Depression, Anxiety, Trauma, & More: The Co-Occurring Disorders of Addiction

Dr. uh lamb, could you give us a brief description of who is sure? Yes, I'm Christy Lamb. I'm a physician and I trained at Georgetown Medical School and the UCSD residency program in family medicine and psychiatry, so I do primary care and psychiatry. health work, but a lot of my work over the last decade has really been focused on psychotherapy and mental health, especially in the area of ​​substance abuse, so I have a real interest and explicit training in combining coping of medications with psychotherapy to try to treat the whole person when it comes to mental health and substance abuse great, well we're actually streaming on our Instagram page and our YouTube channel too if you're watching this on a replay or if you are watching this live and would like to participate.

Sorry, thank you, I appreciate that I would like to participate live and ask your questions. You can do this by signing up for Med Circle's live classes. Just go to medcircle.com live or visit medcircle.com and sign up for the newsletter and there you are. can I sign up for the next classes, um, quick cleanup, real quick, don't you love it when people say that? I just want to make sure everyone knows and remembers that Med Circle Live Classes and Med Circle Original Series are for educational purposes only. The circle does not provide or refer treatment in any way, that being said, uh, Dr.

Lam, why don't you start with today's topic? So today we're going to talk about substance abuse and the correlation between substance dependence in connection with uh.

depression

anxiety

trauma

um and um I think here at Bold Health we really look at substance abuse in a potentially different way than the medical model really looks at substance abuse as its own primary diagnosis. There are programs that market concurrent or dual diagnoses. which is, by definition, the idea that someone has a diagnosis of substance dependence and a primary mental health disorder, so

depression

,

anxiety

, PTSD, um and um, we use those labels and codes to bill and help people get the treatment they need, but we really see Substance dependence is indisputably connected to anxiety, whether conscious or unconscious, and underlying issues regarding tolerance of the human emotional and spiritual experience, for which we see substance abuse as a maladaptive but coping skill that people have learned to use due to anxiety.

They have overcome the feelings that arise by living their lives sometimes in

trauma

tic experiences and relationships, where the feelings are difficult to tolerate and become a numbing mechanism. That doesn't mean you don't know research and biology. behind the

addiction

and that we do not have genetic predispositions for this, but I would suggest that most of us in our lives are addicted to numbing, avoiding in different ways and unfortunately for some people who have the right genetic makeup, the substances become a very quick hook. for that, but for a lot of us it can be social media or food or work and different things that can really become a crutch of how we take care of ourselves in maladaptive ways in the midst of difficult times yeah if you're watching this live by zoom.

Thank you for registering and being part of this live class. You can submit your questions using a q a box below your screen, so there is a q a box. If you put them in the chat, we might miss it, but if you're using the q a box, we'll get to those questions uh dr when we were talking about

addiction

uh a lot of people asked the question is addiction actually a disease? Is it a mental health problem or is it just a symptom of some other problem? As with most of my answers. that you'll hear, both are correct, I would say that's true, this is that they're both, um, I can tell you that in my 15 years of experience I've never met anyone who had a diagnosable substance dependence disorder that wasn't. they also struggle with some type of anxiety, depression, co-

occurring

mental health issue, that they were using alcohol to treat, um, that the number of people who enjoyed parties or celebrations with alcohol or drugs and then have a substance abuse problem is quite low in comparison.

For the general type of patient that I see who has anxiety, they had anxiety or depressive tendencies their whole life, they found alcohol and finally said, "Oh my God, I could survive a social situation because this was in me I finally felt normal." There is a biological basis here that would potentially correlate to a disease process, but I would say that even in general healthcare, I may have a strong family history of diabetes that runs in my family, sometimes I may have the diabetes marker and A blood hemoglobin A1C going up a little doesn't mean you always have active diabetes.

I need to control my sugar levels. I need to control what I eat well, so I think the biological part will really be about that. The biological pieces of the disease about our predisposition and our likelihood, while how we operate in the world and how we have learned to cope is really what fuels the fire of substance dependence taking off as a problem for people, for parents. who listen to this or any other. caregivers, what would you tell them are the big signs to watch for in their young children, in high school, even in the early years of college, that they might be engaging in unhealthy coping mechanisms, such as Substance abuse?

