Neurobiology of Addiction Part 2 | Quickstart Guide

I'd like to welcome everybody to today's presentation. This is part two of the Neurobiology of Addiction. We're briefly going to recap what we talked about in the last presentation on HPA axis activation. And then we're going to move on to what can can you do to help people start recovering from the damage that is caused to their body during stress, during chronic stress, during trauma, and during addiction? And we'll talk about why I'm naming off all of those things. There's a very strong correlation between trauma and addiction. Unfortunately, when you, you know, factor out all of the potential confounds, there is still a much higher rate of trauma in people with addictions than there is in the general population. We do want to recognize that a lot of people, either prior to the beginning of their addictive behaviors or during their addiction, have experienced trauma. And that will have an effect on their brain chemistry, just like trauma does. It doesn't necessarily mean it is forever, but it is important to recognize that if they're experiencing acute stress disorder, PTSD symptoms, even if they don't meet the full criteria for ptsd, it is vital to pay attention to that. We also know that looking back over childhood and looking at the adverse childhood experiences survey, that there is a super high correlation between the number of adverse childhood experiences and the development of mood and addictive disorders. So even if somebody doesn't meet the criteria for ptsd, even if we aren't able to identify a single acute episode, if we look back in their developmental history, we may be able to identify. My gut tells me, in the majority of these people, adverse childhood experiences and traumas, chronic stress that they experienced from a young age and the young brain is so much more. What's the word I'm looking for? Able to be injured, so much more sensitive to chemical changes and neurotoxicity, that in the young brain, we see a lot more physiological changes as a result of stress, stress, trauma, and addiction. People with trauma or addiction show increased emotional dysregulation to general emotional stimuli, such as emotional faces. A lot of times when we're thinking about trauma, we are thinking that people will be aroused by triggers and stimuli that remind them of the trauma. And in these two particular studies, it indicated that people with trauma tend to be more aroused, more emotionally dysregulated in response to any negative trauma, such as sad faces or sad things that they see on tv. And that's really important to consider, especially now. I mean, think about what it's like when you turn on the tv. It's just doom and gloom and the sky is falling. So that can be incredibly dysregulating to people who have a trauma history, even if it doesn't have any relation to their trauma. And people with addiction, especially if they are, you know, not currently actively using and numbing that pain. A lot of people with addiction, one of the reasons they use or one of the reasons they continue to use once they get started is because of emotional dysregulation. They are just overwhelmed when they start to sober up. People with mood disorders or addictions are more likely to experience dysregulation of the HPA axis. And we've talked about the HPA axis before as our threat response system. And when people have addictions or mood disorders and they experience more emotion every time they're emotionally dysregulated, it trips off when or activates that HPA axis. And repeated activations of the HPA axis can create toxic environments in the brain that we're going to talk about in a minute. Other physical complications of people with addictions. Compromised liver function, and we see this mainly in people who abuse alcohol. Compromised liver function leads to problems in metabolism of amino acids. Amino acids are essential to make neurotransmitters. If the liver is not functioning, the body can't make those neurotransmitters that are necessary for mood and all kinds of body functioning, from blood pressure to heart rate to gastric motility. Compromised livers also cause the person to be insufficiently detoxed. And neurotoxins are actually able to build up in the brain as they're result of the body's inability to shunt out all of the toxic byproducts that are in the person's system, which creates a toxic environment in the brain. Additionally, when people have compromised liver functioning, and this doesn't mean like end stage cirrhosis, this means, you know, looking at any time the liver starts to become compromised, you start to see problems because the liver is so vital in detoxifying the body. You will also often see gastrointestinal bleeding, malnutrition, and concurrent renal failure in people with problems with their liver function. Remember, the kidneys also filter out waste, so the liver and the kidneys kind of work simultaneously. One of the things that's important to recognize with this is, is not only is the person not able to get the toxins out, and those toxins are passing over the blood brain barrier into the brain, but you also have malnutrition. So the food that they do manage to eat is not being properly absorbed, so the body's not getting the building blocks it makes. If you're working with a patient who has compromised liver functioning, it's really important to remember and to factor that into their treatment plan that they may need additional assistance nutritionally