WEBVTT - Ep101 "Why do people walk away from bad events with different outcomes?" 0:00:05.080 --> 0:00:09.600 What happens in the brain when we face adversity and 0:00:09.640 --> 0:00:13.240 why do two people with the same hardship walk away 0:00:13.320 --> 0:00:17.760 with such totally different outcomes. Is resilience something that you're 0:00:17.800 --> 0:00:21.040 born with or is it something your brain can develop? 0:00:21.480 --> 0:00:24.160 And if so, how, what does any of this have 0:00:24.239 --> 0:00:27.640 to do with the diving bell and the butterfly, or 0:00:27.760 --> 0:00:32.199 using magnetic fields to zap the brain or the less 0:00:32.320 --> 0:00:35.800 famous partner to the brain's reward system, or. 0:00:35.720 --> 0:00:38.160 What seemingly unrelated. 0:00:37.600 --> 0:00:44.800 Disorders in psychiatry all have in common. Welcome to Inner 0:00:44.840 --> 0:00:48.120 Cosmos with me David Eagleman. I'm a neuroscientist and an 0:00:48.159 --> 0:00:52.320 author at Stanford, and in these episodes we sail deeply 0:00:52.400 --> 0:00:56.120 into our three pound universe to understand why and how 0:00:56.440 --> 0:01:09.080 our lives look the way they do. Today's episode is 0:01:09.120 --> 0:01:14.199 about resilience. We all know someone who's been through hell 0:01:14.600 --> 0:01:18.880 and somehow comes out standing. Maybe you know a person 0:01:19.319 --> 0:01:23.600 undergoing chemotherapy who still manages to raise a family and 0:01:23.640 --> 0:01:27.560 be a good parent, or a refugee who rebuilds their 0:01:27.600 --> 0:01:31.279 life from nothing, or a friend who keeps going after 0:01:31.480 --> 0:01:35.399 losing her job. There's something about resilience going on here 0:01:35.760 --> 0:01:38.760 that's different from what a lot of other people would 0:01:38.800 --> 0:01:40.040 do in the same situation. 0:01:40.760 --> 0:01:41.640 We're thinking about. 0:01:41.400 --> 0:01:45.160 This one a young man who gets an early onset 0:01:45.280 --> 0:01:50.680 motor neuron disease and slowly ends up completely paralyzed in 0:01:50.720 --> 0:01:55.520 a wheelchair and eventually loses his ability to speak, but 0:01:55.640 --> 0:01:59.560 he keeps on plugging along and eventually ends up becoming 0:01:59.560 --> 0:02:03.400 one of the premire mathematical physicists in the world. This 0:02:03.440 --> 0:02:06.560 is the story of Stephen Hawking. How did he stay 0:02:06.600 --> 0:02:11.600 so resilient in the face of a slowly creeping disease 0:02:11.880 --> 0:02:16.040 that ate his body but didn't seem to slow him down? 0:02:16.680 --> 0:02:19.240 That kind of drive, that kind of adaptation. 0:02:19.480 --> 0:02:23.519 It raises the question what enables some people to keep 0:02:23.600 --> 0:02:28.760 going when everything falls apart? What is human resilience made of? 0:02:29.760 --> 0:02:32.200 In this episode, we're going to answer this question by 0:02:32.240 --> 0:02:34.560 diving into the brain. And I'm going to do so 0:02:34.600 --> 0:02:37.920 with my colleague and friend, Jonathan Downer, who's been on 0:02:37.960 --> 0:02:41.360 Inner Cosmos before, and he's one of the most compassionate 0:02:41.440 --> 0:02:45.040 and insightful thinkers that I know. He has an MD 0:02:45.280 --> 0:02:49.400 and specializes in psychiatry, and he also has a PhD 0:02:49.639 --> 0:02:53.200 in neuroscience, and he's become one of the world's experts 0:02:53.320 --> 0:02:57.480 in transcranial magnetic stimulation, which is a technique that we'll 0:02:57.480 --> 0:02:59.880 come back to in a minute now. Jonathan was on 0:03:00.040 --> 0:03:03.280 Inner Cosmos about a year ago to talk about depression, 0:03:03.800 --> 0:03:07.560 and that episode moved and inspired a huge number of people. 0:03:07.840 --> 0:03:10.320 So I've wanted to sit down with Jonathan again to 0:03:10.520 --> 0:03:15.000 zoom out the camera one notch to talk about an idea, 0:03:15.680 --> 0:03:20.160 change and focus the idea that clinical depression is actually 0:03:20.680 --> 0:03:25.839 one expression of a more fundamental issue, one that has 0:03:26.040 --> 0:03:31.120 accidentally surfaced as neuroscientists around the globe have performed hundreds 0:03:31.120 --> 0:03:35.160 and hundreds of individual studies and then looked at the 0:03:35.240 --> 0:03:39.080 emerging shape that all of these studies were pointing to. 0:03:39.840 --> 0:03:42.840 What we'll learn today is an issue that sets right 0:03:42.880 --> 0:03:45.480 at the center of our lives. So let's dive in 0:03:45.520 --> 0:03:53.160 with Jonathan Downer to understand it. So, Jonathan, we've all 0:03:53.200 --> 0:03:56.280 known people who are in very terrible circumstances in life, 0:03:56.440 --> 0:03:58.760 and yet they figure out a way to keep going. 0:03:59.200 --> 0:04:02.640 So we might by this says resilience, So tell us 0:04:02.640 --> 0:04:06.240 about resilience. Yeah, So it's a fascinating topic to get into. 0:04:06.800 --> 0:04:09.440 I think a good example to start us off by 0:04:09.440 --> 0:04:12.040 way of illustration. You and I in our textbook talked 0:04:12.040 --> 0:04:16.280 about the case of Jean Boubie, who was the author 0:04:16.320 --> 0:04:19.719 of The Diving Bell and the Butterfly. I really like 0:04:19.760 --> 0:04:22.760 his examples. He had an absolutely horrific situation in which 0:04:23.000 --> 0:04:26.520 this was a successful author and editor of the French 0:04:26.680 --> 0:04:31.599 fashion magazine a magazine, and he unfortunately suffered a tiny 0:04:31.600 --> 0:04:33.720 little stroke in his brain stem that left him with 0:04:33.800 --> 0:04:37.360 this syndrome called locked in syndrome. And for those who 0:04:37.400 --> 0:04:38.960 are hearing about that for the first time, it's a 0:04:38.960 --> 0:04:42.640 horrible syndrome where the output passages from your the output 0:04:42.880 --> 0:04:45.040 tracks from your brain down to the spinal cord, and 0:04:45.040 --> 0:04:48.200 the muscles are just severed by the stroke. So you're 0:04:48.200 --> 0:04:51.520 perfectly awake, you're perfectly conscious, you can feel sensations, but 0:04:51.560 --> 0:04:54.880 you can't send any signals out to your body, and 0:04:54.920 --> 0:04:57.840 there's no recovery. He was then bedridden and the only 0:04:57.880 --> 0:05:00.359 part of his body he could move where he could blink, 0:05:00.480 --> 0:05:02.800 and that was pretty much all he could do, and 0:05:02.880 --> 0:05:05.880 with the assistance of some of the people who work 0:05:05.920 --> 0:05:09.280 with him, he would use a blinking code to specify 0:05:09.400 --> 0:05:11.120 letter by letter what he wanted to say. 0:05:11.279 --> 0:05:14.440 Specifically, the assistant would read out the letters of the 0:05:14.440 --> 0:05:18.279 alphabet in order of their frequency, and then when she 0:05:18.400 --> 0:05:20.880 got to the right letter, he would blink his eye 0:05:20.920 --> 0:05:23.080 and she would write down that letter and then start 0:05:23.160 --> 0:05:24.520 the process over again. 0:05:24.880 --> 0:05:26.800 Yeah, and so the fact that he was even able to, like, 0:05:26.880 --> 0:05:29.120 I don't know what would happen to you or I 0:05:29.240 --> 0:05:30.440 or most of the people I know if they were 0:05:30.480 --> 0:05:31.240 in that situation. 0:05:31.400 --> 0:05:31.839 Certainly. 0:05:32.000 --> 0:05:34.599 I mean, imagine having an inch which you can't scratch 0:05:34.640 --> 0:05:36.440 because you can't move, or a pain in your leg, 0:05:36.560 --> 0:05:38.400 or a cramping your leg that you can't do anything 0:05:38.440 --> 0:05:41.920 about for hours. It's very hard to maintain a positive 0:05:41.960 --> 0:05:45.280 attitude in a situation like that. And yet he was 0:05:45.400 --> 0:05:49.840 able to laboriously blink out an entire book describing his experience, 0:05:50.000 --> 0:05:53.400 which the butterfly exactly. So, when I think about the 0:05:53.400 --> 0:05:56.200 fact that, to me, the most remarkable part about this 0:05:56.360 --> 0:05:58.880 is that is not the stroke or the fact that 0:05:58.880 --> 0:06:01.599 there's an assistant with this amazing blinking code. To me, 0:06:02.320 --> 0:06:04.839 the astonishing part is the fact that there's a there's 0:06:05.000 --> 0:06:08.480 a resilient spirit in there that's capable of doing that, 0:06:08.480 --> 0:06:10.960 that is laying there in this betting it somehow has 0:06:11.000 --> 0:06:13.520 the patience and the resilience and the I guess the 0:06:13.520 --> 0:06:16.560 inner fortitude to do something like that. 0:06:17.120 --> 0:06:18.120 So what is that about? 0:06:18.960 --> 0:06:21.840 So we I mean, there are a few different ways 0:06:21.839 --> 0:06:23.960 of looking at resilience that's been studied to death, and 0:06:24.000 --> 0:06:27.160 there are whole books that have been written on it. 0:06:27.360 --> 0:06:31.920 You can talk about psychological sources of resilience. You can 0:06:31.960 --> 0:06:37.320 talk about cultural practices and interventions and therapies that support it. 0:06:37.400 --> 0:06:40.840 You can talk about you know, social practices that support it. 0:06:41.360 --> 0:06:43.200 What I want to dive into a little bit is 0:06:43.200 --> 0:06:46.360 the actual neural circuitry behind it. Because we are learning 0:06:46.400 --> 0:06:49.359 a lot about what that neural circuitry is, and it 0:06:49.440 --> 0:06:52.640 turns out that there are indeed specific brain circuits which 0:06:52.680 --> 0:06:56.159 support our ability to be resilient. So, for example, a 0:06:56.200 --> 0:07:00.920 person who suffers a terrible stroke, if these circuits are 0:07:00.920 --> 0:07:04.080 preserved and the person can actually function a lot better 0:07:04.120 --> 0:07:07.160 than you would expect given the circumstances they're in. And 0:07:07.200 --> 0:07:09.760 then surprisingly, if those circuits are damaged in the stroke, 0:07:10.200 --> 0:07:13.640 the person may have minimal physical limitations and yet is 0:07:13.720 --> 0:07:16.520 not functioning at all. Is to sort of emotionally always 0:07:16.520 --> 0:07:19.360 getting stuck on things, cognitively always getting stuck on things, 0:07:19.360 --> 0:07:21.400 and just not able to get up and start moving. 0:07:22.040 --> 0:07:25.320 So I think what would be interesting to get into 0:07:25.320 --> 0:07:27.360 a little bit is the circuitry that we've been able 0:07:27.400 --> 0:07:31.240 to delineate behind the general ability to be resilient to 0:07:31.360 --> 0:07:34.400 life stresses and challenges and the general ability to function. 0:07:34.840 --> 0:07:37.400 And just before we get into the details of the circuitry, 0:07:37.960 --> 0:07:41.840 what is the variation in the circuitry across the population. 0:07:42.560 --> 0:07:43.680 Yeah, so that's fascinating. 0:07:43.680 --> 0:07:46.000 There's been a lot of studies done on that using 0:07:46.080 --> 0:07:49.760 techniques using MRI scans. So, for example, you can have 0:07:49.800 --> 0:07:53.800 a person going the scanner and you can actually map 0:07:53.880 --> 0:07:57.000 the thickness of their gray matter across the hole using 0:07:57.000 --> 0:07:59.840 a technique called boxel based morphometry. So they take all 0:07:59.840 --> 0:08:02.000 the little voxels in the scan and they look at 0:08:02.040 --> 0:08:04.760 how thick the grain matter is in different areas, and 0:08:04.800 --> 0:08:08.680 they can compare people who have more resilience versus less resilience. 0:08:09.360 --> 0:08:11.640 There was a famous study done, I guess about a 0:08:11.640 --> 0:08:14.920 decade ago now where they did exactly the question we're 0:08:14.920 --> 0:08:17.160 asking about. They took a whole bunch of people who 0:08:17.520 --> 0:08:22.120 had suffered horrible adverse childhood experiences. There's actually a psychological 0:08:22.200 --> 0:08:26.240 questionnaire called the adverse childhood experiences questionnaire. So all these people, 0:08:26.360 --> 0:08:29.360 you know, had been through horrible traumatic experiences, and yet 0:08:29.360 --> 0:08:33.000 a subset of them had never gone on to develop 0:08:33.000 --> 0:08:36.640 post traumatic stress disorder or depression or any other sort 0:08:36.640 --> 0:08:40.800 of classic you know, axis one mental disorder, and the 0:08:40.880 --> 0:08:43.760 question was, what's going on with them? It turns out 0:08:43.800 --> 0:08:46.000 that there were specific areas of the frontal lobes that 0:08:46.120 --> 0:08:49.559 had thicker gray matter. In these areas we were pinpointing 0:08:49.640 --> 0:08:51.839 specifically as an area we can get into called the 0:08:51.920 --> 0:08:55.480 left or salalateral prefrontal cortex, but it's actually a network 0:08:55.520 --> 0:08:59.000 of areas in the brain. Who seemed if you just had, 0:08:59.040 --> 0:09:01.200 by luck of the draw, you happen to have more 0:09:01.240 --> 0:09:03.960 gray matter in these areas, then you were more likely 0:09:04.000 --> 0:09:07.920 to be resilient to even quite horrible adverse childhood experiences. 