Yeah, great question, so I think the number one thing I Parent Coach is to look for a child who is showing explicit or implicit signs of anxiety, so if the child is feeling nervous or anxious and doesn't know how to self-regulate or take care of themselves yourself, take a deep breath, or talk about it properly, We will be

more

likely to turn to something external to try to calm this internal anxiety, which is why all of us, as human beings, are programmed for anxiety. It is our security mechanism, it is our alarm system that says something is wrong. um and if a baseball goes through the window we want to have a surprise response so we can move our head to avoid the ball, but many of us our alarm system is activated sometimes through our biology and sometimes through our kind of uh or a family of origin and trauma and stuff, our alarm system tunes itself too much, so we might get scared at the sight of a passing cat, so if a parent notices a lot of anxiety in their kids, really can realize. that will help normalize it and regulate anxiety will be very important because children will be able to notice the unconscious signs of anxiety and if their stomach hurts before going to school, being able to help label and say oh yes, there is a little bit of anxiety , but that could be coming up, yeah, let's see if we can take a deep breath to learn to help notice and then tune into ourselves, this is preventative with regards to substance use, so if I don't know that I'm anxious, it might suddenly you end up in a bar drunk without having seen the correlation, oh man, I lost my job, I had some feelings about it, I got anxious about the bills, so I went to the bar and drank, and if I don't I don't see the causality and I can't see these things and self-regulate and get support when I'm feeling down.

Regulate my anxiety. It makes a lot of sense that I would go to something to try to calm my body because I don't know. what's going on, but I feel bad, but this attunement with ourselves is imperative in regards to really combating substance abuse, not only if you are in it, but also to prevent it, and it is a big part of the work that I end up training well my patients. However, how can I determine if I am 21 and in college and go out on Fridays, Saturdays and Thursdays and drink and party? How can I determine that I am having a college experience and that certainly excessive drinking is not healthy, but Maybe I don't have an addiction and oh my goodness, this person is walking the line of a really scary path, addictive, yes, and Thus with any of the psychological, psychiatric and psychological diagnoses diagnosed, we consider one of the last criteria in the diagnosis. and the statistics manual is that it is having a damaging effect on someone's life so we have to be careful, I think educating our young children about our culture of glorifying alcohol and substances and especially in adolescence and college Help Renee.

Brown talks about defending against cool culture, that this is like a kind of preparatory demystification or glorification of alcohol and substance use, I think it's a problem, it's useful and then once kids are involved, I think You're right, I mean, I think. that the norms in college are drinking to excess and differentiating can be a difficult thing, what really stands out is that I can even think back to my own college experience and there were those kids who not only drank a lot, but drank to the point. of passing out they didn't just drink on Fridays and Saturdays they drank all week they didn't just drink um at night at a party they drank all day or they wanted to start the day drinking and those things are um you know again it can be normalized in common at the university um, but when we start to see grades drop, classes get missed, friendships become chaotic and catastrophic, especially in the type of romantic relationships, alcohol often starts to become the nest or the reason why conflict arises and So when those problems start to arise, we really want to put up a flag and start looking.

This is how I start all my sessions with new patients. Do you know what problem you would like to work on and someone drinking? 10 drinks a night if it's not a problem in their lives, I have no right to tell them that they can't drink well, so they have to see that it is a problem in their lives and that I would say is probably the defining factor, that is the factor and we're going to get into the questions from the participants and if you're watching this live on Zoom, if you're on YouTube or Instagram, we need to go to Zoom. to get your questions answered, but if you're watching live on zoom, use the question box below and we'll answer those questions, but how can you support someone who's in therapy for their depression, their anxiety, their trauma, their PTSD, but will they?

They don't give in to their addictive behavior, they are convinced that I don't have a problem, they don't want help for their addiction, they want help for these other problems, but as a therapist you know well, everything is related to the reason why you abuse the disorder. substances. It's because of all these other mental health issues that you're struggling with and as a supporter, how can I support them? The reason why your depression, trauma and anxiety cannot be helped or not, it is harder to help you. Because you spend every night abusing alcohol and drugs, what do I do for both of you?

I know it's a very asked question, but I find myself here every day, I mean literally, whether we're talking about mental health or substance abuse, is the patient right? I want help, yeah, right, and that's where part of my job is to figure out what you really want help with and that's why I asked you what problem you want. Well, my parents think I have a drinking problem. Great, that's what they think, what do you think? We have to make it very clear where the patient's will is and you know, we talked a little about this.

I think before Kyle, this idea that we have to do motivational interviewing is a long-standing type of intervention. technique that is used with substance abuse, but it is important in everything we do to make it clear who wants this correctly and if it turns out that the therapist wants the patient to get better and the patient then he can retain the part of himself that does not wants. getting better becomes an external battle there is a part of me that wants to stop but there is a part of me that wants to continue using well this is an internal problem it is not external and if I take the will of health and say you really should be so you know that this is really bad for you, the patient will tell me all the reasons why it is not so I can say that maybe it is not a problem, yes, I can let the anxiety and conflict rise in the patient so that he can clear up.

