Introduction and Guest Presentation

Alex: One of the problems that people run into is thinking that their negative emotions are something that you need to get rid of instead of realizing like, no, your negative emotions are tools that your brain is using to try and help you

and the key is really something that I’ve taken a long time to figure out, but this is essentially what now I coach people through. That really all you need is clarity on two things. What is important to you? By contrast, what’s less important to you, and what you have control over, and by contrast, what your limitations are, what you don’t have control over.

Bruce: welcome to the Future of Psychiatry podcast, where we explore novel technology and new innovations in mental health. I’m your host, Dr. Bassi, an addiction physician and biomedical engineer.

Today, we’re going to be focused on the neuroscience of mental health, in particular, depression and anxiety. Our guest today is Dr. Alex Korb, a neuroscientist, writer, and coach. He has studied the brain for more than 15 years. Starting with an undergraduate degree from Brown and a PhD in neuroscience from UCLA.

He’s the author of The Upward Spiral and The Upward Spiral Workbook, which is a neuroscience based program for reversing the course of depression. He’s an adjunct assistant professor at the UCLA Department of Psychiatry and Biobehavioral Sciences. And outside the lab, he’s available for personal coaching, consulting, and speaking engagements.

He’s also a coach, no longer a head coach, of the UCLA women’s frisbee team and is interested in yoga, mindfulness, physical fitness, and stand up comedy, which is a very eclectic group of interests. But they all have an overlap, and maybe Dr. Alex Korb can introduce himself and talk about your interests and your background.

Alex: Great to be here. Thanks for having me.

The beginnings

Bruce: Welcome. Yeah, this is going to be an exciting conversation. I can already tell from the chatter that we’ve had before we started recording. That this just hits on a lot of really thought provoking topics and topics that I think we don’t spend a whole lot of time talking about in psychiatry other than medication and other interventional psychiatry.

But I think it could be helpful for people to know the neuroscience behind yoga, mindfulness, and other non pharmaceutical options. So. How have your life experiences framed your perspective on neuroscience and mental health?

Alex: That’s a great question. I think it probably really starts from my parents, both of whom are physicians, but particularly my mom. Who is a psychiatrist, but also early on her career, recognize some of the limits of psychiatry and psychopharmacology. And so studied to become a psychoanalyst. And so I think from early on, I absorbed a lot of that.

Like obviously, science and drugs can tell us a lot about how to change the brain, but also just talking to people and thinking about your feelings that can also have power. That was the context that I grew up in. And then she actually joined the neuroscience study group.

When I was around in high school and occasionally she just come home like, oh, I learned about this cool study about the brain. And like, oh, that was interesting. And I think I’ve also always been interested in why, my own emotions go all over the place sometimes. Why I feel stressed or overwhelmed sometimes and other times it’s easy to feel confident and how it’s different for different people.

One of the things I noticed early on that they only reflected on later is I would never really said I had anxiety as a kid, but I did have a lot of stomach aches when I was getting on a roller coaster or taking a test. So in college, I took a neuroscience class and everything I started to learn about the brain helped me understand like, there’s this connection between the emotions that you’re having and the sensations in your body.

And sometimes that can be bidirectional and that can be influenced by your environment or your thoughts and everything I learned more about the brain just became really fascinating in and of itself as this is how people work and why we sometimes do things that we don’t want to do or feel things that don’t make sense and it also was really helpful in understanding myself.

And, it’s ultimately like, what I could change about myself and what I couldn’t change about myself and how best to go about that.

Bruce: Yeah, everything you’re saying sounds like we probably take for granted as basic knowledge now, but when you’re a child you have no idea that Your stomachache could be almost entirely manifested by your anxiety. And nobody really explicitly tells you that either. Or, if you were told that, it probably feels like they’re discounting your experience a little bit too.

Alex: Yes. Right. And that’s why it is very helpful to have a mother who understands these things because it is a nuanced Picture that you exactly what you say that it’s very easy to experience that as being invalidating of your Feelings like no jerk like my stomach hurts. It’s not something I’m thinking like even as adults.