0:09:08.400 --> 0:09:11.679 And is it luck of the draw a genetic issue 0:09:11.800 --> 0:09:15.000 or is it environmental practices or social practices. 0:09:15.440 --> 0:09:17.280 It's a really good point there are you know, the 0:09:17.320 --> 0:09:19.600 literature around resilience suggests that there's a lot to this, 0:09:19.800 --> 0:09:22.480 so you know, there is although there is some genetic 0:09:22.520 --> 0:09:26.640 component to resilience that I think that is greatly overshadowed 0:09:26.679 --> 0:09:30.440 by one's environment and one's psychology and one's upbringing and 0:09:30.480 --> 0:09:34.719 the practices that one implements. Early adverse childhood experiences are 0:09:34.760 --> 0:09:37.920 really bad for people's resilience, whereas growing up in a 0:09:37.960 --> 0:09:41.920 supportive childhood environment and having social supports and sort of 0:09:41.920 --> 0:09:44.160 a calm parenting environment and all the rest of it 0:09:44.200 --> 0:09:46.160 can often provide a person with quite a lot of 0:09:46.160 --> 0:09:49.200 resilience that they can tap into later on in life. 0:09:49.440 --> 0:09:52.880 Yeah, although there are you know, like everything it's a 0:09:53.000 --> 0:09:56.360 gene environment interaction. There are these studies done by Steven 0:09:56.400 --> 0:09:59.800 Swami with monkeys where he is looking at these monkey 0:09:59.840 --> 0:10:05.240 t and with half the adolescent monkeys he has them 0:10:05.440 --> 0:10:09.280 with their mothers and the other half he has them 0:10:09.360 --> 0:10:12.200 just with their peers. So they're raised with peers, and 0:10:12.320 --> 0:10:14.760 just like in junior higher high school, monkey peers are 0:10:14.840 --> 0:10:19.480 mean to one another. And so he looks at who 0:10:19.600 --> 0:10:23.679 ends up doing well and who doesn't, and it turns 0:10:23.679 --> 0:10:26.040 out it's not as obvious as you would think. It 0:10:26.080 --> 0:10:29.360 turns out that there are genetic predispositions that cause some 0:10:29.400 --> 0:10:32.079 of the monkeys in the bad group being raised with 0:10:32.120 --> 0:10:36.480 their peers to still do fine and others not. So 0:10:36.880 --> 0:10:40.960 there's definitely an interaction between how you're raised and what 0:10:41.040 --> 0:10:42.679 you come to the table with genetically. 0:10:43.559 --> 0:10:44.920 So let's jump. 0:10:44.679 --> 0:10:49.280 Into what you see when you're looking at this in 0:10:49.320 --> 0:10:51.800 the brain scanner. What are these prefrontal areas that you're 0:10:51.840 --> 0:10:54.160 talking about. So I think that might be a good 0:10:54.200 --> 0:10:57.200 place to start. So on the one hand, you know, 0:10:58.000 --> 0:11:00.960 let's say we have this technique called box based morphometry 0:11:00.960 --> 0:11:04.000 that's capable of pinpointing areas of gray matter they're thicker 0:11:04.080 --> 0:11:07.240 versus thinner in certain groups of people. And let's say 0:11:07.240 --> 0:11:10.120 we've used that to find people were unusually resilient to 0:11:10.640 --> 0:11:14.400 developing access one disorders despite adverse childhood experiences. The flip 0:11:14.440 --> 0:11:16.360 side of that would be looking at people who do 0:11:16.440 --> 0:11:18.880 have access one disorders and saying okay. And this was 0:11:18.920 --> 0:11:21.800 an enterprise that began, and I guess around twenty ten 0:11:21.920 --> 0:11:24.480 or so on. They started being able to gather up 0:11:24.559 --> 0:11:27.679 big data sets of lots of people who had succumbed 0:11:27.720 --> 0:11:32.959 to depression or bipolar disorder OCT substance use anxiety disorders PTSD. 0:11:33.200 --> 0:11:35.000 And this is what you mean by access one disorder, 0:11:35.360 --> 0:11:36.640 So access one disorder exactly. 0:11:36.679 --> 0:11:39.719 So the sort of the classic sort of psychiatric disorders 0:11:40.120 --> 0:11:43.400 DSM one is the Diagnostic and Statistical Manual, and so 0:11:43.440 --> 0:11:45.680 the access one of that is just one way of 0:11:45.800 --> 0:11:51.440 describing formal clinical psychiatric disorders. So this was a team 0:11:51.559 --> 0:11:53.959 led by a meet at Ken at Stanford University and 0:11:54.040 --> 0:11:57.200 Madaline Goodkind was the first author, And in twenty fifteen 0:11:57.240 --> 0:11:59.920 they gathered up over two hundred studies that had been done, 0:12:00.240 --> 0:12:02.040 or close to two hundred studies that have been done 0:12:02.120 --> 0:12:04.439 looking at the thickness of grain matter across all these 0:12:04.440 --> 0:12:07.439 different disorders, and they asked a really interesting question, are 0:12:07.480 --> 0:12:10.080 all the different disorders like OCD and PTSD are. 0:12:10.000 --> 0:12:10.920 They completely different? 0:12:10.920 --> 0:12:13.199 Do they all involve different brain circuits or is there 0:12:13.240 --> 0:12:15.920 some common element like if you did a bend diagram 0:12:15.920 --> 0:12:19.240 and overlaid them all. Is there some common element to 0:12:19.320 --> 0:12:21.720 all the brain disorders that we have lumped into the 0:12:21.760 --> 0:12:25.560 basket of psychiatric disorders as opposed to neurological disorders. 0:12:25.559 --> 0:12:27.240 And so amazing by the way that we can do 0:12:27.280 --> 0:12:30.240 this now because we have enough brain scans from enough 0:12:30.280 --> 0:12:32.960 patients with different disorders that for the first time in 0:12:33.040 --> 0:12:34.199 history we can ask that question. 0:12:34.240 --> 0:12:36.680 It was fair. Yeah, absolutely, So what do they find fascinating? 0:12:36.720 --> 0:12:39.439 So they turn out that yes, indeed, if you overlapped 0:12:39.440 --> 0:12:42.080 all the maps of all these two hundred different studies 0:12:42.080 --> 0:12:45.960 involving I think close to seven thousand patients versus healthy controls. 0:12:47.000 --> 0:12:51.000 There were indeed some areas which were universally thinned out 0:12:51.080 --> 0:12:53.720 across all these different disorders, and as you might expect, 0:12:53.760 --> 0:12:56.920 they belong to the same network that this resilient network was, 0:12:56.920 --> 0:12:59.080 except it was in the other direction. So people will 0:12:59.120 --> 0:13:01.720 then use with quite thick gray matter in this network 0:13:01.720 --> 0:13:04.199 of regions were resilient to disorder. And on the other hand, 0:13:04.240 --> 0:13:07.880 if you looked at people who had these disorders PTSD 0:13:08.000 --> 0:13:10.720 or anxiety, one common element they all had was that 0:13:10.760 --> 0:13:13.880 this specific network of regions was a little bit thinner 0:13:15.840 --> 0:13:18.760 in terms of the gray matter. There are a bunch 0:13:18.840 --> 0:13:22.400 of different networks in the brain that perform various functions. 0:13:22.480 --> 0:13:24.720 Some of them move your upper body or your lower body, 0:13:24.760 --> 0:13:27.640 or do vision or hearing. This particular network having an 0:13:27.640 --> 0:13:29.560 interesting name, it's called the salience network. 0:13:30.200 --> 0:13:31.959 And so what was need about this popped out? 0:13:32.000 --> 0:13:35.080 The common element across all these different disorders when people 0:13:35.120 --> 0:13:38.600 lose their resilience is the salience network. And on the 0:13:38.600 --> 0:13:42.080 other hand, if your salience network is intact, then you 0:13:42.120 --> 0:13:43.880 tend to have this resilience. 0:13:43.520 --> 0:13:45.400 So help us understand this a little bit more so, 0:13:45.840 --> 0:13:51.440 if you have less resilience, how does that connect with 0:13:51.440 --> 0:13:52.559 psychiatric disorders? 0:13:52.679 --> 0:13:55.600 So that's really I think that's a really great question 0:13:55.679 --> 0:13:58.319 and the right way of putting it. So the salience network, 0:13:58.440 --> 0:14:01.480 it helps understand what the salience nets works function seems 0:14:01.480 --> 0:14:04.480 to be. What was need about discovering that the salience 0:14:04.520 --> 0:14:07.600 network was involved is that separately, people had been studying 0:14:07.640 --> 0:14:10.480 the saliens network for fifteen years. I accidentally did my 0:14:10.520 --> 0:14:13.160 PhD audit back in the late nineteen nineties before we really. 0:14:13.120 --> 0:14:13.720 Knew what it was. 0:14:14.160 --> 0:14:17.080 But its job seems to be a thing called cognitive control, 0:14:17.200 --> 0:14:20.440 the ability to self regulate your thoughts and your behaviors 0:14:20.480 --> 0:14:23.920 and your emotions. What's unique about it in terms of 0:14:23.920 --> 0:14:27.960 the brain regions it involves is it has some brain 0:14:28.040 --> 0:14:30.320 reasons that are part of the limbic system, the so 0:14:30.360 --> 0:14:32.560 called emotional system the brain, but it also has some 0:14:32.600 --> 0:14:34.680 areas that are part of the brain's kind of executive 0:14:34.720 --> 0:14:37.400 function and cognitive system. So it's out of all the 0:14:37.480 --> 0:14:40.200 various dozens of brain networks that are there, it uniquely 0:14:40.200 --> 0:14:42.720 seems to break between the limbic system and the cognitive 0:14:42.760 --> 0:14:47.720 system between sort of reason and emotion, and you will 0:14:47.760 --> 0:14:50.240 see people activating it when they have to inhibit a 0:14:50.280 --> 0:14:53.840 particular thought in order to do or a prepotent response. 0:14:54.160 --> 0:14:56.400 So a classic example that would be the go No 0:14:56.520 --> 0:14:59.040 Go task, which is a task where people have a 0:14:59.080 --> 0:15:01.320 signal that tells inn apress button and then another signal 0:15:01.400 --> 0:15:03.240 says no, wait, don't do that, and so you have 0:15:03.320 --> 0:15:05.080 to inhibit that predisposition. 0:15:05.200 --> 0:15:07.520 So for example, if if the banana comes on the screen, 0:15:07.560 --> 0:15:09.560 I pound the button, and if the strawberry appears on 0:15:09.560 --> 0:15:11.200 the screen, I have to not hit the button. 0:15:11.240 --> 0:15:12.840 That's a great example, that'd be it. 0:15:13.560 --> 0:15:17.040 Another example would be the classic stroop task, which in 0:15:17.080 --> 0:15:19.000 the stroop task, this is a tricky one. If you 0:15:19.040 --> 0:15:20.600 ever have to try it, you can They have them 0:15:20.600 --> 0:15:22.040 online if you ever want to go and try them. 0:15:22.040 --> 0:15:24.440 With the word blue will be written in red ink 0:15:24.560 --> 0:15:26.360 or the word red will be written in green ink, 0:15:26.640 --> 0:15:28.720 and you have to not say the word, which is 0:15:28.760 --> 0:15:30.480 the thing you want to do, but you have to 0:15:30.520 --> 0:15:33.560 actually push past that prepotent response and say the color 0:15:33.680 --> 0:15:36.280 of the word, even though there's an interference effect there. 