial nucleus neurons, which in turn mobilize
all those bodily responses downstream, and cause all
these symptoms of fear. The neutral stimulus by
itself doesn't really do that. It is sensory input. You hear something, it
travels to the lateral nucleus of the amygdala. But it's not strong
enough, so to speak, to really cause the amygdala
to activate and fire. And there is no fear. But when you pair them,
is when there's learning and synaptic plasticity
that occurs in the amygdala. An essentially, when
you're presenting the shock and those neurons are
firing, the neurons that cause the shock, and at
the same time presenting a sound, the neurons that
encode the sound, although they were weaker, that input was
weaker, it gets strengthened. The neurons that fire
together wire together. And that strengthening
of those inputs and that synaptic plasticity,
eventually that sound is able to cause the amygdala
to fire and the fear response to occur by itself. Those associations get
formed in the amygdala. We see this with
human imaging, too. If you put people
in an FMRI scanner and you ask them
to look at faces of fearful facial expressions,
and you compare their brain activation while they're
looking at these fearful faces compared to neutral
faces, these yellow blobs here represent the
amygdala activity. And you can see that, people
down here on the right, this is healthy people looking at
fearful facial expressions. This little red blob is
their amygdala telling them this is fear. But you can see and
you can compare it to people with
anxiety disorders, specific phobias,
social anxiety, PTSD. Their amygdala, their red
blob is bigger, right? You see more activation in the
amygdala in anxiety disorders. There is an overdrive of
activation in this area. There is a type of
psychotherapy, behavior therapy, broadly
speaking, that leverages what we know about
learning principles like fear conditioning and fear
extinction, and applies them in therapy to help people
gain control of their fear, and to extinguish
their fear, really. And here I'm really specifically
talking about exposure therapy. So exposure therapy
is something, is a type of therapy, and
you can seek out a therapist who specializes in this. During exposure
therapy, patients will confront their fears, they
will confront fear stimuli. And you can do
this in real life. So if this is a fear of spiders,
you can go out and about and find spiders in
some way, I suppose. Or you can do it by
imagining spiders in the office of your therapist. And some therapists use a
virtual reality technology because perhaps they don't
have life spiders ready to go in their desk drawers. So the principle, though,
is really the same across, is that repeated exposure of
fear stimulate, the patient's anxiety and fear will lessen. And this is really an
extinction principle. This is a detailed
example of what you might do in therapy with
your exposure therapist. Again, this is a
fear of spiders. You are going to come up
with all these situations that you could face that
allow you to face your fears. And you make a list of
gradually more difficult ones. And you might start with
simply thinking about a spider, because that elicits some
fear but it's the first step. And you can see that each
of these steps, it gets-- this patient has rated each of
these steps as a little harder, as eliciting a
little bit more fear. The key here is
that at each step you're going to pause
with your therapist and you're going to
repeatedly do that over, and over, and over again
until, meh, the fear is no longer all that potent. And then you move up
to the next level. So it's a very systematic,
planned therapeutic way to do this. You do this with an experienced
therapist in this way. And it's a very
effective type of therapy for anxiety disorders, for fear. It's evidence-based,
which essentially means that there's a lot
of research studies showing that it works. It has limitations, of course,
just like any psychotherapy. right? It doesn't work for everybody. And I have too much
time to talk about this, but one of the challenges is--
actually, it's very easy to do, most of us don't go
around facing our worst fears every day. So there's a lot of
treatment refusal and people who don't want to continue. And for some people, even after
a successful course of therapy, some of their fear returns. And they may need booster
sessions or retraining on the skills, or
reapplying the skills, or applying them in different
situations, and so forth. So there's a lot
of research going on how to improve the
outcome of exposure therapy. A lot of it has to
do with figuring out how can we enhance extinction. Can we make it happen faster? Can we generalize it better? Can we add certain types
of skills to the therapy, like cognitive skills,
cognitive therapy skills, where you adjust how you think
about your fears, for example, and you'll hear more about this. Some of this examples in
Dr. Beard's presentation. Some medications can be given
before an exposure therapy to enhance the outcome. So I just wanted to
mention that there is one that's been
studied extensively, that's called D-cycloserine,
if you take this before your exposure therapy
session, it can help. This is a big recent
meta-analysis. This graph represents a
review of a lot of studies that have published on the
outcome of exposure therapy across a lot of
anxiety disorders. And patients who
took D-cycloserine before their exposure therapy
session are represented by the white
circle, and patients who took just like a sugar
pill, or placebo pill are in the dark circle. And you can see that
everybody starts off at the same level
of fear or anxiety before treatment, right? And then, people's fear
goes down with treatment. And then you start to see a
separation of these lines. The people who
took D-cycloserine, well, their fear goes
down a little bit faster and they get a little
bit better at the end. So this is the type
of research that can be done to try to
improve our outcomes. So take-away is, I told
you that maybe there's a few fears that are innate
but really most of them are learned. That the amygdala is
positioned to produce many of the physiological
symptoms of fear and it's involved in learning
to fear a new stimulus. That's fear conditioning,
which occurs when you have a
neutral stimulus that becomes able to produce
fear because it's paired with something aversive. Fear extinction occurs
when a fear stimulus is presented repeatedly
over and over again without an aversive consequence. Then you get extinction,
a lessening of fear. And this principle is
applied in exposure therapy to help people manage fear,
extinguish fear, in situations that it's maladaptive. I wanted to mention,
I'm very, very grateful, I haven't talked about
my research to the NIMH, and the Brain and Behavior
Research Foundation, that essentially funded my job. Dana Foundation, as well. And I have fantastic
mentors at McLean Hospital. Scott Rauch and Diego
Pizzagali, in particular. So with that, I'd
like to thank you. [AUDIENCE CLAPS] Dr. Gregory Fricchione. Hello there. It's great to be
here this evening. And I want to thank the
