Rewire Your Nervous System for Optimal Mental Health

Foreign. Welcome everybody to today's presentation on the autonomic nervous system, the biological key to functional health and mental health. This is part of the pieces method series and I AM your host, Dr. Donnelly Snipes. Today we're going to review briefly what the ANS does and why it matters for mental health. We're not going to hit epigenetics nearly as hard today. We're going to kind of get back to basics, if you will. We're going to explore issues caused or worsened by ANS imbalance. Why? Because a lot of people who present in counseling because their ANS is imbalanced, they have co occurring issues that really need to be addressed. And then we will explore functional mental health strategies to integrate into your assessment and the treatment plan. So the autonomic nervous system, our ANS regulates the automatic functions in the body to maintain homeostasis and to adapt to changes or allostasis as they call it. So why do I have autonomic and automatic bolded? Because that's how I remember it. Both of them are auto. So your ANS is responsible for all of those things that you don't think about. The ANS is regulated in part by circadian rhythms. Okay, that was new. I did not realize that. With parasympathetic and sympathetic activity fluctuating predictably across the day and night, contributing to daily variations in heart rate, blood pressure and metabolism. Makes sense when you think about it. Remember, cortisol is high first thing in the morning. And that is cortisol is secreted by the autonomic nervous system and it lowers throughout the day. And so the body can make serotonin or convert serotonin to melatonin in the. In the evening. That is an ANS function that is regulated in part by our circadian rhythms, major branches of the autonomic nervous system. Two of these we've talked about a lot. You're sympathetic, which is your stress, your fight or flight. So your body has sympathy for the fact that there is a threat to you and it triggers that fight or flight reaction. And I know it's more than fight or flight. Fight, flee, freeze, fawn or flop. Those are the five Fs in the stress response. But it too much to say all five of those every time. The parasympathetic nervous system is your brake pedal and it promotes rest, digest and repair. Those are the things that we need. And when we are not rested, when we don't adequately digest our food, and when we don't repair damage that's been done, Guess what we get inflammation. And we know that inflammation triggers epigenetic changes, range, reduces the body's ability to heal, triggers inflammation, and creates a cascade effect. The third one that we really haven't talked about a lot is the enteric system, which runs the digestive tract. Think about aspirin. You can get enteric coated aspirin. Well, that means it's aspirin that's coated, so it doesn't irritate your digestive tract at least as much. So the enteric system runs the digestive tract and communicates with the gut and the brain, which, which contributes to the gut brain connection. And I've done a video before on the gut brain axis, and I'll be doing one, I think in January on it. But our gut brain axis is very important, and it's regulated in large part through communication via the vagus nerve. Little side note, they did a experiment on mice, sorry, Mr. Mice. And they found that when probiotics were given to intact mice, that mood and social behavior was altered when they had a proper probiotic or microbiome balance. When they gave the same, when they gave mice the same probiotics, but they had cut the vagus nerve, there was no change in their behavior. So they disrupted that signaling by cutting the vagus nerve. How many of our clients really struggle with vagal tone, really struggle with getting signals to TR traverse that vagus nerve? A lot of them, probably. The autonomic nervous system doesn't just respond to stress. It helps create our sense of safety or danger by controlling selective attention. My and by modulating arousal levels and preparing the brain to focus on behaviorally relevant stimuli, which is a gobbledygook way of saying. Saying what we've said so many times before. When we are in fight orf flight, we are paying attention to the threats. We are not noticing the bunny rabbits and the happy things. We are not thinking about when we're feeling stressed, when we're feeling overwhelmed. We're not thinking about all the things that are going well in our life. We're thinking about this threat that feels like it's looming, which is one of the reasons that widening our attention to notice the good and the bad is so important, because it really helps not only turn our attention away from the threat for half a second, but it also helps balance that autonomic nervous system, because the body is starting to get signals that, okay, some things are okay, maybe not great, but they're okay. And this crap show over here is just part of life right now. When the parasympathetic nervous system is engaged. Our rest and digest the brain can engage in focused, flexible attention and social engagement. We talked about this in the past couple of sessions, that when our sympathetic nervous system fight orf flight is engaged, we actually disengage the prefrontal cortex area. You know, it's not time to think, focus, you know, problem solve, do all that kind of stuff. It's time to get the heck out of there or fight to stay alive. So it's important that we help people be able to activate their relaxation response, their parasympathetic nervous system, so they can get into their wise mind and make mindful choices. The sympathetic nervous system stress heightens alertness to immediate dangers, increasing distractibility or hyper vigilance. If you are walking through the forest, you're on a hike, you're having a great day, then all of a sudden a poisonous snake, a cottonmouth, slithers across in front of you or worse yet, towards you because they're aggressive little suckers. You, you go on high alert for the next period of time, whether it's the whole rest of the hike or the next five minutes, depending on the person. You are probably hypervigilant to every sound that