0:15:36.320 --> 0:15:39.040 So the stroop task and all these things volitionally activates 0:15:39.040 --> 0:15:43.880 your cognitive control capacity. It essentially allows you to stop 0:15:43.960 --> 0:15:47.080 ruminating to or and to focus on what kind of 0:15:47.080 --> 0:15:49.600 response you're going to make, so the salience network will 0:15:49.680 --> 0:15:52.200 kick in. If a person, I'll give you an example, 0:15:52.280 --> 0:15:54.600 if you, for example, got bored with what I was 0:15:54.640 --> 0:15:56.640 saying right now in your mind started to wander till 0:15:56.720 --> 0:15:57.400 yesterday or. 0:15:57.320 --> 0:15:59.240 Tomorrow or why. 0:15:59.240 --> 0:16:00.760 I usually say this lectures, and you know, it's a 0:16:00.800 --> 0:16:02.960 room full of people, so you know, you could always 0:16:02.960 --> 0:16:04.640 see the people like some people are paying attention to 0:16:05.080 --> 0:16:07.400 It's totally natural. It's very hard to focus your attention 0:16:07.480 --> 0:16:09.320 for a long time, so people start thinking about something 0:16:09.360 --> 0:16:11.800 else and then maybe suddenly I say something interesting and 0:16:11.840 --> 0:16:14.640 their attention comes back again. At that moment when you 0:16:14.720 --> 0:16:18.280 stop mind wandering and you return to the present moment, 0:16:19.040 --> 0:16:23.320 your salience networking is activating at that moment. For people 0:16:23.360 --> 0:16:25.880 who have done mindfulness meditation, we've all experienced this. 0:16:25.960 --> 0:16:27.280 You know, Okay, I'm going to be mindful. 0:16:27.320 --> 0:16:28.960 I'm going to pay attention to my breathing, and then 0:16:29.000 --> 0:16:31.640 after about you know, three seconds, your brain starts wandering 0:16:31.640 --> 0:16:33.680 off to something you have to do later that day 0:16:33.800 --> 0:16:36.160 or whatever. And then and you wander and wander and 0:16:36.160 --> 0:16:38.240 then after about a minute you're like, oh, I actually, 0:16:38.320 --> 0:16:39.920 I wasn't supposed to be doing that. I'm supposed to 0:16:39.920 --> 0:16:41.600 be paying attention to my breath, and at that moment 0:16:41.640 --> 0:16:45.320 of mindfulness you return. So at the moment of mindfulness 0:16:45.360 --> 0:16:48.440 being again, your salience network comes on as you break 0:16:48.480 --> 0:16:51.040 the train of thought. So we can imagine that as 0:16:51.040 --> 0:16:53.440 we go through life, we're often not in the present moment. 0:16:53.480 --> 0:16:55.960 We're ruminating about the past or the future or something else. 0:16:56.000 --> 0:16:58.360 But the moment that we snap out of it and 0:16:58.400 --> 0:17:00.680 return to the present moment the sailing this network seems 0:17:00.680 --> 0:17:04.000 to activate every time that happens. So you can imagine 0:17:04.040 --> 0:17:07.200 what would happen if the sailings network goes down. If 0:17:07.240 --> 0:17:10.040 you lose that capacity to easily snap out of things, 0:17:10.080 --> 0:17:12.280 then your ruminations will just keep going and keep going 0:17:12.320 --> 0:17:15.439 and keep going. And the minute that you can't snap 0:17:15.480 --> 0:17:18.119 out of things, all of a sudden, it's harder to function. 0:17:18.320 --> 0:17:18.560 Right. 0:17:19.080 --> 0:17:21.240 So, you know, all of us, if we're faced with 0:17:21.240 --> 0:17:23.600 a stressful situation, let's say we start worrying about it 0:17:23.640 --> 0:17:26.439 and thinking about something horrible that's happened, you know, if 0:17:26.440 --> 0:17:29.240 we lost someone important to us. But as long as 0:17:29.240 --> 0:17:31.240 we can snap out of that thought and return to 0:17:31.320 --> 0:17:33.680 our task or our work or whatever doing. We don't 0:17:33.720 --> 0:17:37.000 have an access one disorder. We have stress, we have distress, 0:17:37.080 --> 0:17:39.560 but we don't have disorder. But the day you can't 0:17:39.600 --> 0:17:41.680 snap out of it again is the day you flip 0:17:41.720 --> 0:17:42.880 over into having a disorder. 0:17:44.840 --> 0:17:49.280 So, with this understanding coming into focus, what kind of 0:17:50.520 --> 0:17:52.360 therapeutic approaches are there? 0:17:52.480 --> 0:17:54.040 Beautiful? So let's go to that. 0:17:54.119 --> 0:17:56.520 So let me also tie that back to resilience, because 0:17:56.560 --> 0:17:59.160 I'll say, resilience has a few different As we start 0:17:59.200 --> 0:18:01.359 to tease apart this circuitry, we start to realize that 0:18:01.440 --> 0:18:04.480 resilience has a few components to it. One of this 0:18:04.520 --> 0:18:07.040 isn't the only circuit behind resilience, but one of the 0:18:07.080 --> 0:18:10.040 circuits behind resilience is this salience network and its role 0:18:10.080 --> 0:18:12.800 of cognitive control and the ability to snap out of 0:18:12.960 --> 0:18:16.280 mind wandering and rumination. So that thing we call cognitive 0:18:16.280 --> 0:18:20.560 control or cognitive flexibility is one of the ingredients of resilience, 0:18:21.440 --> 0:18:23.240 and it is one that can be enhanced over time, 0:18:23.280 --> 0:18:26.280 as you say, one of the classic ways to enhance it. 0:18:26.320 --> 0:18:29.000 We know that, as I mentioned during Moments of Mindfulness, 0:18:29.160 --> 0:18:32.440 that the salience networks engage. So people who wish to 0:18:32.560 --> 0:18:36.840 enhance their resilience, mindfulness based stress reduction and mindfulness based 0:18:36.840 --> 0:18:39.719 cognitive therapy are tried and true sentxuries old, I mean 0:18:39.800 --> 0:18:43.040 thousands of years old methods that if you spend years 0:18:43.040 --> 0:18:45.840 and years practicing, you can strengthen one your capacity to 0:18:46.840 --> 0:18:48.680 be in the present moment or at least return to 0:18:48.720 --> 0:18:50.760 the present moment when you need to, and to maintain 0:18:50.800 --> 0:18:53.480 yourself there. When you're sitting there meditating for ten or 0:18:53.480 --> 0:18:56.360 twenty minutes, every time you catch yourself and bring yourself back. 0:18:56.400 --> 0:18:58.159 You can think about that as one rep. It's like 0:18:58.160 --> 0:19:00.960 one sit up of this system. And so the idea 0:19:01.000 --> 0:19:03.399 behind ten years of mindful at practices you're going to 0:19:03.400 --> 0:19:04.560 do a whole lot of situps and at the end 0:19:04.640 --> 0:19:06.200 that that system is going to be fairly strong. 0:19:06.280 --> 0:19:09.359 So we have mindfulness meditation is one way to practice this. 0:19:09.760 --> 0:19:13.200 How else are you thinking about this from the neurological point? 0:19:13.280 --> 0:19:15.560 Yeah, I think that's great. So there are Yeah, So 0:19:15.640 --> 0:19:17.520 that's exactly it. So that's one way of doing it. 0:19:18.240 --> 0:19:21.200 When people go for there are. Evidence based psychotherapy is 0:19:21.200 --> 0:19:23.720 like cognitive behavioral therapy, and that's a little bit different 0:19:23.720 --> 0:19:26.159 from mind welellss. You're not merely returning to be present 0:19:26.200 --> 0:19:28.880 with whatever feelings or thoughts are there. But the trick 0:19:29.000 --> 0:19:32.120 is when you get into a difficult situation and your 0:19:32.400 --> 0:19:34.600 emotional state goes out of control or your behavior goes 0:19:34.600 --> 0:19:39.080 out of control. In cognitive behavioral therapy, we teach ourselves 0:19:39.119 --> 0:19:41.840 to reframe situations or thoughts in a different way, so 0:19:41.840 --> 0:19:44.280 we're actually exerting cognive control to look at the situation 0:19:44.320 --> 0:19:47.359 a bit differently and figure out whether our emotions and 0:19:47.400 --> 0:19:50.960 our thoughts are proportionate to the situation or disproportionate, and 0:19:50.960 --> 0:19:53.720 then try and bring them back again. And that also 0:19:53.760 --> 0:19:56.680 involves activatingly at these regions. So those are tried and 0:19:56.720 --> 0:19:58.680 true methods that have been out there. I'm not aware 0:19:58.680 --> 0:20:02.159 of any specific medication that in a targeted way boost 0:20:02.240 --> 0:20:04.480 these things. So there are medications that help with the 0:20:04.520 --> 0:20:07.560 access one disorders, but I'm not aware of a medication 0:20:07.640 --> 0:20:12.159 that specifically does this one thing of enhancing one's cognitive control. Uh. 0:20:12.240 --> 0:20:15.320 You know, stimulants for some people and things like ADHD 0:20:15.440 --> 0:20:17.399 when they are is just a little underactive. There are 0:20:17.440 --> 0:20:20.120 certain groups of people who find that they gain contentitive 0:20:20.119 --> 0:20:23.040 control on you know, people with ADHD, for example, may 0:20:23.040 --> 0:20:26.119 find that medications enhance their ability to exercise or exert 0:20:26.119 --> 0:20:26.959 cognitive control. 0:20:43.600 --> 0:20:47.840 One of your errors expertise is transcriminal magnetic stimulation, So 0:20:47.880 --> 0:20:49.760 tell us about that. 0:20:49.760 --> 0:20:50.760 That's exactly where I was going. 0:20:51.840 --> 0:20:54.440 So first, for the benefit of the listenership, tell us 0:20:54.440 --> 0:20:58.080 what TMS is, and then tell us how it applies here. 0:20:58.280 --> 0:21:01.320 Perfect, Okay, So yes, So right now, we've got this 0:21:01.400 --> 0:21:04.000 target circuit in the brain that we'd really love to 0:21:04.040 --> 0:21:06.120 strengthen because if only we could strengthen it for people, 0:21:06.160 --> 0:21:07.960 they would have more cognitive control, and they'd have more 0:21:07.960 --> 0:21:10.560 resilience and so on. And medications don't do it for 0:21:10.640 --> 0:21:13.480 most people, but and therapy takes a really long time, 0:21:13.520 --> 0:21:15.360 and not everyone has the capacity to do it. 0:21:16.040 --> 0:21:16.920 But if we could. 0:21:16.760 --> 0:21:19.280 Somehow stimulate that area and turn it on over and 0:21:19.320 --> 0:21:23.000 over again, like do the sit ups for people, then 0:21:23.080 --> 0:21:25.320 you know, we could be able to strengthen it. And 0:21:25.400 --> 0:21:28.000 the method that we're using successfully to do that right 0:21:28.040 --> 0:21:33.440 now is called transcranial magnetic stimulation. TMS is the short form. 0:21:33.800 --> 0:21:37.440 It's a method for stimulating the brain non invasively. So 0:21:37.600 --> 0:21:39.560 in the old days, you want to stimulate the brain, 0:21:39.760 --> 0:21:42.080 you have to do surgery, open up the skull and 0:21:42.320 --> 0:21:46.720 implant use an electrode to stimulate the brain. Nowadays we 0:21:46.760 --> 0:21:50.080 can do that non invasively using a device that stimulates 0:21:50.080 --> 0:21:54.680 the brain through the skull using powerful focused magnetic field pulses. 0:21:55.359 --> 0:21:58.240 So a little inductor paddles placed over the target region 0:21:58.240 --> 0:22:02.800 of the brain and it'p little quick pulses. It's powerful 0:22:02.960 --> 0:22:05.119 enough that if you apply the little pulses to the 0:22:05.119 --> 0:22:07.520 area of your hand that moves your thumb, for example, 0:22:07.560 --> 0:22:09.560 you'll actually see the person's thumb move. And I think 0:22:09.560 --> 0:22:11.840 you and I have gone through that as a little demonstration, 0:22:13.560 --> 0:22:15.600 and it was discovered back in the nineteen ninety is 0:22:15.640 --> 0:22:17.320 that if you do this not once or twice, but 0:22:17.320 --> 0:22:19.560 if you do this hundreds of times, you can strengthen 0:22:19.680 --> 0:22:23.760 the circuits that you're stimulating via the mechanisms of neuroplasticity, 0:22:23.800 --> 0:22:27.000 which of course you've discussed elsewhere at length. The neurons 0:22:27.000 --> 0:22:30.080 that you fire together will gradually wire together. So when 0:22:30.080 --> 0:22:32.639 you deliver tms to any area of the brain, not 0:22:32.680 --> 0:22:36.159 only do you activate that area, but the other areas 0:22:36.160 --> 0:22:38.080 it's connected to will also light up, and they all 0:22:38.119 --> 0:22:40.520 fire together, and they all wire together. So you can 0:22:40.560 --> 0:22:42.440 sort of do hundreds of sit ups for a person 0:22:42.480 --> 0:22:46.640 in about three minutes of TMS using these sequences of pulses. 