It’s a very nuanced Message to get across like with things like chronic pain that you can say well, it’s not physically a problem with your shoulder or your neck. It’s caused by The reactivity of certain brain circuits and people interpret that you’re telling me I’m not in pain.

Like it’s not real. No, it is real. It’s just not caused by an injury, in your neck. It’s caused by a real circuit in your brain that is hyper responsive. That doesn’t mean you can just snap out of it. But it also means the solution isn’t necessarily getting surgery. And that all, that same nuanced message is what I try and convey about depression.

That there’s nothing technically, quote unquote, wrong with the brain in depression. And yet it is a problem, it’s a real problem that you can’t just snap out of, that arises from the activity and chemistry of particular brain circuits.

Recognizing when something is “wrong” with your brain

Bruce: I think that word wrong, that how you define wrong, can be explored quite extensively in a longer episode, how we defining wrong Because on the one hand, I think patients sometimes do have a very liberating experience where they’ve taken one particular medication and they’re like, wow, I didn’t realize there was a med out there that could have helped me so much.

And I just. Tried it. I really wish I had been on this one earlier and then vice versa where they’ve tried numerous options And they don’t feel like anything is really working for them And so they wonder is this a different issue with me that not isn’t necessarily wrong with my brain

Alex: And actually I think, I remember, I do some, a lot of trainings for mental health professionals, and I remember this one psychiatrist, Sort of pushing back on this notion I said where there’s nothing quote unquote wrong with the brain and she was like, we Have to do a lot of work to convince people that there’s something wrong with them so that they will take Action because they’re like well, just snap out of it that you know and this is where I recognize one of the limitations of psychiatry where You have a very limited time to talk to someone and you have, one thing to write on a prescription pad and, that might be your only interaction with them for three more months or whatever.

And in that context, yeah, you might need to be like, Hey, buddy, there’s something wrong with you. There’s not something you can just snap out of it. It’s like, it’s a problem with your brain. This medication will help. And. It’s not that even that explanation isn’t wrong, it’s just like incomplete or there’s more nuance that can be made about it in a more helpful way.

Because the benefits of telling someone that there’s something wrong with them is that then they at least stop blaming themselves. They’re like, Oh. This isn’t a moral failing, it’s not that I lack willpower, oh, this is a medical condition and it’s something wrong with my brain. So that actually is helpful for people that have those biological explanations.

It’s just that the simplified explanation that psychiatrists often give about depression isn’t accurate. Like many people think, Oh, it’s a chemical imbalance. Like I have too little serotonin. I just need to rebalance that. That’s not accurate. The other problem with convincing someone that there’s something wrong with their brain is that then they often lose a sense of agency where, Oh, now I only can see the psychiatrist because they’re the only person who can fix My brain and yes, psychiatry and medication can be extremely helpful, but I think even most psychiatrists would agree that yeah, you wish your patients would do more for themselves, but part of the reason they don’t do more for themselves is you could convince them that there’s something wrong with their brain and they don’t understand how they can contribute to that.

And so one of my favorite studies actually came out right after, the upward spiral came out, but it really supported the idea was that, the best path is to illustrate that yes, depression is like a biological issue that arises from the brain and your brain is malleable and can be reshaped that your biology is not fixed because when you convince someone that it’s biological.

People automatically make the assumption like, Oh, therefore I can’t do anything about it. And that’s why it’s so powerful to illustrate there are so many things you can do about it. Yeah, medication is one way to change the activity and chemistry of key brain circuits. But there are dozens of other ways, many of which you can do on your own that are very simple or low cost.

And This is not to say that you shouldn’t see a psychiatrist. It’s just while you’re sitting there trying to figure out if you’re depressed or not just start exercising and getting some sunlight and social activity and practicing gratitude. And maybe that’ll be enough. Your problems will go away.

Or once you’ve scheduled the visit to see a mental health professional and you’re waiting, three weeks to see it. Okay, we’ll just start doing all of these things. Or even if you start taking medication, well, don’t just sit around like, I hope this works. Like just start doing all of these things that can often make the medication more effective.

It’s just, it’s important to recognize there are some things. That you can do to change your brain circuits to alleviate depression and anxiety. And there’s some things that you can’t do on your own. But no one knows ahead of time what combination of things you will need to do. And you may as well start doing all these things.