sounds like another snake rustling in the leaves off the side of the path. And it's important to recognize that people who have a trauma history, who have never resolved whatever it h. Whatever happened in a way that they felt safe and empowered again. They. They are always listening for those rustling leaves. It's hard for them to focus. It's hard for them to relax because they don't feel safe. That's like telling a soldier in a foxhole, hey, just chill out for a while. It ain't going to happen. They can to tone it down a little bit, but they're never going to be able to truly relax because in the back of their mind they feel, or know, depending on the situation, that they're not safe. Physiological processes regulated by the autonomic nervous system. Again, these are all the things we don't think about. Our heart rate, our breathing, our digestion, our immune responses, and our energy use and availability. So let's go through each of those. Our heart rate. Now, so many times we've talked about square breathing, or whatever you want to call it, slowing our breathing to slow our heart rate. And yes, we can do that, but if we're not thinking about, okay, heart beat, beat, beat, we don't have to think about it to get our heart to beat. Like, we have to think about bending our arm to drink or something where it's like, I want this drink, I'm gonna do it. Heart rate is one of those things. Breathing is another. When we start to get stressed, we tend to breathe faster and often more shallowly. When we are more relaxed, we're breathing more slowly and more deeply. When we are breathing more slowly and more deeply, that sends the signal to the brain that, hey, maybe there's not a stressor digestion. We don't think about it. That's just not one of those things. But when we're under stress, our microbiome changes and our digestion changes. Our immune responses, including in inflammation, are regulated by the autonomic nervous system. And then energy use. Your brain doesn't say, okay, you know, I'm going to allocate, I'm going to tell you how to use your energy right now. But we all know it. When we are under a lot of stress or when we're recovering from an illness, we get tired more easily. Why? Because the brain is redirecting energy to repairing. It's like, screw you, I've got to take care of this. So you're not going to have energy to go to the gym or clean the house or whatever it is you want or don't want to do. So the brain will automatically reallocate energy as it sees necessary in order to protect the organism. Which takes us down to homeostasis. And this is the state we want to be in, that constant state of balance. Not too stressed, not too relaxed, just right. We want to be balanced when we are stressed because every once in a while it happens, that's okay. But we want to be able to bring it back into balance when, when necessary. Just like in anything we do, we have times where more energy is required, but then we have times when we rest and recover from that energy expenditure. Allostasis is the process of changing and adapting to stress. Any kind of stress in any piece of life, physical, interpersonal, emotional, cognitive or environmental. When something is causing stress on the body, including thoughts and feelings, the body adapts. That's why we have the ANS and the pns. Chronic overactivation of the autonomic nervous system, particularly the sympathetic nervous system, leads to allostatic load or wear and tear on the body and mind. And why I said ANS in this. Think about it. When, if you go out and you do sprints, it takes a whole lot of energy. You sprint and then you rest, and then you sprint and then you rest. It's still exhausting. It takes a lot of energy. Or if you're driving. Maybe this is a better example. We use a whole lot more gas when we are stop and start when you're driving in the city, when there's stoplights and stuff than we do if we're consistently going. But if the parasympathetic nervous system is activated for too long, that also take causes wear and tear on the system and that sympathetic nervous system becomes dominant in terms of the gut brain connection. And we're not going to go down a deep rabbit hole on this today. But understanding that stress directly alters the composition of the microbiome, gut microbes and, and a lot of people say how does the gut communicate with the brain through the vagus nerve? Well, that still doesn't answer my question. We're going to answer that question now. Gut microbes produce chemicals, you know, so all those little microbes are producing byproducts. They're the bacteria are gobbling up what you eat and you know, producing byproducts that trigger signals that travel up the vagus nerve to the brain. So kind of like the telephone, the chemical signals are being sent trigger the, the vagus nerve to send a message to the brain. So that's how it communicates. Interestingly, it doesn't work both ways. The vagus nerve doesn't communicate from the brain to the gut. Under stress, hormones like cortisol bind to the receptors on the gut cells, changing the environment in which the microbes live, reducing microbial diversity. This is bad. Certain microbes have been associated with pro social behavior. Certain microbes have been associated with mood changes and emotional disregulation. So when we start developing either an unhealthy microbial colony or a lack of microbial diversity, which is usually dominated by the problematic microbes, then we start seeing a lot of symptoms. So under stress, the brain really triggers the sympathetic nervous system. Wow. Releases cortisol. And that cortisol binds to the gut receptor, so it's bypassing the vagus nerve and it's just going directly to the gut. When we see changes, stress induced changes in the gut, we see a reduction in beneficial bacteria such as Lactobacillus and Bifidobacterium. These are a group of bacteria, there are thousands of them and each of them are listed by like bifido bacterium, then it has another name and then it has a number. So you have, you know, different strains of these bacteria and they are, there's thousands of them, but we see a reduction in those because they have difficulty living in the environment, which