0:22:46.840 --> 0:22:50.400 It's been known for a long time dorsal that TMS 0:22:50.440 --> 0:22:53.000 two regions like the dorsalateral proof on cortex and so on. 0:22:54.040 --> 0:22:56.720 Back in nineteen ninety five, it was first demonstrated that 0:22:56.760 --> 0:22:59.000 this can be useful in treating depression, and then it 0:22:59.040 --> 0:23:00.840 turned out to be useful in treating other things like 0:23:00.880 --> 0:23:03.680 anxiety and other targets turned out to be useful in 0:23:03.720 --> 0:23:08.760 OCD and PTSD and binge eating disorder and bolivia orvosa 0:23:08.800 --> 0:23:12.120 and lots of other conditions. Interestingly, when we look back 0:23:12.200 --> 0:23:14.479 at what areas we'd been stimulating back in the nineties 0:23:14.480 --> 0:23:16.000 and later on, it turned out that a lot of 0:23:16.000 --> 0:23:19.480 the areas we were activating with TMS corresponded very nicely 0:23:19.560 --> 0:23:22.879 to this network, this alience network, which had been active 0:23:22.920 --> 0:23:26.200 across many different disorders. For those of us in the field, 0:23:26.200 --> 0:23:28.560 that solved the mystery where we come in and say, look, 0:23:28.680 --> 0:23:30.200 I thought we were just trying to treat the page. 0:23:30.200 --> 0:23:32.600 And when I opened my TMS clinic in twenty ten, 0:23:32.600 --> 0:23:34.479 we kept seeing this. We'd have a person who came 0:23:34.480 --> 0:23:36.399 from the eating disorders clinic. Oh, well, but you know 0:23:36.440 --> 0:23:38.119 you're depressed, so let's see if we can help you. 0:23:38.160 --> 0:23:40.440 So we treat the depression and they come back in 0:23:40.480 --> 0:23:42.359 and they say, well, Doc, you didn't tell me my 0:23:42.440 --> 0:23:45.080 Bolivia was going to go away. And they said, wow, 0:23:45.119 --> 0:23:47.880 that's interesting. How do you think about that? And then 0:23:48.240 --> 0:23:50.520 you'd have a person who came in for depression, but 0:23:50.560 --> 0:23:52.840 their bigger picture they were a veteran with PTSD and 0:23:52.840 --> 0:23:55.400 they come and say, you know, I'm not having flashbacks anymore. 0:23:55.640 --> 0:23:58.920 I can walk into Walmart now without having panic attacks, 0:23:58.960 --> 0:24:02.680 Like my anxiety is way down. You'd have other people 0:24:02.720 --> 0:24:05.159 who'd walk in and say, you know, I took a 0:24:06.080 --> 0:24:08.760 mindfulness course once and I just couldn't do it, but 0:24:08.840 --> 0:24:11.480 I noticed after the TMS, now I can do mindfulness, 0:24:12.560 --> 0:24:14.359 or say I took a therapy course once and I 0:24:14.400 --> 0:24:16.120 tried to learn how to do CBT and I tried 0:24:16.119 --> 0:24:18.560 the techniques and you know, I really I tried for 0:24:18.560 --> 0:24:20.719 two years. I was like teaching it to my roommate 0:24:20.760 --> 0:24:22.440 and she could do it, but I couldn't do it. 0:24:22.640 --> 0:24:24.480 But now after the TMS, I can do it now, 0:24:24.560 --> 0:24:27.719 like it actually works now. So there's a synergy between 0:24:27.760 --> 0:24:30.000 these areas of brain and our ability to stimulate them 0:24:30.040 --> 0:24:32.800 with TMS. And what we've noticed as we stimulate these 0:24:32.840 --> 0:24:35.320 areas is is it turned out to be very hard 0:24:35.359 --> 0:24:38.440 to just treat the person's depression or just treat their PTSD. 0:24:38.600 --> 0:24:41.080 If it kicked in and worked, a lot of things 0:24:41.160 --> 0:24:41.640 got better. 0:24:42.240 --> 0:24:44.800 And it was really fascinating what they would come in 0:24:44.880 --> 0:24:47.000 and you would ask them, Okay, well, okay, I see 0:24:47.000 --> 0:24:49.399 the numbers on your scale are down, but just tell me, 0:24:49.440 --> 0:24:51.560 in your own words, what's different now, And they say, 0:24:51.600 --> 0:24:52.440 you know, it's really weird. 0:24:53.240 --> 0:24:53.439 You know. 0:24:53.600 --> 0:24:57.760 Traditionally, I'm constantly ruminating about my body image all day, 0:24:57.960 --> 0:25:00.280 Like I can't stop thinking about my weight, I can't 0:25:00.280 --> 0:25:02.199 think about the way I look. And then I noticed that, 0:25:03.000 --> 0:25:05.760 you know, I had a and then someone said, someone 0:25:05.800 --> 0:25:08.560 made a comment, my aunt made a comment about my appearance. 0:25:08.600 --> 0:25:11.280 And normally that would have ruined my entire day, and 0:25:11.320 --> 0:25:13.080 I would have been still ruminating about it when I 0:25:13.119 --> 0:25:16.120 went to bed, and it was really weird. I noticed 0:25:16.240 --> 0:25:18.560 an hour later that I just wasn't thinking about it. 0:25:18.760 --> 0:25:20.280 I was kind of over it. I was thinking about 0:25:20.320 --> 0:25:22.680 other things again. And so these are the kind of 0:25:22.680 --> 0:25:25.719 things people would keep on talking about that some challenge 0:25:25.760 --> 0:25:28.479 would come along and what they were used to over 0:25:29.040 --> 0:25:30.200 years of having the disorders. 0:25:30.200 --> 0:25:32.280 Not a challenger come along. Okay, that's my week gone. 0:25:32.359 --> 0:25:35.080 I'm going to be stuck ruminating about this for the 0:25:35.119 --> 0:25:35.680 rest of the week. 0:25:35.800 --> 0:25:36.919 I won't be able to do anything. 0:25:37.400 --> 0:25:39.640 And what they kept noticing was saying, yeah, I get upset, 0:25:39.800 --> 0:25:43.560 and then twenty minutes later, I'm over it. And I said, well, 0:25:43.680 --> 0:25:45.480 is that a weird experience? You feel like you're being 0:25:45.520 --> 0:25:47.439 emotionally numbed or emotionally blunted. 0:25:47.520 --> 0:25:47.680 No. 0:25:47.680 --> 0:25:49.520 No, I still have my emotions, but I can get 0:25:49.520 --> 0:25:52.600 over things now and I don't overreact as much as 0:25:52.600 --> 0:25:54.719 I used to. My reaction is like sort of, you know, 0:25:55.000 --> 0:25:58.280 more proportionate. And I find I can and say, what's 0:25:58.320 --> 0:26:01.840 the experience like? And they use words like willpower and control? 0:26:02.280 --> 0:26:04.520 They say, I feel more like I'm in control again. 0:26:04.640 --> 0:26:06.960 I feel like I have that willpower thing that everyone's 0:26:06.960 --> 0:26:09.800 been telling me. I need more of that. Their subjective 0:26:09.840 --> 0:26:12.919 experience of having this network strengthen is an experience of 0:26:13.000 --> 0:26:15.080 greater willpower, greater control. 0:26:17.200 --> 0:26:20.200 And so does it matter which part of the network 0:26:20.320 --> 0:26:23.720 was stimulated or were these many different studies stimulating various 0:26:23.760 --> 0:26:26.280 different parts, but it all happened to be of this network. 0:26:26.400 --> 0:26:28.320 Well, so it's been a long time piecing that together 0:26:28.320 --> 0:26:31.960 because in the TMS literature, different people targeted. Some people 0:26:32.000 --> 0:26:34.160 will do the left hemispheres, someone do the right hemisphere, 0:26:34.240 --> 0:26:37.400 someone go in the middle between between the two hemispheres, 0:26:37.400 --> 0:26:39.399 and so on. And now that we've got enough of 0:26:39.440 --> 0:26:41.240 these studies and we put them together, it looks like 0:26:41.280 --> 0:26:43.800 you kind of get fairly similar results no matter which 0:26:43.880 --> 0:26:45.919 as long as it's one of the members of this 0:26:46.080 --> 0:26:49.479 network of regions, all the other networks are lighting up 0:26:49.920 --> 0:26:51.920 as well, And so it seems to have a similar 0:26:51.960 --> 0:26:55.119 effect when we scan people while we do TMS. You 0:26:55.200 --> 0:26:58.320 see that when you're stimulating one area, all the other 0:26:58.359 --> 0:26:59.800 areas and its network will light up. 0:27:00.720 --> 0:27:04.240 And how effective is this approach? 0:27:04.400 --> 0:27:07.560 Is it ninety percent of patients get better in some 0:27:07.640 --> 0:27:08.639 way as it ten percent? 0:27:08.920 --> 0:27:12.520 So that's been that remembering the TMS is a technology. 0:27:12.600 --> 0:27:14.960 So if you asked me the question in nineteen ninety five, 0:27:14.960 --> 0:27:17.120 it would be asking a little bit like how far 0:27:17.160 --> 0:27:19.760 can your electric car drive in nineteen ninety five versus 0:27:19.760 --> 0:27:22.119 how far can your electric car drive in twenty twenty five. 0:27:22.080 --> 0:27:23.640 There's the good. Dow says, there's progress. 0:27:24.800 --> 0:27:28.159 The early TMS studies were only getting about ten or 0:27:28.160 --> 0:27:31.040 fifteen percent of people their emission, but they were also 0:27:31.080 --> 0:27:33.560 only doing about ten or fifteen sessions of treatment. And 0:27:33.600 --> 0:27:36.040 then later studies did about thirty sessions of treatment and 0:27:36.080 --> 0:27:38.160 got about thirty percent of people better. And then later 0:27:38.200 --> 0:27:40.560 studies did about fifty sessions of treatment and sometimes you 0:27:40.560 --> 0:27:43.920 get fifty percent of people better. And then other studies 0:27:43.960 --> 0:27:47.159 were using MRI guidance to kind of fine tune the 0:27:47.200 --> 0:27:50.040 location of the stimulation, and it turns out some people, 0:27:50.280 --> 0:27:52.360 it turns out there because of their anatomy, you need 0:27:52.359 --> 0:27:55.320 to have map their anatomy a little more closely to 0:27:55.320 --> 0:27:58.720 get the coil over the right spot. But the biggest breakthrough, 0:27:58.760 --> 0:28:00.240 I think in the last two or three years is 0:28:00.320 --> 0:28:06.240 noticing that TMS require, as we mentioned, it requires the 0:28:06.240 --> 0:28:11.320 brain to have neuroplasticity. Right. There are implantable brain stimulators 0:28:11.320 --> 0:28:13.479 that people use for Parkinson's and depression and so on, 0:28:13.520 --> 0:28:15.440 and then a surgeon will implant them like a little 0:28:15.440 --> 0:28:17.760 pacemaker in the target circuit and then you walk around 0:28:17.760 --> 0:28:20.679 with it all day long. TMS isn't like that you 0:28:20.720 --> 0:28:22.520 sit in the chair, you get a session a treatment 0:28:22.560 --> 0:28:24.639 for three minutes, and after a bunch of sessions you 0:28:24.720 --> 0:28:27.480 then it has to keep lasting for weeks or months, 0:28:27.760 --> 0:28:31.200 even after you've gotten the treatment done. So the only 0:28:31.240 --> 0:28:34.520 way that that works is if you have neuroplasticity, and 0:28:34.560 --> 0:28:36.480 some people just don't have very much. We don't know why, 0:28:36.520 --> 0:28:38.520 but there's a lot of variation. So when we treat 0:28:38.520 --> 0:28:40.640 a bunch of people with depression, about twenty percent of 0:28:40.640 --> 0:28:43.800 people show really strong and really rapid response, and then 0:28:43.840 --> 0:28:46.000 about ten percent of people show nothing at all, and 0:28:46.040 --> 0:28:47.800 everyone else is somewhere in the middle. 0:28:48.200 --> 0:28:49.640 It's almost like you're bailing. 0:28:49.360 --> 0:28:51.040 A bit of a leaky boat, so you're kind of 0:28:51.240 --> 0:28:53.240 bailing it out, but they're getting worse, and then they 0:28:53.280 --> 0:28:55.440 tend to keep coming back. These are the ones who 0:28:55.480 --> 0:28:57.840 seem to need more plasticity. And one of the ways 0:28:57.920 --> 0:29:00.000 that has just come out in the last two orths 0:29:00.240 --> 0:29:03.080 years to make TMS a lot better is it turns 0:29:03.080 --> 0:29:05.880 out that there are some simple, off the shelf old 0:29:05.920 --> 0:29:09.720 medications that enhance the brain's plasticity, and if you take 0:29:09.760 --> 0:29:12.160 those medications a little like an hour or so before 0:29:12.200 --> 0:29:14.720 you get your TMS sessions, it works a lot better, 0:29:14.880 --> 0:29:16.440 and it lasts a lot longer. 0:29:17.160 --> 0:29:19.280 Give us a sense of what some of these meds are, 0:29:19.400 --> 0:29:21.240 just in case the name strikes that any was familiar. 