And if you can’t do any of these things, Perfect. Then be more decisive and committed to going to see a mental health professional sooner.

Different ways to change your brain

Bruce: What we’re talking about kind of reminds me of, I think it was Sam Harris who had this insight in one of his podcasts, but he was mentioning how it’s often oversaid from patients that they don’t want to be on something that’s going to affect their brain.

But He pointed out that literally everything we do affects our brain in some way. The toast we ate has affected our brain. Being out in the sun has affected our brain. All of these things have some impact on the underlying biology of our brain and our mood at the time. So it makes me wonder, is it a double edged sword that, to some extent, we know there are many factors that impact our underlying biology, but at the same time, we also don’t know an explanation for a lot of mental illness, mental experiences, anxiety and depression, where does that leave clinicians in trying to explain the importance of something, a behavioral intervention when at the same time we, we also don’t really know exactly what we’re shooting for

Alex: Yeah, I mean, that’s the issue that I struggled with for a long time. Where in getting a PhD and learning about all this background research and also seeing things that I found really helpful to boost my mood or reduce stress and understanding the neuroscience behind them, I was like, I should share this information with people, but I was like, ah, we don’t fully understand how any of these things work. We have some explanation for, you know, why exercise boosts your mood or why sleep is beneficial, but we don’t fully understand them and do we really understand the full underlying mechanisms for depression or the etiology of depression and anxiety. And that’s where I was like, okay, just because we don’t understand everything doesn’t mean we understand nothing.

And already, currently, people and psychiatrists and drug companies are already telling people a very simple explanation of what depression is using neuroscience. That explanation is really helpful getting people to take medication, but it’s not accurate.

It’s also incomplete, and therefore I realized, oh, well, yes, medication can be extremely beneficial to people. For some people, it’s the entire answer. Like all can you do is take a pill, and we just don’t know ahead of time which person you are. Are you going to be the person who all you need to do is take a pill?

Or are you going to be the person who like, nope, you need to just exercise and sleep better and go to therapy? And that’s going to be your answer. So I thought it was extremely important to help people see the neuroscience of depression more empowering way to realize, Oh, No, you don’t have to blame yourself for moral failing, it is an issue in the brain, but it’s not like something’s broken about your brain that somebody else needs to fix.

It’s this subtle pattern the brain gets stuck in, and I have a really helpful analogy that I like to use, but the point is That okay, you can tell people a very simplistic story to increase their motivation to take medication. I can tell you similar stories about exercise and, sleep and social interaction and gratitude.

And scientifically, we just call those stories theories or hypotheses. We don’t fully understand everything. But you don’t need to fully understand everything in order to explain some of the stuff that you do understand. And we don’t fully understand why SSRIs work. We know that they can be extremely beneficial.

They do work. We have some understanding of the short term mechanisms of how they work. But we don’t have a full and complete understanding of why they work and yet we’ve been using them for decades. So I was like, right we should at least explain the neuroscience of all of these other things, so that people can be more motivated to exercise.

They realize that, there’s not just one way to change my brain. It’s not just going to see a psychiatrist. There’s many ways to change my brain. They might not all be successful in the way that I want, but it’s very empowering and research shows it increases people’s agency, which, in and of itself is helpful in combatting depression where people have this loss of agency.

And the other benefit, at least for psychiatry is that People often have this unhelpful black or white thinking around depression. That either there’s something broken and wrong with me and I need someone else to fix me or there’s nothing wrong with me. And if I take medication, that means there’s something wrong with me.

And so there’s this almost stigma against taking medication because it means there’s something fundamentally wrong with you. And One of the benefits of explaining the nuances of the neuroscience is I think it eliminates a lot of that stigma. Like, yeah, we all have the same brain circuits. They’re all wired in the same way.

Some people’s brains might respond really strongly to exercise and how it influences the serotonin system. Other people’s brains might respond really strongly to gratitude. Other people’s brains might respond really strongly to medication. Doesn’t make you a better or worse person or indicate some moral failing if your brain responds really well to medication because there’s not a specific thing wrong with the brain in depression and medication isn’t fixing the thing that’s wrong with you.