often becomes more acidic. When we're stressed, likewise, we see the proliferation of other bacteria which you can recognize as bugaboos, Streptococcus, E. Coli, Salmonella, and H. Pylori. I think most people can look at those and go, yeah, I don't want those flourishing in my gut. We need some of them. Okay. We do need a certain amount of each of these things because they actually do help make neurotransmitters. But when they become dominant, then we start having a lot more problems and they will start attacking, killing the lactobacillus, the phytobacterium. The environment becomes inhospitable for the positive gut bacteria. One of the things that we can encourage our people to do, and this is why I talk about prebiotic and probiotic foods all the time, because when we eat those, our, our probiotic foods like yogurt and sauerkraut, kefir, are very rich in Lactobacillus and Bifidobacterium strains. And that can help give sort of a extra dose of those microbes to the gut. And yeah, a lot of them don't survive, especially if the gut is inhospitable, but some of them will. So increasing that a little bit, you can overdo it. You actually can eat too much yogurt and drink too much kefir and then you end up with other digestive issues. But that is one of the things that we want to encourage people to do, especially under stress. Your prebiotics are your fiber rich foods that when they are digested, they feed those bacteria. That's food for the bacteria. And we want to help them or provide that in order to help create a hospitable environment. So the vagus nerve is in an environment that it is getting the chemical signals it can send up to the brain. That says, all clear here. We've got a good balance. Everybody that we need for work is reporting to work. It's all clear down here in this station. In terms of the connection between anxiety and depression. We've gone over this before, but for people who haven't seen the other 17 videos, chronic stress causes glucocorticoid resistance, which means chronic stress means that our receptors for cortisol become less receptive. This causes high cortisol in the bloodstream because it's not attaching to the receptors. It's just floating around going, nobody's paying attention to me. High cortisol damages the prefrontal cortex and the hippocampus, which regulate emotion modulation. So people who have chronic high stress and that's anxiety is kind of general. It can be from ptsd, it can be from chronic environmental stress, it can be from true anxiety, whatever is causing that sympathetic nervous system to stay active. They often have high cortisol levels which are damaging parts of the brain that help them regulate and modulate their emotions. So we see a lot more emotional disregulation. High cortisol also triggers inflammatory responses that contribute to depressive symptoms by interfering with neurotransmitter systems like dopamine, glutamate and gaba. Glutamate is our main stress neurochemical and GABA is our main relaxation neurochemical. And if that system gets messed up, then a lot of times we have people that have low motivation and no energy because there's just, there's not enough glutamate and there's not enough gaba and they feel stressed out all the time. These disruptions lead to emotion, emotional dysregulation and what we've referred to in, in my classes as the flat to the furious or the flat to the frantic. They just don't feel much of anything until there's enough of a stressor that triggers enough of a cortisol release to actually wake up those cortisol receptors. And then, oh my, it's a tsunami. I mentioned at the beginning that a lot of the people who present for counseling have an imbalanced autonomic nervous system. If they present with depression, it could be unipolar, straight up depression. I have found in my practice over about 25 years that probably about 70% of the people that present with depressive symptoms have co occurring or long standing anxiety. So they've gotten to this place where at when we talk about the stress response, fight, flee, freeze, fawn or flop. They're at flop and they're feeling exhausted. They don't have the motivation, they don't have the energy, and they also often have other issues that are being caused as a result of the cortisol resistance and the high stress. Healing requires healing the whole person. If for example, they developed insulin resistance as a result of chronic stress, then that means that their, their blood sugar is difficult to manage, which means there's another stressor on the body. And for that person to truly heal and be able to effectively manage their autonomic nervous system, that's one of those stressors we want to look at because that's one of those. We may not be able to fix it, but they may be able to work with their doctor to manage it better. So there's less stress on the body. When I was asked to start working on a suicide prevention program for fire rescue and one of the things that we talk about is the fact that in fire rescue circadian rhythms not going to happen when you're off. On their days off they can maintain their circadian rhythms but when they're working their 12 or 24 hour shift depending on the state, there are many, many nights, if not every night, they're not going to sleep through the night. So there is no way to regulate circadian rhythms as well as we would like. We have to mitigate it. We have to try to figure out what is the best we can do. The best we can do is maintain a consistent schedule on the days off and on the days they are working. Try to maintain that same schedule to the greatest extent possible. But recognize that you're going to get call outs. That's one of the stressors, one of their vulnerabilities for distress that we can't completely eliminate and it's part of the job. So accepting that is part of the treatment plan and, and recognizing okay, we can't completely fix this. What other stressors might we be able to minimize or mitigate in order to bring the stress overall stress level on the body in every piece of life for that person bring it down, we're not going to eliminate it, but what can we do to bring it down so it's more manageable? We that was the long