0:29:21.400 --> 0:29:22.800 Happy to do it, so there is. 0:29:23.200 --> 0:29:26.600 So my colleague Alex McGear at the University of Calgary 0:29:26.640 --> 0:29:28.920 back in twenty twenty two publish a paper in Gemo 0:29:28.920 --> 0:29:32.720 Psychiatry using an old it's actually an old anti tuberculosis 0:29:32.800 --> 0:29:37.400 medication called de cyclosarine. Decyclo Sarine works on the brain's 0:29:37.400 --> 0:29:39.760 glutamate system. If we want to get really nerdy, it 0:29:39.880 --> 0:29:43.400 acts on the NMDA receptor. The NMDA receptor is the 0:29:43.440 --> 0:29:46.200 receptor that detects whether two neurons are being fired at 0:29:46.200 --> 0:29:49.080 the same time and then responds to that by strengthening 0:29:49.080 --> 0:29:51.800 the connection between them. So you need your NMDA receptors 0:29:51.800 --> 0:29:54.080 to do that whole plasticity thing where the neurons that 0:29:54.120 --> 0:29:57.240 fire together wire together. So what happens if you add 0:29:57.280 --> 0:29:59.960 a medication that tickles the NMDA receptor and kind of 0:30:00.160 --> 0:30:02.520 helps it stay open a little bit longer and then 0:30:02.600 --> 0:30:05.200 do the tms. Decycoserian has been around since the fifties 0:30:05.240 --> 0:30:08.000 and psychiatrists have been using it and medical researchers have 0:30:08.040 --> 0:30:10.160 been using it not for tuberculosis, but to try and 0:30:10.320 --> 0:30:13.560 enhance plasticity while they give therapy and give other kinds 0:30:13.560 --> 0:30:18.120 of treatments exposure therapy and phobias and OCD and so on, 0:30:18.520 --> 0:30:22.040 And I think one of my colleagues described the results 0:30:22.040 --> 0:30:25.080 as myth after many many years, the result was sort 0:30:25.080 --> 0:30:27.880 of some But interestingly, it might just be that those 0:30:27.960 --> 0:30:30.600 kind of therapies don't provide the direct kind of potent 0:30:30.720 --> 0:30:33.920 immediate stimulation of the neural connections the way that TMS does. 0:30:33.960 --> 0:30:37.280 Because the first time this was tried for TMS, the 0:30:37.320 --> 0:30:41.680 effect was not small. It doubled the remission rate, and 0:30:41.680 --> 0:30:44.040 that was just giving it for the first ten out 0:30:44.040 --> 0:30:46.920 of twenty sessions of TMS. You know, instead of the 0:30:46.960 --> 0:30:49.840 twenty percent remission rate you might expect with twenty sessions, 0:30:49.840 --> 0:30:53.040 it went up to forty percent. And then actually just 0:30:53.120 --> 0:30:55.560 two months ago Alex mcgerr's team went back and they 0:30:55.720 --> 0:30:58.880 tried it again for all twenty sessions and the remission 0:30:58.960 --> 0:31:03.960 rate went from twenty percent to seventy percent, eighty five 0:31:03.960 --> 0:31:06.360 percent of people showing at least. So it turns out 0:31:06.360 --> 0:31:09.200 there are a lot of people who just need more 0:31:09.240 --> 0:31:11.680 plasticity to do well on TMS, and TMS actually can 0:31:11.760 --> 0:31:14.920 be extremely powerful if you just enhance the plasticity first. 0:31:15.280 --> 0:31:18.120 So that was and then of course this is just 0:31:18.160 --> 0:31:21.000 about depression. So he also went to a different brain 0:31:21.040 --> 0:31:24.520 area that was involved in OCD. Because there is a 0:31:24.520 --> 0:31:28.360 TMS protocol for OCD, OCD is a tough nut to 0:31:28.400 --> 0:31:32.880 crack among TMS researchers. We think of it obsessed with 0:31:32.920 --> 0:31:35.280 compulsive disorders reckoned to be one of the toughest things, 0:31:35.760 --> 0:31:40.000 just for when they do clinical studies on OCD, they 0:31:40.000 --> 0:31:43.239 will often declare thirty five percent improvement in symptoms as 0:31:43.640 --> 0:31:46.680 a strong response, and they if you like, we don't 0:31:46.720 --> 0:31:48.600 expect to cure you of your OCD. If we can 0:31:48.640 --> 0:31:50.480 even get your thirty five percent better, we'll call that 0:31:50.520 --> 0:31:54.760 a win. That's often how structure studies are done. Alex 0:31:54.880 --> 0:31:57.600 mcgear's team when they did this in OCD, they found 0:31:57.600 --> 0:32:01.560 that twenty sessions. Uh, there's a school or there's a 0:32:01.560 --> 0:32:04.200 scale from zero to forty called the Yale Brown Obsessive 0:32:04.240 --> 0:32:07.200 Compulsive Score. It's the standard clinical scale you used to 0:32:07.240 --> 0:32:11.360 measure how bad somebody's OCD is. And you know you'll 0:32:11.360 --> 0:32:13.240 have a person who might have a score of twenty 0:32:13.280 --> 0:32:15.480 six which would be severe, or thirty which would be 0:32:15.600 --> 0:32:20.800 very severe, and twenty sessions of TMS would reduce their 0:32:20.840 --> 0:32:24.520 score by about two or three points, but with decyclicerine 0:32:24.640 --> 0:32:27.479 it was closer to ten points of reduction in twenty sessions. 0:32:27.600 --> 0:32:29.640 Great, so it's a big difference. 0:32:29.720 --> 0:32:31.760 And you know, the question is, well, okay, TMS is 0:32:31.800 --> 0:32:34.000 used for lots of other things, like TMS is being 0:32:34.040 --> 0:32:36.480 used for other brain circuits and Parkinson's and Alzheimer's, so 0:32:36.880 --> 0:32:39.320 could this be used to treat lots of things. There's 0:32:39.360 --> 0:32:43.360 a second wave of enhancing plasticity, which is dopamine. So 0:32:43.520 --> 0:32:45.240 dopamine has a lot of roles in the brain, but 0:32:45.280 --> 0:32:48.360 it does look like TMS relies upon dopamine for at 0:32:48.400 --> 0:32:51.600 least some of the plasticity. And there have been studies 0:32:51.640 --> 0:32:54.280 done in both in laboratory and in the real world 0:32:54.640 --> 0:32:57.520 in which if you give people medications that boost their 0:32:57.560 --> 0:33:01.040 dopamine levels, like el dopa for example, Parkinson's drug that 0:33:01.360 --> 0:33:03.800 adds dopamine to the brain, and then you do the 0:33:03.840 --> 0:33:07.400 TMS the excited where ATMs protocols get stronger, the effect 0:33:07.400 --> 0:33:09.880 of the TMS gets stronger, so you're boosting plasticity. 0:33:10.040 --> 0:33:10.560 So it looks like. 0:33:10.560 --> 0:33:13.440 There's at least two or three different receptor and neurotransmitter 0:33:13.480 --> 0:33:14.040 systems that. 0:33:14.000 --> 0:33:16.280 Can be used to do this. How about a seedyl colin. 0:33:16.720 --> 0:33:17.680 That's an interesting one. 0:33:17.760 --> 0:33:20.760 So that hasn't been try yet, but you know there 0:33:20.840 --> 0:33:24.200 are easily four or five or six different methods for 0:33:24.280 --> 0:33:26.480 doing this. I don't know if you've had Lee Williams 0:33:26.560 --> 0:33:28.520 come in and talks of Lee Williams here at Stanford 0:33:28.560 --> 0:33:33.239 has been looking at it at guanphisine, not necessarily on 0:33:33.240 --> 0:33:35.200 a cell colin, but looking at guanfessine to see what 0:33:35.400 --> 0:33:41.680 that's a third neurotransmitter system involving neuropinephrin, and has been 0:33:41.720 --> 0:33:45.160 showing that people with problem there are specific people with 0:33:45.240 --> 0:33:49.640 depression who stand out for having particularly prominent difficulties with 0:33:49.720 --> 0:33:53.960 cognitive control. And here's a medication called guafisene that isn't 0:33:53.960 --> 0:33:57.600 normally used as an antidepressant, but in these patients, they 0:33:57.680 --> 0:33:59.680 who happen to have what they call the cognitive control 0:33:59.760 --> 0:34:04.000 that fense. This medication does work as an antidepressant for 0:34:04.000 --> 0:34:07.840 these folks, probably by enhancing their cognitive control so they 0:34:07.840 --> 0:34:09.600 don't get stuck in rumination all the time. 0:34:09.920 --> 0:34:12.800 Right, Yeah, you know, this is such an exciting moment 0:34:12.800 --> 0:34:17.040 in time. We're in neuroscience where everybody has been doing 0:34:17.120 --> 0:34:21.560 these studies and we well know that to get a 0:34:21.640 --> 0:34:24.719 patient and do a study and so on a ton 0:34:24.760 --> 0:34:27.960 of work to do one patient, two patients, and suddenly 0:34:27.960 --> 0:34:31.080 we can do these meta analyzes and put together the 0:34:31.120 --> 0:34:35.080 big picture and start seeing the jigsaw puzzle more broadly. 0:34:35.200 --> 0:34:38.680 So what our next steps. We're almost halfway through twenty 0:34:38.680 --> 0:34:40.160 twenty five. Now where is this all going? 0:34:40.200 --> 0:34:43.920 Absolutely so, first of all, one of the there are 0:34:43.960 --> 0:34:46.960 two directions that the field is going in right now. 0:34:47.040 --> 0:34:49.400 One of them, which I think is a broader trend 0:34:49.440 --> 0:34:52.480 in psychiatry in general, is the field of personalized medicine. 0:34:52.520 --> 0:34:54.360 So let's look at your symptoms and let's see if 0:34:54.400 --> 0:34:57.879 we can achieve a higher chance of success by looking 0:34:57.960 --> 0:35:01.000 at your specific symptoms and personalizing maybe the frequency of 0:35:01.000 --> 0:35:03.000 treatment or the type of medication we use, or the 0:35:03.040 --> 0:35:06.479 location of the coil based on your specific parameters. Which 0:35:06.520 --> 0:35:08.600 is great if it works, but the downside of courses, 0:35:08.640 --> 0:35:10.520 it also has a lot more complexity. So you know, 0:35:10.600 --> 0:35:13.080 psychiatric treatments are already costly and hard to get, and 0:35:13.120 --> 0:35:15.080 so this makes them more costly and more hard to 0:35:15.120 --> 0:35:18.279 get the other potential approach that we could try not 0:35:18.320 --> 0:35:19.640 to say that then there's certainly going to be a 0:35:19.719 --> 0:35:22.160 role for that. Personalized medicine is certainly looking very exciting. 0:35:22.560 --> 0:35:25.799 But there are some things there's a different approach where 0:35:25.840 --> 0:35:27.960 we try not to personalize and when we simply try 0:35:27.960 --> 0:35:29.880 to come up with the sort of greatest good for 0:35:29.920 --> 0:35:32.400 the greatest number approach. And so I want to unpack 0:35:32.440 --> 0:35:36.160 that a little bits to point at the idea that 0:35:36.200 --> 0:35:38.239 there might be some brain story. I mentioned earlier, there 0:35:38.280 --> 0:35:41.040 are some brain circuits that are universally involved across a 0:35:41.120 --> 0:35:44.160 variety of different disorders. And so one of the questions 0:35:44.160 --> 0:35:45.920 I asked one of my colleagues at Harvard who have 0:35:45.960 --> 0:35:48.399 been doing one of these brain mapping type studies and seeing, 0:35:48.440 --> 0:35:51.320 instead of mapping the circuits that are associated with depression 0:35:51.640 --> 0:35:55.600 or PTSD or addictions or whatever, we notice that some 0:35:55.640 --> 0:35:58.760 people just have resilience, so they actually function much better 0:35:58.800 --> 0:36:01.560 than expected. For those of us whore working clinics and 0:36:01.560 --> 0:36:03.320 see thousands of patients, you'll see these people who have 0:36:03.440 --> 0:36:06.600 like terrible depression and yet somehow like they're still functioning 0:36:06.640 --> 0:36:09.440 really well. Or people who have terrible Parkinsons and can 0:36:09.440 --> 0:36:12.560 barely move, and somehow they're still kind of functioning or 0:36:12.600 --> 0:36:14.359 you know, have had a stroke that's crippling to them, 0:36:14.360 --> 0:36:17.359 and as we mentioned earlier, somehow still functioning and then 0:36:17.600 --> 0:36:20.719 functioning mentally and in the activities of daily life, like yes, 0:36:20.760 --> 0:36:24.239 they're super you know, there's somehow still. I actually saw 0:36:24.280 --> 0:36:27.600 a gentleman, what was it, I don't know whose name. 0:36:27.600 --> 0:36:29.799 We were having brunction pol Walta just up the road 0:36:30.680 --> 0:36:33.279 and there was a little man, it looked in his 0:36:33.360 --> 0:36:36.040 nineties in a wheelchair by himself, and he was out 0:36:36.040 --> 0:36:38.160 for a while. He was using one leg and his 0:36:38.200 --> 0:36:40.880 heel to drag his wheelchair along one foot at a time, 0:36:41.200 --> 0:36:42.920 and he smiled and waved to us, and he kind 0:36:42.920 --> 0:36:45.719 of crept along sidewalk for his morning stroll. And he 0:36:45.920 --> 0:36:48.040 was and I don't know who got him into the 0:36:48.120 --> 0:36:49.759 chair or how he's getting along, but there he was, 0:36:49.760 --> 0:36:52.000 just using one foot to drag himself around the block 0:36:52.040 --> 0:36:54.320 for a little morning scroll. And so we can evaluate 0:36:54.360 --> 0:36:57.440 how severe your symptoms are, but we can independently evaluate 0:36:57.520 --> 0:37:00.560 how well you're functioning in daily life. So that gentlemen 0:37:00.600 --> 0:37:02.200 I mentioned would be an example of someone who if 0:37:02.239 --> 0:37:04.520 you measured their physical symptoms, they would be totally crippled. 0:37:04.520 --> 0:37:06.120 But if you actually they're still. 