organizers of the Longwood seminars for inviting me. Also, I'm really
happy to be here on this panel with these two
wonderful young scientists tonight. So we're going to talk further. You're going to hear-- I'm so glad that
Isabelle started off by talking about the amygdala. You're going to hear about
that again in this talk. I have some disclosures. Honoriaria, royalties, a patent. W.H. Auden, you remember him,
he said that the 20th century was the age of anxiety. What do you think about
the 21st century, so far? Well, point of fact, every
age is the age of anxiety. And I think that's part of the
take-home message of my part of the seminar this evening. Hopefully you'll see why that's
the case as we move along. Stress is really
what the brain does to itself and to the
rest of the body when it faces a threat, a
challenge, or sometimes even an opportunity. And it's really the amygdala
driving that stress. And you heard about fear
conditioning from Doctor Rosso. And that sets the stage for an
igniting of our stress response system. And one of the topics that
I'm going to try to reach is the fact that the world
is in the midst of a plague. And this plague or the
stress-related non-communicable diseases. Everyone, everyone
agrees that this is the most challenging
medical problem the world over, whether you're on high income
countries or low income countries. And we'll get to
that in a moment. This is an old story. This is the stress
diathesis model. And if you start over
here, then you're having a nice day, right? There are positive
environmental experiences. And you're moving along, then
all of a sudden maybe you get a note from your
bank that they're going to foreclose on you. You see yourself
drift into negativity with the potential
negative outcome. Perhaps your angina kicks
in, or something like that. There are some of
us, however, who, because of what we
call resilience, are able to weather that storm. And to come out of that
stressor in a positive state. So that's the stress
diathesis model. There's also something called
the Yerkes Dodson Curve. Two psychologists at
Harvard came up with this, many years ago. The idea here is that, hey
listen, life is stress, right? You wake up in the morning and
a very important stress hormone called cortisol bumps
because your brain knows that, hey, it's not
going to be a picnic, you're going to have
some challenges today. Life is stress. Sometimes, even, it
improves performance. Think about when your
teacher said, "Hey, you're going to have
a test on Friday. You better study". Well, your stress systems
kicked in and perhaps instead of getting a C+,
you got you a B+. However, all of us have a
point we go over the top. And you may have been reading
in the papers about young doctor who are suffering big
time from burnout. OK? This is what we're
talking about. You're working 24,
32, 36 hours straight and you're making
mistakes, unfortunately sometimes, because you're human. You're going to be subject
to the Yerkes Dodson Curve when your stress
exceeds your resilience. And your health and
your performance may very well suffer. Now, this slide brings us to
this beautiful, most complex biological organ ever
evolved, your brain. OK? And you heard
about the amygdala, this almond-shaped pair
of nuclei sitting here in the medial side
of the temporal lobe. Now, basically, you
can make your fist and this is you
temporal lobe, and this is the rest of your cortex,
this is your frontal lobe. And basically, a large part
of what we're talking about is a triangulation in the brain. Which involves this part of
your brain, prefrontal cortex, the medial prefrontal cortex,
and the dorsal anterior cingulate, which some people
are now going the mid cingulate. And the amygdala, and
the hippocampus, OK? And these structures-- this
is a very ancient structure, the hippocampus, which
does have some ability to tell the amygdala
to chill out. However, this area,
more recently evolved, is really equipped to tell
the amygdala, "OK, you saw something threatening,
but don't overdo it. You're going to live, OK?" And so, very quickly we have-- I'm not really mastering
this machinery very well-- we have the amygdala calling
the tune, "Hey, listen, you're under threat" but we
have this more recently-evolved structures that are telling
the amygdala, "Don't worry, we've got it, you're
going to be safe". So immediately we
talk about how do we reduce the stress emanating
from a amygdala talking to hypothalamus. And I will show you
that in the moment. And how do we build
up these structures to be better able to tell the
amygdala everything is OK. A large part of
psychiatry is right there. This slide I'm going to skip. It basically is
saying the same thing. When your brain is under
stress, your amygdala is calling the tune. When your brain is
settled in calm, it's this prefrontal area
that's calling the tune. This is the work of
Amy Arnsten from Yale. Now, this guy is somebody
who very devoted to. I had the opportunity
during the sabbatical to spend time with him
down at the Brain Evolution Lab at the National
Institutes of Mental Health in Poolesville, Maryland. This gentleman's
name is Paul McLean. Who is really the father
of the limbic system. And he was brilliant,
and he was kindly, he was a wonderful
man, a real naturalist. And Paul wrote to me
in his magnus opus, Triun Brain in
Evolution, "Best wishes for studies on the most
painful mammalian condition separation". OK? So let me ask you a question. How many of you are mammal? All right, that
makes me feel better. And immediately-- you
see, you didn't even have to get that message
deeply into your cortex, your limbic system
started laughing before you even processed that. You are mammals. That makes all the difference. And there's no way you
can turn back the clock. That was decided for you
325 million years ago. And no matter how sophisticated
we are in the 21st century, no matter how many
gizmos and apps we have, you're still a darn old mammal. And you're going to
need to feel attached in order to feel healthy. You're going to need to feel
attached in order to have your stress under control. You can't escape that. And that's why Paul wrote that. Paul knew more about the
brain and its evolution than any man alive. And that's why he wrote that. He knew that. Those of you who
are mothers, you know that the first anxiety, the
first fear of your little baby, is being separated from you. That separation anxiety, it is
the pregenitor of every anxiety you're going to
have in your life. OK. That's very important,
that you're a mammal. And we know this. Holmes and Rahe, Thomas
Holmes and Richard Rahe, former Navy guys who became
psychologists and did this normative study on stress. In quote unquote,
"normals" in Seattle. And they asked them,
what really makes you freak out with stress? Normal people. And as you see, out of
the top 11, eight of them are separation challenges. That's because
these people, when they process that
question, understand that separation is
what makes you fearful, makes you stressed out. Now, I don't know if
you guys know him. Some of the older
folks may know him. But he was another wise old man. His name was Niko Tinbergen.