or with, you know, talking with their doctor or their registered dietitian, of course, nutritionally or with detoxification protocols to keep that toxicity from building up. People with diabetes who also have addictions or co occurring disorders do experience some additional complications. When people have uncontrolled diabetes or if it's not controlled well, they can experience fatigue and irritability. Some of our clients may have uncontrolled or undiagnosed diabetes and those are the symptoms that we're seeing in them. We also want to look for increased thirst, increased hunger. There's a whole list of signs that you can look for that may indicate pre diabetes or undiagnosed diabetes, which is really, really very common in our country. So it's important to pay attention to that, but also to recognize that these symptoms of fatigue and irritability can also trigger relapse. Sometimes people are going to self medicate. They'll try to use stimulants to wake themselves up, or they'll try to use something like alcohol to quell their irritability. Low blood sugar activates the HPA axis. So when somebody is diabetic, they have a difficult time regulating their blood sugar. When it goes low, what happens? The HPA axis is activated, cortisol's released, norepinephrine is released, which causes the release of what? Drumroll please. Blood glucose. So you can see where it becomes even more difficult for somebody in recovery to manage their diabetes. Because stress and that HPA axis will trigger the release of blood glucose, which has to be balanced out with insulin, substance use itself and detox stress. Remember last time we talked about how when people are going through withdrawal or detox, it triggers the HPA axis? Because the HPA axis is saying, wait a minute, I was used to, I was functioning with all this other stuff coming in from the outside, and I got my homeostasis kind of settled that way. Now I'm not getting it. Now I'm imbalanced again, which is where the cravings and all of the detox symptoms and stuff come from. But that is extremely stressful on the body, which triggers the HPA axis. So whether you're using stimulants and, you know, triggering that HPA axis or you're detoxing and triggering it The HPA axis is triggered a whole lot more in people with diabetes. So we need to pay attention to that and recognize the impact of detox on their blood sugar and recognize the impact of their blood sugar levels on their mood and their propensity for relapse. A final issue that comes up with people with diabetes, which isn't so much cognitively connected, but it is important to recognize that people with addictions often have a suppressed immune system and have more difficulty healing from wounds. I mean, their body is just, it's in fight or flee, it's not into, you know, repair right now, it's trying to protect. And people with diabetes also have more difficulty with wound healing. So you put the two of those things together, you may have people that have, it takes them a longer time to heal from wounds. Now when you think of wounds, you think when you get a cut, when you think when you stub your toe. But you also need to think about wounds such as those internal wounds that are caused by the internal wounds that are caused by using substances and the excitotoxicity from repeated HPA axis activation. And this applies to type 1 or type 2 diabetes. Anytime the body is having difficulty managing that blood sugar level on its own, you're going to potentially have excessive activations of that HPA axis. Hypocortisolism we talked a little bit about in part one is seen in stress related disorders such as chronic fatigue syndrome, burnout and ptsd. I read an interesting article a couple of days ago that the level of cortisol dysfunction in burnout is more related not to whether the person has it or not, but to the severity of the symptoms. The more severe the burnout symptoms, the more dysregulated their HPA axis probably is. We also see hypocortisolism in addiction because again, that person on a daily or multiple times a day basis is probably super stimulating, especially those that are using stimulant type drugs, cocaine, methamphetamine, those sorts of things is probably super activating the HPA axis. And you know, eventually, just like in response to chronic stress, the body is going to say, I need to protect myself. So it's going to start reducing the frequency that it lets those chemicals through. Remember we talked about knocking on a door and normally you just have to knock lightly and the door opens, but eventually when the body is flooded with these stress chemicals often enough, it says, you know what, we're just not going to open the door for anybody. We're going to wait till somebody has an emergency and they're pounding on the door. And so only the people that pound on the door get it opened. Hypocortisolism is actually a protective mechanism designed to conserve energy during threats that are beyond the organism's ability to cope. Now, we talk a lot about fight or flee, but there are two other parts to fight or flee. There's the fight, flee, freeze, and to use a G rated term, forget about it. Freeze is when the body just doesn't know what to do. The person is literally frozen in place. And forget about it is when they have experienced so much stress and it's that sense of learned helplessness. It's like, heck with it. I don't have any energy. I just, I can't do one more thing. I can't deal with this. I'm over, I'm