version of we need to screen people for some of these co occurring issues and if they might have them, make sure that they we are working in a multidisciplinary team with their doctor and or their physical therapist. So diabetes and insulin resistance. Chronic sympathetic nervous system activation increases cortisol disrupting insulin and glucose metabolism. These stress hormones alter dopamine and serotonin signaling, worsening mood and motivation. So that stress that's caused by the blood sugar disruption contributes to increased sympathetic nervous system activation and worsening of mood. We've all been in a place before where our blood sugar's gotten too low. Not everybody's had blood sugar too high. But when our blood sugar's gotten too low and we've gotten freaking hangry, you know, our mood changes when our blood sugar is out of whack even for a little bit. So for people who have difficulty regulating their blood sugar, think about how much stress their body is under. Pcos Polycystic ovarian syndrome. For women, elevated sympathetic nervous system activation increases testosterone and lowers estrogen in most areas of the body and impacts Dopamine, serotonin, and other pathways regulating mood, impulse control, and contributing to anxiety and depression. I've done several other videos and I'm going to be doing one on the hypothalamic pituitary gonadal axis in the next couple of weeks. And we're going to talk about how stress alters our gonadal hormones and how altered gonadal hormones actually will affect the availability of neurotransmitters, which will directly impact our mood. This is not just because of emotional stress. It can be. We see it in people who have eating disorders because of physical stress from malnutrition. We see it in people who are alcoholic. We see it in people who start taking and not necessarily pcos, but we do see disruptions in neurotransmitters and alterations in mood in people who start taking hormonal birth control. Because all of a sudden what the body recognizes as homeostasis has been turned upside down on its head. Many, many, many people with stress, chronic stress, with depression, also have hypothyroidism, an imbalance in the autonomic nervous system. Sympathetic dominance reduces hormone, thyroid hormone release. The body says, okay, there's a lot of stress and we need to conserve energy. I know it seems counterintuitive, but that's what the body does. This in turn affects serotonin and dopamine metabolism. Remember, your gonadal hormones, your thyroid hormones, and your neurotransmitters all work in concert with one another. So when one gets out of whack, the whole system goes kaplooey. This can cause fatigue and depressive symptoms. Additionally, as we get stressed, the not only do we have a reduction in thyroid hormone release, we have an increase in reverse T3. That's the enzyme that breaks down T3. So our body is breaking down the thyroid hormone that's supposed to give us energy before our body can actually use it. And that's again part of that conservation mechanism, if you will, an energy conservation mechanism. But it's really frustrating because a lot of people, and I'm one who has excessively high RT3, when we have a lot of stress, that RT3 stays up and it just breaks down the, the, the free T3 as quickly as, almost as quickly as it's made. So we need to figure out what's causing the high RT3 and what can we do to reduce it. In many cases, it's reducing stress. Easier said than done. But that is again, reducing stress in any area of life. If cognitively you've got a Bunch of crap hitting the fan right now. Okay, well, what can we do in other areas of life to take some of the stress off the body? Chronic fatigue syndrome is also caused and or worsened by chronic stimulation of the stress response. Overactivity of the stress response depletes norepinephrine and dopamine reserves in brain areas controlling energy and motivation, promoting fatigue and cognitive disease dysfunction. When norepinephrine is our focus, neurochemical, it's our attention neurochemical. When that gets depleted, guess what, we're going to have a hard time focusing. Dopamine is our motivation chemical. It's the I want to do that again chemical. When we don't have that, guess what? Not only can we not focus, but we don't want to focus. We have no motivation. It also adds to fatigue and hence chronic fatigue syndrome. Remember I said the autonomic nervous system controls our energy utilization. And in people with cfs, a lot of times they've got a lot of systemic inflammation. And as stress goes up, inflammation goes up. What's the body going to do? It's going to direct a lot of energy to try to figure out how to deal with that inflammation so you don't have as much energy to like, get out of bed. Cardiovascular issues can also be caused by an imbalance in the autonomic nervous system. And I will say that as we age, we see a lot more people, we see people develop a lot more cardiovascular issues as we age. We also see naturally because of the reduction of testosterone and estrogen, as well as other physiological changes that represent stress on the body. Most older adults are sympathetic dominant. And most older adults benefit from even the ones that don't have mood symptoms. Most older adults benefit from activities that can help balance their autonomic, their sympathetic and parasympathetic nervous system. It'll help reduce inflammation, it slows the progression of a lot of diseases. And it also, they've shown, can help with helping to clear brain fog. But I digress. When sustained increased stress and increased vasoconstriction caused by stress triggers the release of inflammatory cytokines, leading to changes in neurotransmitters like serotonin and dopamine that regulate mood and thinking. So the common thread here, stress, one way or another, alters our neurotransmitters. And we need to take a look at that, that sympathetic nervous system, when it's engaged, then it alters the availability of, of neurotransmitters. Sleep apnea is another one that a lot of people have Irrespective of weight, trauma history and chronic stress are super strong indicators or correl things that are strongly correlated with