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Turning Fear into Power: Understanding and managing anxiety - Longwood Seminar

Jan 13, 2022
Hello. Good night. My name is Gina Vild. I recognize many of you from years past. I am the Associate Dean for Communications and External Relations at Harvard Medical School. And it is my great pleasure to welcome you to our second Longwood Seminar of 2017. This is the ninth year that I have presented Longwood Seminars. And as you know, we asked previous participants to choose the themes each year. And I can't remember in nine years that a topic has received so many votes and so many people registered. So I think we're all very excited about tonight's speakers and about the topic. 16 years ago, we introduced the Longwood Seminaries, or the Mini-Med School, as a way to give back to our local community, to our neighborhoods.
turning fear into power understanding and managing anxiety   longwood seminar
And we wanted to share our research, achievements, and medical breakthroughs with our neighbors. We have changed our way over the years and now we broadcast live. Last year, the Longwood

seminar

s were viewed live in 36 different countries. So to everyone watching from those 36 or more countries, and everyone in the auditorium tonight, welcome. Is there anyone here who has never attended a Longwood

seminar

before? Ah, quite a few. Well, I hope you're in luck. And we hope you will become a part of our Longwood Seminary family. On the screen in a minute, you will see some information. If you would like to receive a certificate of completion, or if you are a teacher and would like to receive professional development points, we have information on how you can do so.
turning fear into power understanding and managing anxiety   longwood seminar

More Interesting Facts About,

turning fear into power understanding and managing anxiety longwood seminar...

If you would like to view any of our previous Longwood seminars, or if you would like background reading material on this seminar or previous seminars, please visit our website. And I want to ask you to please turn the volume down on your phone but don't turn it off because we hope you'll join the conversation on Twitter, and we encourage you to tweet with the Mini-med hashtag. Mad And now for our show. Fear is a feeling induced by the perception of a danger or threat. It causes changes in the functioning of our brain and organs, as well as in our behavior.
turning fear into power understanding and managing anxiety   longwood seminar
Fear is a catalyst for fight or flight. It provokes a primordial response that has safeguarded the survival of our species. But this healthy defense system can also be a catalyst for

anxiety

and

anxiety

disorders. As author Jodi Picoult said, anxiety is like a rocking chair, it gives you something to do but doesn't get you very far. So what can we do about it? Tonight, our expert faculty from Harvard Medical School will explore the roots and origins of anxiety, and most importantly, tell us how it can be managed. Our moderator is Dr. Isabelle Rosso, Director of the Anxiety Disorders and Traumatic Stress Laboratory, at our HMS McLean Hospital.
turning fear into power understanding and managing anxiety   longwood seminar
Her lab was founded in 2014 and as part of the Center for Depression, Anxiety and Stress Research. Dr. Greg Fricchione is Professor of Psychiatry at the Mind Body Medical Institute at HMS. He is the founding director of the Chester M. Pierce Division of Global Psychiatry at Mass General Hospital. In 2006, he became Director of the Benson Henry Institute for Mind-Body Medicine at Mass General. Succeeding Dr. Herbert Benson, who was once a speaker at our Longwood seminary. Dr. Courtney Beard is a clinical psychologist with expertise in anxiety disorders, cognitive biases, cognitive behavioral therapy, and treatment outcomes research. She is Associate Director of the Clinical Research Program at McLean Hospital Behavioral Health Partial Hospital Program and Assistant Professor of Psychology here at HMS.
She is internationally known for her work on cognitive bias modification. Please join me in welcoming our esteemed panel. Everything's fine. Many thanks. Is my microphone on? Yes? I hear it now. So thank you very much for that great presentation and thank you for having me here today, and all of you. Those of us in Boston are here today instead of outside on the first 80 degree day we have this spring. Thanks for being with us. So I'm going to talk today about

