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Show Notes
This is a ~1 hour discussion with Dr. Alex Schmidt (www.schmidtpsychologicalservices.com) and Alexey Tolchinsky, Psy.D. (https://montgomerycountypsychologist.com/). We touch on issues of trauma, somatic memory, dissociation, and protective mechanisms at the interface of the psychiatry and developmental biology.
In private practice, Dr. Schmidt works with children and adults who exhibit severe and lasting emotional and physical trauma and who present with assorted presentations of PTSD. She has treated both victims and perpetrators of sexual violence since 2010, conducts comprehensive sexual risk assessments for the courts, and offers expert witness testimony as needed. She supervises clinicians at an outpatient treatment center for adjudicated sex offenders, with a combined secondary caseload of approximately 500 clients. Throughout 2022 and 2023, Dr. Schmidt offered a somatically-based treatment program for adolescent offenders at a California Youth Authority detention center, based on a new modality she is developing to target and treat traumatic injury at its’ source. She also offered tools to participants for management and care of their own mental and physical well-being while incarcerated, specifically designed to address the considerable negative effects of incarceration. She is a vocal and committed advocate for dramatic reform of California's jail and prison systems.
Dr. Tolchinsky is a licensed clinical psychologist and an Adjunct Professor at the George Washington University. He is a clinical fellow of the Neuropsychoanalysis Association. He runs a private practice in psychotherapy, where he specializes in dysregulated anxiety, panic, and trauma treatment. He works with neurodiverse patients and young adults struggling with life transitions. His peer-reviewed work includes papers on acute trauma, integration of chaos theory in psychotherapy, narrative fallacy in psychotherapy, and OCD. He is currently working on a paper about dissociative experiences.
CHAPTERS:
(00:00) Clinical Backgrounds And Regeneration
(08:34) Self-Perpetuating Memory Patterns
(21:42) From Thoughts To Selves
(34:48) Dissociation Attachment And Time
(47:01) Somatic Memory And Regeneration
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Transcript
This transcript is automatically generated; we strive for accuracy, but errors in wording or speaker identification may occur. Please verify key details when needed.
[00:00] Alex Schmidt: I'm Dr. Alex Schmidt. I'm a forensic psychologist with a multi-pronged practice in Los Angeles, and I treat primarily the symptoms of severe early childhood trauma. It has branched out for me into a lot of different places, but primarily perpetrators and victims of sexual violence are the populations I work with the most. I do risk assessments for the courts where people are about to be convicted of some sort of sexual crime against a child. I try to help the courts understand what has happened, how that person may have come to those behaviors or actions, and where and if there are places they might be amenable or appropriate for treatment. In my private practice, I see kids from the foster care system who have histories of severe and extreme trauma, being trafficked, who are not responding to standard therapeutic interventions. They retain me to treat kids who have sometimes shut down or gone mute or are acting out in ways that are violent or inappropriate, either against themselves or other kids. I teach and I work with probation officers a lot, helping them understand what's going on in the population of people on supervised release.
[01:30] Michael Levin: Yeah, great. Okay. And Alexei.
[01:36] Alexey Tolchinsky: Hi, I'm Alexey Tolchinsky. I'm a clinical psychologist in Maryland. I do clinical work, most of it. I work a lot with anxiety disorders, including obsessive presentations. Alex and I share an interest in trauma. I work with acute PTSD, complex PTSD, and attachment trauma, but not to the level of severity that Alex works with. This is very noble work that you're doing, very hard work. I also work a fair amount with immigrants and people who go through life transitions, such as young adults trying to be in college and survive it, or people who go through divorce. A fair amount of my practice is neurodiverse individuals with dyslexia, dyspraxia, Asperger's. I've been writing papers on different topics related to neuropsychoanalysis. Michael, you and I recently published a paper with George Ellis, Sarka, and Jeffrey; that's also my interest. I very much look forward to this. I learned so much from both of you; it's educational for me, and I really appreciate it.
[02:51] Michael Levin: Fascinating. I'd love to hear you guys talk about what led us to connect in the first place and how you see your work connected with the kinds of things that we do. It's super interesting to me that we do work in frogs and worms and cells and things like that. We get a lot of outreach from people who work in therapy and in the psychological sciences. It's very interesting to me what those connections are and what you guys see there. I'd love to hear more about that.
[03:26] Alex Schmidt: Sure. There's more overlap than not at this point. The thing that brought you and I together, Mike, was I was reading The New Yorker, a magazine that I no longer have time to read, so it wouldn't have happened now. But I was reading an article in The New Yorker about the work you were doing around regeneration and the idea that a cell could be nudged to replicate or to heal something, to finish a feedback loop where there had been traumatic injury. One of the practices that I'm building and working on is based on the idea that I strongly believe that the somatic piece that we carry as a result of trauma, whether it is trauma from childhood or even trauma that we carry from previous generations, things that have happened recently or long ago, it's all held as a cellular record. The body is a living record of those experiences. I look around at many of my colleagues and we are treating trauma downriver. We are treating the symptoms. We are managing the hypervigilance or the anxiety or the panic attack or the dissociative moments, but we're not treating it upstream at the source. It seems to me that the more we are able to find and access the source places, the more we are able to facilitate a downriver repair. Not just playing whack-a-mole with the things that are happening as a result of trauma, but actually shifting the shape of the rings in the tree that hold that memory. That's going to impact people on a somatic level across domains. We see all of these manifestations that perpetuate — high blood pressure and inflammation and all of these different conditions that are connected to those kinds of experiences. In particular, I have more questions than answers, but I think there are practices that we can engage in ourselves that would necessitate facilitation at first. I think the call can come from inside the house to repair some of these systems. I have a research interest and a whole other lane with the brain and the impact of the way our brain structures affect our feedback loops, the PTSD, all the axes that are affected by that. I think there are things that we can do even with my youngest client, who is 5, and my oldest client, who is 85. Even on the level of my little kids, there are things that we are beginning to play with that are activating a cellular cascade that could help with repair. You and I have talked before about how to document that or how to find. That's what brought us in. I read this article and I have to talk to this man. That was the entry point.