Is this a problem and is this really difficult for our supporters, family members and partners because we have to face the reality that we have absolutely no ability to force anyone to do anything and so as a therapist my job is um , I had a great mentor who said Christy in the therapy room um everyone um in the therapy room someone has to be in touch with reality and you've been nominated and I was like and I realized that's all so good, come on in with some story or fantasy they have been telling. themselves that has prevented them from getting the treatment or the care or doing the work that they need to do and my role is just to be a mirror and point that out so I can say, I guess I drink 10 drinks a night and I don't make it.work that works for you if it's not a problem I guess it works for you and the patient waits no no that doesn't work well they can start to see reality yeah so my role is just to help them see reality so that they can choose. what they want because as soon as I start telling them what to do and I want them to get better, but there's nothing I can do, I have to own my humanity and my ability, there's nothing I can do to make anyone quit, you know.

Many of the members of our medical circle are professionals like you, counselors, psychiatrists, social workers, etc., and they carry a lot of that responsibility with them when they leave work and what you have just given them is a permission slip and the reminder that say you can't save. The whole world today we can't even save anyone, yeah. We're just trying to get on with today. I'm going to ask the questions. I'm going to do my job, but it's other people's responsibility to do their job too to help people see, notice reality and understand what they feel. help them process, but the patient has to present one hundred percent, absolutely correct, if I give one hundred percent and they give zero, we will have a result of zero percent and if I give one hundred percent, I also have to admit that I have no no control over the other person's commitment and that it's up to them, yes, you are watching a free Med Circle live class.

This is one of the many offers offered by Med Circle, including full access to our prize. -Winning mental health video streaming library. There you will find a series of in-depth interviews on virtually every mental health topic. As a member of the Medical Circle, you will also have access to our members-only live classes. Tomorrow we have one with Dr. Christie Lamb. an hour and a half going over narcissism, borderline personality disorder and addiction, link and strategies for both individuals and supporters, if you would like to register for that event please visit medcircle.com live again, the event tomorrow or only for members of the medical circle, but you can start with a free trial, so if you get the free trial, you will get a free week.

You can come say hello to Christy and then make a decision after that nightcircle.com live event. Let's get to our question from a viewer, is that okay with you? Dr. Christie, okay, bh question: Do you feel like anxiety often correlates with just people not having the opportunity or a sympathetic ear or the right time to talk about things and feel accepted for their conflicts? She says I feel like there is a lot of control and competition. In our society, this type of quote, human expression becomes an external performance, drinking, etc., trying to change reality through substance abuse when correct communication has not allowed it at all, so whether let's talk about explicit, correct or, um, I would say

more

important communication. that external communication is internal communication, so can I allow myself the space to say man, if only the silly analogy of like losing a job I have feelings about it I get anxious because the bills end up at the bar right, I'm willing to look and see how?

I really feel the anger I might feel toward my boss. The guilt I might feel for not showing up as I should at work. The pain you might have from the loss. Anxiety and fear. The real fear I might have about my boss. Can I pay my bills successfully if I can allow myself to feel these feelings processed? Yes, it's awesome to have someone else you can do this with, but it's also a really inside job. Am I willing to watch and sit with him? these feelings physiologically, if I push down a feeling, the anxiety increases, so if I try to hold back tears properly and we've all tried to do this before your throat gets a little tight, you might start to yawn a little. a little restless like no, no, nothing's wrong here, we get physiologically anxious when we try to suppress a feeling and I feel very uncomfortable, this is where we turn to substances to try to numb things to try to not have to feel to suffocate. anxiety about falling asleep at night, yes, so I would completely say that we need the space and time to process what we feel, think about it, talk about it, and most importantly, feel it to let these feelings settle. metabolize through our body experientially, literally through our bodies, yes, you and I filmed a great series on the conflict triangle, yes, yes, that's great too, so if what he just said resonated, look for that series by Dr.

Christie Lamb, or just send an email. I'll send it to you kyle medcircle.com let's move on to our next question uh ml says as a practicing family doctor I was trained years ago to avoid benzos in patients who have anxiety they interfere with CVT what is the current recommendation for medications? ssris snris, etc. in treating anxiety with or without concomitant substance abuse, I'm sure I said it wrong, but did you understand the question? Yeah, okay, great, yeah. So, great question, this is the question if I understand correctly, right? Should we be using benzodiazepines so things like valium adivan xanax di um klonopin to treat anxiety because they work very well to calm anxiety quickly but they are highly addictive we develop tolerance pretty quickly so we need people to need doses every time higher and are greatly abused, um within the world of substance abuse, benzos are kind of a strong no-no, that being said, benzodiazepines are used for people who are experiencing acute withdrawal due to alcohol dependence, so they attack the same receptor in the brain, the gaba receptor. in the brain that helps calm things down, so when we're trying to prevent someone from having a seizure or withdrawal, we'll give them a benzodiazepine to administer in a controlled medical environment, so I agree, 100 um, stay away.