fear

and how we learn to

fear

, how we learn not to fear. A little bit about where and how that happens in the brain.
And then go on to explain a little bit how, in psychology, we've applied some of what we know about the principles of fear learning to how we do psychotherapy, to one of our psychotherapies. So there we go. So, as mentioned a moment ago, fear is really an emotional response. And it is activated when we perceive a danger or a threat in our environment. It causes a change in the functioning of our brain, in the functioning of our body and in our behavior. And of course most if not all of us are familiar with the idiomatic fight or flight response, or the fight or flight or freeze response, which is really the behavioral part of fear, right?
Fear can cause us to face danger, it can cause us to run from danger, and it can cause us to freeze at times. Types of things we fear. There are some that are innate. And the fear of heights is really the fear of falling is an example of that. This is seen in babies and young children. We have this wired. But really most of our fears or learned. And you see here at the bottom of the slide, a little boy who's reaching for a hot stove. There is no innate reason for you to be afraid of this stimulus, of this situation.
But if he touches that hot handle and then gets burned, he will most likely learn that it is a dangerous stimulus. And he will learn to fear and avoid that stimulus. And this is adaptive, of course. This is an example of adaptive fear learning. What is very important to remember is that fear is actually programmed into our brains because it allows us to survive or escape from dangerous situations. This is a well known schematic from Joe LeDoux, one of Joe LeDoux's publications. Dr. LeDoux is an internationally renowned researcher and truly a pioneer in the field of fear.
And he brings up the idea that if you're walking through the woods and you see a snake, your body and your brain will mobilize a fear response very quickly and out of your awareness. And essentially what happens is, of course, your eyes initially see the snake, and very quickly there's a very fast pathway by which this information is carried to an area of ​​the brain called the thalamus, and then to the amygdala, which is really a region that I'm going to talk about a little bit today because it's in a central position to then mobilize all of your body systems and create fear responses.
So this is an example of adaptive fear, right? If you run away from the snake, it doesn't bite you. There are also times when fear becomes maladaptive. So now you have fear responses, for example, when there is no real danger or they are excessive in some way. And that's when we start talking about anxiety disorders or fear-related disorders, like PTSD. People with PTSD have experienced a very traumatic event, something that was actually fear-inducing at the time and was probably adaptive at the time. But then they want to continue to experience anxiety and hypervigilance, memory impairment, like reliving the trauma through flashbacks and nightmares.
All manifestations of continued fear despite the trauma or frightening event that has now passed. And this becomes maladaptive. So that's an example where fear can become maladaptive. I wanted to briefly mention panic because panic attacks are also commonly talked about. And actually, panic is fear. This is a description. Someone describe what it is like to experience a panic attack. And you could see it, he says: "Suddenly I feel dizzy. My legs gave out and I couldn't catch my breath. It felt like someone was suffocating me. I could feel my heart beating too fast, I was terrified, I was dying, I knew that he had to escape before he lost control".
This description of a panic attack really covers many of the symptoms of fear. And really, when we talk about panic attacks and anxiety disorders, we're talking about fear attacks. And fear attacks or panic attacks actually occur in all anxiety disorders, and in many psychiatric disorders, it's kind of a common thread. And everyone has this physiological fear response component. So the amygdala. The amygdala is a small structure in your brain and we know that the amygdala drives fear. It is the command center of fear, in a way. It is located in the temporal lobe of the brain, which is on the side of the head, behind the ear, behind the temporal bone, deep inside.
You have one on each side of your brain. And to understand how the amygdala works in fear, it's very helpful to know a little bit about how it's connected to other parts of the brain because it's actually positioned to receive sensory input. So, information from all of our senses converges on the amygdala, in the input area called the lateral nucleus of the amygdala. What we see, what we hear, what we touch, pain. All that information is transmitted to the amygdala. All very relevant information for threat processing. And then the output of the amygdala through this central medial nucleus, which is connected to a bunch of other hard-to-pronounce brain areas, brainstem areas.
The point is that these are all areas that control bodily functions that are involved in emotional responses. So when the amygdala connects and talks to the lateral hypothalamus, it can control how fast your heart beats. When you talk to the parabrachial nucleus, you can control your respiratory rate. And it could really modulate your emotional response. So it takes in some sensory input and also controls your bodily response, and it can trigger fear. The amygdala is also very involved in learning to fear. Conditioning is a fancy word for a type of learning. Fear conditioning, simply put, is how an animal learns to fear a stimulus.
And this is an experimental paradigm in psychology that has been widely studied. So you can go to the literature and find all these studies of fear conditioning experiments in mice, in primates, in people. In a typical fear conditioning experiment, you'll find that what happens is you give what's called an unconditional stimulus, in this case to a mouse, a mouse gets a painful tap on the foot, and this is an unconditional stimulus because it's kind of universally aversive. stimulus that will produce in each mouse a fear response. The mouse is probably going to freeze. In this case, he is running away, but he is going to be afraid.
Part of the experiment will also present a neutral stimulus, and this is a sound. A sound by itself is not aversive, right? So if you present the sound on its own, the mouse is not afraid. This is how we model fear learning, fear conditioning. The part of fear conditioning is matching the sound with the shocks. Then the neutral stimulus is presented. And then comes the shock. Of course shock produces fear. And if you do that repeatedly, sound, crash, sound, crash, sound, crash, sound, crash, the mouse is going to learn, geez, these two things are associated. Sound predicts shock, sound predicts something bad will happen.
And that learning is fear conditioning. And the sound becomes capable by itself, now it becomes capable by itself of producing fear. Now we call him, excuse me, and I'll be right back? A conditioned stimulus because it is a learned fear and produces a conditioned response. We learn the response to fear. So now you have learned that something neutral has become aversive. Fear extinction is a closely related concept, it is also a form of learning. What you can do now is you can present your tone, your sound, which is fear. But what if you just keep presenting it alone, without the scare, without any aversive consequences?
The mouse now learns something new. Now learn that sound does not predict shocks. Sound predicts safety. Any way you want to put it, but that the shock and the sound are no longer associated. And the fear response diminishes. And we call this extinction of fear. Until again, we've done this repeatedly, showing the sound over and over again, there's no more fear response. And the reason we study this in the lab is because it translates to how we learned fear in real life. So, as I mentioned earlier, a disorder like PTSD requires exposure to a traumatic event.
And here I have used the example of a really bad car accident. It's an example that many of us, especially in Boston, can perhaps relate to being in a car accident. This is a very bad one. You can see the car is crushed, maybe it happened on a highway, there are trucks, maybe there was a collision with a truck at high speed, it is a serious car accident. Most, if not all, of us would react in fear. This is an unconditioned stimulus that will cause fear. And probably at that point that's really adaptive, right? Maybe that will allow us to grip the wheel tighter, to steer out of the truck's path enough not to die.
In the hours and days, and maybe even weeks after that happens, we may still be alittle nervous Maybe we are thinking a lot about the accident, maybe the sight of the trucks makes us anxious. Maybe going on the highway makes us more nervous than usual. Maybe we really don't want to drive. We avoided it a bit. And that's an example of conditioning that has occurred, where the stimuli that were present at the event now trigger fear. And that's pretty typical and normal. If we continue to go about our daily lives driving and so forth, eventually we are now going to extinguish this response, because trucks and cars and roads are not causing accidents, most days they would be extinguished.