[06:31] Michael Levin: It's very interesting because there are a couple of things here that are strong themes for us. So this idea of chasing down the ultimate manifestations of things, the symptoms, is mainly what a lot of medicine today is about. We have ways to address specific symptoms, but it doesn't actually fix anything. It doesn't get to the root cause of it. I hope today we'll talk more about some of these issues with somatic memories and some other things that I wanted to ask about. And Alexi.
[07:06] Alexey Tolchinsky: I had several phase transitions in my development, and Mark Solmes and Neuropsychoanalysis Discovery at the third year of my graduate program was one of them. Chaos theory was another. Your work, Michael, when I found out about it through chance events on YouTube and following Carl Friston and Mark Solmes, shook me to the core. It was a big pivot because we have been taught all along about the singular intelligence, singular consciousness, and your thought that we have intelligence at the level of skin cells completely changes the outlook on everything. Then I started following and reading your papers and watching your lectures with gratitude. Part of me was like, why haven't we been taught that? Part of me is like, we need to introduce it to the graduate programs in psychology and psychiatry. It's revolutionary and useful. I found a lot of resonance in what you shared in your technological approach to the "Mind Everywhere" paper and team. It resonated with Carl Friston's work. This is why I think I approached you for this depersonalization paper, because it's a powerful instrument, a powerful prism to look at the clinical phenomena that Alex and I work with, and very useful, I think.
[08:34] Michael Levin: I'm really interested. The experiences that you guys have clinically are such an important body of knowledge for what we can do both biomedically and in model systems. We have such a limited ability to see the different manifestations of memories and the somatic impact of different kinds of memories. This is the thing I really want to dig into. One thing that I've wanted to ask you from a clinical perspective is: To what extent do you see the ability of specific memory or behavior patterns to perpetuate themselves? This is something I'm working on now very heavily: the idea that originally we can think there's an agent, let's say the human patient, they have a cognitive system, they've got a brain and some other stuff. Within that, there are patterns that are memories, but they're passive data and we can talk about how the agent processes that information. I want to flip it around and ask, what if we look at things from the perspective of the memory patterns themselves? William James has said that thoughts can be thinkers. Thoughts are thinkers themselves. This idea is that we too are temporary dissipative patterns in metabolic media. We can look to other patterns to see what degree of agency they might have. One thing that they might do is want to perpetuate themselves. They might do niche construction to manipulate their environment; this could be synaptic mechanisms, but it could also be lifestyle or behavioral, putting the person in certain environments. What can you say about that clinically? Is there a phenomenon where some of these patterns — repetitive intrusive thoughts, depressive thoughts, PTSD, complex — do you see that they change the physical and behavioral aspects of the patient so that they are more likely to persist, that they persist their own survival? Is that something you see?
[11:00] Alexey Tolchinsky: If you'd like Alex, I can share a viewpoint and I'm sure you will share the traumatic examples as well. One of the features of your question, Michael, is the loss of the sense of agency where we feel like we have no choice anymore. I use the term hijacking of the trait of thought and the course of action; it can happen clinically for multiple reasons. Obsessive-compulsive presentation is one of them. Delusion is another. A craving and addiction is a third one. A post-traumatic flashback is yet another one. All of these scenarios have something in common. It's useful to have an example that is a bit more extreme than personality but clear: obsessive-compulsive disorder with checking subtype. Let's say I leave the house and I lock the door and I step away 3 feet. A thought pops into my head: "What if the stove is on?" The thought is powerful. It's something I can't not think, which is what we call obsession. In addition to it, there's a push, there's a drive to open the door. It's the impulse to act; I cannot not act, which is what we call a compulsion. These things we're pretty much aware of most of the time. What we're not aware of is the entire regime, the state of the mind and the brain and the body. If we attend to it, we'll realize that we're tense. There's some tension, there's some threat. Specifically, what if the house burns down? That has anatomy and chemistry and profound effects on everything: attention, perception, the bed nucleus of the stria terminalis fires, there's cortisol, there's vigilance. We can call it anxiety, which is a state of uncertain threat. This is the key component that actually does the hijacking. While the thoughts and the actions, the compulsions, are the tips of the iceberg that manifest: worry — the "what if the stove is on" — is a cognitive component of anxiety. The impulse to act is a behavioral component of anxiety; it's compulsion. The whole tone, the whole state, the regime change of the body is important. In and of itself, for an emotional state to hijack the course of action is normal. Let's imagine that I'm reading a book on accounting, which is emotionally neutral, and suddenly I feel air hunger. What if I suffocate? If I don't attend to that feeling, I die. We have the internal hierarchy of needs where air hunger will be more important than thirst, which is more important than hunger, et cetera. We can trace this idea of an emotional state hijacking the behavior even in a single-celled organism. Kevin Mitchell has an example of paramecium in his book. Paramecium is busy searching for food. It is moving toward the gradient of food. Suddenly it's getting bumped from the back, which to paramecium means it's being attacked by a predator. If it doesn't change, it dies. This redirects; the proto-fear reaction changes the course of action and changes the plan abruptly. That's the example of hijacking. Because emotions are usually survival needs, where it goes south in psychopathology is when the emotional system is dysregulated. Then we fire and we get hijacked for pretty much no real reason. For example, if I go and check the stove, come back, close the door, and walk away 3 feet, the thought pops right back: "What if the stove is on?" and the compulsion is right there. Then I'm detached from reality. The reality testing didn't update my super salient belief. It is still hyper salient and I'm compelled to do it again. I'm stuck. This is one of the examples of how this hijacking — loss of sense of agency — happened in a specific presentation of obsessive kind. Alex, do you have any other thoughts about it?