Nobel Prize winner 1973. He and Conrad
Lorenz, ethologists, won the Nobel Prize for their
work looking at animal behavior and then thinking
about human behavior. And he, very wisely,
taught us that whenever you want to understand
anything biological or anything psychological, you better ask
yourself these four questions. OK. How does it work? How did it develop? What the heck is it for? And how did it evolve? And I've taken to calling
these four important questions, the WD40 of life science. You know that product, right? That loosens things up. If you want to
understand anything biological or psychological, ask
yourself these four questions. And then, go to
the web and study up about these four questions. And you'll understand better. So this is the brain simplified. The brain does the work of life. Every living thing has
to sense its environment, has to analyze the
information, and has to affect a motor response. Whether you're talking
about an amoeba or you're talking about a tree, or you're
talking about a human being. That's what life is all about. So I'll give you an example. I'm from the Bronx. I don't know much about planting
trees, but a couple of years ago I planted two
trees, a red maple tree and an American linden
tree in my yard. No one told me
that a buck, deer, is going to look for the two
youngest trees in your yard and root, I don't know
even if that's the word, but get all of that fur
off with their antlers. This buck girdled my two threes. So those trees had big
time stress, didn't they? And they had to sense
their environment, they had to analyze
the data, and they had to affect the motor response. How am I going to get more
nutrients from the ground? Past that girdling, where
the bark is taken off of me? How am I going to turn
to get more sunlight? That's the secret of life. And your brain
evolved to do that. It's a specialized organ. And Dr. Rosso showed
you the thalamus. Specialized to the sensory
part of your brain. And you have your cortex
in its many different parts to analyze and affect
the motor response through your basal ganglia and
your pedunculopontine nucleus and so on. That's what your
brain is really doing. It's a sensory motor
analyzer reflector. Now, because we know that,
and we don't have time to go into how the
brain is made up of segregated, integrated
loops that do that work for us. But we do know that
all vertebrates need to attach to two things. They need to attach to
sources of metabolic energy, and they need to attach
to sexual objects. Because you need those for
self preservation and species preservation, right? So amphibians, reptiles,
mammals, all do that. However, only mammals
need to attach to parental and social objects. And birth is an example
of convergent evolution. So you're starting
to see robins, right? In your yard. Usually there's a pair
of them popping around because they are connected,
they're attached, to one another. And they're going to
raise a robin family. So they discovered that
secret too, after mammals did. And then, the fourth
attachment is to the future. And that, really, only we
have, to a great extent, as human beings. So we attach to
the future as well, that's why you plotted your
course, you had a trajectory, I want to be this,
or I want to be that, and I've learned what
I'm going to need to do, I have to delay gratification, I
have to focus on getting there. So you would attach, as
human beings, to four things. To food, metabolic
energy, to sexual objects, to parental and social
objects, and to future objects. When these things are
threatened, or thwarted, or challenged, that's stress. So that's really what
the brain is all about. And I'll show you something. This is an early mammal brain. You see that stippled part? Reptiles don't have that. That's your cingulate. And that is, to a large
extent, responsible for helping you decide to approach or to
avoid, separate, or attach. And it's a convergence zone
of a lot of evolved material in the brain. And early mammals had it. Reptiles didn't OK? So they're at a disadvantage
in terms of attaching to parental or social objects. Although crocodiles are
not that bad at taking care of their young, comparatively. And this is your brain
in all of its glory. This is from the
neurosurgeons at Mass General. And you see the amygdala,
you see the hippocampus, you see this beautiful part,
the stippled part, the anterior cingulate, medial orbital
frontal, insular cortex. These areas called
the paralymbic region. They are essential
for making you human. And they have a
large role to play in telling your amygdala,
"OK, I can understand why you got excited
when you saw that snake, the snake that Dr.
Rosso showed you" OK? And you erupted. Your sympathetic
nervous system erupted, and you had all of these
catecholamines surging through your body. And your skeletal
muscle got tense. OK? And your cortisol exploded,
and the third axis of stress is your inflammatory response. Took off. Your cell-mediated
immune response took off. So you already started to
have an inflammatory response because you, as a
human being, realized that if you face
a threat, you may need to fight off an infection. OK? If you get stabbed, or if
you fall off a mountain or whatever. Your immune system is then
going to be ready to go. But think about all
the false positives you face in the course of the day. When your amygdala fires
for no good reason. You have to have a way of
telling the amygdala, "What the heck are you doing? You don't have to stay on
putting all of that energy into protecting this person". That is the key. That's the key to
chronic illness. There are some of us, Dr.