0:37:06.120 --> 0:37:08.640 Getting up every morning and walking around and having breakfast 0:37:08.640 --> 0:37:10.919 and doing all their stuff, So on that level, they're 0:37:10.920 --> 0:37:13.400 better than expected. So the question becomes, let's run an 0:37:13.320 --> 0:37:16.360 analysis of strokes or lesions or other things and figure 0:37:16.360 --> 0:37:19.600 out are there areas that correlate with your better than 0:37:19.760 --> 0:37:22.640 expected or worse than expected number if we think of that, 0:37:22.719 --> 0:37:25.360 But and they do, they pop out and one of 0:37:25.400 --> 0:37:27.000 the two There are two circuits that popped out of 0:37:27.000 --> 0:37:30.799 that analysis, which was led by Beatrice Milano and with 0:37:30.840 --> 0:37:33.200 my colleague Shan Sidiki and his group over at Harvard. 0:37:33.440 --> 0:37:35.200 They went through a whole bunch of stroke patients and 0:37:35.239 --> 0:37:39.680 they looked at their ability to function in general. And 0:37:39.719 --> 0:37:43.120 the circuits that popped out. Number one involved this one 0:37:43.120 --> 0:37:45.840 of these salients network circuits that I talked about. But 0:37:45.880 --> 0:37:48.560 there was a second circuit that was down just above 0:37:48.560 --> 0:37:50.719 the eye in another circuit we haven't gotten to yet, 0:37:50.719 --> 0:37:54.640 called the orbit of frontal cortex, and it was also involved, 0:37:54.640 --> 0:37:56.920 but in the opposite polarity. In other words, it was 0:37:56.920 --> 0:37:59.120 actually good to have lesions in this area. And if 0:37:59.120 --> 0:38:01.080 this area was preserved you were more likely to be 0:38:01.120 --> 0:38:03.880 functionally impaired. How do we understand that? So that's an 0:38:03.880 --> 0:38:07.280 interesting one because this circuit is also pretty well studied 0:38:08.120 --> 0:38:11.080 and it is the counterpart to the brain's so called 0:38:11.120 --> 0:38:13.640 reward circuit. So the brain most of us know, has 0:38:13.640 --> 0:38:15.359 this sort of a reward circuit whose job it is 0:38:15.400 --> 0:38:19.200 to identify goals that are worth pursuing and to motivate 0:38:19.280 --> 0:38:21.840 us to go and pursue those goals. The problem is 0:38:21.840 --> 0:38:24.160 that that would only allow us to pursue positive goals. 0:38:24.200 --> 0:38:28.320 We also need a partner circuit to identify potential pitfalls 0:38:28.360 --> 0:38:32.440 or problems, challenges, threats, and to establish goals to avoid 0:38:32.440 --> 0:38:35.160 those things and motivate ourselves to avoid those. If you 0:38:35.200 --> 0:38:37.719 don't have both circuits, you're in trouble. The brain needs 0:38:37.760 --> 0:38:40.240 to be motivated to seek out stuff, but also needs 0:38:40.239 --> 0:38:43.319 to be motivated to avoid the bad stuff. And the 0:38:43.360 --> 0:38:46.960 circuit that was overactive in these stroke patients, or so 0:38:47.000 --> 0:38:49.440 to speak, or was the one that was the so 0:38:49.480 --> 0:38:53.000 called non reward circuit, whose job it was to be 0:38:53.040 --> 0:38:57.480 motivated to essentially to generate negative motivations. 0:38:58.640 --> 0:39:01.120 It looks like, so you said that was overactive in 0:39:01.120 --> 0:39:03.759 the stroke patients is that there's a specific thing we 0:39:03.800 --> 0:39:06.080 think is happening in that circuit, it can enter into 0:39:06.080 --> 0:39:07.560 a feedback loop, right. 0:39:07.640 --> 0:39:10.560 And this is a theory by a professor in the 0:39:10.680 --> 0:39:14.239 UK called Professor Edmund Rules. He'd been studying the orbit 0:39:14.280 --> 0:39:17.600 of frontal cortex region in monkeys and humans for decades 0:39:18.560 --> 0:39:21.640 and he after many years, realized that this circuit tended 0:39:21.640 --> 0:39:24.600 to get stuck in a feedback loop in depression, and 0:39:25.360 --> 0:39:29.040 he proposed what I think is a very lovely theory 0:39:29.040 --> 0:39:31.920 called the non reward attractor theory of depression. So, in 0:39:31.960 --> 0:39:34.759 the non reward attractor theory of depression, you have a 0:39:34.800 --> 0:39:38.560 circuit whose job it is, to what it's functioning properly, 0:39:38.680 --> 0:39:41.239 is to identify threats, so you can then start to 0:39:41.280 --> 0:39:44.440 think about solutions and go and solve them. But if 0:39:44.480 --> 0:39:46.279 it gets stuck in a feedback loop, then you can't 0:39:46.280 --> 0:39:48.640 stop thinking about it even when you're not solving it. 0:39:49.080 --> 0:39:52.200 I think all of us have experienced the sensation at 0:39:52.200 --> 0:39:54.480 times of the difference between you know, working on a 0:39:54.520 --> 0:39:56.960 problem versus just worrying about a problem where you're not 0:39:57.000 --> 0:39:58.520 really solving it, but you're awake at two in the 0:39:58.520 --> 0:40:00.319 morning years thinking about the same thing over and over 0:40:00.360 --> 0:40:02.040 and over again, and you're not really getting anywhere, but 0:40:02.120 --> 0:40:03.839 you just keep going and keep going, and you can't 0:40:03.840 --> 0:40:05.840 get back to sleep, and you really just need to 0:40:05.880 --> 0:40:07.719 stop thinking about it because you're not going to solve 0:40:07.719 --> 0:40:09.160 it right now, and snap out of it and go 0:40:09.200 --> 0:40:12.080 back to sleep now if you can't. And if that 0:40:12.120 --> 0:40:14.440 goes on all day long, you're not functioning because you're 0:40:14.440 --> 0:40:17.080 sitting there ruminating and going round and around on problems. 0:40:17.400 --> 0:40:19.200 Maybe it's a one out of ten problem that your 0:40:19.239 --> 0:40:21.080 brain is treating as a ten out of ten problem. 0:40:21.800 --> 0:40:23.440 Maybe it's a three out of ten problem that your 0:40:23.440 --> 0:40:26.239 brain should be spending five minutes on and spending eight 0:40:26.280 --> 0:40:28.640 hours on. But the point is that while it's doing that, 0:40:28.880 --> 0:40:31.800 you're not getting up, you're not having breakfast, you're not functioning, 0:40:31.840 --> 0:40:33.680 you're not going to work, you're not really you're not 0:40:33.719 --> 0:40:52.400 fully present, you're not doing things. 0:40:53.440 --> 0:40:54.680 I'll give you an example of this. 0:40:54.719 --> 0:40:57.960 There was a woman described in the literature who is she, 0:40:58.880 --> 0:41:02.600 among other things, had she had sought treatment for many 0:41:02.640 --> 0:41:04.919 years for alcohol dependence. So she was somebody who drank 0:41:05.160 --> 0:41:08.520 about ten drinks a day and somehow functioned through this 0:41:08.640 --> 0:41:10.640 recently well. But was drinking ten drinks a day, and 0:41:10.680 --> 0:41:13.600 it sought treatment from physicians for this in a variety 0:41:13.600 --> 0:41:14.080 of different ways. 0:41:14.120 --> 0:41:15.320 Not a boich. You have been successful. 0:41:15.760 --> 0:41:19.120 In her fiftyes, she suffered a stroke and the strength 0:41:19.480 --> 0:41:22.200 was the stroke happened to land. It was a small stroke, 0:41:22.360 --> 0:41:25.960 just in this little circuit, and she immediately found it 0:41:26.120 --> 0:41:28.520 that she no longer had any desire or interest in 0:41:28.560 --> 0:41:31.680 consuming alcohol, and the alcohol, the use that she'd been. 0:41:31.560 --> 0:41:33.440 Trying to get her over for years just kind of 0:41:33.440 --> 0:41:33.920 went away. 0:41:34.239 --> 0:41:36.120 Other people with strokes in these areas, there are people 0:41:36.120 --> 0:41:39.200 who have obsessed with compulsive disorder and have suffered this 0:41:39.280 --> 0:41:41.399 is a weird thing that they had OCD for thirty 0:41:41.480 --> 0:41:42.960 or forty years, and then one day they have a 0:41:42.960 --> 0:41:45.560 stroke in their old age and the OCD goes away. 0:41:45.920 --> 0:41:50.839 So yeah, So there are situations where this circuit gets 0:41:50.840 --> 0:41:53.080 stuck in a feedback loop and the best thing you 0:41:53.120 --> 0:41:54.719 can do here function is to just get out of 0:41:54.719 --> 0:41:58.080 the feedback loop. Now, losing the circuit altogether is pretty drastic, right, 0:41:58.120 --> 0:42:00.279 That's what we'd rather do is just turn it down 0:42:00.280 --> 0:42:03.000 a little bit, and TMS can be used to do that. 0:42:03.520 --> 0:42:06.720 Back in around twenty sixteen seventeen, I had a patient 0:42:06.719 --> 0:42:10.040 who had come for TMS, and we tried the standard 0:42:10.320 --> 0:42:12.960 TMS of one of these salience network cress and we 0:42:13.040 --> 0:42:16.000 didn't get anywhere. So then we tried another salience network 0:42:16.000 --> 0:42:18.080 cretion and for reasons you know and I've described, that 0:42:18.080 --> 0:42:20.680 didn't do much either. And then she said, well, please, 0:42:20.719 --> 0:42:22.960 I please try something else because I you know, the 0:42:23.000 --> 0:42:25.520 next step normally would have been to go to electroconvulsive 0:42:25.560 --> 0:42:28.040 therapy or shock therapy, and she really didn't want to 0:42:28.040 --> 0:42:30.080 do that. So I said, well, there is this other 0:42:30.160 --> 0:42:34.640 area that's been tried in OCD, and you don't have OCD, 0:42:34.760 --> 0:42:37.200 but you do have a kind of depression that reminds 0:42:37.239 --> 0:42:39.600 us of OCD because you just kind of get obsessed 0:42:39.640 --> 0:42:43.440 with the same negative things about yourself. And when you 0:42:43.480 --> 0:42:45.680 described me what your depression is like, it sounds almost 0:42:45.719 --> 0:42:48.759 like an ocd ish flavor of depression. So if you will, 0:42:49.000 --> 0:42:50.799 like you can come in and I'll give you this 0:42:50.920 --> 0:42:53.239 treatment which has been used for OCD, and we'll say, 0:42:53.239 --> 0:42:56.760 maybe let's see if your OCD ish depression gets somewhere. 0:42:57.040 --> 0:42:59.800 And it was a complete remission. We also had scans 0:42:59.840 --> 0:43:02.040 on her and we were able to show that normally 0:43:02.080 --> 0:43:05.239 when we do TMS, we strengthen this salience network, and 0:43:05.280 --> 0:43:07.120 you can see this connection strengthened. 0:43:07.440 --> 0:43:08.000 In her case. 0:43:08.040 --> 0:43:10.560 We scanned her before and after, and when she got better, 0:43:10.600 --> 0:43:13.239 it had nothing to do with the salience network. Instead, 0:43:13.320 --> 0:43:17.319 we had suppressed the over connection between this orbit of 0:43:17.320 --> 0:43:20.520 frontal region and its little loop of activity down into 0:43:20.560 --> 0:43:21.520 the reward circuitry. 0:43:21.800 --> 0:43:23.440 So what happened to her after was what was what 0:43:23.520 --> 0:43:24.359 was it like for her? 0:43:24.440 --> 0:43:28.120 What she said was that essentially she was now free 0:43:28.120 --> 0:43:31.759 of ruminations. I'll give you, and we had other people 0:43:31.800 --> 0:43:33.319 come and do it, So I'll give you a really 0:43:33.320 --> 0:43:36.120 illustrative example of one person who had a little bit 0:43:36.160 --> 0:43:37.880 of both. She had a bit of column AN and 0:43:37.880 --> 0:43:39.640 a bit of COLUMNB. So not only did she have 0:43:39.680 --> 0:43:42.719 a tendency to be really obsessive and self critical and ruminative, 0:43:43.000 --> 0:43:44.960 but she also tended to be quite impulsive and a 0:43:44.960 --> 0:43:47.600 bit ADHD like and had difficulty with the cognitive control. 0:43:47.680 --> 0:43:48.800 So she really struggled. 