[15:14] Alex Schmidt: Very interesting. Please don't self-edit. You can go on. I know that you, Alexi, work more with OCD as a specialty. It is something that I experience as a side effect of deep trauma with some of my clients, although I do have some clients where that would be the predominant headline diagnosis, that the OCD has taken precedence over the other things, but they're all connected. They relate to obsession. And when I say obsession, I'm talking about involuntary obsession. I'm not talking about the fact that I have a lot of vintage mugs in my house. That's on purpose. When there is that lack of agency, there's still consciousness around it. You illustrated it beautifully because there's that sense of "what am I doing? But here I go," where the conscious mind is observing, but the subconscious is driving. And that is a very profound feeling of helplessness and frustration that has somatic components to it. So when I look, particularly at OCD, I think of the obsession as our survival drive that's a reflex, that is the fundamental, if you talk about that hierarchy of needs, not getting killed is the very bottom of that platform. Do not die, continue to carry on. And that is not a decision we make. That is something that our brainstem is monitoring all the time. We're not looking at someone in the supermarket thinking if we should kill them, or if they're a threat, but subconsciously we are all the time. It's exhausting. Obsession is largely checking and cleaning. It's those two things. It's contamination or "am I safe?" Is the oven off or is this dirty? Those are the two places where those come in. Those are fundamental to survive. If we are either in immediate danger or we're going to be infected by something, it's game over and nothing else gets to come in. When we see OCD, we see this misfire. So it's a survival drive going "what if, what if," and we're not able to. We know in the brain structure that people who live with that have a smaller volume in certain parts. This is more pronounced in DID. In obsessive brains, there is this misfire where the thalamus is not getting enough stimulation and the oxytocin or the endorphins are not coming when we've completed the task. So you turn the oven off and you wait for, you stick the landing at the end of your gymnastics routine and you're going to get some endorphins or some oxytocin, but in an OCD brain, you don't. And so it propels us to do it again because we're searching, trying to push the lever to get that reward and it doesn't come in and it creates and scales up somatically into anxiety, into shame. And I'm saying somatically but referencing emotional states because they're all playing out physically. Your blood pressure goes up, your heart races, there's an adrenal cascade that happens, and those things begin to accrue momentum over time. This is why we see people. I had a client who was bleeding from having washed his hands so many times that the skin had cracked. He's trying to function while trying to satiate that impulse. So I think it's an old reflex that occasionally misfires. We can talk about how that plays out physically as well?
[18:58] Alexey Tolchinsky: There's one part of what you shared, Alex, that I wanted to pick up on, and Peter, Michael, what you think is in addition to this emotion, which is front and center important in OCD: checking is a different subtype and a different presentation from contamination. So this paper that Michael and I and George and Sarka and Jeffrey wrote was about disgust activation. If a person was in a terrible event and witnessed a terrorist blow themselves up and pieces of flesh landed on their skin, they may develop a post-traumatic contamination obsession and washing compulsion, which is qualitatively different from checking. This is a hyperactivation of disgust. But to go back to one other aspect of it, there is automatization in OCD. There is habit formation, a cycle where we get stuck. I like the metaphor from Norman Deutsch in his book, "The Brain That Rewires Itself", where obsessive tendency is like being stuck on page 16 and being unable to move the page. And I wonder if Michael has examples; I don't know enough about the biology of, perhaps, a planarian or another organism making a repetitive behavior that is not functionally necessary. It's just getting stuck in a loop doing something that we can't place. You've mentioned thalamus, and these people talk about the cortico-striatal-thalamo-cortical network. Interesting experiments in OCD animal studies, using optogenetics in mice, were able to activate the projections from basolateral amygdala to the medial prefrontal cortex, and the mice started showing checking behaviors. So we can induce that state through the activation of a certain neuronal network. Again, on a network level, not at the level of a singular molecule. But this habituation — I know, Michael, you talked to Ian McGilchrist, who did a lot of work on routine, stable, highly optimized behavior, which he called left hemisphere, and spontaneous novelty-seeking, exploratory behavior, which he called right hemisphere. In OCD, it very heavily gravitates to that routine, and the basal ganglia is involved in that, and other areas of the brain are involved, but I'm interested in the biology of how it becomes that cycle where we get stuck.