Rosso talked about those people with PTSD, there
are some of us who have a really hard time telling
the amygdala to chill out. And once that happens, it
often happens to people who've had trauma in the past. Once that happens, you're
in a chronic stress stage that makes you
vulnerable to illness. This slide says, "Oh
crap, was that today?" So I have a test for you. Are those two little
critters reptiles or mammals? Anybody? They're mammals. Because, look, they are scared. They're saying, "Oh my
gosh, I'm separated" Isn't that what you
feel right now when you look at that simple cartoon? Yes. That's where it all lives. And your brain is on that
stuff like a cheap suit. It's never going to let
go of separation fear. It's never going to stop
wanting to have attachment solutions to life's challenges. I don't know if we
have time, but this is what we're calling
what your brain does now. Allostasis, where your
brain is seeking stability in the face of constant change. Your brain has to be flexible. It has to keep your
physiological systems within, as we say, one
standard deviation of the mean. In a normative range. That takes a tremendous
amount of energy. So if you are living
a stressful life, and think about
people in poverty, think about their brains, think
about the amount of energy that your brain
needs to keep you feeling connected, and safe,
and your physiological systems within a normative range. Think about those poor
people, single mothers raising five kids without
any money, think about the amount of energy
that a single mother is expending trying to do that. That's allostatic load. That's a bad place to be
in terms of your health. I'm going to skip
through some of these. And this is a slide similar
to what Dr. Rosso showed, and I'm not going to spend time
except to tell you resilience resides here, largely. Stress resides here. And the more you can
do to build this up, the better off you're going to
be with dealing with stress. This just came out a couple
of weeks ago from a team at Mass General. And we are collaborating
with Dr. Tawakol and Dr. Pitmen and others. And what they were
able to show is-- gosh, I keep doing that. What they were able to show is
that stress, affecting amygdala does a couple of bad things. It causes your bone marrow
to start over overproducing white blood cells. Macrophages and neutrophils. And these white
blood cells start to populate your bloodstream
and wind up causing arteriosclerotic inflammation. It's an elegant experiment. We don't have time to get into. But the point is, think
about how this sets you up for those stress related
non-communicable diseases. Think about the risk
of chronic stress in amygdalar hyperactivity
and vigilance for things like
cardiovascular disease, or cerebral vascular disease. Science is teasing
apart the causal links, and making it more
and more important for us to institute ways
to reduce stress and build resilience. And this slide just
shows you the magnitude of the problem we face with
these chronic non-communicable diseases. That's cardiovascular
disease, it's chronic pulmonary disease,
it's chronic GI disease. OK? It's also neuropsychiatric
diseases, as you'll see here. In fact, diseases like
depression, anxiety, epilepsy, stroke, severe mental
illnesses, are fully-- 30% of these
non-communicable diseases. But make no mistake, they're
coming from the same place. Chronic stress. If you have a
vulnerability to one of those
non-communicable diseases and you have chronic
stress, your chances of developing it at
some point in your life are going to go up. Now I want to talk about the
good news part of the story. What can you do about it? Well, this is from Steve
Southwick and Dennis Charney. Dennis Charney is
the Dean at Mt. Sinai School of Medicine. But he's a psychiatrist. And they have been really
focusing on resilience for a long time now. Because we've learned a
huge amount from the wars in Iraq and Afghanistan. The Department of Defense
has spent lots of money to try to understand stress
and resilience, because of the invisible
wounds of those wars. When you look at
these, many of them are attachment-based because
of the evolutionary story I just told you. So when you are facing
stressful situations that make you think, "Oh my god,
I'm going to be separated from my attachments"
the idea is, how do I find solutions,
attachment solutions? John Bowlby,
English psychiatrist and the father of attachment
theory, he always said, "Men's environment of
evolutionary adaptiveness has to be one of secure
base attachment". This is what he
was talking about. This is where
resilience resides. And At the Bensen Henry Institute,
we work off of this equation. Stress numerator resilience
is the denominator in all of these varieties. That if your
numerator is too high, your denominator is
too low, you better watch out because
that allostatic load I was talking about is
going to come and bite you in the behind. And you're going to be more
vulnerable to whatever illness you're vulnerable to. So if you know that your
parents died of heart disease, and you don't pay
attention to this equation, don't cry about the
fact that you're going to have heart disease. Now, there may be some of us
who have such vulnerability genetically that
this equation is not going to play itself out with
a huge amount of importance. But for most of us, there is
variability in understanding this equation. And doing something
about it is important. So we focus on something called
the relaxation response, which is the physiological opposite
of the stress response. And really, what you see when
people are able to integrate it into their lives, is that you
get enhancement, we think, of the medial prefrontal cortex. And the somatic markers
of secure attachment. Your heart rate goes down,
your blood pressure goes down, your oxygen
consumption goes down. Your heart rate
variability goes down, which means that your
parasympathetic nervous system is predominant. And your sympathetic
nervous system is reduced. That's what happens when you're
a baby in your mother's arms. OK? Your physiology changes. Think about that, mothers,
when you're breastfeeding. Right? And the baby is
cuddled in harmony. And then the baby
takes a little nibble in the wrong sort of place
and the mother goes, ouch! And the baby has a motor reflex
and the sympathetic nervous system goes wild. What does the mother do? Using motherese, the
mother says, "Oh, it's OK. It's OK. It's OK". The baby then goes into
relaxation response and secure attachment again. And cultures have
discovered meditation as a way to mimic that
early sense of attachment. And so it's simple, we think. If you get comfortable somewhere
and you close your eyes, and you roll your neck around
and get that stiff neck out of you, and you put
your hands on your belly and you do belly breathing,
you take a deep breath and let see your belly expand,
and then, when you exhale, the breath comes out. And you do that rhythmically. And you say to yourself,
"peace on the in-breath, calm on the out-breath". Or you say a prayer
while you're doing it. Chances are, if you do that
regularly, 10 or 20 minutes a day, you're going to be
able to elicit the relaxation response. And that will have
carryover effects and help your amygdala
to be less vigilant. Mindfulness. You all read about
mindfulness-based stress reduction. That builds off of this
relaxation response with focused
awareness breathing, like I just said, and then
expands into open awareness. Where in a
non-judgmental way, you focus on feelings or thoughts. And then you can even
expand to compassion, where you're thinking
compassionately about people in your lives,
or people across the seas. Or you're thinking-- you
can do visual imagery, you can transport