From benzos and anyone with a substance use dependency, there are a lot of great alternatives, as far as a family doctor is concerned, things like vistaril, which is an antihistamine that can help decrease anxiety. Gabapentin is a medication that has been shown to reduce cravings and is used. to help regulate anxiety, um, but on the anxiety side, benzodiazepines should really only be used short-term as a bridge while people adjust their dosage of ssri or snri, so traditional antidepressant medications, um, and that, really, you know. I have to be transparent about my main preference for therapy, that medications, in mind, you and I've said this before, are really like a life jacket that helps us in the middle of a storm to breathe hard to keep our head up. water, they're not going to work, that takes us swimming to the island, you know, on that island we all swim to the right paradise, yeah, hey, exactly, and that's the job of therapy, exercise, sleep and relationships, so medications can be really helpful. give us um to be able to give us a little bit of protection to be able to do that job and so yeah, the most common thing recommended is going to be ssris or snris, use really very low doses to start with to avoid side effects because people with anxiety a They often have anxiety about overdoing the medications and any side effects will often make them want to avoid the medication, so I start with small doses and little by little I adjust the dosage for people to see if we can get some benefit, but really the therapy goes to be very important. as a pillar for anxiety absolutely for those looking at that circle perhaps for the first time whether you are a student, teacher, member of the military, healthcare worker or professional, we have discounts for you.

Email Kyle me at medcircle.com. and I'll be sure to offer you a discount on your monthly kyle medical circle membership medcircle.com uh let's move on to our next consequence consequence our next question which says what the consequences will be if a therapist directly tells a patient with addiction that they need to stop side your addiction um yeah I don't think that approach works very well um so it usually doesn't work very well when I mean the patients are in the room and they know it completely as soon as I take the health will and say this It's really bad for you at that point the patient comes in and starts defending themselves to say well you know it's not that bad, I've been able to cut back a little bit, and they start defending that in all of us there is a healthy side and a more destructive side. , and if we can really let the patient have this choice, and it doesn't mean that they never say "hey, God, I care deeply about you and I can see that if we" are honest with each other, we can see how destructive that This is in your life, right, and I can list it well, you know you had to drop out of school, you don't have money in the bank, your relationships are in the bathroom, right, um, but I don't.

I have no right to tell you that you can't keep drinking. I see that there is a way you can have a better life, but again, I can't tell you how to live your life well and then the anxiety and conflict and questioning of "I want this for myself" stay within the patient instead of within, Instead of this type of external conflict that is too often created and created from the top down, this is what needs to be done. In my experience, it doesn't work, yes, Dr. Christie Lam is a psychiatrist, but she also does therapy and that's one of the reasons I love talking to you is you know I've seen a lot of psychiatrists who just write me scripts and then I honestly don't even know your last name, but you are very detailed and involved.

I appreciate jw saying that I struggle with depression and suicidal desires and I don't want to listen to my counselor, I want to totally crawl and not worry about anything. I'm caught between what I feel and what my counselor tells me. Thoughts. Yes. I would suggest there is something going on right now. We are in this exterior. My therapist thinks he should do one thing. and I want to do another good and I'm wondering, is there something inside this person that still shows up for therapy that says there's a part inside you that wants some health and how do we help give it voice and that means?

It's like looking at where things are and what you want for yourself instead of what therapists want for you, but yes, what do you want for yourself and what keeps you coming back so that you can be willing to participate in therapy despite feeling bad. is not what you want, there is a part of you that is still motivated to keep showing up and that is an incredibly healthy internal drive, so how do we help cultivate it? It may be worth exploring with your own therapist what is happening in this dynamic. where he or she has all the health and how we help cultivate that desire within you sounds like the willingness to participate right when we talk about therapy we have to have a couple of criteria um I have to have a problem I have to work on it, I have to wanting to work on it here now with you and if any of them are missing, we don't actually have a patient in the room, so some people come in and it's just because their partner wanted them to.

Come on, they don't have a problem they want to work on, that's great, I mean we could have finished your coffee, but since we don't have to do this, they can have a problem, but they can say I'm not ready to do it. work on it yet or I don't want to work on it and I've been there yeah and I have no right to tell anyone to work on something they don't want to work on they might not want to work on it now they might not work on it and they want to work on it here or with me and that's okay, and that's another thing I often tell people: it's okay to fire your therapist and I tell my own patients that it's okay not just you.

I know they fire me or criticize me, they let me know what we are doing is not working and I check it. works and what doesn't work here, well my goodness my will is not on board yet. Great, thanks for letting me know and what we should do about it. Yeah, and you know, I answered the viewer's last question that I asked him in therapy. therapist, I don't want to do that, you're asking me to do something or you're suggesting or whatever or you're making it so I don't want to do it and I just let them know where I am.

On the other hand, I've been in a lot of places where I don't want to do these things, But I think you know what I'm going to do anyway and I'm going to hate it while I'm doing it and then I might even regret doing it, but at least I'm going to be the person who said I did it and I tried and I tried, so I was on the lower end, you know, I've taken hikes. that I didn't want to continue because they said I had to go out and try to walk, so I did it even though I didn't want to do it, I think, Dr.