[21:42] Michael Levin: There certainly are examples of overgrowth where the normal checkpoints that say, okay, you've reached the location in morphospace that you were trying to reach — your skin is contiguous, the volume of your tissue is correct, you've got the right number of fingers, whatever it may be — do not trigger the cessation of growth. And the cells continue to abnormally proliferate. There's the old description of cancer as the wound that never heals. I think that has some truth to it. I don't think it captures all of what's going on there, but I think that has some validity to it. There certainly are these kinds of phenomena. I wonder if you guys have any thoughts on, or maybe you might think that this whole idea is not the right thing. In a recent paper, I floated again looking at things from the perspective of thoughts, from the perspective of patterns. What does the world look like from the perspective of the patterns? I try to flesh out a continuum where you could have fleeting thoughts — these are cognitive patterns, they come and they go — and then you might have intrusive/persistent thoughts that tend to stick around and are a little more persistent; as we talked about, they may even exert some changes on the brain and body to help them stick around. After that, you might have something like a dissociative personality alter, which is more than just a persistent thought. It has cohesion, it has its own opinions and so on. And then eventually, you have a full-on personality and what comes after that. But that's a spectrum that I imagine. Do you think of any other waypoints on that continuum? Are there any other phenomena, especially clinical phenomena, that I'm missing? I feel like some of these are very far apart. What else belongs on that spectrum?
[23:58] Alex Schmidt: Well, the first thing that comes to mind when you talk about that is the aspects of fragmentation. In the way that when we connect or if we compare cancer as Cancer, essentially, at least to my eye, is a kind of cellular misunderstanding. I am suddenly being attacked. I must return in kind, and the cells begin to attack in our own body. We wall off in deep trauma. We dissociate reflexively. When something is too much for us to integrate, I compare it with my kids. If you're trying to move a couch through a door, that's very difficult. If you're trying to move two couches through the same door at the same time, it's impossible. That happens often with people. We get overloaded, we dissociate. The physical and the intellectual experiences are separated. It's a surge protector. It's a way for us to put these things into manageable places and tend to them in time. For most of us, we don't lose the memory of where we put those things. We know what happened. We just might not be feeling all of the integrated symptoms of that. This is why people come to therapy, is to put those pieces back together. The fact that it is protective allows us to keep going. With deep trauma, and Alexi referenced this with disgust and revulsion, it's not just fear for loss of life, but it's related to bodily fluids and things like that. So if someone is attacked in a way that blood or other bodily fluids are involved, that tends to trigger a much more fundamental nervous response. We see this in the PTSD presentation. You've got your more common PTSD with vigilance and preparing to fight. We all talk fight or flight. Then there's a subtype where 10 to 15% of people, more closely associated with that deep trauma and that overwhelming two couches at one sensation, have a different reaction: they go into a syncope reaction — collapse, shut down, play dead. When you have memories with this kind of experience, people talk about recovered memories. In my experience, working with people who have that relationship to their past, the cliché is that it's pulled whole cloth suddenly and you remember the whole thing. It isn't like that. It's on the shelf. It's there and present, but it's protectively abscessed. There's a layer of recognition that has not yet been penetrated. I don't really relate to OCD as the spectrum that becomes DID, that becomes a dissociative disorder, although there are elements of dissociation, particularly when people with OCD are engaging in those practices. They tune out a little bit because they're tending to something else. The fragmentation that we see in DID, and my experience with it is limited — I've worked with a couple of clients and I did a big eval on one particular case that came in — is fragments that are holding the whole together in order to perpetuate survival. This experience, this age, this identity is over here. This one is here. You take them all together and you get a sense of the person over time. I think we see that sometimes in disease models as well, but I have more questions than answers about how physically that happens and is supported. There's definitely a neurochemical component to that. Maybe Alexi can speak more to what he's thinking.