yourself to a place where you'd much rather be. All of those things
can be bridged off of a simple meditation. But resilience also means
being physically active. And there are always
changing recommendations about physical activity. But try to be physically active. Take the stairs instead
of the elevator. Walk somewhat to work. Those kind of things. So physical exercise
is important. Healthy diet, eating
as much as you can a low glycemic
diet, lots of greens, olive oil, the kind
of Mediterranean diet. That's important,
too, because it's filled with the reduction in
the physiological downside of stress, which we
call oxidative stress. It's your mitochondria that has
to process glucose and oxygen to give you energy, and if
you're eating a crappy diet and you're full of
stress, it's going to be processing a lot
of oxygen in glucose and causing a lot
of oxidative stress. Diet can, to some
extent, help with that. Sleep. Really important. And hopefully you'll
have these slides-- we don't have time to go through
each of these bullet points. But sleep is restorative. It's regenerative. It helps your mitochondria
to be more effective. And to maintain your health. We have a program
at the Benson Henry Institute, eight
sessions, eight weeks, focused on all of these things. I'm going to skip ahead. This slide is interesting. This is from our Cardiac
Wellness program. If you have a heart attack
and you do cardiac wellness, exercise, nutrition, and build
resilience and reduce stress, look what happens
in three years. We didn't do this. This was done by the
federal government. The Center for Medicare
and Medicaid Services, they studied our
program and look. At three years, this is
just mortality, 3%, 10%. If you do traditional cardiac
rehab, where treatment is usual at three years. This is a really
big improvement, if you pay attention
to these factors. And there have been
meta-analyses as we say, looking at these
approaches for a variety of these chronic stress
related illness showing some effectiveness. And you can actually see this
in those white blood cells because we now can look
at gene expression. And when you're successful in
integrating these processes into your life
regularly, you can change which genes are
expressed by yourself. So when we take
white blood cells, we call them peripheral
blood bone and nucleus cells, and we look at the gene
expression in people who have learned
to meditate, we see a movement in the activation
states of their genes towards a healthier profile. And this is called the heat map. And you see, these
are novices, these are experienced meditators. The red boxes are genes
that are activated. The green boxes are genes
that are under activated. And you see, after we teach
these novices how to meditate, this is only after
eight weeks, you see them moving closer towards
the experience meditators. So we have to build a system
where there is wellness, a culture of wellness, a
health care system-- lord, don't get me started on that. Because think about
the messages that we're telling you about tonight
and think about what it's like to go to your
doctor's office these days. There's a disconnection, right? Disconnection equal separation. And that's not what
human beings are about. So we need somebody,
somebody with power, to think about the fact that
our patients are mammals. They need to be attached. And so you can't do it with
electronic medical records alone because in many cases,
the electronic medical record is separating the
doctor from the patient. So this is really where
the rubber hits the road. And so I would say,
and this is just personal, we need an
attachment-based medical system, we need a
community-based public health system, we need more research
in how the mind, brain, and body connect. We need to build these
resiliency factors and there are many
ways to do that. We need something
that people are starting to call
whole-person integrated care. And with that,
I'm going to stop. Thank you for your attention. [AUDIENCE CLAPS] I'll introduce myself. It's OK. I'm actually going to
step out into the open and see if this is OK. Hi everybody. Well, thank you. I'm Courtney Beard and I'm
excited to talk with you today about some of the work
that I've been doing. Studying the mental habits
that keep us anxious. And most importantly, how we
can actually change those. So let's see if I can work this. Excellent. So I'm a clinical psychologist. And I was trained to do
cognitive behavioral therapy to treat anxiety disorders. And just out of
curiosity, how many of you are familiar with cognitive
behavioral therapy? Ever heard of it? Oh, good. All right. A nice handful. So some of you may already be
familiar with this part then, but in CBT, we break down our
experiences into this triangle. Into these three parts. So we look at our feelings,
our thoughts, and our behavior. So what we do or
what we don't do. And we draw it as a
triangle so that we can do these arrows that are
pointing in all directions, showing that each of these
parts affects the other. And just to go
through an example so you know what
I'm talking about. So as I was preparing
for this today, I was starting to
get a little anxious. This is kind of a big
audience and they tell me that there's thousands of people
live streaming it, as well. So I was getting ready
and I was noticing that I was having a lot
of thoughts about this. And I wasn't sitting there
trying to worry or think about it, these things were
just popping into my brain automatically. Thoughts like, I'm going
to say something stupid, I'm going to stumble
over my words, I'm just going to blank
out, and so on, and so on. So then I notice my heart
started racing, started getting a little faster, I
get butterflies in my stomach, I start breathing a
little quicker, etc. So all those feelings in my
body, which then, of course, lead to more anxious thoughts. And you can see how quickly
this can get out of control. And for some people, might
lead them to call in sick. Or get out of this, some way. Now, I'm a CBT therapist,
so of course I came. But in general, in CBT,
for anxiety disorders, we're going to be focusing on
breaking down our experience into these three parts. And the good thing about the
fact that they're all related is that if we
intervene on one part, it can have positive
effects on the others. So you heard in Dr. Rosso's
talk about exposure therapy, which focuses a lot on
the behavioral aspect. And that's actually what I
focus the most on, as well, in my clinical practice. But today, I'm going to talk
with you about the thinking part, so the thoughts. And I could actually do a whole
hour talk on each of these but I just wanted to
show you some examples. And I'm going to focus on
one for the rest of my talk. So there are a lot of
different mental habits that characterize
someone with anxiety. We know that people
with anxiety disorders really overestimate
the risk of threat, so they think bad is way
more likely to happen than it actually is. And they really
catastrophize that outcome, so they think it's going
to be way worse than it might actually be. And at the same time, they
underestimate their ability to cope with it. Other cool things that
happen when you get anxious. So, you've heard a lot about how
your body changes in the fight or flight response
and that prepares you for a physical danger. Well, your thinking
changes, as well, I'm sure you've noticed it feels
like your thoughts are racing, and your attention
really narrows. So it gets very focused on
potential threats and exit strategies. How to get out of it. And again, that's
very helpful if you're in actual physical danger. But when you have
these false alarms, where you're anxious about
all sorts of things that have nothing to do
with physical danger, that narrowing of your attention