And we experience less fear until we return to our daily driving experience. Most of us, the vast majority of us. For some proportion of people, they will continue to have fear and these types of symptoms, and more, when they see memories of that accident. And then they might meet the criteria for PTSD because that fear doesn't diminish or go away. And that's how we've come to think of PTSD and phobias as disorders that involve fear conditioning and extinction. And these are some of the statistics that you can look up in the literature that really show that most of us, up to 75% of us, experience trauma at some point in our lives.
And most of us, in the days and weeks afterward, will experience some symptoms of fear, and that's normal and adaptive. But then most of us will eliminate that, and only 7% of people develop PTSD after trauma. And we think that's partly due to persistent fear and a failure to extinguish fear. What happens in the amygdala? Much of this happens in the amygdala. So I told you earlier that the amygdala receives sensory input. When you go into shock, that's sensory information traveling to the amygdala and strong input causing neurons in that side nucleus to fire. And then those neurons are strong enough to trigger neurons in the central medial nucleus, which in turn mobilize all those bodily responses downstream and cause all these fear symptoms.
The neutral stimulus by itself doesn't really do that. It's sensory input. You hear something, it travels to the lateral nucleus of the amygdala. But it's not strong enough, so to speak, to make the amygdala kick in and fire. And there is no fear. But when you pair them, that's when there's learning and synaptic plasticity that happens in the amygdala. Essentially, when you present the discharge and those neurons fire, the neurons that cause the discharge and at the same time present a sound, the neurons that encode the sound, even though they were weaker, that input was weaker, that gets stronger.
Neurons that fire together wire together. And that strengthening of those inputs and that synaptic plasticity, eventually that sound is capable of causing the amygdala to fire and the fear response to occur on its own. Those associations are formed in the amygdala. We also see this with human imagery. If you put people in an FMRI scanner and ask them to look at faces with fearful facial expressions, and compare their brain activation while looking at these fearful faces versus neutral faces, these yellow spots here represent amygdala activity. And you can see that the people down here on the right are healthy people looking at fearful facial expressions.
This little red speck is your tonsil telling you that this is fear. But you can see it and you can compare it to people with anxiety disorders, specific phobias, social anxiety, PTSD. His tonsil, his red spot is bigger, right? You see more activation in the amygdala in anxiety disorders. There is an excess of activation in this area. There is a type of psychotherapy, behavioral therapy, broadly speaking, which takes what we know about learning principles such as fear conditioning and fear extinction, and applies them in therapy to help people control their fear and actually extinguish it. And here I'm really talking specifically about exposure therapy.
So exposure therapy is something, it's a type of therapy, and you can find a therapist who specializes in this. During exposure therapy, patients will face their fears, they will face fear stimuli. And you can do this in real life. So if this is a fear of spiders, I guess you can go out and find spiders somehow. Or you can do it by imagining spiders in your therapist's office. And some therapists use virtual reality technology because they may not have living spiders ready to go in their desk drawers. So the principle, however, is really the same, is that repeated exposure to fear stimulates, the patient's anxiety and fear will decrease.
And this is really a beginning of extinction. This is a detailed example of what you might do in therapy with your exposure therapist. Again, this is a fear of spiders. You are going to come up with all these situations that you could face that allow you to face your fears. And you make a list of those that are gradually more difficult. And you can start by just thinking about a spider, because that's kind of scary, but it's the first step. And you can see that each of these steps, it becomes... this patient has rated each of these steps as a little bit more difficult, a little bit more scary.
The key here is that at each step you are going to pause with your therapist and you are going to do it repeatedly over and over and over again until the fear is no longer as potent. And then you go to the next level. So it's a very systematic and planned therapeutic way of doing this. You do this with an experienced therapist this way. And it is a very effective type of therapy for anxiety disorders, for fear. It's evidence-based, which essentially means that there are plenty of research studies that show it works. It has limitations, of course, like any psychotherapy. right?
It doesn't work for everyone. And I have far too long to talk about this, but one of the challenges is... it's actually very easy to do, most of us don't face our worst fears every day. So there is a lot of rejection of treatment and people who don't want to continue. And for some people, even after a successful course of therapy, some of their fear returns. And they may need booster sessions or retraining on the skills, or reapplying the skills, or applying them in different situations, and so on. Therefore, a lot of research is being done on how to improve the outcome of exposure therapy.
A lot of this has to do with figuring out how we can improve extinction. Can we make it happen faster? Can we generalize better? Can we add certain types of skills to therapy, like cognitive skills, cognitive therapy skills, where you adjust how you think about your fears, for example, and will you hear more about this? Some of these examples in Dr. Beard's presentation. Some drugs can be given before exposure therapy to improve the outcome. So I just wanted to mention that there is one that has been studied extensively, it's called D-cycloserine, if you take it before your exposure therapy session it can help.
This is a recent large meta-analysis. This graph represents a review of many studies that have been published on the outcome of exposure therapy in many anxiety disorders. And the patients who took D-cycloserine before their exposure therapy session are represented by the white circle, and the patients who took it as a sugar pill or a placebo pill are in the dark circle. And you can see that everyone starts out with the same level of fear or anxiety before treatment, right? And then people's fear goes away with the treatment. And then you start to see a separation of these lines.
The people who took D-cycloserine, well, their fear subsides a little faster and they get a little better at the end. So this is the kind of research that can be done to try to improve our results. So to take away, I told them that maybe there are some fears that are inborn, but actually most of them are learned. That the amygdala is positioned to produce many of the physiological symptoms of fear and is involved in learning to fear a new stimulus. That's fear conditioning, which occurs when you have a neutral stimulus that becomes capable of producing fear because it's paired with something aversive.
Fear extinction occurs when a fear stimulus is presented repeatedly over and over again without an aversive consequence. So you get extinction, a lessening of fear. And this principle is applied in exposure therapy to help people manage fear, extinguish fear, in situations where it doesn't fit. I wanted to mention, I'm very, very grateful, I haven't talked about my research with NIMH and the Brain and Behavior Research Foundation, which essentially funded my work. Dana Foundation, too. And I have fantastic mentors at McLean Hospital. Scott Rauch and Diego Pizzagali, in particular. So with that, I would like to thank you.
Dr. Gregorio Fricchione. Hello. It's great to be here tonight. And I want to thank the organizers of the Longwood seminars for inviting me. Also, I'm very happy to be here on this panel with these two wonderful young scientists tonight. So let's talk more. You're going to listen... I'm so glad Isabelle started talking about the amygdala. You're going to hear about that again in this talk. I have some revelations. Fees, royalties, a patent. W. H. Auden, you remember him, said that the 20th century was the age of anxiety. What do you think of the 21st century, so far?
Well, in fact, every age is the age of anxiety. And I think that's part of the final message from my part of the seminar tonight. Hopefully, you'll see why that's the case as we go along. Stress is really what the brain does to itself and the rest of the body when faced with a threat, a challenge, or sometimes even an opportunity. And it's really the amygdala that drives that stress. And you heard about fear conditioning from Doctor Rosso. And that sets the stage for