[28:15] Alexey Tolchinsky: Mike, I think you asked about classification of thoughts such as fleeting, intrusive, dissociative. Maybe this is an oversimplified perspective, but I think thoughts are stable things in the mind. For example, if I have a thought that I need to go to a grocery store, it's an audio verbal thought, but I keep it in my working memory for the time being. It sits there, and it is constructed as a sequence of words. I can have a visual thought such as an image. I can have a musical thought. They stay in working memory for a while. In that regard, they're a bit more deterministic than emotions. I think emotions are always a flow. Emotions are cascades, such as a fear cascade. They're different things. We can average them out on a higher time scale, such as saying that anxiety is usually lasting. It's a state of a certain threat, while fear is a flash, high up and high down. From the standpoint of neuropsychology, I think thought is not that different from an action. There's a sequence of words. If I get up from this chair, there's a sequence of contraction and relaxation of the muscles that I've learned. It's a memory, it's a procedural memory that the infant doesn't know, and then we develop it and we have it. In OCD, there's a proclivity, and even in milder things like obsessive tendency and a personality that, Michael, you mentioned, to do and think, and not to feel. There's a certain isolation from the body and from the emotional tone. Personality formation is extremely complex, but maybe briefly, one of the small parts I wanted to say about it is that I like Frank Putnam's take on it, and Alex probably knows him well as a renowned traumatologist and specialist in dissociations and researcher. He talks about a collection of mental states or brain-mind states. We know that term well: there's a state of being awake, a state of being in REM sleep, and a state of being in deep sleep. There can be a state of hyperarousal, a state of being obsessive. As the baby matures, the baby develops a personality, which is a certain pattern of states. Carl Friston called it a manifold or an attractor of states. There's itineracy of going from one state to another. Now in trauma, for example, or in the onset of psychopathology for another reason, that landscape changes; the attractor state becomes different. Then, as opposed to having a coherent self in the autobiographical component of self, we can start getting alters in DID and hop from one to another. This is the change in psychopathology. Personality formation from childhood is gradual and then it solidifies into some stable personality pattern, and in trauma it's abrupt. We see neurological changes in that. A classical example is Phineas Gage, who was a railroad worker and had a rod going into his brain, particularly in the ventromedial prefrontal cortex, which is involved in impulse inhibition. This person who was very gentle, cordial, kind and nice, became obnoxious. The abrupt personality change from a neurological injury. There are many other examples of how personalities change in aging and Alzheimer's, in trauma, in stressful environments such as COVID-19.
[32:05] Alex Schmidt: It's so interesting because there's so many places where we overlap and then there are places where our interpretations are very, very divergent. I have observed that thought is always concurrent with emotion. The way I describe it is that we have these three gears going of our lived experience, our interpretation, which is both intellectual and emotional, and then the physical manifestation of that. In the same way that everything in light casts a shadow, those things are connected. Very often I see that thought is last to the party where the physical memory or the physical association rises first and then produces sometimes a narrative about it. You have some people who experience one profound, horrific trauma, and you will see the splintering. You will see the creation of different, even entire identities, personality shards that are kind of walled off from one another. Then you have another person who's gone through 12 of those situations, and they're seemingly fine. They wake up every morning and have a job and are troubled by X and Y, or perhaps they have a different kind of therapeutic relationship, hopefully, to deal with that. But why does one person develop this and the other person seemingly continue to integrate? So the predisposing factors to that — the analogy for PTSD is that you have a vase that's been hit with a small hammer and there's a little crack, and that is the person who maybe is relatively intact, relatively prepared, or fundamentally more ready to absorb other issues, other trauma. There's going to be a small crack. But then you have someone who might be more the equivalent of a vase that's been tapped 100 times before, and something comes along and it falls to pieces. It's this sort of tipping point. What determines that? Is it resilience? Is it the personal capacity to resource and cope? Is it things we're born with where we are prone to hypervigilance, that major startle response, high blood pressure, inflammatory reactions, et cetera? Is it a combination? Is it life stressors? Is it our capacity to resource ourselves? We know that there are physical differences that make us susceptible to it.
[34:48] Michael Levin: My understanding is that trauma is a major initiator of this, but is there anything else that causes dissociation? In serious dissociative identity disorder, is it always trauma or is there anything else that can lead to that?
[35:08] Alexey Tolchinsky: Alexi, you want to speak first? I'm reading this wonderful book by Frank Putnam, "The Way We Are." Again, I think that if we go back to the history of this, William James tried the funny gas, is it nitrous oxide? and he experienced certain things and he developed a strong interest. I think substances were prior to dissociative states. When we talk about disorder, full-on DID, full-on PTSD, we're talking most often associated with traumatic events, but I think a neurological issue can lead to dissociations. When I spoke with my colleagues who are experts in DID and I said, patient HM or Clive Wearing, who have bilateral damage to the hippocampus and live in the here and now, they say if they were to look at his presentation, he looks perpetually depersonalized. There's no continuity. They live in the fragment. And that's in neurology. Chemical substances such as ketamine, psilocybin, and high doses of THC will result in a dissociative experience. I think it's useful to define the terms because I've seen people define dissociation as a very nuanced, very small thing, where all of us experience a benign dissociation every week, and then a big pathological state. Stress can cause these things as well. When we talk about trauma, we're talking about extreme stress, overwhelming stress, where the stress regulation network in the brain, including the HPA axis, is flooded. We have an inability to cope with what's coming at us. One theory is that the hippocampus becomes inactive because it has a lot of cortisol receptors and we're flooded with cortisol in an acutely traumatic event, which is why we don't encode a stable episodic memory of the event. There are shards, the fragmentation that I actually talked about: pieces of semantic memories, pieces of procedural memories, phobic memories, but there's nothing that glues them together coherently and cohesively. There's this gap, or sometimes it's a full gap of traumatic amnesia when somebody experiences the murder of a loved one. These are maybe my thoughts about it.