Judy, and I talked a lot about people. I always talk about how they will live once their depression goes away instead of just living that way even though their depression has taken over and I get it when you don't want to get out of your bed to check the mail it sounds like a monumental measure. task, but yes for me, at leastyou can force it and that's what I'm doing to get the call in the mail to win and just say okay at least I did it today you absolutely know so I think they're like that. there are the basics and they are there, and making sure that I can allow myself to give myself permission to figure out what I can do for my health and towards my health and oh my gosh, going to a regular therapy session is a lot of willpower, even if you're Sitting there all the time not saying a word not wanting to do anything man that's a huge boon for me it's huge that he's willing to commit to getting you out the door like you said or getting out of bed and up front. from the zoom session these days and then it's those little things that we can latch onto to say these are things that I know make me feel better and my willpower in the moment may be low, but I know that I want to do these things for me.

I know I want to take one step ahead of the other and sometimes it's literally like if you said get the mail or show up for the appointment, even if I don't say anything right, I spent this hour moving towards something. to me, a viewer, asks if antidepressant medications have the same effect as other addictive substances. He also asks if medications can be used to avoid reality and the painful processes that result in growth. Great question, so any substance that we take can result in a physiological dependence so umel physiological dependent, so if we take Advil, if you take 800 milligrams of Advil three times a day for chronic migraines, if you stop doing that, you will have a rebound headache, so if we stop whatever we are taking on a regular basis, we can Now I have some withdrawal.

Different medications depending on how they are formulated and how we metabolize them are more or less likely to cause dependence. Tolerance. Abstinence. We define that as some of the characteristics of addiction. The characteristic of addiction. um, that's above and beyond, it's the behaviors to then get those medications. I have never in 15 years seen anyone use an ssri or snri of the traditional medications for depression or anxiety in that way taking more of them that they should look for early prescriptions for them, they just don't give the same effect that that would actually cause, but If you are taking an antidepressant medication at a moderate to high dose and you just stop it, it will feel real. lousy so we always taper off medications because you can become physiologically dependent on them that just means your body is used to having this and then we just gently wean you off so you don't have to take them so when you come off of it like when you get off Advil, if you take it every day for a month, we slowly reduce it so that your nervous system regulates itself again, so that is the big difference between addiction and physiological dependence. chronic pain maybe with opiates never requires an early prescription taking it exactly as used has no consequences on their lives that's why and we wouldn't call them addicted to opiates we would call them physiologically dependent because if they just stopped taking them they would have the withdrawal effects that someone experienced but have no consequences in life and that is where addiction or substance dependence as a type of mental health condition differentiates itself.

This idea that medications get in the way of therapy is important and even for patients who aren't necessarily on therapy, we can talk about getting over the cushion that some of these medications may feel now, some people don't get this effect, but for many people there is a kind of sweet spot where they have a limited effect. limited, they don't feel much of anything and then they start to really feel like wow, I feel less raw, I feel less nervous, you know, just being aware of whatever comes up, you know, it sends me a shock to the next level.

It would be excessive if we started to feel numb. Many people will start therapy with me and start to feel a little better. They will understand your anxiety a little better. They will use some internal controls like the example to regulate anxiety and we will start to wean you off your medications so you can feel more because these medications calm the nervous system, that's what they are supposed to do so you can function, but if we calm you down too much, you may feel numb or uh. a little bit dull and so we have to keep an eye on that and that's a really important communication with your psychiatrist to tell you if we've gone too far here, right?

Is this depression or maybe I'm just a little dull from the meds and it's real, you know? Something real we need to be aware of is excellent. I was asked if one's DNA influences a person's tendency to be addicted and another person actually asked if addictive behavior is genetic, so I'm going to group those two together, absolutely, so there's a wonderful article. um, I should probably cite the original scientific study, but there's a wonderful article in the Atlantic that came out probably two years ago about this alcohol dependence thing and there's a receptor in the brain that they did studies on in rats and, um, something like that. this receptor in the brain of the rats and that population was more likely to have substance dependent behaviors, so they had more cravings to go towards and develop addiction characteristics, so we know that 15 of the population has um. a high probability of substance dependence and it turns out that this receptor in the brain is about, you know, statistically it appears in about 15 people, and absolutely this is the reason why it is hereditary and I would say It's not just substance dependence our trends.