done. And that is the body's way of saying, you know what, we're not going to secrete the norepinephrine for this. You're just going to kind of bow down low. Cortisol has been found to relate to more severe hyperarousal symptoms and an exaggerated or glucocorticoid stress response, which we talked about last time in terms of flat or furious. When somebody's body has gotten to the point where it said, this HPA axis is getting activated too much, I'm dumping too much cortisol, dumping too much glutamate, it's getting toxic in my brain. And the body starts shutting down those systems or ramping them back. Then we see that when they do respond normally, they're kind of Eeyore. But they go from Eeyore to Tigger. I don't know. There wasn't somebody that was extremely, I guess maybe Eeyore to Piglet, you know, like that because their response is exaggerated. Instead of having a moderate response of, oh, okay, I ought to do something, it's just like everything's a crisis. It's either just fine, you know, whatever, or it's an extreme crisis. There is no middle ground. Dysfunctional HPA axis activation can result in or be caused by hypocortisolism. When somebody has hypocortisolism, it perpetuates dysfunctional HPA axis activation. So initially, repeated activation causes it, but then once it's set in place, the hypocortisolism can maintain it. There's an increased risk of PTSD development in people who have low cortisol levels because of that flat to furious. When they're flat, they're, they're just kind of Blah. But then when they are triggered, when they go into that furious state, they have just extreme dumps of cortisol and norepinephrine, which cue fear processing and really ramp up that amygdala they have. People with dysfunctional HPA axis activation can result in addiction relapse. If they are feeling, you know, furious, if they are getting that exaggerated stress response, they may try to self medicate their anxiety with opioids or benzodiazepines or marijuana. Those are the ones. Sometimes alcohol too. Generally they're not going to turn to cocaine for this or one of those other stimulants. But it's important to recognize the function of the substance or the addictive behavior for that person. Once they relapse, they are flooding their system with dopamine, flooding their system with other neurochemicals, depending on the substance of choice, which perpetuates dysfunctional HPA axis activation. It causes stress in the system, which perpetuates problems. The development of mood disorders. We know that when cortisol and norepinephrine are released, it reduces certain serotonin HTP5A1 and may increase serotonin HTP5A2. You don't need to know that for the test, but it increases some types of serotonin, reduces other types and alters the levels of testosterone as well as estrogen, all of which reduce relate to the availability of dopamine and norepinephrine. So the whole system gets wonky. I mean, that's just the best way to say it. And you know, think of it as I had somebody who didn't know what marinara sauce was. So I'll use a different example. If you're trying to make soup and you're putting different things in and different flavors in, think of each thing you put in your soup as a different hormone or neurotransmitter. And all of a sudden somebody comes along and dumps a whole bucket of chicken broth in there or something. How does that affect the flavor of the whole pot of soup? Same thing happens when we alter our neurotransmitters. When we have a flood of certain neurotransmitters, how does that affect the flavor of the neurotransmitter soup, if you want to think of it that way, in our brain, you know, does it dull it out? Is it too bland now? Is it too, is it too strong? Maybe there's way too much salt. You know, think about it. I think about everything in terms of food, but we also see Abnormal immune system activation. We see more inflammation, which inflammation causes HPA axis activation, and HPA axis hyperactivation causes inflammation. So we see it causes and is caused by. We also know that inflammation is associated with. And increased allergic reactions are also associated with major depressive disorder, as well as, in some studies, anxiety. So we're seeing that these mood disorders, because of their effect on the HPA axis and causing that additional inflammation, we're seeing, you know, a concurrence of those things, which also means we see a higher rate of autoimmune disorders. We see more irritable bowel syndrome, such as constipation and diarrhea in people with HPA axis problems. Because, you know, when you're fighting or fleeing, it's not time to digest. So sometimes things go flying through that system, or other times it just says, you know what? We're not going to worry about that right now. Think about when you go, you know, your mom always told you not to go swimming for at least an hour after you ate because your body was digesting its food. Well, you know, same sort of thing happens sometimes when we're stressed. The body diverts energy and it may just say, you know what? Not going to worry about that stuff in there right now. There's reduced tolerance to physical and mental stresses, including pain. And they've done multiple studies that have shown that people's perception of pain goes down as their HPA axis activation goes up. And the more chronic their HPA axis activation, the lower their pain threshold goes. We do want to recognize that people who are experiencing pain, even if it's idiopathic, there is