turning

on our stress response system. And one of the themes that I'm going to try to touch on is the fact that the world is in the midst of a plague.
And this plague or stress-related non-communicable diseases. Everyone, everyone agrees that this is the most challenging medical problem in the world, whether you are in high-income or low-income countries. And we'll get to that in a moment. This is an old story. This is the stress diathesis model. And if you start here, then you're having a good day, right? There are positive environmental experiences. And you're moving, then all of a sudden you might get a note from your bank that they're going to foreclose on you. You see yourself drifting in negativity with the potential negative outcome. Maybe his angina kicks in, or something like that.
However, there are some of us who, due to what we call resilience, are able to weather that storm. And come out of that stressor in a positive state. So that's the stress diathesis model. There is also something called the Yerkes Dodson Curve. Two Harvard psychologists came up with this, many years ago. The idea here is that, listen, life is stress, right? You wake up in the morning and a very important stress hormone called cortisol shoots up because your brain knows it's not going to be a picnic, you're going to have some challenges today. Life is stress.
Sometimes it even improves performance. Think about when your teacher said, "Hey, you're going to have a test on Friday. You better study." Well, your stress systems kicked in and maybe instead of getting a C+, you got a B+. However, we all have a point where we cross the line. And you may have been reading in the newspapers about a young doctor who is suffering greatly from exhaustion. OKAY? This is what we are talking about. You're working 24, 32, 36 hours straight and you're making mistakes, unfortunately sometimes, because you're human. You will be subject to the Yerkes Dodson Curve when your stress exceeds your resilience.
And your health and performance may very well suffer. Now this slide takes us to this beautiful and most complex biological organ ever developed, your brain. OKAY? And you've heard of the amygdala, this pair of almond-shaped nuclei that sits here on the medial side of the temporal lobe. Now basically you can make a fist and this is your temporal lobe, and this is the rest of your cortex, this is your frontal lobe. And basically, a lot of what we're talking about is triangulation in the brain. What involves this part of your brain, the prefrontal cortex, the medial prefrontal cortex, and the dorsal anterior cingulate, which some people are now in the middle cingulate.
And the amygdala and the hippocampus, okay? And these structures... this is a very old structure, the hippocampus, which has some ability to tell the amygdala to relax. However, this more recently evolved area is actually equipped to tell the amygdala, "Okay, you saw something threatening, but don't overreact. You're going to live, okay?" And then, very quickly we have-- I'm not really mastering this machinery very well-- we have the amygdala calling out the tune, "Hey, listen, you're underthreat" but we have these more recently evolved structures that are telling the amygdala, "Don't worry, we got it, you're going to be safe." Right away we talked about how we reduce the stress that emanates from an amygdala by talking to the hypothalamus.
And I'll show you that in the moment. And how do we build these structures so that we can better tell the amygdala that everything is okay? A lot of psychiatry is right there. I'm going to skip this slide. It's basically saying the same thing. When your brain is under stress, your amygdala is getting attention. When your brain is quiet, it's this prefrontal area that's getting attention. This is the work of Amy Arnsten from Yale. Now this guy is someone very devoted. I had the opportunity during the sabbatical year to spend time with him at the Evolutionary Brain Laboratory at the National Institutes of Mental Health in Poolesville, Maryland.
This gentleman's name is Paul McLean. Who is he? really the father of the limbic system. And he was brilliant and kind, he was a wonderful man, a true naturalist. And Paul wrote to me in his magnus opus, Triun Brain in Evolution, "My best wishes for studies on the separation of the most painful conditions in mammals." OKAY? So let me ask you a question. How many of you are mammals? It's okay, that makes me feel better. And immediately... you see, you didn't even have to take that message deep into your cortex, your limbic system started laughing before you even processed it.
You are mammals. That makes all the difference. And there's no way you can turn back the clock. That was decided for you 325 million years ago. And no matter how sophisticated we are in the 21st century, no matter how many gadgets and apps we have, you're still a fucking old mammal. And you're going to need to feel attached to feel healthy. You're going to need to feel attached to keep stress under control. You can't escape from it. And that's why Paul wrote that. Paul knew more about the brain and its evolution than any man alive. And that's why he wrote that.
He knew that. Those of you who are mothers know that the first anguish, the first fear of your little baby, is that they will separate you. That separation anxiety is the precursor of all anxiety that you will have in your life. IT'S OKAY. That is very important, that you are a mammal. And we know this. Holmes and Rahe, Thomas Holmes and Richard Rahe, former seafarers turned psychologists, did this normative study on stress. In quotes, "normal" in Seattle. And they asked them, what is it that really makes you go crazy with stress? Normal people. And as you can see, of the first 11, eight are separation challenges.
That's because these people, when they process that question, understand that the separation is what scares you, stresses you out. Now, I don't know if you know him. Some of the older people may know him. But he was another wise old man. His name was Niko Tinbergen. Nobel Prize winner in 1973. He and Conrad Lorenz, ethologists, won the Nobel Prize for their work on animal behavior and later for thinking about human behavior. And he very wisely taught us that whenever you want to understand something biological or something psychological, you better ask yourself these four questions. IT'S OKAY. How does it work?
How did it develop? What the hell is it for? And how did it evolve? And I've gotten used to calling these four big questions the WD40 of the life sciences. You know that product, right? That loosens things up. If you want to understand something biological or psychological, ask yourself these four questions. And then go to the web and study these four questions. And you will understand it better. So this is the simplified brain. The brain does the work of life. Every living being has to feel its environment, has to analyze the information and has to produce a motor response.
Whether you're talking about an amoeba or you're talking about a tree, or you're talking about a human being. That's what life is about. So I'll give you an example. I'm from the Bronx. I don't know much about planting trees, but a couple of years ago I planted two trees, a red maple and a basswood in my yard. Nobody told me that a fallow deer, deer, is going to look for the two youngest trees in your garden and is going to root, I don't even know if that's the word, but to remove all that fur with its antlers.
This dollar girded my two three. So those trees had a lot of stress, right? And they had to feel their environment, they had to analyze the data, and they had to affect motor response. How am I going to get more nutrients from the soil? Beyond that ring, where do they remove the bark? How am I going to rotate to get more sunlight? That is the secret of life. And your brain evolved to do that. It is a specialized body. And Dr. Rosso showed you the thalamus. Specialized in the sensory part of your brain. And you have your cortex in its many different parts to analyze and affect motor response through your basal ganglia and your pedunculopontine nucleus and so on.
That is what your brain is actually doing. It is a motor sensory analyzer reflector. Now, because we know that, and we don't have time to go into how the brain is made up of segregated integrated loops that do that job for us. But we know that all vertebrates need to be attached to two things. They need to attach themselves to metabolic energy sources and they need to attach themselves to sexual objects. Because you need them for self-preservation and species preservation, right? So amphibians, reptiles, mammals, they all do that. However, only mammals need to become attached to parental and social objects.
And birth is an example of convergent evolution. So you're starting to see robins, right? In your yard. Usually there's a couple of them showing up because they're connected, they're linked together. And they're going to raise a family of robins. So they found out that secret too, after the mammals did. And then the fourth attachment is to the future. And that, really, only we have, to a large extent, as human beings. So we're also attached to the future, that's why you charted your course, you had a trajectory, I want to be this, or I want to be that, and I've learned what I'm going to need to do, I have to delay gratification, I have to focus on get there.
So, as human beings, you would stick to four things. To food, to metabolic energy, to sexual objects, to parental and social objects, and to future objects. When these things are threatened, thwarted, or challenged, that's stress. So that's what the brain is really about. And I'll show you something. This is a primitive mammalian brain. See that dotted part? Reptiles don't have that. That's your cingulate. And that is, to a large extent, responsible for helping you decide to approach or avoid, separate or unite. And it's a convergence zone for a lot of evolved material in the brain. And the first mammals had it.
The reptiles were not well? Therefore, they are at a disadvantage in terms of attachment to parental or social objects. Though crocodiles aren't that bad at taking care of their young, comparatively. And this is your brain in all its glory. This is from the neurosurgeons at Mass General. And you see the amygdala, you see the hippocampus, you see this beautiful part, the dotted part, the anterior cingulate, the medial orbital frontal insular cortex. These areas called the paralimbic region. They are essential to make you human. And they have an important role to play in telling the amygdala, "Okay, I can understand why you got excited when you saw that snake, the snake that Dr.
Rosso showed you." It's okay? And you erupted. Your sympathetic nervous system blew up, and all these catecholamines surged through your body. And your skeletal muscle tensed. OKAY? And your cortisol exploded, and the third axis of stress is your inflammatory response. took off His cell-mediated immune response took off. So, you've already started having an inflammatory response because as a human being, you realized that if you're facing a threat, you may need to fight off an infection. OKAY? If you get stabbed, or if you fall off a mountain or whatever. Your immune system will then be ready to go.
But think of all the false positives you deal with throughout the day. When your amygdala fires for no good reason. You have to have a way of telling the amygdala, "What the hell are you doing? You don't have to keep putting all that energy into protecting this person." That is the key. That is the key to chronic diseases. There are some of us, Dr. Rosso talked about people with PTSD, there are some of us who have a hard time telling the amygdala to relax. And once that happens, it often happens to people who have had trauma in the past.
Once that happens, you are in a stage of chronic stress that makes you vulnerable to disease. This slide says, "Oh shit, was that today?" So I have a test for you. Are those two little creatures reptiles or mammals? Any? They are mammals. Because, look, they are afraid. They're saying, "Oh my gosh, I'm separated." Isn't that what you feel now when you look at that simple cartoon? Yes. That's where everything lives. And your brain is in it like a cheap suit. He will never let go of the fear of separation. You will never stop wanting to have attachment solutions to life's challenges.
I don't know if we have time, but this is what we call what your brain is doing right now. Allostasis, where your brain seeks stability in the face of constant change. Your brain has to be flexible. You have to keep your physiological systems within, as we say, one standard deviation of the mean. In a normative range. That requires an enormous amount of energy. So if you're living a stressful life and you think about people living in poverty, think about their brains, think about the amount of energy your brain needs to feel connected and safe, and your physiological systems within a normative range.
Think about those poor people, single mothers raising five children with no money, think about the amount of energy a single mother is expending trying to do that. That's allostatic charge. That's a bad place to be in terms of your health. I'm going to skip over some of these. And this is a slide similar to what Dr. Rosso showed, and I'm not going to waste time except to tell you that resilience resides here, to a large extent. Stress resides here. And the more you can do to build this, the better you'll do at dealing with stress. This just came out a couple of weeks ago from a team over at Mass General.
And we're collaborating with Dr. Tawakol and Dr. Pitmen and others. And what they were able to show is... My God, I still do that. What they were able to show is that stress affecting the amygdala does a couple of bad things. It causes your bone marrow to start overproducing white blood cells. macrophages and neutrophils. And these white blood cells start populating your bloodstream and end up causing arteriosclerotic inflammation. It is an elegant experiment. We don't have time to go inside. But the point is, think about how this prepares you for those stress-related NCDs. Think of the risk of chronic stress in amygdala hyperactivity and vigilance for things like cardiovascular disease or cerebrovascular disease.
Science is unraveling the causal links and making it increasingly important for us to institute ways to reduce stress and build resilience. And this slide shows you the magnitude of the problem that we face with these chronic noncommunicable diseases. That's cardiovascular disease, that's chronic lung disease, that's chronic gastrointestinal disease. OKAY? They are also neuropsychiatric diseases, as you will see here. In fact, illnesses such as depression, anxiety, epilepsy, stroke, and severe mental illness account for 30% of these NCDs altogether. But make no mistake, they come from the same place. Chronic stress. If you are vulnerable to one of those noncommunicable diseases and have chronic stress, your chances of developing it at some point in your life will increase.
Now I want to talk about the good news part of the story. What can you do about it? Well this is from Steve Southwick and Dennis Charney. Dennis Charney is the dean of the Mt. Sinai School of Medicine. But he is a psychiatrist. And they've been really focused on resilience for a long time. Because we have learned a lot from the wars in Iraq and Afghanistan. The Department of Defense has spent a lot of money trying to understand stress and resilience, due to the invisible wounds of those wars. When you look at this, a lot of them are attachment based because of the evolutionary story I just told you.
So when you're faced with stressful situations that make you think, "Oh my gosh, I'm going to break away from my attachments," the idea is, how do I find solutions, attachment solutions? John Bowlby, English psychiatrist and father of attachment theory, always said: "The environment of evolutionary adaptability in men has to be one of secure basic attachment." This is what he was talking about. This is where resilience lies. And at the Bensen Henry Institute, we work with this equation. The resilience of the stress numerator is the denominator in all these varieties. That if your numerator is too high, your denominator is too low, you'd better be careful because that allostatic charge I was talking about is going to bite you in the ass.
And you will be more vulnerable to anydisease to which you are vulnerable. So if you know your parents died of heart disease and you don't pay attention to this equation, don't cry over the fact that you're going to have heart disease. Now, there may be some of us who have such a vulnerability genetically that this equation is not going to play out to a great deal of importance. But for most of us, there is variability in