is actually not helpful. We also tend to jump
to negative conclusions and I'm going to talk a lot
more about this one in a moment. And once your
brain has generated a negative conclusion, if
you're an anxious person, you find it really
hard to set that aside and go about your day. You get stuck with your thoughts
and gets very ruminative. And so on, and so on. So there's lots of
mental habits that make us and keep us anxious. OK, Siri. For those of you-- anyone live streaming,
someone's talking to me. OK. So I'm going to focus on
one particular mental habit that I've done a lot
of work on in my lab. And that's the one
where we tend to jump to a negative conclusion. And the reason that that is
so impactful on our lives is because life is full of
ambiguity and uncertainty. So all throughout your
day, going about your day, you're facing ambiguous
situations and uncertainty all the time. And you might not
even be aware of it because our brains are
filling in the pieces. So our brains are
interpreting things for us and jumping to conclusions
for us very efficiently. So much so that
you're not even aware you're making an interpretation. And it's trying to be
helpful in this regard. But if you have a tendency to
jump to negative conclusions, it's not so helpful. So let me go through
some examples you know what I'm talking about. All right. So let's say your friend has
not returned your text message and it's been a day or two. So some people's
brains are going to say, "Oh, they
must be really busy", whereas other people are
going to start to wonder if their friend is mad at them. Let's say your heart starts
racing just out of the blue, there's nothing going on. Some people might
interpret that as, "Oh, I must be excited or
nervous about something". But if you have
a panic disorder, you're going to interpret
that as a sign of something seriously wrong with your heart. Let's say you're having a
conversation with someone and they start to
yawn, most people-- why is that so funny? Happens to me all the time. [AUDIENCE LAUGHS] Most people might assume
their friend is tired. If you have social
anxiety, though, you're going to start to wonder, "Oh
my gosh, am I being boring?" And then you're going to
get stuck in that cycle. Finally, a personal example. These are my little monkeys. And my son Joey clutched
his leg and said his leg hurt all of a sudden. And I think most parents
would not make much of that, I think it's something
benign, like a muscle ache. But if you have a very
creative, anxious mind, you might come up
with the blood clot. I did. Don't laugh. I did. So even if you know it's
really unlikely that it's a blood clot, just the
chance that it could be, and that uncertainty,
can get you going. So these are just
a few examples, but I hope you see now
that throughout your day, you're constantly
interpreting things. And you may not
even be aware of it. And it has a huge impact
on how anxious you feel and then what you do
about the situation. So what do we do about
this mental habit, given that we may not even be
aware that it's impacting us? Fortunately, we have
really good treatments. And the first step
in this treatment is to actually make
you aware of it. So we start by having
people just getting used to identifying these thoughts. So we have people write it down
for a week, every time they notice that they're anxious,
what were you thinking? What are the thoughts? And this can be very powerful
because very quickly, people start to see that they have
the same types of thoughts over and over again, they
start to notice patterns. And it's not usually
about positive things that might happen. It's all bad, it's all over
here, so it's very biased. And it's not their fault.
It's your anxious brain, as you've seen,
you can't control that, that's just what it
does, it's trying to help you. The other thing that this does,
just identifying the thoughts, gives you some
distance from them. So instead of them
operating automatically in the background and
you just accepting that it's fact and
reality, identifying that they are just
thoughts let's you start to see them
for what they are. It's just crap your brain
is sending you constantly. So that can be very helpful. So I already told you some of
the thoughts that I was having. Here are some more. So I might get lost and
never find the building, I might be late and
then they'll be angry, I will stumble over my
words and look stupid, I can't handle this, I'm going
to trip in front of everybody. And so on, and so on, and so on. So I spent a lot
of time identifying all the thoughts and all
the bad things that I think might happen. Then I want to pick just one. It's really hard to think
about all of these things and evaluate all
of these things, so pick one thought
to evaluate further. And so the next
step is going to be let's evaluate how accurate
or useful this thought is. So I picked just
the first thought. I might get lost and
never find the building. Now, if you've ever seen a
therapist helping you do this, they're going to ask
you a bunch of questions to help you evaluate
the thought. So things like, how likely
is it that I would never find the building? Are there ways I could cope
that I'm not thinking of? And, am I ignoring
other possible outcomes? They might have you
weigh that evidence for or against a particular
prediction or thought. Or even have you think
about what would you tell a friend who was
in a similar situation. So you would do
this for a while. And when you feel like you've
sort of evaluated the thought as much as you
can, then it's time to put all that together and
really reframe or reappraise the whole situation. Before we get to
this, though, I want to make a really important
point about this process. So for some people,
they may look at this and simply think that this
is just positive thinking, and it is not. So if you find that you just
need to think more positively, that's not going to
be helpful either because just as
thinking only negatively was not accurate
and not realistic, thinking only positively is
also not accurate or realistic. So the point of
this is not that. But it's rather to take
a more balanced objective and realistic view. So with that in
mind, I might replace that thought with something
like, "Well, if I get lost I can reroute, or I can ask
for directions", or something like "I might get lost
but it won't be forever", so taking the extreme out
of my anxious thoughts. And then, the absolute best
way to challenge your thoughts or evaluate them is to
actually test them out through behavioral experiments
or through exposure, like Dr. Rosso
was talking about. So if I were
working with myself, I would have myself get
lost on purpose a lot. We do this a lot. So get lost on purpose,
see what happens, see how bad it is and
learn to cope with it. If someone has a
public speaking fear, since that's the
example we're using, I would certainly have them
practice public speaking in a lot of different ways. And I might even have them
stumble over their words or their feet on purpose. And this is where
most of my patients try to walk out the door. But you guys stay. I'm not going to make
you do any of this. But stay and think about
how this is actually not so extreme to do these
things on purpose. Because at least I'm doing
these things all the time, anyway, it's just accidentally. The differences here is that
we're doing them intentionally, on purpose, for a
very important reason, to test out these thoughts, to
test out some of our beliefs. So that's a big part
of CBT, as well. OK. So that was a five minute
description of CBT. There's a lot more to
it, as you can imagine. But hopefully you get
the idea of how we target the thoughts in there. Sure. Can I go back to