sleep apnea. They believe that chronic stress keeps airway muscles tight, increasing apnea risk. Apnea related oxygen drops throughout the night cause more stress and, and sleep fragmentation which causes even more stress and more inflammation. If they snore, have them have it about, encourage them to have it evaluated. And finally, bruxism. Tooth grinding. How many of you out there wear. I call it a bite plate. I think my, my dentist calls it a splint, but I wear a splint at night because I grind my teeth like nobody's business. Chronic stress disrupts dopamine pathways that control motor activity and amygdala fear processing function, causing increased jaw muscle clenching, jaw muscle tone and anxiety related muscle activity. So people when they're stressed often will clench their teeth or grind their teeth a lot more. If they are going to sleep and not downregulating, they're stressed. When they're sleeping, they guess what, they're going to be grinding. Pain. A lot of people that we work with have chronic pain and you're like okay, well that causes stress. Yes it does. But pain itself actually sensitizes or stress itself actually sensitizes pain pathways in the brain. And serotonin deficits increase pain sensitivity which can worsen pain perception. So not only do our pain pathways become more sensitive, more raw if you will, but the reduction in serotonin makes us more sensitive, makes us more aware of the rawness. So it's a double whammy when we're under stress, when we've got a lot of glutamate coursing through our system over a long period of time. Helping people with chronic pain understand the connection between stress and increased pain perception can also be helpful. It. We're not saying it's in your head, we're not saying you're imagining it or you're just overreacting. That's not what we're saying. We're saying you actually are feeling more pain and you're actually more aware of that pain when you're under stress. Which is why it's important to engage in some of these stress reduction activities to lower glutamate, which takes off, which helps desensitize some of those pain receptors. Think about it, you know, if you've ever rubbed your arm for a long enough time or you've had a little kid just sit there and mommy, mommy, mommy. Eventually it starts to get a little irritated, you know, and that's the glutamate. That's the stress that's being added. When we reduce our stress, either slowing down or eliminating the agitator completely, then those nerve endings, those pain pathways, aren't being stimulated and they get a chance to kind of breathe and become less sensitive. If you come back two seconds later, it's still tender, it's still sensitized, so it's going to become irritated more quickly. If you give it a complete chance to re recover, then when you come back, and if you start doing it again, it will take a while. I'm not sure if you followed that metaphor in terms of the gut microbiome, the sympathetic nervous system, or stress increases gut permeability. We've talked about leaky gut so many times. Leaky gut allows bacteria to leak into the system and trigger systemic inflammation. Stress triggered secretion of neurotransmitters also affect that microbial composition, which produce neurotransmitters. So the microbes in your gut produce gaba, serotonin, dopamine and acetylcholine. If those microbes don't report for work because it's an inhospitable work environment, then your body's not going to be able to produce the neurotransmitters that you need, which influences systemic levels of these neurotransmitters contributing to cognitive, mood and GI symptoms. Remember, neurotransmitters have receptors throughout the entire body, not just in the brain. So when your, for example, serotonin gets out of whack, you're going to start seeing changes in heart rhythm, you're going to start seeing changes in pain perception, you're going to start seeing a lot of somatic symptoms in addition to cognitive and emotional downstream impacts. Elevated norepinephrine and reduced GABA and serotonin due to stress amplify fear responses and hyper arousal. So when people are chronically stressed, you know, we've talked about stress being a bucket. And when that bucket is constantly full, it doesn't take much to get the bucket to start to overflow. And that's where you see anger or anxiety start to come out. We want to help people reduce the level, the, the level of their bucket. It's probably never going to be completely empty, but we want to reduce the level so every little tablespoon of water doesn't cause it to overflow. In depression, we see elevated cortisol increasing the expression of serotonin transporters, leading to increased reuptake and reduced availability of serotonin. So cortisol actually reduces serotonin and you know, that's important to remember. We see the same thing at night when cortisol stays high at night. So serotonin isn't made available to be broken down to converted to melatonin. So seroton, Serotonin and cortisol are, are kind of enemies. Cortisol releases increased monoamine oxidase or MAO activity which breaks down serotonin and dopamine further decreasing their levels. The old fashioned antidepressants were MAOIs, MAO inhibitors. The whole goal was to prevent serotonin and dopamine from being broken down as quickly. Cortisol acts to increase the break, increase the MAO and the breakdown of serotonin and dopamine. So we have less and less available to even activate the receptors. Chronic stress and cortisol also reduce brain derived neurotrophic F factor bdnf. We've talked about this a lot before in terms of neurogenesis. Our brain can heal, our brain can regenerate those neurons that are lost as a result of chronic stress. However, we have to have bdnf. And when chronic stress and cortisol are just constantly there, BDNF is low. So we don't have an environment that supports neurogenesis. We don't have an environment that supports brain healing. What do we do? This is, this is the part you've been waiting for. Addressing mood symptoms with interpersonal, like humanistic or cognitive behavioral therapy alone is like trying to fix a car by only changing the oil. You know, you gotta look at the fluids, you