[37:33] Alex Schmidt: Association is difficult to pin down. At least to my eye, it's one of those things that is happening continually. You called it, the phrase you used, what we would think of as day-to-day dissociation. Dissociation is necessary to do anything. The definition of sanity itself is the appropriate integration of emotion, events, and personality. If all those gears are meshing, then we are thought to be functioning relatively well. And yet even within that, if we were immediately emotionally impacted by everything that happened throughout the day, it would completely overwhelm us. So there's always this level of dissociative buffer, a gentle soft focus, an Instagram filter that's happening. But it sometimes becomes involuntary and overwhelming. And that is definitely a sense of the wheels coming off the bus for people. This is the difference too: when we are having it. For example, if I see something irritating happening, and I don't immediately give in to my feelings of it, and I'm not swept away with it, that's appropriate. And I'm aware that I'm managing that. There's a meta awareness, which is also an element to that idea of sanity. That's a rocky road to get into, really defining that. But when it becomes involuntary, it's a whole nother matter. You mentioned the HPA axis and that when it's overtaxed and there's too much cortisol and there's not that feedback loop happening. It gets there in a million ways. There are those headline-news traumas that get there, but there's also the systemic piece-by-piece overload of ongoing stressors, even microaggressions. I use those because people are aware that you can't put your finger on it and you can't point to one of those and go, "Well, this guy looked at me in a way that was patronizing and now I have trauma." But if that happens to you 20,000 times, they collectively become a traumatic experience for the brain to hold. This is why I'm so interested in the different things that send us down that road.
[39:51] Michael Levin: That's a very interesting point, this, the smaller version of it. The reason I asked, it's a weird reason, is this, Bernardo Castrop and Rupert Spiras expressed an old idea recently that they said that all of us are dissociative alters of the great universal mind. This was the idea that we're all in these sub-personalities of this giant universal consciousness. I heard, when I was thinking about that, I was thinking, well, so what caused the fragmentation event? Because if you're the giant, the universal mind, what is causing you to fragment in the first place? For us, we typically think about trauma and then the things that you just said. But I wondered if boredom or a severe version of it, like sensory deprivation, is a thing, because really, if you are the only mind around, if it's just you and you're massive, every theorem is a tautology to you. Everything is obvious. There's no one to talk to, nothing to, that intuitively seems pretty stressful. And you might think that would just cause it right there. But I don't know. That's what I was bouncing this off. If you think that's a reasonable addition to their theory of how it gets going.
[41:17] Alex Schmidt: I'm struck by the two opposite ends of that. If you're talking about either the universal consciousness creating sentient life in order to amuse itself, which is a pretty potentially yes. And then we look at the Romanian orphanage study, during a time when Czeczewski was in charge, when there were a lot of orphans going into the facilities and the nuns who were tasked with taking care of them did everything they could, but it had to be this Henry Ford factory style: every day at its time we change all the babies. It's time we feed all the babies. It's time we change them again. Now it's time to bathe them. They had to do it just to keep going because there were too many. So these children were essentially warehoused in cribs, little filing cabinets, with no stimulation, no attachment-based attunement. And the mirror process that goes on is what stimulates that growth. So they were left to their own devices. Years later, when Jeff Jessica was overthrown and they came in, their brains were shrunken. I use the slide in a study, but I always give people a trigger warning because it's just really difficult to see. Their brains were shrunken and the families who adopted them talked about how these kids were not only internally attuned. The only thing they had to play with or amuse themselves was their own hands. So they were completely inwardly focused, but they also recovered to an extraordinary degree. Even to a limited extent, some of the recovery of the actual physical matter of the brain rebounded upon being placed in contact with people. I say this as an introvert, as a deep introvert; it bothers me to admit that we do have to have this contact, and yet it's necessary. We just have to find ways to titrate it to what we can bear, or what we find pleasurable.
[43:21] Alexey Tolchinsky: I think, Alex, you highlighted one. This is an extreme example of Romanian orphanages, but what we often see that correlates with psychopathology is the disorganized attachment style. These children experience severe neglect, which is often more harmful than abuse. They also had abuse. A lot of integration is being felt and experienced between the baby and the mom from birth. Their developmental period is significantly different from other children. I also wanted to go back to this key term you're both using, fragmentation, which to me is a spatial term where something broke. We're talking about this idea of breakage and what Michael mentioned, the boredom leading to fragmentation. If we go from space to time, the analog of that is discontinuity. What does it mean that PHNHM lives in there 10 minutes of the here and now? There's no continuity into the past and into the present. What does a flashback mean? A flashback happens, and I re-experience what happened to me 10 years ago. I broke from the here and now of where I was. So this work that we're doing now, Michael, with colleagues, about depersonalization, is that there's disruption not just in space, but in time as well. Can it be benign? Sure. When we wake up, we're not immediately back to who I am and where I am and what's going on. It takes us a little bit to get oriented in space-time and everything else. Is it Tuesday or is it Wednesday? It's not immediate. We go through these dissociative experiences many times. Your favorite example with propofol and general anesthesia talks about complete utter biological fragmentation and discontinuity. I do think there may be benign examples of both fragmentation and discontinuity in time.
[45:23] Alex Schmidt: If we're going to talk about fragmentation of any kind, and I appreciate the way you illustrated that, we have to acknowledge that most behaviors, whether involuntary or voluntary, tend to be preparatory in service of survival. In other words, it's paranoid thinking. It's rarely, almost never preparation for something good. That is because we needed that and we still need that in order to get through the day, to not get killed, to not be contaminated, et cetera. And we don't need to pass on to our children, genetically speaking, the knowledge that cake is delicious. They're going to figure that out on their own and it's not going to kill them. But we do need, and we always need to be on the lookout, that patrolling, perimeter-checking part of us that is monitoring for that. When we see it getting out of balance or out of control, when there are misunderstandings on a cellular level, and this is, unfortunately, Alexa, you deal with this too, clinically, people don't tend to come in with really happy, pleasant things that they do obsessively. It tends to be something that is very much related to dread and survival.