the previous slide? In theory. Oh, no. That's the pointer, sorry. That one? Got it? Do they make the
slides available? They don't. OK, so get it. You can email me after this. The video will be posted. OK. So that approach,
as you've heard, cognitive behavioral
therapy, exposure therapy, extremely effective
for anxiety disorders. This is very helpful for people. Yeah. It also has some challenges. So one is just an
access problem. So we will never have
enough therapists who are well-trained in CBT
to treat all the people who need treatment, in this country,
and certainly not worldwide. So we need to think about other
options to improve access. Probably using technology. The other issue, though, is the
efficiency of this approach. Specifically when we're
talking about the targeting of the thoughts and
the mental habit. So just think for a minute
about how this would go. So you're going about
your daily life, your brain is making
hundreds if not thousands of interpretations
throughout your day that you're not even aware of. And then you go to
see your therapist and you pick one of those
interpretations to evaluate. And you do it after the fact. Maybe it's been like five days
later of when it happened. After 30 or 45 minutes,
you've really evaluated it and reappraised the situation. And like I said, that
can be very helpful. And if you do it
enough over time, it can become
automatic, as well. But it takes a
long time and it's very effortful, very laborious. So it would be nice
if we had another way to try to help people become
more aware of their thinking habits and shift them. So that's why I'll
tell you about next. Is some work I've
been doing in the lab. An approach called cognitive
bias modification, or CBM. And this is using very simple
computerized training tasks to target the same problem,
the same mental habit but in a very different way. And it's lots of
repeated practice making healthier interpretations. And you're making the
interpretation as soon as you encounter the situation. Not five days after. So let me show you what I mean. I think it's helpful
to see an example. So in the task that
I used, the computer presents people with
an ambiguous situation. So people laugh after
something you said. And then a word is going
to flash very quickly and your job is to
decide, is the word related to this situation? OK. Ready? Yes? No? Yes. No. You're incorrect. So I'll give you another one. You see the same situation. This time it's
paired with funny. Yes. Now, you're correct. So, this task is very simple. But it's-- and I give people
hundreds of these situations and then they get feedback
about their responses, and they quickly learn that
the more benign or positive interpretations are correct,
and the negative ones are incorrect. And it seems like what's
most helpful about doing it this way is that in
about 10 minutes, you've gone through
a hundred examples. And that's very
powerful in showing you how often you jump to
a negative conclusion and how many times
your brain doesn't even think of the positive one. So you can much more efficiently
increase people's awareness of this mental
habit, so that they can start to get
some distance from it and maybe not pay so much
attention to those thoughts. All right. But so, what do people
think about this approach? I've done a lot of randomized
controlled trials now of this treatment,
and I ask people, what do you think of this? Well, sometimes I
get this response. Not often. But I can see why
people would say that. It's a pretty
different approach. It's on a computer. And like you were saying,
we need attachment, how is a computer going
to help my anxiety? People don't like to be
told they're incorrect. So I get it. But actually, what's
much more common is, if people stick with it,
they say things like this. That it seemed simple,
but it made an impact on my perspectives. And this person went on to say
that one way it was helpful was by simply making them
aware of their reactions, like I was saying. Other people say
things like, "I can see how this can be applied
to my everyday life", which is really important
because we worry that an artificial computer
task isn't going to generalize people's daily lives. But people say things like,
"I can shop in Target now without feeling overwhelmed". So seeing some real concrete
behavioral improvements after doing a simple
task like that. And as a researcher, I want
to know, but does it work? And that turns out to be a
much more complicated question to answer than you might think. I thought I would just show you
what the treatment development process looks like and
what goes into it, to be able to answer that very
simple question, does it work? First, researchers
spend years trying to measure and understand
the mental habit in the lab, and confirming that, yes, it
does play a role in anxiety. That's the first step. Identify the mechanism. And we now have
tons of research. It's very clear that
a tendency to jump to a negative conclusion has
a huge impact on your anxiety. So then, we want to
translate those findings from basic science
into a new treatment. And we want to
test that treatment in a very well-controlled
laboratory setting, where we know exactly what's happening
and we have a very homogeneous group of people. And I've done a lot of studies
myself, as have others, and we have some good evidence
that this simple computer task actually does work. It helps people's
anxiety in the lab. It's the second
phase of translation where it gets really tricky. What happens to
this treatment when you let it go wild in the
real world with real people that aren't carefully
screened, and in real world clinical settings. And also thinking about how do
we actually get it to people? How do we implement it? And so that's the
phase that I'm in now. I'll show you a couple
of examples of how I'm trying to do this currently. So this is a graph or an
actual participant in one of my studies,
where I'm delivering this type of treatment
in primary care settings. We know most
people, that's where they go when they're
anxious and they want to get mental health treatment. So it's important for us
to have some more options available to people there. And this is showing you
their performance on the task over the eight
sessions of treatment. And each session is only
about 10 minutes of this task. You can see in red, there. The reaction time is going
down so they're getting faster and faster at this task. And in blue is their accuracy. So they're getting more and more
accurate at endorsing a more benign interpretation style. And then, when I look at
everybody's anxiety scores together, we're seeing
some promising results. So this is showing
you, let's see, before and after the treatment. And about 2/3 of our
samples, their scores fell below a clinical
cut-off on our measure. So a clinically
significant improvement from a very low-intensity
type of treatment. Very promising. We're continuing to
further test this in more rigorous and larger
studies, if we can get funding. I thank them for the
funding we do have. So that's in primary care. But I was also curious if this
would be helpful where I work currently, at McLean Hospital. I'm at the Behavioral Health
Partial Program there. We treat over 800 people a year. And they come to us for really
intensive day treatment. So their symptoms are usually
very severe by the time they come see us. Lots of suicidal ideation,
lots of life crises, so extremely real world
and difficult to treat. And I was curious if my
simple computer task, if I gave it to people every
day while they're with us, maybe seven or eight days,
if that would actually improve their response to
our regular treatment, which was already quite good. And something really
interesting happened. So let me walk you
through this a little bit. So for my older