I always come back to this. You know, Kyle mentioned the conflict triangle. It's kind of a cornerstone with respect to understanding the path back to mental health. So as humans we all have interactions with people that are good, bad and different that generate feelings, if we have not learned to tolerate our feelings, navigate them, we can feel anxious and then fall into any of the many different defenses, so Some people can, genetically and familially, fall into substance use. get depressed, some people can panic, oc, eating

disorders

, right, these are hereditary, there is a lot of research regarding the genetic underpinnings and again, it is always correct, as we said at the beginning, there is this. brain wiring, but then if you grew up in a family where you saw your parents get stressed and have a glass of wine at night to de-stress, you're socialized that way too or if you had a parent who got very anxious and panicked or um overproductive at work when she became anxious at that moment, you'll be more likely to see that she's unconsciously preparing you to um how to tolerate stress or difficult emotions, so it's both, so there's this genetic foundation that we know about and There's a ton of research on this realm, and then there's also, oh my gosh, my parents do this and this is what I've seen, so it goes hand in hand, that makes sense.

This is a bit longer question, but it's something. Many people ask it. This user says that in New Zealand we are about to have a general election that will legalize cannabis at the potency of 15. I am very concerned because of the number of dependent clients I have met or still have who have high levels of dependency. ace scores and a deep attachment to citing marijuana, any suggestions for my own calm in this changing and legalizing environment, when I know that normalizing use has many disadvantages even more. I'm a healthy promotion graduate, but I have doubts about hp theory, so I think This goes back to therapists and providers being able to own what we can, um and I, and also own the reality of the autonomy of our patients, that we can counsel and educate, and I think that's imperative and I think that's probably the best thing we can do is help get back to being the face of reality in the room because there are a lot of distorted fantasy beliefs about marijuana.

Now there are some people for whom it can be relaxing and have no adverse consequences. THC levels are now two, three or four times higher than the amount of THC and marijuana they used to be, the rate of psychosis is definitely increasing, so I had a patient who hadn't smoked since high school and he had a flare Complete psychotic and He had to be hospitalized because he became very paranoid and we have to be very, very careful in educating people about the reality of what is possible and the consequences that can happen, but when the time comes again, I have no right or tell anyone whether they can or can't use this and I have no ability, even if I thought I had the right to do it, I have no ability to stop them from doing it, so the best thing we can do is help educate our patients and help them continue to question and ask if this works well for you because you know if it does, then who am I to say that you can't use it, but let's be clear what the possible consequences are, especially in the activating effect regarding to possible psychotic

disorders

and people under the age of 25, so there have been excellent studies showing that because the prefrontal cortex the executive function of the brain is not fully formed until age 25, the use of marijuana in families with psychotic disorders the risk of suffering from a psychotic disorder significantly increases. like those predispositions that just because you have the receptor for alcohol dependence doesn't mean you're going to end up in a bar, you know, drinking all day, we have to know our biology and then operate accordingly, um, I have a family history of diabetes, right, I really have to be careful not to be overweight, uh, consume sugar all the time because I'll end up getting diabetes, um, but there are things I can do to mitigate that, but it's up to me and it's my responsibility now.

As a therapist, my role is then to educate to simply question any false beliefs or any blind spots that people have. Well, it's working really well, it really calms my anxiety, okay, and then when you come down from the high, how is it? your anxiety, wow, it really increases, oh interesting, so you have some rebound anxiety after this, that's important to note. I had a patient who was in therapy and he was wondering why he has these great ideas and then we kept talking about the same thing. because I keep forgetting them, well what are you doing outside while I smoke a bowl later?

Okay, so you're erasing what we've done well, like you can do that, but if you want this to stay there, you're like, yeah. Let's be, let's look at the reality about what's really happening and then it's really in the patient's right and like you said, it's a huge relief for me to know that I don't have the ability to change anyone because then I don't have to. sit at home at night and say, "Oh my God, they're going to smoke, they're going to smoke, what are they going to do, it's not my responsibility, yeah, but I really respect their autonomy and I respect the fact that their inner wisdom and if Look The truth is, if we look at what is really happening, they will make the best decision for themselves and I can help them, support them and help them be a kind of mirror with a flashlight, but that is the extent of my role.

Yes, it is a great reminder and I'm actually going to share my screen real quick because a lot of people may not know exactly how they can take advantage or use Med Circle for any mental health education that they need. We have three main offerings. What I just want you to know is people be very clear the first thing is that we have access to this very large video library, if you see on your screen right now, we have in-depth video interviews on a variety of topics with a variety of psychologists and psychiatrists. you can search or search your favorites we also have an app if you go to medcircle.com you can download the app for free it comes with I think six series for free also the app has changed the rules of the game for our members it allows them to download their videos, take them with them, view their history, share content easily with friends and family, so thank you to all of our members who are using that and we also have our live events, which is what you're seeing.

Now this one is free but we also have events for our members, you can just see we're with Dr. Christie and there's her picture so today we're talking about the co-

occurring

disorders of addiction, depression, anxiety, trauma and More and tomorrow we'll have this members-only event that will discuss narcissism, borderline personality disorder, and addiction. You can go to medcircle.com live, become a member, and start a trial to attend that class. Download the app and also get access to our series. Of course, if it is, I think doctor, are we okay? We'll see her now or me.