gotta look at the air pressure and the tires. You've got to look at other stuff, I'm sure, but fan belts and alternators and I know there's a lot of words I can throw out another metaphor. It's like relying on the quarterback to carry the whole team to a winning season. Now I know sometimes it happens. You know, at UF we had Danny Werfel for a while and you know, he was a great quarterback, but he relied on his line, he relied on his receivers in order to create a winning season. He couldn't go out there and just do it by himself. It was a team effort. Our body is like, I've always said, it's like a factory. And getting the factory to run well is a team effort. People who engage in counseling or exhibit mood or behavioral symptoms often have multiple other issues contributing to their distress. Physical issues caused by or causing their distress. Interpersonal, emotional, cognitive and environmental. An empowering, holistic, multidisciplinary approach will produce the most effective and efficient treatment. If you identify, okay, here are all the places where there you're experiencing stress in each piece of your life. Now, we can't tackle all of them at once. You know that that's foolhardy. But what are you most motivated to work on? What are you willing to do? And what areas can we start addressing to turn down some of the stress, if you want to think of it like a knob, or to empty out some of the stress, if you're talking about the bucket. In terms of comprehensive assessment and education, when we do our assessment and throughout treatment, we want to focus on a few areas. What is going well and what is not. We want to help them look at that big picture because that helps provide more balance to what's going on. I don't want to negate what's not going well because that's why they're probably in my office. But I also want to make sure that they're not completely missing the other parts. Which symptoms are most bothersome? These are the ones they're going to be most motivated to work on. And it's kind of like a woven blanket distress. Any place you start unraveling that blanket, eventually the whole thing is going to unravel. So you can start at any point. So tell me which symptom is most bothersome and what are you most motivated to. To change or to do to address that symptom? Additionally, instead of just telling people what to do, and I can't tell you, literally, I don't have the numbers. It's astronomical percentage the, the percentage of therapists that I've worked with that do an assessment for somebody, then they write a treatment plan and they tell the person what to do without even asking some of these questions. And, and it's just mindboggling. We want to ask them what, what they've tried because they have been trying things, trying not to have to come to counseling. Most likely they've been trying things to feel better, and it hasn't worked. So tell me what you've tried and what hasn't worked for you, but also tell me what has worked for you, even if just for 10 minutes or a day or a short period that can help us figure out what types of tools will work better. It also, again, helps them look at the big picture. Yes, I've tried a bunch of things that have failed. They haven't done the job. And, you know, I felt powerless, I felt hopeless. But, but there were some things that I tried that did work. A little bit. There's some hope there. If it worked for a little bit, we can tweak those things usually and help them work a lot. A bit. What is different in your life when the symptoms or the symptom is decreased? And that's another one of those solution focused questions that we often don't ask. Tell me what's different when you're not having this problem and then let's see how we can recreate that. Let's, let's look at what's, what might be going on now that's causing the problem that wasn't going on then. And for each symptom you have, I define at least five progress points. So I have, we'll say I, I, I'm coming to you because I'm feeling depressed. Okay? Now depression, that's that feeling of anhedonia, the blues. However you're defining it, that's where you are right now. That is a zero. You want to get to a five. So what is one thing you think you might be able to do over the next week or so to move you half a step forward? So from a 0 to a 0.5 and then to a, to a 1, or what is one thing you think you might be able to do over the next week that can help you move to a one and then talk about that. See if one week is realistic. It usually isn't. And say, okay, let's, let's do half of that. Let's set a realistic goal that we know you can achieve over the next week. What's one thing you can do? Those progress points are really important because we need to, as humans, we need to be able to notice progress. Just like when you're on a diet, you may not realize that you're losing weight because it comes off kind of slowly. So you don't notice the quarter pound or half pound that you lost, which is why you weigh once, once a week when you're on a diet to see how much progress you've made. And that helps keep motivation up when you see your progress. Same thing with cognitive and behavioral changes in terms of the comprehensive assessment and education. And I'm not going into the education a lot here, but it's important to provide the people that you're working with a why, why am I suggesting this? Not only it's important that you do this, but why? So they have a reason. Not just because my therapist said so. So physically, we'll look at diet nutrition. If they are presenting, for example, with, especially with depression, but also with Anxiety blood test suggestions looking for Anemia B12, which is now I read a study this morning. They're encouraging doctors to quit testing for B12 and instead test for homocysteine levels because it's a more accurate measure of what's going on. So I there will be another video on that. But it's important for the doctors to be able to assess people's iron levels, their anemia levels, their vitamin D when it comes to thyroid, TSH free T3 and T4 and reverse T3 because reverse T3, remember you can have perfectly normal levels of T3 and T4, but if your RT3 is way up here, then that T, your free