understanding

this equation. And doing something about it is important. So we focus on something called the relaxation response, which is the physiological opposite of the stress response.
And really, what you see when people are able to integrate it into their lives, is you get an enhancement, we think, of the medial prefrontal cortex. And the somatic markers of secure attachment. Your heart rate goes down, your blood pressure goes down, your oxygen consumption goes down. Your heart rate variability decreases, which means your parasympathetic nervous system is predominant. And your sympathetic nervous system is reduced. That's what happens when you're a baby in your mother's arms. OKAY? Your physiology changes. Think about that, moms, when you're breastfeeding. Right? And the baby is hugged in harmony. And then the baby takes a little bite in the wrong place and the mother says, ow!
And the baby has a motor reflex, and the sympathetic nervous system goes crazy. What does the mother do? Using motherese, the mother says, "Oh, okay. Okay. Okay." The baby then goes into the relaxation response and secure attachment again. And cultures have discovered meditation as a way to mimic that early sense of attachment. And that's simple, we thought. If you get comfortable somewhere and close your eyes, turn your neck and get rid of that stiff neck, put your hands on your belly and breathe with your belly, take a deep breath and let your belly show. expand, and then when you exhale, the air comes out.
And you do it rhythmically. And you say to yourself, "peace on the in breath, calm on the out." Or say a prayer while doing it. Chances are, if she does it regularly, 10 to 20 minutes a day, she will be able to get the relaxation response. And that will have creeping effects and help her amygdala to be less alert. Consciousness. Everyone has read about mindfulness-based stress reduction. That builds on this relaxation response with focused mindful breathing, as I just said, and then expands into open awareness. Where, without judging, you focus on feelings or thoughts. And then you can even expand into compassion, where you're compassionately thinking about the people in your life, or the people across the sea.
Or are you thinking... you can make visual images, you can transport yourself to a place where you would rather be. All those things can be saved with a simple meditation. But resilience also means being physically active. And there are always changing recommendations about physical activity. But try to be physically active. Use the stairs instead of the elevator. Walk a bit to work. That kind of things. That is why physical exercise is important. Healthy diet, eat all you can, low glycemic diet, lots of vegetables, olive oil, the Mediterranean type of diet. That's also important because it's related to reducing the physiological drawback of stress, which we call oxidative stress.
It is your mitochondria that have to process glucose and oxygen to give you energy, and if you have a poor diet and are full of stress, you will process a lot of oxygen into glucose and cause a lot of oxidative stress. . Diet can, to some extent, help with that. To sleep. Really important. And I hope you have these slides -- we don't have time to go through every one of these points. But sleep is restful. It is regenerative. Helps make your mitochondria more effective. And to maintain your health. We have a program at the Benson Henry Institute, eight sessions, eight weeks, focused on all of these things.
I'm going to jump ahead. This slide is interesting. This is from our cardiac wellness program. If you have a heart attack and you do cardiac fitness, exercise, nutrition and build resilience and reduce stress, look what happens in three years. We didn't do this. This was done by the federal government. The Center for Medicare & Medicaid Services, they studied our program and searched. At three years, this is just mortality, 3%, 10%. If you do traditional cardiac rehabilitation, where treatment is usual at three years. This is a huge improvement, if you pay attention to these factors. And there have been meta-analyses, as we say, looking at these approaches for a variety of these stress-related chronic illnesses that show some effectiveness.
And you can actually see this in those white blood cells because now we can look at gene expression. And when you succeed in regularly integrating these processes into your life, you can change which genes you express yourself. So when we take white blood cells, we call them peripheral blood, bone, and nucleus cells, and look at gene expression in people who have learned to meditate, we see a movement in the activation states of their genes toward a healthier profile. And this is called the heat map. And see, these are newbies, these are experienced meditators. The red boxes are genes that are turned on.
The green boxes are genes that are underactivated. And you see, after we teach these newbies to meditate, this is only after eight weeks, you see them closing in on the experienced meditators. So we have to build a system where there is wellness, a culture of wellness, a health care system. Sir, don't get me started on that. Because think about the messages we're telling you tonight and think about what it's like to go to your doctor's office these days. There is a disconnect, right? Disconnection equal separation. And that's not what human beings are about. So we need someone, someone with