no particular cause that we can see. They didn't fall and sprain their ankle or something. Their perception of pain, their achiness, their joints, those sorts of things, that's real pain that they're experiencing. It's not. They're not making it up. And it's important for us to help them reduce their stress levels, calm down, or reregulate that HPA axis as much as possible so they can stop feeling as much pain. And there's also altered levels of your sex hormones, testosterone and estrogen, which we talked about in the last class, which are both involved in increasing or making available levels of dopamine and serotonin. So there's a lot of stuff that gets wonky when our stress response system is out of whack. And this isn't all of it. This is just the highlights. Addiction and the HPA axis both impact dopamine levels, which means people's levels of arousal, their perseverance for tasks, motivation, attention and their mood are all going to be affected in addiction. Obviously initially it's going to go up, but, but as they detox, it's going to go way down and it's an exaggerated response. Instead of going down to baseline, it's typically going to go down a little bit lower. Norepinephrine is responsible for energy, attention, motivation, depression and prevention of depression and creation of anxiety. So when norepinephrine levels are out of whack, remember, HPA axis causes the release of norepinephrine. So people who are experiencing activation are going to potentially experience sputters in their energy when they start becoming hypocortisolistic. That's not a word, but I'm making it up. But they will also have difficulty in early recovery with because they're not having as much, having as much norepinephrine. Now they're going to probably have problems with energy, attention, motivation and depression. Now anxiety may or may not be there. My experience is it's there too. But it's important to recognize the impact of altered levels of norepinephrine. Glutamate provides, remember, energy, but too much of it becomes neurotoxic. When that HPA axis is regularly activated, you're going to have develop a toxic environment which starts causing death of brain cells, especially in white matter. Now, interestingly, I was reading an article today that has shown that they have seen in people who have extended periods of sobriety that there is some recovery of some of the brain tissue, but they're not sure why it happens for who it happens or what to do to make it happen, because it doesn't happen to everybody. The cool thing is our brain does create a lot of workarounds, which is why people who've had strokes are often able to, after extensive physical therapy and stuff, resume a very high level of quality of life. So I believe that most people's brains can find find workarounds, especially if they don't have a lot of other concurrent confounding conditions. Addiction and the HPA axis both reduce thyroid hormones. So when that HPA axis is over activated, levels of T3 and T4 go down your thyroid hormones. With addiction, we know that the substances themselves can actually create create reductions in thyroid and sex hormones, serotonin. During addiction, depending on the substance, you may see an increase in serotonin. But we know that during withdrawal, when that HPA axis is activated, we see increases in 5 HT2, which is the stimulatory or stimulating serotonin. And symptoms include increases in glutamate, anxiety, and hypertension. And we also see a decrease in the. What I call the good. The good serotonin, the 5ht one. And people will have increases in depression, anxiety, and pain because each one is responsible for something slightly different. In people with addiction and trauma, we found that there are decreased peripheral benzodiazepine binding sites, which means GABA isn't as effective for doing everything it needs to do in people who have a history of trauma. And GABA also inhibits the regulation of norepinephrine or inhibits the release of norepinephrine. So when there aren't as many GABA receptors out there, then you don't have as many crossing guards or policemen or whatever you want to call it, keeping the norepinephrine from going through. Which means there's increases level. Increased levels of norepinephrine, which relates to increased stress, potentially increases in blood glucose, you know, all kinds of stuff. Endogenous opioids act upon the same CNS receptors activated by exogenous opioids like morphine and heroin. Okay, we knew that. And they exert inhibitory influences on the HPA axis. So people who have a really hyperactive HPA axis, People who are experiencing flat and furious, you know, they've got some hypocortisolism going on, or people who are just, you know, have a lot of chronic stress, may find the effects of opioids extraordinarily rewarding because it does help dampen down that HPA axis response. One treatment they found is naltrexone, which basically blocks the opioid receptors. So the person has to deal with it in real time. But it also stops the HPA axis from being as inhibited. So what's the point? Why did we go through all that? Well, addiction, trauma, and mood disorders all alter the body's stress response. Altered stress responses lead to alterations in all major neurochemicals, gonadal and thyroid hormones. So we're throwing our body soup into a frenzy. Imbalances in these systems lead to continued mood symptoms because, you know, if dopamine, norepinephrine, serotonin, acetylcholine, or GABA or