Okay, it's not my screen anymore. And if you're a professional student, a teacher, a military healthcare worker, but I mean, we have discounts for everyone. So if you think you're eligible for a discount, contact me and Kyle at medcircle.com. He isgood. Let's get back to some more questions from members. Dr. Lam. There are many good questions here. This person says I think anxiety and depression are a problem. chemical imbalance, although I'm sure every case is different and can involve both a lack of human compassion combined with the chemical imbalance, uh, I guess she's asking your opinion on that thing about depression being a chemical imbalance absolutely, so I apologize for being broken. record, but I really believe in this interaction between our biology and our psychodynamics and that's how I often talk about mental health with my own patients: we have neurotransmitters, we have electrical wiring in our brain through the neurons that we have.

We have the structure of our brain, some people have large or small amygdalae, which is a kind of core of the limbic system where our emotions are channeled correctly, so we have this biology that we have to work with and this is where medications play a role. big role. a huge role and there is absolutely no doubt that someone who has an off thyroid who has, you know, different types of endocrine disorders, different types of cancer, correct stimulation of the brain, we can see a direct correlation where, so Otherwise, someone is doing really, really well. we stimulate a part of the brain or alter very low we make their thyroid very very low and they will get depressed there are certain women for him who try a certain method of birth control every Tuesday before their period they are like crying and they are like I don't know what's going on, for The rest is fine with me, so we know there is a biology that works independently of our psychodynamics, however they go hand in hand and can often play off each other, so if my mood is low due to my neurotransmitters, things in my life will probably become unbalanced and I will have feelings about it that can then make me anxious and then sink me further into a depressive breakdown.

This can cause my serotonin levels to drop. and things can spiral Medication can help things get better and my life can start to improve and then it can feed back and my serotonin levels can increase because of the things in my life that stimulate improvement in my experience. It's very rare to have anything strictly biological. Another thing is depression, there is almost always a triggering background, which means that something at some point happened, at that moment we fell into depression, depression is often not sadness, right? If I have a death in my family I may cry and feel horrible pain inside and feel sad depression is more of a dank numbness uh detached self loathing is a different animal and most people who have experienced depression can really tell they say oh yeah, those are very, very different, right, if we've never had space or learned or been supported to feel what we feel, not just pain or sadness, but even anger, it can be repressed, we get anxious and then we turn on it. ourselves and this is one of the most common things I see is anger or guilt increasing. pushed down I get anxious and I can tell if I wouldn't have done it if I was right and then I start in this spiral of self attack and the depression hits and then that affects my neurotransmitters they go down um everything slows down and there is It's true that there are beautiful anatomical studies of what happens to the brain that's depressed, but it's bidirectional, so the neurotransmitters do their thing, but so does our life and how we've learned to navigate our feelings, um, and that they go hand in hand. right, and there's some interesting work that challenges even the structural piece around God, does the size of your amygdala matter?

Well, there is a feeling that if you had a trauma, your amygdala may have developed differently due to the external trauma, so again, it is neither one nor the other. Really both and you know different people have different perspectives on that, but I would say the answer is yes and okay, this is a great question. Laura says okay so while you were talking about marijuana I was watching another psychiatrist talk about the benefits of magic mushrooms on depression and alcohol alcoholism uh dr what do you think so there's some research going on really interesting right now with respect to psychedelics and addiction treatment, as well as trauma treatment, um, and I think within a controlled environment.

Well, again there are some really amazing protocols that show controlled environments to access levels of consciousness where perhaps people can then work through connections of past trauma with addictive tendencies. I think the research is still developing, it's not something I prescribe, it's not something. Mind you, but I really believe in the kind of medical model of doing no harm and that if people find benefits within kind of experimental trials that are working and that are safely controlled and monitored to determine outcomes and side effects. that some of these things may be, you know, really treatments of the future with ayahuasca and mmda and, you know, ketamine, are all studies that are flourishing right now to see how we use these substances in a controlled environment to relieve pain. and hopefully not only will the symptoms be reduced at the moment, but a space will be created.

There are many people there. There are some people in San Francisco and in Canada doing ketamine psychotherapy studies so that it is not just a one-time experience, but a practical experience. through past trauma so that once the ketamine is out of your system you still have something to hold on to for continued growth and change and I think that's the most important thing about this is that the medications that we take that kind of the Things will calm things down in the moment, but it's the therapy that will really make it work to understand why and prevent future relapses.