0:43:49.800 --> 0:43:51.760 And she came to us from the eating sort of program, 0:43:51.840 --> 0:43:54.799 and she bring she had blimior nervosa, so she would 0:43:54.800 --> 0:43:56.520 spend a couple of hours a day binge eating and 0:43:56.520 --> 0:43:59.359 then purshing it up and binge eating, and pershing. She 0:43:59.440 --> 0:44:01.640 also had a lot of intrusive thoughts about her body 0:44:01.640 --> 0:44:05.040 image and negative body thoughts. She had PTSD symptoms. She 0:44:05.080 --> 0:44:07.319 had a lot of different things. So we gave her 0:44:07.360 --> 0:44:11.000 the standard TMS and her depression scores went down by 0:44:11.000 --> 0:44:14.520 about half, and she said, well, this is really interesting, 0:44:14.560 --> 0:44:17.600 Like I feel somewhat better, like I noticed, like I'm 0:44:17.640 --> 0:44:20.640 feeling less anxious and less depressed. And you certainly helped 0:44:20.680 --> 0:44:23.000 me with my bolimia because I haven't had any urges 0:44:23.040 --> 0:44:25.359 to beings or pursed, like those impulses are just gone. 0:44:26.080 --> 0:44:29.000 But I still think about suicide every day, and I 0:44:29.000 --> 0:44:31.799 still think about how horrible my body looks every day, 0:44:32.000 --> 0:44:36.080 and I can't enjoy anything. And so we talked about 0:44:36.120 --> 0:44:37.920 it a bit. And when I heard about these obsessions, 0:44:37.960 --> 0:44:40.520 I said, well, you know, we could try going to 0:44:40.600 --> 0:44:43.439 this other area that's typically an OCD area and see 0:44:43.440 --> 0:44:45.840 if these obsessive thoughts you have about body image and 0:44:45.840 --> 0:44:48.200 suicide and so on, let's see what that does. Because 0:44:48.200 --> 0:44:50.839 a couple of other patients have been helped by it. 0:44:50.840 --> 0:44:52.160 It was a while before we could get her in. 0:44:52.239 --> 0:44:54.960 The clinic had a lineup, so we treated her and 0:44:54.960 --> 0:44:57.719 then she came back in. This was lovely about She 0:44:57.840 --> 0:44:59.359 came in and I asked her how she was doing, 0:44:59.360 --> 0:45:01.319 and her scores down to the single dishits she was 0:45:01.320 --> 0:45:04.040 doing really, really well. And I asked her, but what 0:45:04.120 --> 0:45:05.960 was it like? And she said, well, I'll tell you 0:45:05.960 --> 0:45:08.680 what I noticed. It was this past weekend. I was 0:45:08.719 --> 0:45:10.759 playing with my niece and nephew, and I noticed that 0:45:10.800 --> 0:45:13.800 I was smiling, and I noticed I was feeling pleasure, 0:45:14.000 --> 0:45:16.520 like joy, which is weird. I hadn't felt that in 0:45:16.560 --> 0:45:18.880 twenty years. And then I thought about it, and I 0:45:18.920 --> 0:45:21.440 realized I actually hadn't thought about suicide all day, and 0:45:21.480 --> 0:45:23.359 that hasn't happened for twenty And I realized I hadn't 0:45:23.360 --> 0:45:26.560 thought about suicide for days, which hasn't happened. 0:45:26.719 --> 0:45:27.919 I was able to enjoy things. 0:45:27.960 --> 0:45:30.359 And then I realized I'd eaten a hamburger four days ago, 0:45:30.680 --> 0:45:32.319 and normally i'd still be thinking about that. 0:45:32.280 --> 0:45:36.480 Hamburger, regret about you, regret exactly. 0:45:36.800 --> 0:45:38.759 I'd still be thinking like, why did you do that you? 0:45:39.480 --> 0:45:42.440 And I realized that I just wasn't worried about the burger. 0:45:42.880 --> 0:45:44.960 I'd eaten it, and yeah, I was a little upset 0:45:44.960 --> 0:45:47.360 about it, but then I just wasn't thinking about it anymore. 0:45:47.600 --> 0:45:50.800 But this was three or four months after her original treatment. 0:45:50.840 --> 0:45:52.400 She said, but could I come back and have the 0:45:52.440 --> 0:45:54.640 previous one again, because I'm starting to get back into 0:45:54.680 --> 0:45:57.319 my binging and pershing behavior. That's that part is coming 0:45:57.360 --> 0:45:59.919 back again. So you can see it what we would 0:46:00.280 --> 0:46:04.960 in neuropsychology, a double dissociation, where treatment of one circuit 0:46:05.040 --> 0:46:07.720 is helping with the person's impulses and their cognitive control. 0:46:07.840 --> 0:46:10.719 And after treatment there she felt a stronger sense of 0:46:10.760 --> 0:46:13.800 agency of self control with this first set of areas 0:46:13.800 --> 0:46:14.880 around this alience network. 0:46:15.200 --> 0:46:16.120 With the second set of. 0:46:16.120 --> 0:46:19.440 Areas, she was feeling freedom from being trapped in a 0:46:19.480 --> 0:46:22.840 circle of rumination on negative thoughts. But as the first 0:46:22.920 --> 0:46:26.120 one wore off, she was losing that control piece. And 0:46:26.160 --> 0:46:28.920 that highlights the two elements of resilience that come from this. 0:46:29.000 --> 0:46:31.880 That what the ingredients of resilience seed be these two circuits. 0:46:31.920 --> 0:46:35.279 Number one, having more self control or agency or a 0:46:35.320 --> 0:46:37.760 sense of will to snap out of things or control 0:46:37.800 --> 0:46:41.279 what you're thinking about. And number two, the ability to 0:46:41.400 --> 0:46:43.480 not get stuck in a circle of rumination on the 0:46:43.480 --> 0:46:46.239 same stuff, the ability to exit that circle. If you 0:46:46.320 --> 0:46:48.040 have those two things, you're resilient. 0:46:49.000 --> 0:46:53.399 So cut to a quarter century from now when this 0:46:53.440 --> 0:46:57.359 is all very well worked out and every shopping mall 0:46:57.520 --> 0:47:01.160 has a TMS clinic that you can walk into and. 0:47:01.120 --> 0:47:01.839 I hope are there soon. 0:47:01.920 --> 0:47:06.800 Yeah, Okay, The question is how will people know whether 0:47:07.840 --> 0:47:10.319 they should go in and get this stream. It's like 0:47:10.360 --> 0:47:12.200 it's like doing a tune up on your car. But 0:47:12.320 --> 0:47:14.680 how do you know, you know, is there some variety 0:47:14.800 --> 0:47:19.879 that would be useful to have in our society. How 0:47:19.880 --> 0:47:22.160 do you know when you should get it at what level? 0:47:22.280 --> 0:47:25.120 Yeah, it's a really interesting question, particularly because TMS is 0:47:25.120 --> 0:47:27.799 a technology, so it gets better, it gets faster, it 0:47:27.800 --> 0:47:30.720 gets cheaper over time. So you know, it's the example 0:47:30.760 --> 0:47:32.680 of you know, when I was a kid, we talked 0:47:32.680 --> 0:47:35.040 about flying to like space tourists who would go up 0:47:35.040 --> 0:47:37.399 to flying space hotels, and that hasn't happened yet because 0:47:37.400 --> 0:47:39.040 the cost of flying a space would have to come 0:47:39.080 --> 0:47:41.160 down a lot before most of us can afford to 0:47:41.200 --> 0:47:44.800 do that. And likewise, TMS presently is still pretty expensive. 0:47:44.840 --> 0:47:46.320 But you know, the costs are coming down and the 0:47:46.360 --> 0:47:49.200 availability is going up, and so the threshold for and 0:47:49.280 --> 0:47:52.960 TMS happens to have an excellent safety profile, So the 0:47:53.040 --> 0:47:55.440 question would become of when to go and get TMS. 0:47:55.560 --> 0:47:59.640 Right now, it is an FDA cleared technique, and it 0:47:59.719 --> 0:48:02.080 is the FDA is the cleared to be a prescription treatment, 0:48:02.160 --> 0:48:04.440 so one one does go to a physician and obtain 0:48:04.480 --> 0:48:06.800 a prescription to get TMS. 0:48:07.520 --> 0:48:08.000 And in the. 0:48:08.000 --> 0:48:11.120 Past, most insurers and pairs would require people to have 0:48:11.200 --> 0:48:13.600 tried three or four or five or six different medications 0:48:13.600 --> 0:48:16.319 before they often four medications or more before they were 0:48:16.840 --> 0:48:19.800 allowed to apply for coverage for TMS. Now those numbers 0:48:19.800 --> 0:48:22.359 are coming down and people are able to go earlier on. 0:48:23.520 --> 0:48:28.520 So I think what we'll see is that it may 0:48:28.600 --> 0:48:32.120 be that you'll be able to go for TMS to 0:48:32.280 --> 0:48:35.520 enhance your functional capacity. Just knowing that we have these 0:48:35.520 --> 0:48:39.000 two target circuits, people will be able to go in and. 0:48:38.760 --> 0:48:40.800 Across a wide variety of disorders. 0:48:40.800 --> 0:48:43.200 So at the moment, TMS is FDA cleared in depression, 0:48:43.239 --> 0:48:46.200 it's FDA cleared in OCD, and in chronic pain a 0:48:46.200 --> 0:48:48.960 couple of other conditions. But what might happen is it 0:48:49.040 --> 0:48:51.640 might be cleared across a wide basket of different conditions. 0:48:51.680 --> 0:48:54.719 And because the TMS really isn't what's interesting is we 0:48:54.840 --> 0:48:56.760 discovered the TMS isn't treating the depression. 0:48:57.160 --> 0:48:58.960 It's indirectly treating that by just. 0:48:59.000 --> 0:49:03.040 Generally enhancing your self control and allowing you to not 0:49:03.040 --> 0:49:05.200 get stuck in rumination. And that turns out to be 0:49:05.280 --> 0:49:07.400 useful not just for depression, but for lots of things. 0:49:07.719 --> 0:49:10.759 So where I hope we end up in hopefully a 0:49:10.800 --> 0:49:12.920 lot less than twenty five years, maybe in five years, 0:49:13.800 --> 0:49:16.120 would be in a situation where people can come in 0:49:16.320 --> 0:49:20.040 across a wide variety of conditions and maybe not waiting 0:49:20.080 --> 0:49:22.520 until they're extremely severe and until they've tried lots of 0:49:22.560 --> 0:49:24.799 other things. But you know, there may even be a 0:49:24.800 --> 0:49:26.960 world where you know, even and this is one thing 0:49:27.000 --> 0:49:30.120 people are working on, is even before going to medications, 0:49:30.120 --> 0:49:32.360 where people might be able to go and pursue this 0:49:32.400 --> 0:49:35.960 treatment right away. As you know, So when a person 0:49:36.000 --> 0:49:39.640 first starts to realize that they're encountering significant difficulty functioning 0:49:39.719 --> 0:49:42.239 because of the severity of their anxiety or depression or 0:49:42.239 --> 0:49:44.439 whatever it be, that they can go in and get 0:49:44.560 --> 0:49:46.200 essentially a top up of resilience. 0:49:47.640 --> 0:49:48.879 The thing that we all wish we had. 0:49:49.440 --> 0:49:51.640 That comes back to a dinner conversation we had ten 0:49:51.719 --> 0:49:54.200 years ago where I was sitting with some friends and 0:49:54.360 --> 0:49:57.440 as a dinner conversation starter, we said, okay, let's go 0:49:57.440 --> 0:50:00.160 around the room and let's say you had the abilit 0:50:00.280 --> 0:50:03.240 to just rub a magic lamp and a genie would 0:50:03.360 --> 0:50:05.880 would you could say one word and then everyone in 0:50:05.920 --> 0:50:06.640 the world would. 0:50:06.440 --> 0:50:08.760 Be gifted that thing. So what would you? 0:50:08.800 --> 0:50:10.560 And we all went around the table, and the one 0:50:10.600 --> 0:50:13.320 I chose was happened to be resilience. I said, the 0:50:13.400 --> 0:50:14.920 world would just run better if we could all have 0:50:14.960 --> 0:50:17.080 a little bit more resilience. So I would love to 0:50:17.080 --> 0:50:19.040 get to a world where we just generally have this 0:50:19.120 --> 0:50:23.359 treatment that enhances one's ability to be resilient, And if 0:50:23.360 --> 0:50:25.799 we could get that out to everybody with you know, 0:50:25.880 --> 0:50:26.960 a relatively short. 0:50:26.719 --> 0:50:28.320 Treatment, not that we shouldn't. 0:50:28.360 --> 0:50:30.839 Also, you know, people can go and do mindfulness and 0:50:30.880 --> 0:50:33.080 cognitive therapy and all these other things, and that. 0:50:33.280 --> 0:50:35.200 That takes time and skill set. 0:50:35.239 --> 0:50:37.440 It's it's like piano lessons, You've got to put putting 0:50:37.440 --> 0:50:40.000 your time and your hours to do it. But I 0:50:40.000 --> 0:50:42.359 think those piano lessons will go faster for people if 0:50:42.400 --> 0:50:46.319 we can use if we can drop on their inner strengths. 0:50:46.760 --> 0:50:49.120 Let's pull out your maximum because we all have these 0:50:49.120 --> 0:50:53.399 circuits and we all have neuroplasticity. So every human being 0:50:53.480 --> 0:50:56.360 has every human beings brain, as you've discussed many times, 0:50:56.400 --> 0:50:59.320 has the ability to rewire and change itself, and every 0:50:59.360 --> 0:51:02.160 human being has somewhere in though theo's circuits that allow 0:51:02.239 --> 0:51:05.240 us to do cognitive control and to escape from rumination 0:51:05.320 --> 0:51:07.719 and so on. These are all innercapacities that are hit 0:51:07.920 --> 0:51:09.640 that are within all of us, and some of them 0:51:09.680 --> 0:51:12.200 it's on the surface the highly resilient people, but in 0:51:12.239 --> 0:51:14.879 people who aren't feeling resilient, where people do have these 0:51:14.920 --> 0:51:18.120 access one disorders, it's not that they don't have that capacity, 0:51:18.120 --> 0:51:21.120 it's just it's latent, it's hiding, and we're now having 0:51:21.160 --> 0:51:26.520 a capacity by combining targeted brain stimulation with neuroplasticity enhancement, 0:51:27.040 --> 0:51:29.600 we can bring out the person's inner strengths. And I 0:51:29.640 --> 0:51:33.000 think that's something that is just would be I wish 0:51:33.040 --> 0:51:34.920 if we could have everybody listening to is just no 0:51:35.000 --> 0:51:37.439 one thing, is that all of us have these inner 0:51:37.440 --> 0:51:40.120 strengths inside us, and some of us has been hidden 0:51:40.360 --> 0:51:43.279 en dormant for a long time. But I think every 0:51:43.320 --> 0:51:45.680 one of us those abilities are there and we can 0:51:45.760 --> 0:51:46.720 bring them to the surface. 