T3 is getting broken down before it can actually do its job. A1C levels, your basically your ability to manage your insulin and insulin resistance and C reactive protein, that is an inflammatory marker. All of these, your people's insulin resistance, their insulin sensitivity should improve as stress comes down. Their C reactive protein, their systemic inflammation should improve as their stress comes down. As there's less stress, as there's less stuff triggering inflammation, we should start seeing these changes. They may also look at genetic testing for MTHFR mutations. That's one of those genes. Again, read another article by from the Cleveland Clinic this morning. This morning was a great morning that indicated that it's less important to test for the MTHFR genetic mutation and more important to look for the symptoms. If you have the mutation but your homocysteines are in the right area, then you're probably fine. So you can have the mutation and have no symptoms and be fine and it's not a big deal. So you've wasted 300 bucks getting the genetic test. If your homocysteine levels are elevated, then there are two or three things that could be indicated, but B12 deficiency is one of them. So that will guide your doctor's treatment plan. So I thought that was really interesting. We want to have them do a sleep assessment. Now, I don't mean going to the doctor, I mean just doing a worksheet that evaluates their sleep hygiene and trying to improve any problems they're having with their getting to sleep, staying asleep, quality sleep. We want to help them reset their circadian rhythms. This is probably one of the best things you can do for somebody because that circadian clock, when it gets out of whack, everybody's reporting to work in the different body departments at the wrong time. Identify if they've got chronic pain, develop strategies to, to address that. Because chronic pain increases, stress increases depression increases Anxiety increases emotional disregulation, address substance abuse and addictive behaviors. We're, we're doing an entire video on addiction in the ans next week or the week after because it is even behavioral addictions are so hard on the body and so stressful to the body. And have them take a look at medications, maybe medications they started taking and then started having symptoms. We're not telling them to decrease them. We're not telling them anything. We're telling them if you started taking this medication and you then you started having symptoms the next day or the next week, talk to your doctor. Anything that is outside of our lane, refer them back to their doctor. Interpersonally, we want to talk with them about their sense of self esteem and self efficacy, their attachment issues. Help them heal their attachment style, if you will, so they can start developing a secure attachment with self and a secure attachment with others. Now, obviously we're not doing all these things in a week or a month or necessarily even 10 weeks. This is a progressive thing, some of which they can work on on their own. But we want to figure out where the areas of stress are and then have them tell us what they're willing to work on. What's most important? What are the top three things they want to address first and then we can go from there. We want to evaluate trauma, especially as it relates to their ongoing sense of unsafeness and and powerlessness. Evaluate their communication skills. How effective are they at identifying and articulating their needs in a way that other people hear without becoming defensive? How effective are they at identifying, setting and maintaining their boundaries? This is a huge one for a lot of people because they e their boundaries partly is because of attachment issues are either too rigid or too weak, which makes them feel unsafe. They either feel rejected when it's too rigid or they feel invaded when their boundaries are too weak emotionally. Start out simple emotion identification and labeling. What does this feeling look like to you? What does it feel like to you? Practice this week noticing and labeling. When you feel angry, you know, that's it. We're not doing anything further. I just want you to start becoming more mindful of when you feel angry, when you feel happy, when you feel curious, have them start identifying. After they're comfortable recognizing their emotions, start to look backwards and say, what was the trigger for that emotion and what can I do about it? And then move on to modulation and addressing disregulation. Now you know what the feeling is you're having, you know, possibly what triggered it. Now what strategies are you going to Take to downregulate and modulate that feeling so. So it doesn't overwhelm you cognitively. Have them look at distortions. An somewhat new mnemonic. I've used it a few times before. Feel. Have them look at the facts in this context at this time. What are the facts supporting their belief or their feeling? What are explanations? What are alternate explanations for what's going on besides personalization or all or nothing thinking? Exceptions. Are there any exceptions? Most things don't happen all the time or never. So what exceptions are there? And L stands for likelihood. What is the probability that this is actually going to happen? Is it possible that the sky could fall? Maybe. What is the probability that. That it's going to happen, Especially in the next six months? Okay, so feel facts, explanations, exceptions, and likelihood. Evaluate their learning and memory. Are they having difficulty with these things? And a lot of that will improve as stress abates. But right now, if they're struggling, help them develop tools to support themselves so that it's not causing them extra stress. When they're trying to learn something, what can they do to make it easier? Taking notes, Removing distractions, chunking it. If they have difficulty focusing for long periods of time, there are lots of different little hacks that they may be able to do so they don't feel so frustrated every time they've got to try to learn something. Problem solving. If they're stuck in a box and they can't think of what to do next, okay, again, a lot of that will