glutamate are out of balance, then people often experience mood symptoms. So it's a very delicate thing. And there is hyper or hyporeactivity to stress and cravings, which increases people's relapse potential. Sometimes they are likely to relapse because There is no color, there is no excitement. They are in that hypocortisolis stage where everything is just kind of gray and they are sort of like a depressed Eeyore. And people have a difficult time staying motivated when life seems that much like drudgery every day. But also some people have hyper reactivity to stress still. So when something happens and they go from flat to furious, they feel dysregulated, they feel overwhelmed, and they try to self medicate that as well. So. So we do need to recognize that it can happen on either end of the spectrum. Recovery is multifaceted. We need to ensure that people are providing their body the building blocks necessary to make the hormones and neurotransmitters and recover. If you don't have the ingredients, you can't make the soup. We need to assess and address imbalances in gonadal and thyroid hormones. Obviously a medical doctor is going to do that, but it is important to recognize if there are underlying physiological pathologies that are slowing down or maybe even preventing full recovery. We have people with hypotestosterone, People with low testosterone often experience symptoms very similar to depression. People with too much estrogen often experience a lot of anxiety symptoms and irritability. So just those which, you know, fluctuate on a semi regular basis can be problematic. We also want to recognize that if we have female patients who are on birth control or if we have transgender patients that are taking any sort of hormones, that that is also going to impact their HPA axis as well as the balance of their neurotransmitters. And we need to make sure that they advocate for themselves so they are feeling okay. We need to help people reregulate their circadian rhythms. Dysregulated sleep increases the HPA axis activation, so we want to reduce their stress and increase hormone synchrony. Our circadian rhythms are responsible for our sleep, wake hormones. They're responsible for our hunger and satiation hormones. They're responsible for the release of a lot of different hormones. I mean, think about how many different things that happen in our body cyclically. Well, that sick cycle is related to our circadian rhythms. And if our circadian rhythms are out of whack, everything's going to be kind of, kind of wonky. Help the person develop skills and tools to tolerate and mitigate stress, to prevent HPA axis overstimulation and reduce excitotoxicity on the brain. It is so important to help people remember and focus on the fact that it is vital to allow their brain and body to recover. If they had open heart surgery, you know, would they be doing the same thing? Just because this isn't a physical injury that we can see, you know, it is a physical injury, but it's not like getting cut open for surgery. Just because it wasn't actual surgery doesn't mean we don't have actual injuries that need to heal. And a lot of that has to do with our, our brain chemicals and our HPA axis and our thyroid axis and all kinds of other axes that we've got going on. We also want to help people actively increase the natural release of gaba, dopamine and serotonin. And I'm not talking about by taking supplements or anything. I'm talking about doing things that, oh my gosh, make them happy and help them relax. Things that will naturally force their body to release those chemicals, like deep breathing. Imagine that, like doing things that make themselves laugh. You know, laughing releases endorphins and dopamine and increases serotonin levels. Light exercise will help increase serotonin levels. So there's a lot of things that people can do and people can even be doing, you know, right now. So let's start with nutrition. Protein, thyroid hormones, dopamine and norepinephrine. So those are four biggies. T3, T4. Dopamine and norepinephrine are derived from the amino acid tyrosine. Now remember, amino acids are basically the building blocks of complex proteins. We get it when we eat any kind of protein. If you're working with a client who is vegetarian or vegan, make sure that they are working with a dietitian or they are very knowledgeable about how to get enough complete proteins in their diet. There are vegetarian and vegan sources of complete proteins. Totally doable, but it does take a little bit more planning than people who are omnivores. Serotonin and melatonin are made from tryptophan. We know serotonin in 5 HT1A is responsible for helping us relax and modulate mood. And five HT2A is responsible for, you know, increasing blood pressure, increasing norepinephrine levels, etc. Either way, they're both synthesized from tryptophan. We need to have it. Glutamate and GABA are made from an amino acid called glutamine. All of these are widely present. You don't need to go digging down. If you're eating complete proteins, you're getting these in your diet. And gonadal hormones, interestingly enough, are made from cholesterol we do need some fat in our diet because a lot of our vitamins, not all of them, you know, there are a lot of vitamins that are fat soluble. That means they have to have fat in order to be able to be used by the body. Carbohydrates provide energy and increase serotonin and dopamine and fats provide a lot more energy, increased serotonin and