Yes, that makes a lot of sense and Med Circle has a great series on ketamine with Dr. Dominic Sportelli. If he is interested in learning more about that topic, I suggest he check it out. This is a little off topic today, but I still think it's a great question from an anonymous attendee asking: can a person heal from trauma bonding while still with their abuser a great question um I think you all know I think anything is possible um I think um the key piece is internal healing means um oh my gosh, I would have to have a little more information, but yeah Imagine a scenario where someone lives with their abuser who is still abusing them until they heal. it would probably mean being able to set boundaries that say yes, you can't touch me like that anymore, you can't hit me, or you can.

Don't talk to me that way so that you can access the feelings that arise, so that you can navigate the relationship in a healthy way, and so that you can set clear boundaries. I think often in an abusive relationship, you know, we can I have a position where a patient has been really traumatized before the point where they've never stood up for themselves, but those aren't generally relationship dynamics where Someone may set a boundary and the person hearing the boundaries says, “Oh, I'm sorry, if only you had said.” something that I would have done something about, unfortunately these are often very pathological relationships and the person who is abusing is not necessarily going to respect the boundaries that are said and a lot of trauma work in my opinion is possessing agency. and setting boundaries and being able to feel comfortable with all the feelings that come up towards past abusers, so is it possible?

I never say never, but I think it would be very difficult because you don't reach your goals. consistently, they constantly reactivate you to what you're trying to work on and which is pretty hard for us to deal with on our own when someone is like that, man I'm so glad you said something I didn't have. idea that I was hurting you that way, I'm actually right, it's very hard to set a boundary and stay clear in the middle of someone saying I don't care what you think or you're right, I said, "it's okay, it didn't matter anyway." , TRUE?" It can go back to taking a one-down position, so we often need to be in a really supportive environment where someone welcomes us and really encourages us to set boundaries, and that's not very likely within an abusive relationship.

Thanks for that below. I wonder if a person struggling with anxiety or depression has a comorbid addiction, what is treated first and why? I would say we treat all of the above at the same time, but we can't actually do the treatment if we don't have a patient in the room, so if someone hasn't detoxed from substances we can't actually communicate properly, so I would suggest that substance use works, um, really becomes part of the addiction of anxiety, depression works once. the patient has achieved sobriety now we can start filtering those things out and start navigating the anxiety in the moment and I think they always have to go hand in hand because a craving is really just anxiety, right?

I feel so uncomfortable in my skin. What I want to use is anxiety, so if I can regulate it correctly, then I can avoid using it. It sounds a lot easier than it is right, but of course, but yeah, you know, in our outpatient program we can't, we can't have Someone who comes to groups intoxicated because they're not going to get the right information, we can meet with people who are still using and tell them we need you to be sober for this, as if you know you have to at least commit to not doing it.

Use until later or if you're coming, maybe we're using medication assisted treatment to help you get sober so you can then participate in therapy, but I would suggest that the work of substance dependency is anxiety regulation, that is, navigating depressive tendencies. that can go away when we're anxious about feeling, so we were actually one of the only programs in the country that combines primary mental health with addiction treatment because we see it as the same thing, that if I struggle to navigate my feelings they become anxious. . I can slip back into depression, slip into substance use, slip into OCD symptoms or eating disorder symptoms, so this is the human condition, so we have to figure out what we call it in psychological terms. , what defense am I using to avoid my feelings and everything. of this job is the same.

Can I tolerate the feelings that arise in me without becoming too anxious? Can I regulate my anxiety and really allow myself to feel exactly what I feel in a supportive environment? So I would say they go hand in hand. hand, but sobriety is really imperative to start with, sure, if that resonates with you, I suggest you look into other series that we've filmed with Dr. Christie Lamb, especially the Triangle series Triangle of Conflict, in fact, we did a um a an . Instagram post of that triangular conflict and I forget how many times it was shared, but like hundreds of times, I mean, it was one of our most shared posts on Instagram and it's because we can all relate to it, whether you're here as an addict or it's not irrelevant we all have we all went through that triangle of conflict and last week we moved on yes, as humans we are addicted to avoiding reality we are addicted to avoiding the things that we have learned to protect ourselves in all In many ways, I think that is the something else with addiction, that is, really with compassion, because of your genetics, your upbringing and your circumstances.

You know certain circumstances. This is the maladaptive way you learned to numb yourself to take care of yourself when you felt out of place. right control and I mean empathy when we see that this is the human condition that we are all addicted to, numbing, we are all addicted to avoidance and the more we can learn to regulate our anxiety and tolerate the painful feelings that arise, the less we have to doing all those destructive defenses that can really keep us stuck with mental health, challenges, yes, tomorrow Dr. Christie will be back in the medical circle, we're going to be in for an hour and a half, not just an hour.

Have more opportunities to get answers to her questions and learn about the link between narcissism, narcissistic personality disorder, borderline personality disorder, and addiction, register at medcircle.com live, dr. Christie, thanks for being here and we'll see you tomorrow, always, thank you very much, whatever it is. going through this you have this and