power

, to think about the fact that our patients are mammals.
They must be attached. So you can't just do it with electronic medical records because in many cases, the electronic medical record separates the doctor from the patient. So this is really where the rubber hits the road. So I would say, and this is just personal, we need an attachment-based medical system, we need a community-based public health system, we need more research into how the mind, brain, and body are connected. We need to build these resilience factors and there are many ways to do it. We need something that people are starting to call integrated whole person care.
And with that, I'll stop. Thanks for your attention. I'll introduce myself. It's okay. In fact, I'm going to go out there and see if this is okay. Hello everyone. Good thank you. I'm Courtney Beard and I'm excited to talk to you today about some of the work I've been doing. Study the mental habits that keep us anxious. And most importantly, how can we change them. So let's see if I can work this out. Great. So I'm a clinical psychologist. And they trained me to do cognitive behavioral therapy to treat anxiety disorders. And just out of curiosity, how many of you are familiar with cognitive behavioral therapy?
Have you ever heard of that? Oh God. Everything's fine. A good handful. Some of you may already be familiar with this part, but at CBT, we divide our experiences into this triangle. In these three parts. So we look at our feelings, our thoughts, and our behavior. So what we do or what we don't do. And we draw it as a triangle so that we can make these arrows pointing in all directions, showing that each of these parts affects the other. And just to go through an example so you know what I'm talking about. So as I was preparing for this today, I started to feel a little anxious.
This is kind of a huge audience and I'm told there are thousands of people streaming it live as well. So I was preparing myself and I realized that I had a lot of thoughts about this. And I wasn't sitting there trying to worry or think about it, these things just popped into my brain automatically. Thoughts like, I'm going to say something stupid, I'm going to stumble over my words, I'm going to blank out, and so on. Then I noticed my heart start to race, it started to speed up a little bit, I get butterflies in my stomach, I start to breathe a little faster, etc.
All those feelings in my body, which then of course lead to more anxious thoughts. . And you can see how quickly this can get out of hand. And for some people, it could lead them to call in sick. Or get out of this, somehow. Now, I'm a CBT therapist, so of course I came. But in general, in CBT, for anxiety disorders, we will focus on dividing our experience into these three parts. And the good thing about all of them being related is that if we intervene in one part, it can have positive effects in the others. So they listened in on Dr.
Rosso's talk on exposure therapy, which focuses a lot on the behavioral aspect. And that's actually what I focus on the most, as well, in my clinical practice. But today I am going to talk about the thought part, the thoughts. And I could actually do an hour talk on each of these, but I just wanted to show you a few examples. And I'm going to focus on one for the rest of my talk. So there are many different mental habits that characterize someone with anxiety. We know that people with anxiety disorders actually overestimate threat risk, so they think something bad is much more likely to happen than it really is.
And they really catastrophize that outcome, so they think it's going to be much worse than it really could be. And at the same time, they underestimate their ability to cope. Other cool things that happen when you get anxious. So you've heard a lot about how your body changes in the fight or flight response and that prepares you for physical danger. Well your way of thinking changes too, I'm sure you've noticed your thoughts racing and your attention really shortening. Therefore, it focuses a lot on potential threats and exit strategies. How to get out of it. And again, that's very helpful if you're in real physical danger.
But when you have these false alarms, where you're anxious about all sorts of things that have nothing to do with physical danger, that narrowing of your attention isn't really helpful. We also tend to jump to negative conclusions and I'm going to talk a lot more about this in a moment. And once your brain has generated a negative conclusion, if you're an anxious person, you find it very difficult to put that aside and go about your day. You get stuck in your thoughts and become very ruminating. And so on and so on. So there are many mental habits that make us and keep us anxious.
It's okay, Siri. For those of you: anyone streaming live, someone is talking to me. IT'S OKAY. So I'm going to focus on one particular habit of mind that I've worked on a lot in my lab. And that's where we tend to jump to a negative conclusion. And the reason why that is so impactful in our lives is because life is full of ambiguity and uncertainty. So throughout the day, throughout the day, you are faced with ambiguous situations and uncertainty all the time. And you may not even realize it because our brains are filling in the pieces.
So our brains interpret things for us and draw conclusions for us very efficiently. So much so that you are not even aware that you are making an interpretation. And it is trying to be helpful in this regard. But if you have a tendency to jump to negative conclusions, it's not that helpful. So let me see some examples, you know what I'm talking about. Everything's fine. So let's say your friend hasn't returned your text and it's been a day or two. So some people's brains will say, "Oh, they must be so busy," while other people will start to wonder if their friend is mad at them.
Let's say your heart starts racing out of nowhere, nothing happens. Some people might interpret that as "Oh, I must be excited or nervous about something." But if you have a panic disorder, you'll take it as a sign that something seriously wrong with your heart. Let's say you're having a conversation with someone and they start to yawn, most people, why is that so funny? It happens to me all the time. Most people would assume that their friend is tired. However, if you have social anxiety, you'll start to wonder, "Oh my gosh, am I being boring?" And then you're going to get stuck in that cycle.
Finally, a personal example. These are my little monkeys. And my son Joey grabbed his leg and said his leg hurt all of a sudden. And I think most parents wouldn't make a big deal of that, I think it's something benign, like a sore muscle. But if he has a very creative and anxious mind, the blood clot may occur to him. I made. Do not laugh. I made. So even if he knows that it's highly unlikely that it's a blood clot, just the possibility that it might be and that uncertainty can help him keep going. These are just a few examples, but I hope you now see that throughout the day you are constantly interpreting things.
And you may not even realize it. And it has a big impact on how anxious you get.you feel and then what you do with the situation. So what do we do with this habit of mind, since we may not even realize it is affecting us? Fortunately, we have very good treatments. And the first step in this treatment is to make yourself aware of it. So we started by getting people used to identifying these thoughts. So we have people write it for a week, every time they notice they're anxious, what were you thinking? What are thoughts?
And this can be very