participants, and older, unfortunately,
means 37 or older. Almost me. It's very sad. But for my older
participants, it didn't matter if you got my CBM
treatment or a placebo task. Your improvement and your
well-being was the same. So people improved
because they were getting our standard treatment. But it didn't matter if
you got this extra thing. But in my younger
participants, there was a big effect where this
additional simple computer task actually improved
their response to treatment. So this is sort of where
the field is at, right now. Is figuring out
what's the best way to put this into clinical
care and for whom? It may be that if
you're older and you've had these mental habits for much
longer, they're more ingrained, and we need a slightly
different approach, or more. There's a lot of really
interesting and important questions we can answer
as we study this more. And so that's pretty much
where I will leave it. It's just thinking
towards the future. Technology is going to be really
important, both from an access standpoint and from being
able to harness technology to do things in really
innovative and different ways that might speed
up the improvement to our typical
treatments, and reach people who wouldn't get it. And I'm certainly not
the only one doing this, there are lots of
people just at McLean, at our new Institute for
Technology and Psychiatry, that are working on
these issues, as well. And I think I'm
going to stop there. Thank you so much. [AUDIENCE CLAPS] All right. Thank you everybody. I know it's at 7:30
and we had said that we would take a couple of
questions, or some questions. And I think, given the time,
we'll try to take a couple. And I know there's
also going to be a way for us to respond
to more questions online after this is over. So I have a stack of
really great questions from people here
and on the internet. I'll try to pull out
a few that maybe we can answer in a few minutes,
and then we'll get to the rest as best we can after the show. So one question is
asking about exercise and why exercise is so
helpful for anxiety. Can we say a bit
about how that works? Well, exercise seems to
be good for everything. And we start at the top,
we start at the brain. One thing we know
about exercise is that it improves this
ratio of building new brain cells in the hippocampus
and perhaps other areas. Something we called
neurogenesis. There's a ratio of building
new cells to dying off cells. And exercise seems to
improve that ratio. So that's one thing. And the hippocampus, as I said,
is an area where it really profits us to get new cells
because that area is important, not only for memory,
but also for having some control over the
amygdala functioning. So in a way, it will
help with anxiety from that point of view. But then, at the
cellular level, we know that exercise is something
that helps your mitochondria to work better in terms of
processing, as I mentioned, glucose and oxygen. So after
the challenge of exercise to the mitochondria,
there seems to be, just like in muscles, where
you break down muscles and they get stronger, seems
like cellular processing of metabolites improves. And so that means that you
get more for your money, in terms of like
oxygen consumption, and something we call the
mitochondrial reserve capacity improves. That's good for
functioning, in general. And it also means
that you're going to have more of that
resilience to manage the everyday challenges. You're going to
be able to absorb more stress in the course
of your everyday life. And that's basically
what resilience is about. A lot more. The other thing. We have is this epidemic
of obesity, right? And I mentioned to
you just a little bit, we don't have time to
get into, inflammation. But your fat cells, once
you develop obesity, your fat cells become a
source of inflammation. And so, if you
exercise and you're able to successfully
reduce obesity, you're doing yourself a favor
on that end of the ledger, too. In the sense that if stress
is increasing inflammation, and you're reducing that
source of inflammation, you're reducing that illness
vulnerability, as well. And I think in terms of a
more psychological standpoint in the moment, immediately
during and after exercise, depending on what you do, it
can be a form of mindfulness. Right. If I take my Zumba
class, I'm really focused on trying to do the
steps rather than my worries, and it gives me extra
help disengaging from those thoughts, having
a moment of mindfulness and getting out some of
those stressful feelings. Courtney is absolutely right. So some people prefer what
we call mindful exercise, and it is yoga, it's
dancing Zumba or-- Walking the woods. Absolutely. Yeah. Terrific. I'm going to summarize this
next question, which is great. It's very lengthy, but
essentially it says, a psychiatrist told me an
enlarged amygdala is what's causing anxiety, a physiology,
different professor, told me it's an
underdeveloped hippocampus, and then another professor
told me is really the prefrontal cortex that helps
you calm down your amygdala. Which is it, is it
all of the above? So I think that we didn't talk
as much about the network. But really, those are
all nodes of a network that is on balance, where all
those regions work together. And in some ways it can
be all of the above, and one of the interesting
things in research studies is that we work with
averages, and we summarize. We represent things,
we summarize things based on averages. But really you can
imagine that there's different nodes in that circuit
that you could affect and get anxiety. So you could have an
enlarged hyperactive amygdala in one person, and
then another person who is under a lot
of chronic stress, has a lot of hippocampus
atrophy as well. Or particularly that could
be the driving force. And the medial
prefrontal cortex, we didn't talk about very
much, but very important in terms of differentially
recalling fear memories and extinction
memories, for example. And in particular context. So it's kind of a
complex response, but I think this is very
astute that, indeed, all of those brain
areas are involved. Totally agree. And then, maybe a more
clinical question. Can a person have a panic
attack in their sleep? And wake up feeling like-- Yes. It's happened to me before. Yeah. Nocturnal panic attacks
are fairly common. And actually I haven't read
a lot about that recently, so my response actually
might be outdated. If you know something,
please jump in. But in general, if you
have panic disorder and you have panic attacks,
go back to Dr. Rosso's lecture on fear conditioning. Well, if every
time your heart has jumped a little strange way, if
that has led to a panic attack, it only takes one time. That's going to be
a learned response. So that if your
brain is detecting subtle changes in
your physiology when you sleep that are
normal, that can be enough, the conditioning
can be so powerful that it can trigger
that as well. You can be asleep. Yeah. It's not an unusual
presentation of panic to see folks coming in
with nighttime panic. And there are certain
things, physical conditions, that make you more vulnerable. So, for example,
menopausal women, if there's a connection
between hot flashes occurring at night in sleep and panic. And also, sometimes
we have to rule out seizures, which can also occur
in the middle of the night. People with sleep apnea have
a reduction in their oxygen saturation, and that can
precipitate hyperventilation panic sort of symptoms. So it can become pretty
complicated pretty quickly, but the answer is,
yes, they can occur. So I think those were actually
the two three-minute questions that we could answer. So I think this would be
a good stopping point. And thank you all for sticking
around little after this. [AUDIENCE CLAPS]