[46:42] Michael Levin: I assume that somebody else might send them. If they're having too much fun, obsessive, somebody else might say, you might want to go see someone.
[46:52] Alex Schmidt: They're not coming into my office, but.
[46:54] Michael Levin: Yeah.
Alexey Tolchinsky: We have a joke about that, Michael. How many psychiatrists does it take to change a light bulb? One, when the light bulb is ready to be changed.
[47:01] Michael Levin: Could we talk a little bit about somatic memory? What are your experiences around the rest of the body carrying things that can be treated as a memory medium? To what extent is the body a memory medium for behavior, for personality?
[47:24] Alex Schmidt: First of all, they're inextricable, right? They become sometimes separated. These memories are held, placed, shelved in different ways, but the record is retained throughout the body. I find, particularly in trauma work, it's so interesting. We all have smaller experiences of this. If you're sitting in a movie theater and someone grabs your shoulder in a firm way, we jump, right? There's a reflex that we don't go, "I bet that's someone who's very happy to see me." We are all prepared in that way for a bad thing to happen again, right? There's that, and these are just basic human reflexes, because we're wired for bracing for the worst in many cases. But somatically, when those things come back, it's a delicate process to sync up the body and the experience, to put the words with the music, because it has already been experienced as unbearable, which is why the dissociation has happened in the first place, right? So to cultivate a relationship with someone else. I do this with really little kids and I do this with adults. There's a different language that's used, but to return to that place, even though it's not happening now, the body remembers, right? It's keeping the score, as we all know. And those reactions will present to be integrated in a space where I call it stepping in and out of the boat. It's like you have one foot on shore, you're putting your foot in the canoe, and when it starts to feel shaky, you come back. That's the reparative process, right? Because you're no longer being pushed out beyond your capacity to have agency. You are agentically empowered. You are deciding to return to that. And then a lot of times those feelings will come in, right? The trembling, the adrenal stuff, the stomach and the throat. This is the fireplug shape of our emotional highway, right? Pain is read and remembered along these paths. But when we are able to touch in on it piece by piece, we see repair.
[49:46] Alexey Tolchinsky: I'll add to what you shared, Alex, and it resonates, with an example. I try to filter it so I don't disclose anything about patients. What happens often in trauma work is the patient says, I feel very off and I don't exactly know what it is. It's decontextualized, no content, no meaning. I say, tell me about how it feels in the body. They will tell me a specific profile. I will mention details, but let's say tightness in the chest. Then we do a psychodynamic thing and say, just relax, don't think, don't analyze, concentrate on that state of your chest — it's tight — and tell me what pops in the head. We're doing a memory thing because memories are strung together through associations. I had several experiences like that. The patient comes up with an event that happened in their lives which was traumatic. I wanted to add to what Alex shared. It's not a brainless somatic memory. Certainly the central nervous system was involved, but this is how it laid down. The state of my body was the trigger through which the person, not really recovered, talked about something that we haven't even mentioned in a year of work together that was indeed overwhelming, traumatic, intrusive. Does the body keep the score in that regard? Perhaps, but I think it's a component. These traumatic memories are like trees with multiple roots. They have physiology, but they also have a specific emotion in there. It could be disgust, fear, or other emotions. When we say somatic memory and this book Alex mentioned, Bessel van der Kolk's book, "The Body Keeps the Score" — in my experience, a lot of people, not professionals, take it a bit literally by saying this itch in my back is somatic memory. I think it's brain-aware somatic memory, not brainless somatic memory.
[51:48] Alex Schmidt: There are so many ways physically that we prepare for or endure trauma, stress, or tension. We can take it to the whole spectrum of those. But the fundamental way that we do that, both psychologically and physically, is that we brace. Anyone you talk to in body work or in trauma work is going to talk about the bracing: the tightening of the teeth, the tensing of the back of the neck, the scalene muscles, et cetera. There's a reason that I refer to a large group of different kinds of body workers for my clients as well, because it's held throughout. You find it in myofascial knots. We carry it here. No surprise that this place where we carry the most tension is also the seat of our most fundamental patrolling security dog. The brainstem and the nervous system are all centered here, where all of the cranial nerves come down to listen throughout our body. But it is that tightening that plays out, again, across domains. From blood pressure to the muscles in your back, you will see this preparation for something bad to happen.
[53:03] Michael Levin: This is not a crazy idea. I have no idea how you could practically implement this, because you don't know when the trauma is going to happen. But I wonder, given that some of these things use the body in this way to store some of these memories. And I wonder if we could make a prosthetic decoy, they make prosthetics for extending senses and actuation. There's all kinds of prosthetics. I wonder if you could give the stress something else, some other medium to write into that you could then take off at some point. So instead of locking in your neck muscles or whatever other changes, maybe there's something else that you could be wearing that could be recognized. Because the one thing we do know is when you do give people prosthetics, they rapidly, all the stuff by Baki Rita and so on, sensory augmentation and substitution. People learn to use all kinds of really wacky and evolutionarily novel, both sensors and effectors. The extra arms and the weird structures that are just not anything they were prepared for, but that plasticity is there. I wonder if that same system whereby these stress patterns try to solidify in the body, if we could give them a decoy medium of some sort.