power

ful because very quickly, people start to see that they have the same types of thoughts over and over again, they start to notice patterns. And usually it's not about positive things that can happen. It's all wrong, it's all over here, so it's very skewed. And it's not his fault. It's your anxious brain, as you've seen, you can't control that, that's what it does, it's trying to help you. The other thing that this does, just identifying the thoughts, gives you some distance from them. So instead of them automatically operating in the background and you just accepting that it's fact and reality, identifying that they're just thoughts, let's start seeing them for what they are.
It's just junk that your brain is constantly sending you. So that can be very useful. So I already told you some of the thoughts I was having. Here are a few more. So I could get lost and never find the building, I could be late and then they'd get mad, I'd trip over my words and look stupid, I can't handle this, I'm going to trip in front of everyone. . And so on and so on and so on. So I spent a lot of time identifying all the thoughts and all the bad things that I think could happen.
So I want to choose just one. It's really hard to think about all of these things and evaluate all of these things, so pick one thought to further evaluate. So the next step will be to assess how accurate or useful this thought is. So I chose only the first thought. I could get lost and never find the building. Now, if you've ever seen a therapist help you do this, they'll ask you a bunch of questions to help you test the thinking. So things like, what is the probability that I will never find the building? Are there ways I could cope that I'm not thinking of?
And am I ignoring other possible outcomes? They may have you weigh that evidence for or against a particular prediction or thought. Or even have you think about what you would say to a friend who was in a similar situation. So you would do this for a while. And when you feel like you've evaluated the thought as much as you can, then it's time to put all of that together and really reframe or reevaluate the whole situation. However, before I get to this, I want to make a very important point about this process. So for some people, they can look at this and just think that this is just positive thinking, and it's not.
So if you find that you just need to think more positively, that won't help either because just as thinking only negatively wasn't accurate or realistic, thinking only positively isn't accurate or realistic either. So the point of this is not that. But it is rather to adopt a more balanced objective and realistic vision. So, with that in mind, you could replace that thought with something like, "Well, if I get lost, I can take a detour, or I can ask for directions," or something like, "I might get lost, but it won't be forever." , thus taking the butt out of my anxious thoughts.
And then the absolute best way to challenge your thoughts or test them is to really test them through behavioral experiments or through exposure, as Dr. Rosso was talking about. So if I was working on myself, I would miss a lot on purpose. We do this a lot. So get lost on purpose, see what happens, see how bad it is, and learn to cope. If someone is afraid of public speaking, since that's the example we're using, I would certainly get them to practice public speaking in many different ways. And you might even trip over your words or feet on purpose.
And this is where most of my patients try to get out the door. But you stay. I'm not going to force you to do any of this. But stick around and think about how this isn't actually extreme enough to do these things on purpose. Because at least I'm doing these things all the time, it's just accidentally anyway. The difference here is that we are doing them intentionally, on purpose, for a very important reason, to test these thoughts, to test some of our beliefs. That is also a big part of CBT. IT'S OKAY. That was a five minute description of CBT.
There is much more, as you can imagine. But I hope you get an idea of ​​how we focus thoughts there. Of course. Can I go back to the previous slide? In theory. Oh no. That's the point, sorry. That? Understood? Do you make the slides available? they don't. Well then get it. You can email me after this. The video will be published. IT'S OKAY. So that approach, as you may have heard, is cognitive behavioral therapy, exposure therapy, extremely effective for anxiety disorders. This is very useful for people. Yes. It also has some challenges. So one is just an access issue.
So we will never have enough well-trained CBT therapists to treat everyone in need of treatment, in this country and certainly not around the world. So we have to think about other options to improve access. Probably using technology. However, the other problem is the efficiency of this approach. Specifically when we are talking about the focus of thoughts and mental habit. So just think for a minute about how this would go. So you're going about your daily life, your brain is making hundreds if not thousands of interpretations throughout the day that you're not even aware of. And then you go see your therapist and you choose one of those interpretations to evaluate.
And you do it after the fact. Maybe it's been like five days after it happened. After 30 or 45 minutes, you've really assessed and reassessed the situation. And like I said, that can be very helpful. And if you do it enough over time, it can become automatic too. But it takes a long time and is very strenuous, very laborious. So it would be nice if we had another way of trying to help people become more aware of their thinking habits and change them. So that's why I'll tell you next. It's a job I've been doing in the lab.
An approach called cognitive bias modification, or CBM. And this is using very simple computerized training tasks to address the same problem, the same habit of mind, but in a very different way. And it takes a lot of repeated practice to make healthier interpretations. And you are doing the interpretation as soon as you come across the situation. Not five days later. So let me show you what I mean. I think it's helpful to see an example. So, in the task I used, the computer presents people with an ambiguous situation. So people laugh after something you said. And then a word is going to flash very quickly and your job is to decide, is the word related to this situation?
IT'S OKAY. Ready? Yes? Not? Yes. No. You are wrong. So I'll give you another. You see the same situation. This time is combined with fun. Yes. Now, you're right. So, this task is very simple. But it's… and I give people hundreds of these situations and then they get feedback on their responses, and they quickly learn that the more benign or positive interpretations are correct, and the negative ones are wrong. And it seems like the most useful thing about doing it this way is that in about 10 minutes, you've seen a hundred examples. And that's very powerful in showing you how often you jump to a negative conclusion and how many times your brain doesn't even think about the positive one.
So you can much more efficiently increase people's awareness of this habit of mind, so they can start to distance themselves from it a little bit and maybe not pay as much attention to those thoughts. Everything's fine. But then what do people think about this approach? I've done a lot of randomized controlled trials now of this treatment, and I ask people, what do you think of this? Well, sometimes I get this response. Not often. But I can see why people would say that. It's quite a different approach. It's on a computer. And as you were saying, we need attachment, how is a computer going to help my anxiety?
People don't like to be told they're wrong. So I get it. But really, what's much more common is if people get attached, they say things like this. That seemed simple, but it impacted my prospects. And this person went on to say that one way he was helpful was simply by making them aware of his reactions, as he was saying. Other people are saying things like, "I can see how this can be applied to my everyday life," which is really important because we're concerned that an artificial computing task won't generalize people's everyday lives. But people say things like, "Now I can shop at Target without feeling overwhelmed." So seeing some real, concrete behavioral improvements after doing a simple task like that.
And as a researcher, I want to know, but does it work? And that turns out to be a much more complicated question to answer than you might think. I thought I'd show you what the treatment development process is like and what it involves, so I could answer that simple question: does it work? First, researchers spend years trying to measure and understand mental habit in the lab and confirming that it does play a role in anxiety. That is the first step. Identify the mechanism. And now we have tons of research. It is very clear that the tendency to jump to a negative conclusion has a huge impact on your anxiety.
So we want to translate those basic science findings into a new treatment. And we want to test that treatment in a very well-controlled laboratory setting, where we know exactly what's going on and we have a very homogeneous group of people. And I've done a lot of studies myself, as have others, and we have good evidence that this simple computing task really works. It helps people's anxiety in the laboratory. It's the second phase of the translation where it gets really tricky. What happens to this treatment when you release it into the real world with real people who are not carefully tested and in real world clinical settings?