dopamine and are necessary for fat, fat soluble vitamin utilization. When we eat carbohydrates and fats, it is hardwired into our brain that that is causes the release of dopamine and serotonin because it gives us energy for the long haul. They speculate that, you know, back in ancient times, eating those foods, since it was, you know, hard to come by food, those were really rewarding because it encouraged the person to have enough fuel stores to hunt and fight the tiger and whatever else they did back then. Water, simple water, supports chemical reactions in the body. Most chemical reactions take place in a fluid system. So when we're dehydrated, we're keeping those things from connecting as well. It improves cognitive performance and energy levels and helps remove toxins from the body, which contribute to fog and inflammation. So flushing out those toxins as much as possible. Remember that too much water is just as bad as not enough water, because you can actually flush out too much sodium and too much of your other stuff and create an imbalance. So, you know, there, there is that happy, realistic medium that we want to shoot for 64 ounces to like a gallon and a half a day, but much more than that, and you start getting waterlogged vitamins and minerals found in food. Equivalent ratios is recommended. You know, when you can get your vitamins and minerals from natural substances, they are so much more bioavailable to your whole system because they're in the proper ratios to be utilized by your body. Multivitamins don't do quite the same thing. Some doctors actually recommend not taking a multivitamin if you're eating a relatively healthy diet. It's important for clients to ask their doctor, should I take a multivitamin? And what should I be eating? If they don't know? But colorful eating, having three colors at each plate is helpful because vitamins and minerals are needed for converting fats, carbohydrates and proteins, our macronutrients, into hormones and neurochemicals, which I will show you right here. Here's one example. This is to make serotonin. You eat tryptophan and it's yummy. But in order to break tryptophan down into 5 HTP, you have to have iron, magnesium, calcium, B6 and folic acid. In order to convert 5 HTP into serotonin, you also need vitamin C, vitamin B6, zinc, and magnesium. So there's a lot of ingredients required for the chemical reactions to make these neurotransmitters. Serotonin is broken down to make melatonin, which helps us fall asleep. Serotonin is associated with regulating our cardiovascular system, our digestive system, pain conditions, as well as cravings. Low serotonin is associated with cravings for carbohydrates, alcohol, and certain drugs. If somebody is not eating a healthy diet and their body can't get enough tryptophan and break it down to make serotonin, then it may be contributing to cravings and mood symptoms. And we want them to recognize this. A lot of our culture, you know, the majority of Americans, according to one study I read, which, you know, I don't know how, it wasn't peer reviewed, but whatever, we can speculate that it was right, that the majority of Americans have inadequate or imbalanced levels of neurotransmitters because we expose ourselves to so much stress and have dopamine and or not dopamine, but norepinephrine and glutamate dumping multiple times a day because we ingest caffeine like it is going out of style. There are a lot of things we do because we're not getting enough sleep. There are a lot of things we do that cause an overactive HPA axis, which can lead to those neurochemical imbalances. And a lot of us, not all of us, but a lot of us also don't eat a healthy diet. So that's one of the areas that's relatively easy to start improving. Trauma and anxiety and depression are all highly correlated with sleep disturbances. I know that's not surprising to you. Addiction is also highly correlated with sleep disturbances. When people are using depressants, they're sleeping, often sleeping too much. When they're using stimulants, they're often not sleeping enough, or they're sleeping sporadically. They may be up for days on end. And all of this disturbs not only the quality of sleep, but also circadian rhythms, which we already talked about, why that's important. Circadian rhythm disruption impairs sleep quality. If you are not obeying or following good sleep hygiene practices, then you are often undermining yourself and impairing your own sleep quality. Sleep deprivation or impaired sleep quality Causes HPA axis activation, worsening of autoimmune diseases, worsening of pain, reduced stress tolerance. And that ever present adenosine buildup, which is adenosine, remember, is the byproduct from, basically from thinking throughout the day that builds up in our brain and during the night it gets cleared out. As it builds up during the day, we start to feel sleepier. Adenosine creates what they call sleep pressure. The more that's in our brain, the sleepier we are, the harder it is to focus. So we need to help people recognize that and recognize the importance of, of good quality regular sleep. So encourage people to stick to a schedule. Create a sleep routine. The same 3ish things every night. Eat dinner, read a book, or eat dinner, take a shower, read a book, whatever you want to do. It doesn't have to be super involved, but it needs to help cue your body that, hey, it's time to go to sleep. Does that mean you can't stay up for an extra couple hours once in a while? Of