It’s just one of many different ways to modulate key neurotransmitters and key brain circuits.

Science of Individualized Prediction Models of Treatment Response

Bruce: let’s maybe jump overahead to how was you speculate on the future, given the topic of this podcast, the future of psychiatry. And then we can come back to present and talking about motivation and self confidence and imposter syndrome and things of that nature. We’re touching on this relationship between neuroscience and psychiatry.

And I think. Individuals, professionals in these two fields would agree the holy grail is to be able to predict with 100 percent accuracy what treatment a patient should be on before they start it. It’s been elusive, it’s been very difficult to get to that level because of the variability between depression among certain individuals, among various individuals.

Where do you see things going from here?

Alex: Well I think that is what brought me into this field, at least at the PhD level, I was like, there’s gotta be something that we can measure about the brain that would tell you like, you should get medication or even better. You should get this medication, you should get that medication and you, you just need to exercise more.

You just need to snap out of it. And what I discovered in that is , there’s some biomarkers that kind of indicate some likelihood of how the treatment is going to go, but they’re generally non specific. It really comes down to the complexity of the problem. Because the brain is this complex dynamic system and complex dynamic systems are governed by chaos theory, which doesn’t nicely fall into like our understanding of how most things work. And so I just think this idea that we’ll be able to 100 percent predict it. Isn’t feasible, partially because there’s not a clear distinction neurobiologically between what it means to have depression versus what it means to be human.

 There’s not just an easy way that you can just draw a line like, you have depression. With most disorders, there’s some clear– like in the body at least– there’s some clear measurement that you can take like well This is what is normal and 99 percent of the population and this is the disease process Like diabetes.

Well, you should have your blood resting blood sugar below a hundred and if it’s above that Well, there’s a problem. Oh and we have this drug that rest restores that.

In depression You can’t Say the same story. There’s no measurements that you can make. There are studies that will tell you, Oh, if you scan 20 people with depression and 20 people without , people with depression have, greater reactivity and in the amygdala or whatever.

But that’s complicated by, well, they may have had greater reactivity before they got depressed. That’s part of the reason why they got depressed. So is it a cause or is it an effect?

But it’s not completely separable from a quote unquote normal population where there are many people without depression who also have a highly reactive amygdala.

And so you could come up with all these different markers and say that with increasing likelihood that you, even have depression, but those, there’s no brain scan or lab tests that can diagnose you with depression. It’s just a matter of likelihood. And the challenge with predicting treatment response I think is kind of the best analogy for is predicting the weather. Or say, predicting the path of a hurricane.

We are clearly much better at it than we were 20 or 30 years ago. With satellite imagery and better models, but even with more and more data, chaos theory says there’s always some small little piece that you can’t measure that can have exponential effects.

And so we will get better at predicting the path of a hurricane, but we’re not necessarily gonna be able to Predict with 100 percent accuracy where exactly it’s going to go. Like we could predict it maybe three days and then maybe we’ll get better presenting four days. But over time, those little minuscule differences can add up to be exponential and we can be way off.

So we don’t even know when they form exactly. We just essentially have tendencies like, okay, we know around this time of year. In this location, hurricanes start to form, and that’s what I think we will get much better at, is identifying, who are the people, or under, the specific people, or under what conditions, they’re more likely to experience a depressive episode, so we can get better at identifying it faster.

We will be able to more rapidly identify, which medications or treatments are more likely to work for that individual. Not with 100 percent accuracy, but at least with like, okay, well you probably need to exercise more and, change your sleep patterns and that’s 80 percent chance of working in the short term.

Whereas, you know, just taking a medication is only a 30 percent whatever, like we’ll get better because right now, it’s sort of like well, you can take this medication and it has a 67 percent chance of working, or you could take that medication and it has a 54 percent chance of working, or you could do placebo and that has a 46 percent chance of work, like, so we’ll get better at identifying which specific people and whatever, and, you know, which treatments in the timeline are likely, but they will be tendencies, not, clear predictions.

Can SPECT scans diagnose any mental illness?