And also thinking about how we make it reach people. How do we implement it? And that's the phase I'm in right now. I'll show you a couple of examples of how I'm currently trying to do this. So this is a graph or an actual participant in one of my studies, where I deliver this type of treatment in primary care settings. We know most people, that's where they go when they're anxious and want mental health treatment. So it's important to us to have more options available to people there. And this shows you your performance on the task over the eight treatment sessions.
And each session is only about 10 minutes of this task. You can see it in red, there. The reaction time is decreasing, so they are getting faster in this task. And in blue is its accuracy. So they're getting more and more precise in endorsing a more benign style of interpretation. And then when I look at everyone's anxiety scores together, we see some promising results. So this is showing you, let's see, before and after the treatment. And about 2/3 of our samples, their scores fell below a clinical cutoff on our measure. So a clinically significant improvement from a very low intensity type of treatment.
Very promising. We continue to test this further in more rigorous and larger studies, if we can get funding. I thank you for the funding we have. So that's in primary care. But I was also curious if this would be useful where I currently work, at McLean Hospital. I'm in the Behavioral Health Partial Program there. We treat more than 800 people a year. And they come to us for a really intensive daytime treatment. Therefore, their symptoms are usually very severe when they come to see us. Lots of suicidal thoughts, lots of life crises, a world so extremely real and hard to deal with.
And I was curious if my simple computer homework, if I gave it to people every day while they were with us, maybe seven or eight days, if that would really improve their response to our regular treatment, which was already pretty good. And something really interesting happened. So let me walk you through this for a bit. So for my older participants, and older, unfortunately, it means 37 and older. almost me It is very sad. But for my older participants, it didn't matter if they received my CBM treatment or a placebo task. Your improvement and your well-being were the same.
So people got better because they were getting our standard treatment. But it didn't matter if you had this extra thing. But in my younger participants, there was a large effect where this simple additional computer task improved their response to treatment. So this is where the field is, right now. Isfigure out how best to bring this to clinical care and for whom? It may be that if you are older and have had these mental habits for much longer, they are more ingrained and we need a slightly different approach, or more. There are a lot of really interesting and important questions that we can answer as we study this further.
And that's pretty much where I'll leave it. It's just thinking about the future. Technology is going to be really important, both from an access point of view and being able to leverage technology to do things in really innovative and different ways that could speed up the improvement of our typical treatments and reach people who wouldn't get it. . And I'm certainly not the only one doing this, there are a lot of people at McLean, at our new Institute of Technology and Psychiatry, who are also working on these issues. And I think I'll stop there. Thank you. Everything's fine.
Thank you all. I know it's 7:30 and we had said that we would take a couple of questions, or a few questions. And I think, given the time, we'll try to take a couple. And I know there will also be a way to answer more questions online after this is over. So I have a bunch of really great questions from people here and on the internet. I'll try to get a few out that maybe we can answer in a few minutes, and then we'll get to the rest as best we can after the show. So one question is about exercise and why exercise is so helpful for anxiety.
Can we say a bit about how it works? Well, exercise seems to be good for everything. And we start at the top, we start in the brain. One thing we do know about exercise is that it improves this rate of building new brain cells in the hippocampus and perhaps other areas. Something we call neurogenesis. There is a ratio between the building of new cells and the death of cells. And exercise seems to improve that ratio. So that's one thing. And the hippocampus, as I said, is an area where it really benefits us to get new cells because that area is important, not only for memory, but also for having some control over the functioning of the amygdala.
So in a way it will help with anxiety from that point of view. But then, on a cellular level, we know that exercise is something that helps your mitochondria work better in terms of processing, as I mentioned, glucose and oxygen. So after the challenge of exercise to the mitochondria, there seems to be, just like in the muscles, where you break down the muscles and get stronger, it seems that cellular processing of metabolites is enhanced. And that means you get more for your money, in terms of oxygen consumption, and improve something we call mitochondrial reserve capacity. That's good for performance, in general.
And it also means you'll have more of that resilience to handle everyday challenges. You will be able to absorb more stress in the course of your daily life. And that's basically what resilience is all about. Much more. The other thing. What we have is this obesity epidemic, right? And I did mention to you a little bit, we don't have time to go into inflammation. But your fat cells, once you develop obesity, your fat cells become a source of inflammation. So if you exercise and can successfully reduce obesity, you're also doing yourself a favor on that end of the ledger.
In the sense that if stress increases inflammation and you reduce that source of inflammation, you also reduce vulnerability to disease. And I think in terms of a more psychological point of view in the moment, immediately during and after the exercise, depending on what you do, it can be a form of mindfulness right. If I take my Zumba class, I'm really focused on trying to do the steps instead of my worries, and it gives me extra help to tune out those thoughts, have a moment of mindfulness, and get some of those stressful feelings out. Courtney is absolutely right.
So some people prefer what we call mindful exercise, and it's yoga, it's Zumba or-- Walking in the woods. Absolutely. Yes. Fantastic. I'm going to summarize the next question, which is great. It's very long, but essentially it says, a psychiatrist told me an enlarged amygdala is what's causing anxiety, a different physiology professor told me it's an underdeveloped hippocampus, and then another professor told me it's really the prefrontal cortex that's causing anxiety. helps you calm down. your tonsil. What is, is all of the above? So I think we don't talk about the network as much. But really, those are all the nodes in a network that's in equilibrium, where all those regions work together.
And in a way it can be all of the above, and one of the interesting things in research studies is that we work with averages and we summarize. We represent things, we summarize things based on averages. But you can really imagine that there are different nodes in that circuit that you could affect and have anxiety. So you could have an enlarged overactive amygdala in one person, and then another person who is under a lot of chronic stress, also has a lot of hippocampal atrophy. Or particularly that it could be the driving force. And the medial prefrontal cortex, we don't talk about much, but it's very important in terms of remembering fear memories and extinction memories, for example.
And in a particular context. So it's kind of a complex answer, but I think it's very clever that in fact all of those areas of the brain are involved. Totally agree. And then maybe a more clinical question. Can a person have a panic attack while sleeping? And wake up feeling like-- Yeah. It's happened to me before. Yes. Nighttime panic attacks are quite common. And actually, I haven't read much about it recently, so my answer might be out of date. If you know something, please participate. But in general, if you have panic disorder and have panic attacks, go back to Dr.
Rosso's lecture on fear conditioning. Well, if every time your heart has jumped in a little weird way, if that has led to a panic attack, just take once. That's going to be a learned response. So if your brain is detecting subtle changes in your physiology when you sleep that are normal, that may be enough, the conditioning may be so powerful that it can trigger that as well. You can be asleep. Yes. It's not an unusual presentation of panic to see people panic at night. And there are certain things, physical conditions, that make you more vulnerable. So, for example, menopausal women, if there's a connection between hot flashes that occur at night while they're sleeping and panic.
And also, sometimes you have to rule out seizures, which can also occur in the middle of the night. People with sleep apnea have a reduction in their oxygen saturation, and this can precipitate hyperventilation panic symptoms. So it can get pretty messy pretty quickly, but the answer is yes, they can happen. So I think those were actually the two three-minute questions that we were able to answer. So I think this would be a good stopping point. And thank you all for sticking around for a bit after this.

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