probably clear up as stress abates. So encourage them to identify supports for now. When you're trying to solve a problem and you're stuck, what can you do? Can you call a friend? Can you look it up online? What can you do to figure out what other people have done in similar situations? And brain fog is another one that'll likely clear up for a lot of people as stress abates. But while you've got brain fog, it can be exasperating. Taking notes, that's the biggest thing I tell people. And being patient with themselves. When you've got brain fog, it takes longer to find the words, to find the answer, to find the response that you want. Okay? So instead of getting upset about it, accept it and say, all right, this is where I'm at right now. I'm kind of navigating pea soup fog, just like you do when you're driving, you're not driving at the speed limit. Hopefully you're slowing down so you can be safe environmentally. Encourage them to evaluate positive triggers in the environment and add more of those and identify distress triggers in the environment and do what they can to either eliminate them or buffer against them. I've shared with you before that Christmas trees were a huge trigger for for my stepfather. Now he couldn't get people to never put up a Christmas tree. What he did do was he avoided going to the the stores and stuff where there were a lot of Christmas trees and Christmy decorations and things. So he didn't feel as triggered. He kept his house where there wasn't a Christmas tree. Safety and stability. This means do you feel safe in your home and do you have a stable roof over your head? If you don't, that's the bottom of Maslow's hierarchy. If your housing, food and medical care are not taken care of, yeah, you're going to be freaking stressed. So we need to figure out how to address that and then address toxins and pollution as much as possible. Filtered water, good air, you know, have people define their rich and meaningful life. These are initial tools that they can potentially pluck from that helps them ask themselves before they do anything or when they're having a moment and they're angry, they can ask themsel. Is staying angry about this or is making this choice helping me use my energy to move toward my rich and meaningful life or is it moving me away or using energy that moves me away from my rich and meaningful life? Encourage them to do mindfulness morning and evening reflection in the morning, how am I feeling? What are my needs? What are my goals for today? Kind of envisioning walking through the day in the evening, how am I feeling? What am I needing? How did I. How well did I do today? What did I succeed at? What did I not get done or not do so well? What can I learn from it? Okay, end of story. You know, you're looking at what went well as well as what you can learn. Have them identify stressors that can be eliminated or mitigated. So going back over that assessment, they can pick out things that can be twice tweaked a little bit. Help them develop downregulation skills in order to slow their heart rate. Whether it's blowing bubbles or square breathing or going out on a walk, whatever it is that helps them, encourage them to start practicing 20 minutes of positivity a day. That's 20 minutes of focusing on what went right. Not be not this weird hopium out there that maybe this will h no what actually factually did go right today. Begin completing cognitive distortion worksheets using that feel mnemonic to help them identify and restructure core beliefs contributing to their distress. Have them explore self talk triggers where what the origins of that script is and the accuracy. Do they actually believe what they are telling thems or is it something that their fourth grade teacher told them and they've just held on to it for 20 years? And try using hardiness, commitment, control and challenge. Looking at that rich and meaningful life, let me examine all of the things that I'm committed to in my rich and meaningful life. Of the things that are going well, you know, what parts of those can I control? Of the things that are not going well, what parts of those can I control? And for the things, how can I view it as a challenge to use my energy to focus on the things that I can control, to nurture what's going well and to improve what's not going well. The autonomic nervous system responds to promote survival of the organism. Anything amiss in any piece of life will trigger allostasis or adjustment. Emotional distress adds stress to every piece of our life. And rebalancing the autonomic nervous system requires more than meditation and breathing. It requires modulating each of the stressors in the person's life. Are there any questions? Oh my gosh, Todd. It's not something I came up with. It's something that's evidently a common saying in the, in the crypto verse, crypto circles. And it's one of those that irritates me now because I'm just like, I don't want to hear about hopium, I want to hear about facts. But. I agree, Robbie, most doctors are not taught a lot about healthy nutrition. There's a lot of research that's coming out now that is showing that most people that live to be over a hundred actually have high cholesterol. Their healthy cholesterol is really high. Their unhealthy cholesterol is low. So it's all about that ratio. To somewhat oversimplify it, they've also shown that having higher healthy cholesterol actually buffers against cognitive decline in older adults. So you know, that's a lot of really interesting new research about cholesterol has been coming out over the past two years. Jesse, I'm glad you appreciate the thoroughness. I know some people, after an hour they're. Well, after about 20 minutes they're like, oh, I can't take anymore. But I am sort of the deep dive person. The Beautiful thing about YouTube is people can pause it and go back and listen and even download the transcript if they don't want to listen to me ramble, so I'm glad you appreciate it. I'm glad. I love doing the deep dive. I like knowing the whys and the hows. So. Okay, everybody, have an amazing rest of your day, and I will see you on Monday if you come to the AMA or next Wednesday for the next live CEU presentation.