course not. That wouldn't be living. But most of the time it's important to try to maintain that same sleep routine. Like, I know a lot of people right now, especially youth, are sleeping in until 10, 11, noon, and you know, it just makes me shudder to think about how that's disrupting their circadian rhythms and what the fallout of that might be when they eventually do go back to school. Whether that's in a month or four months. Reduce things that wake you up. And each person needs to figure out what that is. Light. If you have light coming in your bedroom, I know occasionally the moon will shine in through the blinds in my room. And even though I have the blinds closed, enough of it comes in and it's that bright blue light that it wakes me up. So I sleep with a sleep mask on just for that noise. And this can be, and I'm sorry for y' all that snore, but it can be your partner. If your partner is snoring loud enough to pull the paint off the walls, that could be disrupting your sleep. So considering whether you want to use earplugs or noise canceling headphones, what you need to do so you're getting good quality sleep, a CPAP machine can be helpful. I know one person whose spouse got a CPAP machine and she said that the noise from the CPAP machine was almost as bad as the noise from the snoring. So you got to figure out what works for you. Sleep is so important. Allergies. If you're allergic to the cats. Don't let them sleep on your bed all day long. I'm guilty. And dogs. Dogs will tend to thrash. My Dog Brewster is 85 pounds and he thinks he's 8.5 pounds and will get up and press himself against me hard enough to kind of push me off the bed and in the middle of the night. And that's not good for sleep because I know it wakes me up when he does it. I may not realize it till the morning, but I know it must have stirred me at least a little bit. So anything that you can identify in your sleep routine in your bedroom that keeps you from getting good quality sleep? Engage in relaxation activities before bed. Explore guided imagery. There's lots of of recorded guided imagery scripts on YouTube and online that you can find. Same thing with progressive muscular relaxation. There are scripts, there are YouTube videos that will walk you through it. Anything to help you calm your mind as well as your muscles is really important. Cooling Down Our body has to cool down to go to sleep. So getting in the hot tub, taking a sauna, taking a super hot shower right before bed actually works against you. According to the research, you judge for yourself, but it is recommended that you do something that helps you cool down before bed and make sure you kind of stay cool. Dress coolly and pay attention to whether you've got too many covers or whatever. Do pay attention to sleep ergonomics. You want to make sure that your spine is in alignment, which often means they have little pillows if you're a side sleeper for between your knees and for your neck and all those sorts of things. But it does make a difference if you are comfortable. You don't want to wake up with a kink in your neck, and you certainly don't want to be inadvertently tossing and turning all night because you're uncomfortable. And finally, reduce caffeine six hours before bed because it takes about 12 hours to get out of your system and reduce nicotine at least two hours before bed and have a blood alcohol concentration of zero at bed. Now, if you're working with somebody who's in recovery from addiction, hopefully they won't have any alcohol in their system ever. But it is really important because alcohol greatly impairs sleep in the last half of the night and it also slows respiration, which makes sleep apnea worse in the first half of the night for people who have sleep apnea. Ideally, you want to reduce caffeine 12 hours before bed, but that's not practical for most people, so at least six hours is a Good happy medium Get a physical Addiction and mood disorders are stressors on the body and can cause or worsen stress related illnesses which lead to continued activation of the HPA axis. Stress related illnesses include cardiovascular issues, especially high blood pressure. Remember serotonin and norepinephrine and glutamate all increase blood pressure. Blood sugar issues, especially related to prediabetes, diabetes, back and neck pain, migraines and headaches. Polycystic ovarian syndrome, which is caused actually after there's a bunch of somebody's under stress for a while. When people develop hypocortisolism, they also often develop polycystic ovarian syndrome, which is an interesting correlation and you can read about why that happens, but just know there is a correlation. Which means their gonadal hormones, their estrogen levels are completely out of whack and it would be helpful for a lot of reasons, probably for them to see a doctor. With pcos, women start to lose their hair, they get a lot of facial hair, they gain a lot of weight, they start to get a much oilier complexion. The side effects of PCOS are not pleasant. So getting that addressed can also be a huge help to somebody's energy levels as well as their self esteem. Low testosterone, many cancers, and low thyroid are also associated with consistent stress for coping and prevention. Skills and tools. Now y' all know most of these, so I'm just gonna kind of hit them really quick. Evaluate their physical, affective, cognitive, environmental and relational causes of stress. Just go through them one by one with the person to