[54:27] Alex Schmidt: Meaning that the stress reaction would be directed toward.
[54:34] Michael Levin: Exactly. We've been thinking about, for example, decoys — in-body decoys for metastasis, to give the metastatic cells a more attractive place to go.
[54:48] Alex Schmidt: Give the dog a bone, he won't eat the couch.
[54:50] Michael Levin: Exactly. Give them something, some other kind of bioreactor, something to go into, and toss it every once in a while. Again, I'm not claiming this is practical with real patients, but I do think it's interesting. I wonder if you could have some sort of an integrated wearable thing that lets that thing have the stress and not lock up the muscles, something like that. Maybe it's not.
[55:17] Alex Schmidt: Well, the thing it isn't actually, but yes, on its surface, but it also isn't because it's a call and response there. The stress is the question, "Am I in danger?" And the answer is, "No, you are safe." I'm sure Alexi does this too. The work often is not so much to bring in the stressor itself, but to teach or engender a capacity to have that answer, "Yes, you are safe." So it's call and response. And although in deep trauma work there is very much a role for symbolism, I, particularly with my kids, will say, "Let's take everything that happened in that house and we're going to put it in a ball." And you are going to design, and we'll draw, sometimes, all the things that keep the ball contained. They'll draw it in a safe, inside a locked box, etc. And then I will hold it all symbolically and move it toward them. They can track the somatic activation. We typically end with them sending it out to outer space where it can't come back unless they give it permission to get agency.
[56:28] Michael Levin: That's exactly right. That's the thing that I was thinking of. But you're doing it with the conscious part. And I'm thinking that exact same thing, but for the somatic part underneath.
[56:43] Alex Schmidt: And there are things that calm the body. There are tones that calm the body, humming practices that soothe, external things that vibrate. Mike, I remember you had put me in touch with a guy who works with pediatric kids who have to undergo repeated surgeries, and he had the practice of — it's just bilateral stimulation for calming the nervous system, but it works even when they're under anesthesia.
[57:13] Alexey Tolchinsky: I also wanted to agree with Alex and Michael, but I know the idea of decoy or the way to handle the traumatic experiences. There are different scales of analysis here, and one of them is a very macro scale: culture. How do babies handle stress? Mom — we call it in therapy containment, where the presence of another loving, caring human being helps metabolize the stress, and this is what we do. My colleagues from Israel talk about Holocaust survivors and the sense of community that is super important in Jewish culture; they would sit down together and share. In Okinawa, people live longest on planet Earth. The sense of community is extremely strong. But to get back to somatic and biological: if we look at stress regulation, one of the brain parameters that increases resilience is the hippocampus. There are studies; they're a little controversial — we don't know what's the chicken and the egg — that the size of the hippocampus is one of the predictive factors of resilience. Larger hippocampi tend to be associated with less traumatization. So, Michael, if you can come up with regenerative medicine to heal the hippocampus that may have shrunk in trauma, that may increase the capacity to sustain stress. It's a wild idea, but people do write about that.
[58:37] Alex Schmidt: We see the brain repairing itself. Even with the orphans, scans years later show this improvement. You're talking about the hippocampus, the figurehead of the entire limbic system, and we know already that the volumes of those structures in the brain are diminished in people with severe trauma. How do we then facilitate regrowth, the repair? There are reflexology points and things that are said to stimulate the pituitary gland, but whether repeated stimulation, potentially involuntary or subconscious, provokes a physical cascade, we don't know.
[59:24] Michael Levin: That's a super interesting relationship with regeneration, because on the one hand, you might think that once we crack regeneration and we're able to rejuvenate and restore brain tissue, that might help take care of it. One thing that we see in planaria is that if you train them and cut their entire head off, they build a new brain and then they imprint the old information onto this new brain. Some kinds of memories can actually travel and make it into the new tissue. Who knows whether these things will be persistent enough that, yes, you do introduce new brain tissue into the brain and they go and colonize it. I don't know how that's going to turn out.
[1:00:06] Alex Schmidt: This is the tricky thing with inherited trauma. There's that study with the mice where 5 generations later they paired an unpleasant shock with an innocuous smell. It's the smell of cherry blossoms. And 5 generations later, without the presence of any kind of nasty shock, their great-great-great-grandkids were jumping in the air in terror at the smell of cherry blossoms. This stuff is dictated beyond anything that we choose to do because it's protective. And that's where we get this maladaptation. We want the next generation to stay alive. We want them to be afraid of dark places and bears and things with big teeth. But we don't want them rocking back and forth in terror, afraid to go outside, because there's a volume control that is currently missing. In modern people, we're seeing a much more marked issue with that imbalance because we are suddenly much more sedentary. For many of us there are many more resources; my granddad was struggling for food to stay alive. I don't have that problem. Am I wrapped a little more tightly as a result? Probably.
[1:01:17] Michael Levin: Fantastic. I've got lots more questions, but I think we'll have to do them next time. Thank you so much for this conversation, and thank you in general for the work you do. It's unbelievable. It's amazing. Thank you so much.