0:51:49.880 --> 0:51:52.560 That's beautiful. Let me just ask one last question I 0:51:52.640 --> 0:51:57.520 wanted to come back on, which is the influence of 0:51:57.560 --> 0:52:00.000 our social lives on resilience. 0:52:00.920 --> 0:52:03.799 That's beautiful and I'm really glad you brought that up, 0:52:03.920 --> 0:52:06.239 because up until now, everything we've been talking about with 0:52:06.360 --> 0:52:10.520 resilience is are like are like. The human atom he's 0:52:10.520 --> 0:52:13.520 just started for individuals in isolation is one human brain 0:52:13.719 --> 0:52:16.000 just by itself, a bunch of circuits inside a skull. 0:52:16.600 --> 0:52:18.799 But we don't live as little atoms. No, no human 0:52:18.840 --> 0:52:19.480 as an island. 0:52:19.560 --> 0:52:20.040 We all have. 0:52:20.520 --> 0:52:23.919 We live within a broad social fabric. And I think 0:52:23.960 --> 0:52:26.439 you can delve into any number of beautify written books 0:52:26.480 --> 0:52:28.680 on resilience, we'll talk about one of the greatest and 0:52:28.719 --> 0:52:32.800 most important things supporting a person's resilience is the social 0:52:32.840 --> 0:52:36.480 supports and fabric that they have around them. Most challenges 0:52:36.680 --> 0:52:38.960 can be faced if they're not faced alone. 0:52:40.600 --> 0:52:41.320 I think most of it. 0:52:41.600 --> 0:52:43.160 I talked to a colleague of mind, and he talked 0:52:43.200 --> 0:52:45.600 about how his favorite part of medical training was actually 0:52:45.640 --> 0:52:47.920 in medical school, which some people see is the toughest part. 0:52:48.040 --> 0:52:49.840 So but the thing is, I had these two buddies, 0:52:50.200 --> 0:52:52.080 and the three of us we did all our studying together. 0:52:52.080 --> 0:52:53.960 We worked through it was all we were these comrades, 0:52:53.960 --> 0:52:55.560 and we felt like when we faced the world, we 0:52:55.560 --> 0:52:58.200 were unstoppable. Like you know, it's a very stressful thing 0:52:58.239 --> 0:53:00.000 going through training in medical school, but as long as 0:53:00.200 --> 0:53:04.160 I have my two buddies with me, we could face anything. Yeah, 0:53:04.200 --> 0:53:05.960 and I think a lot of us have that experience. 0:53:06.080 --> 0:53:08.600 So there's been is, you know, a tremendous amount of 0:53:08.600 --> 0:53:11.120 research done on the importance of social fabric and social 0:53:11.160 --> 0:53:12.880 supports and a strong social network. 0:53:12.920 --> 0:53:14.960 Well, what would you recommend for people? What do you 0:53:15.040 --> 0:53:18.640 recommend for people in terms of building a social life. 0:53:18.760 --> 0:53:20.279 Well, it's I mean, it's tricky. 0:53:20.560 --> 0:53:22.200 I think there's certainly been a shift over the last 0:53:22.280 --> 0:53:24.719 decade in terms of, you know, how people spend their time, 0:53:24.760 --> 0:53:27.080 and if everybody else is just locked away on, you know, 0:53:27.200 --> 0:53:30.239 in solitary activities of one type or another, then it's 0:53:30.280 --> 0:53:31.879 harder and harder to go out there and find people 0:53:31.920 --> 0:53:35.440 to do social things with. But I find that the 0:53:35.440 --> 0:53:39.440 way people build social communities is often either through mutual 0:53:39.480 --> 0:53:43.040 connections or through mutual activities. So you can meet friends 0:53:43.040 --> 0:53:45.839 through other friends, and you can and so friends are 0:53:45.840 --> 0:53:48.839 good at introducing other friends, and activities are also good 0:53:48.920 --> 0:53:50.399 at introducing and connecting people. 0:53:50.480 --> 0:53:50.800 Together. 0:53:51.640 --> 0:53:53.520 So one way you can kind of get two birds 0:53:53.520 --> 0:53:56.760 of one stone is you know, running clubs have become 0:53:56.800 --> 0:53:59.720 incredibly popular, just to take one random example of ways 0:53:59.719 --> 0:54:02.280 that people have decided to sort of quit dating apps 0:54:02.280 --> 0:54:03.759 and instead of just go out and go on these 0:54:03.760 --> 0:54:05.839 big running clubs. And this is how young singles are 0:54:05.920 --> 0:54:07.920 kind of meeting each other is by finding some kind 0:54:07.920 --> 0:54:10.319 of activity in common. But whether you fall into that 0:54:10.360 --> 0:54:13.839 category or not, I think there are I think a 0:54:13.960 --> 0:54:16.040 variety of different websites and so on out there, like 0:54:16.120 --> 0:54:18.320 meetup dot com is an old one that's been around forever. 0:54:18.719 --> 0:54:20.319 I thought it was quite clever, the idea that you 0:54:20.520 --> 0:54:22.920 just have various activities and people could connect over an 0:54:22.960 --> 0:54:25.560 activity or an interest that they had in common. So 0:54:25.600 --> 0:54:28.080 I think whether it's reaching out to a faith community 0:54:28.080 --> 0:54:30.640 if you're somebody who follows a particular faith, or whether 0:54:30.640 --> 0:54:33.520 it's an interest group, or whether it's a physical activity 0:54:33.520 --> 0:54:37.120 like exercise or running, I think finding activities to connect 0:54:37.120 --> 0:54:40.080 with other people who have that common interest is a 0:54:40.200 --> 0:54:43.040 really really great way of strengthening your connections with other people. 0:54:43.120 --> 0:54:46.400 Finding common purpose among cultures. 0:54:48.040 --> 0:54:50.240 It's interesting if you go read up on the culture 0:54:50.239 --> 0:54:54.759 of Okinawa Okinawa's for various is identify as one of 0:54:54.800 --> 0:54:57.480 these blue zones where people live unusually long and so on. 0:54:57.719 --> 0:54:59.319 But one of the interesting things that they talk about 0:54:59.400 --> 0:55:03.000 is the unusual psychological resilience of people in Okinawa and 0:55:02.400 --> 0:55:07.120 the concept of which I was introduced to recently. I'm 0:55:07.239 --> 0:55:09.759 probably going to say it wrong, but eke guy is 0:55:09.800 --> 0:55:12.520 a there's a word, eke guy. I'm probably going to 0:55:12.600 --> 0:55:14.759 butcher this, but as I understand it, it is the 0:55:14.800 --> 0:55:16.960 idea of having a purpose or a calling or a 0:55:17.000 --> 0:55:20.960 cause and part of the culture there is that you know. 0:55:21.000 --> 0:55:23.160 And it could be something incredibly small, it's like literally 0:55:23.239 --> 0:55:25.320 like breaking a beach and keeping it tidy, or it 0:55:25.360 --> 0:55:27.319 could be or it could be something lars like trying 0:55:27.360 --> 0:55:30.600 to save the world from a resilience deficit. 0:55:30.600 --> 0:55:31.719 It could be anything whatsoever. 0:55:33.040 --> 0:55:37.919 But the idea that part of resilience involves in making 0:55:37.960 --> 0:55:39.840 sure that your life is imbued with meaning and that 0:55:39.920 --> 0:55:41.840 you have some kind of compass or some kind of 0:55:41.880 --> 0:55:44.200 guidance to it. And so I think if you can 0:55:44.200 --> 0:55:46.399 find that activity that you choose with the people around 0:55:46.480 --> 0:55:48.560 you to be a meaningful activity, something you find that 0:55:48.560 --> 0:55:50.919 gives you purpose and meaning in life, that carries eke guy. 0:55:51.440 --> 0:55:52.960 And if on top of that it's not just a 0:55:52.960 --> 0:55:54.839 personal meaning, but if you can then use that as 0:55:54.880 --> 0:55:58.160 a nucleus to build a community of other people around 0:55:58.160 --> 0:56:02.680 that common purpose, there incredibly resilience to be had and 0:56:02.880 --> 0:56:05.359 being a member of a community of other people, all 0:56:05.400 --> 0:56:08.160 of whom are dedicated to a common and meaningful cause. 0:56:09.000 --> 0:56:11.080 And I think if you don't have access to a 0:56:11.080 --> 0:56:13.279 TMS machine, I think that's certainly the compass that I 0:56:13.320 --> 0:56:14.040 would lean into. 0:56:18.719 --> 0:56:24.520 That was my conversation with Jonathan Downer. So what is resilience. 0:56:25.040 --> 0:56:28.600 We've long thought about it as a psychological trait. We 0:56:28.640 --> 0:56:33.640 talked about grit or determination or optimism. But what today's 0:56:33.680 --> 0:56:38.239 conversation hopefully makes clear is that resilience has a physical 0:56:38.280 --> 0:56:41.440 footprint in the brain. It's not just about what you 0:56:41.600 --> 0:56:45.719 choose to think. It's about how your networks are operating. 0:56:46.320 --> 0:56:51.719 It involves a carefully orchestrated interplay between brain areas involved 0:56:51.719 --> 0:56:55.120 in emotion and reward and control and so on. And 0:56:55.200 --> 0:57:01.080 these brain networks can dip the balance between breaking down 0:57:01.520 --> 0:57:04.319 and bouncing back. And I think this is some of 0:57:04.320 --> 0:57:09.080 the most exciting and practical work happening in neuroscience. People 0:57:09.080 --> 0:57:13.959 are identifying these circuits and they are influencing them using 0:57:14.040 --> 0:57:19.080 tools like PMS, and this can, when it works, enhance 0:57:19.200 --> 0:57:24.480 a person's ability to function across a whole spectrum of disorders. 0:57:25.120 --> 0:57:28.960 And so one lesson that emerges is that resilience isn't 0:57:29.000 --> 0:57:33.480 just something we summon after disaster strikes. It's something we 0:57:33.520 --> 0:57:37.200 can build ahead of time. It's something we can cultivate 0:57:37.280 --> 0:57:41.720 in the brain like a form of mental infrastructure, one 0:57:41.760 --> 0:57:45.640 that helps us face whatever is coming down the pike next. 0:57:46.440 --> 0:57:50.320 And as our knowledge improves and the technology improves, this 0:57:50.400 --> 0:57:54.760 all may eventually lead to a paradigm shift in mental health. 0:57:55.080 --> 0:57:59.400 Instead of treating one disorder at a time, like depression 0:57:59.520 --> 0:58:04.480 or anxiety PTSD, what if we focused upstream, What if 0:58:04.520 --> 0:58:09.160 we try to increase resilience itself across the board. Of course, 0:58:09.200 --> 0:58:13.280 biology is only part of the story. Social support, culture, 0:58:13.520 --> 0:58:18.360 personal meaning. These are all powerful factors and addressable factors 0:58:18.600 --> 0:58:22.080 when we're thinking about resilience in our lives. But it's 0:58:22.120 --> 0:58:25.800 amazing to realize that even in the hardest moments, the 0:58:25.880 --> 0:58:30.200 exact state of the networks in your brain matters for 0:58:30.320 --> 0:58:33.840 the degree to which you can be an active participant 0:58:33.880 --> 0:58:38.920 in recovery. Maybe if we come to understand resilience in 0:58:38.960 --> 0:58:42.919 the brain and psychologically and socially, we can help more 0:58:43.000 --> 0:58:46.440 people to thrive. So thanks for tuning in today. If 0:58:46.480 --> 0:58:50.760 this episode moved you or challenged you, or sparked questions, 0:58:51.080 --> 0:58:53.440 I'd love to hear from you. Pop me an email 0:58:53.560 --> 0:58:56.760 at podcast at eagleman dot com and if you ask 0:58:56.840 --> 0:58:58.920 me to, I can pass your note on to Jonathan 0:58:59.040 --> 0:59:02.320 as well. And if this episode made you think about 0:59:02.360 --> 0:59:06.280 someone in your life who embodies resilience, please share this 0:59:06.360 --> 0:59:10.160 episode with them. Science is catching up to something that 0:59:10.480 --> 0:59:13.080 people have known in their bones for a long time. 0:59:13.800 --> 0:59:18.160 The mind can bend without breaking, and sometimes in that 0:59:18.280 --> 0:59:22.840 bending it gets stronger. So until next time, take care 0:59:22.880 --> 0:59:25.840 of your brain so you can take care of each other. 0:59:29.560 --> 0:59:32.480 Go to Eagleman dot com slash podcast for more information 0:59:32.600 --> 0:59:36.680 and to find further reading, and check out and subscribe 0:59:36.680 --> 0:59:40.000 to Inner Cosmos on YouTube for videos of each episode 0:59:40.040 --> 0:59:43.920 and to leave comments. Until next time, I'm David Eagleman 0:59:44.080 --> 0:59:52.760 and this is Inner Cosmos.