figure out what is causing stress for you right now. Identify any that can be prevented and then mitigate the rest of them. Encourage them to learn mindfulness skills so they become aware of when they're starting to feel stressed before they go into a full scale HPA axis activation, fight or flee sort of thing. If they notice what's going on and, and they notice, better yet ahead of time, they notice that okay, I know this situation might be stressful for me. Then they can mitigate that ahead of time with guided imagery, with mental rehearsal, distress tolerance skills. There's a lot of things they can use. Psychological flexibility will help them deal with life on life's terms because you know, life is unpredictable and people need to be able to deal with it as it comes and not get triggered and hyperactivated, you know, multiple times a day. We need to help them figure out when something happens, how can they take a breath and literally use that belly breathing to start getting the GABA released and what can they do in order to turn their mind so they're not stewing on something that is causing them extreme distress. So they can get into their wise mind and focus a little bit better and then address cognitive distortions. Finally, actively increase the natural release of gaba, dopamine and serotonin. Some easy ways to do this physically. Sunlight helps increase the release of neurochemicals. We know there's a lot of receptors for vitamin D in the same area of the brain that there are a lot of serotonin receptors. They're not sure how they're related, but they know that there's a strong correlation. So sunlight can be good exercise, light exercise, not anything that's going to trip out your adrenals, but light exercise, walking, gardening, cleaning, house cleaning, whatever it is you like to do, even once restrictions are lifted. When you can go, if you can go to the mall and just walk around, anything like that can help reduce cortisol levels. Massage, you know, that helps relax the muscles and releases calming, relaxing, calming, relaxing neurotransmitters. And you don't have to necessarily go somewhere and get a massage. You can get one of those shiatsu back pillow seat things. You can find something that works for you, that helps you feel a little bit relaxed and then just relaxation exercises, whatever works for the person. Encourage them to try a multitude of different things. You can go online and search for relaxation activities and you know you'll get hundreds and just start picking from them. Try one each day to figure out which ones work for you. Affective, encouraging people to do whatever makes them happy, curious or enthusiastic even, you know, whatever it is. Watching videos, I know I play videos for you guys before class. Anything that makes you happy or laugh. And Pat points out back to physical that reflexology is also a technique that can be used and you can look online and find techniques for reflexology points on the ears, on the hands, on the feet, and you can do them for yourself. Sometimes you can use your own hands or you can use the, you can get little balls or the, or the little rolly things, foam rollers in order to help with some of that deep tissue massage and even some reflexology points. So there are a lot of options out there. Cognitive, Encourage people to focus on gratitude, what they did successfully that day and things that went well that day. Just spend 10, 15, 20 minutes focusing on the positive. Environmentally. Encourage them to pay attention to smells, sights and sounds. What can they do to make it more pleasant relationally? Encouraging them to connect with positive people. All of these things will help tampen that HPA axis some and help bring out the calming chemicals. Remember the analogy I used of the bath the last time? If you are running hot, if you're anxious, you have anxiety, agitation, any of these things that increase the release of gaba, dopamine and serotonin is like turning on the cold water to cool it off so it's not too hot, it's not burning you anymore. Recovery from addiction and mental health issues requires attention to the whole person in the environment. For brain chemicals and hormones to rebalance, the body needs to have building blocks. You got to have good nutrition water and it needs protection from repeated HPA axis, hyperactivation from pain, sleep disturbances, circadian rhythm disruption, hormone imbalances, illness, stressful thoughts, environmental triggers, yada yada yada, the list goes on. But it is important that people figure out what is causing my stress response to kick off and what can I do to improve that for me. And in this context, right now what people are doing is very different maybe than what they're going to be doing a month from now. But right now, while they're on quarantine, you know, there may be a lot of additional stressors because they're starting to get restless. Are there any questions? I think that's hilarious that your cat snores, Camille. So in addition to our regular, you know, cognitive, behavioral, humanistic, existential interventions that we do, we also do need to remember to pay attention to other things that might be causing the HPA axis to overreact and cause imbalances in neurotransmitters. Everybody have a fabulous weekend. Please try to do something that is enjoyable and relaxing and I will see you on Tuesday. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. 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