Bruce: you’re in L. A. and I know L. A. has a reputation for there being boutique kind of mental health practices. Have you had any interactions with anybody who’s done SPECT scans and has used those, the data from that to draw conclusions about their mental health?

Alex: I don’t associate that with Los Angeles, specifically, but the people ask me about that all the time because this is what my PhD research was on. Biomarkers of predicting treatment response. And people were like, Oh, have you heard about this guy? He’s doing spec scans and like he, can predict treatments outcomes. And I was like, really? And I like looked, how have I not heard of this? And I like read, media reports on it. And I was like, Oh my God, like he’s figured it out.

And then I looked at the research and I was like, No, like, yes, he’s doing a brain scan. But then he’s just like telling you a story, sure, it’s a plausible story, but there’s not a useful level of information to be gained from an individual brain scan. Like, yeah, we can see that your amygdala might be reactive, but okay. Like, what do you do with that information? Like, that’s, yeah, the amygdala’s more reactive to emotional information, and maybe that was that way before you were depressed, and now it’s exacerbated because you are depressed, or whatever. Basically, you don’t need the scan in order to have that same story to explain that theory.

So sure, if someone’s going to charge you thousands of dollars, you could do that, but like, it’s mostly a useless scan because I can explain to you the same biology and , what is going on and measuring exactly how, the blood oxygenation level dependent signal or whatever, that signal is measuring.

 But it doesn’t actually tell you any new information. Now you’ve exposed yourself to unnecessary radiation and paid someone else a lot of money. But people will probably swear that it works because I would guess, has a much stronger placebo effect when you look at your own brain and here’s this doctor in a white coat telling you about it.

But to me, feels like such a betrayal of the trust in physicians, because it’s like no, there’s no research on that. It’s basically just a fancy, complicated placebo. And yeah, placebos do work, but basically I was like, Oh, you can understand just as much about your brain, if not actually more about your brain.

By reflecting on your own experience and how neuroscience can inform that awareness, then you can just by looking at a little dot on a SPECT scan or an fMRI scan, because your brain’s own ability to think and reflect is a much more powerful tool than an fMRI machine, and this is why to diagnose depression, what do we do?

Do we have a scan and say, Oh, you have depression? No, you ask someone a series of questions. How’s your sleep been? How do you feel guilty? Because in depression, that is the problem. Like what would it even mean? If someone did a brain scan of you and say, Oh no, you’re not depressed even like I feel depressed.

It’s funny that I sometimes feel I’m arguing against what people would say but you’re a neuroscientist, you should measure The brain, and it’s like, yes, I understand these tools are extremely helpful in understanding mechanism at a group level.

You can take 20 people with depression and 20 people without them and put them under tightly controlled laboratory conditions and see, oh, there’s subtle statistical difference between these two groups in this area, whatever that is very different than taking an individual and saying, I know exactly what is wrong with your brain and I can fix it because that is not true.

But you as an individual probably do have a lot of information to understand what you can do and what you can’t do and understand your options and to empower yourself to gain a better understanding and mastery of your own brain, and start to explore all these different areas that we know based on lots of scientific evidence tend to help the brain function better and break out of depression and anxiety.

How to stop overthinking and ruminating

Bruce: Let’s talk a little bit about the concept of overthinking. I hear this topic come up a lot in my practice, well even my own experience quite frankly, they say, I can’t stop thinking about this, and in the back of my mind I’m like, Well, we don’t want to put you under anesthesia. We can’t get you to stop thinking about thoughts.

You know, you do have a brain, you do have thoughts. And frankly, if we did give you a medication that slowed down thoughts, then people would complain of cognitive fog, which is a common thing they do complain of some medications. So it’s a really fine balance. I would love to hear a neuroscientist’s take on the concept of overthinking, why we have that perception and what you can do about it, if there’s anything that can be done?

Alex: I’m glad you recognize the limitations of medication because I think that’s the only time when psychiatry really, starts to go wrong is when psychiatrists believe they have greater ability to fiddle with these little nuanced differences with these very coarse medications.

Like, oh, you have this problem, oh, let me give you this. It is so incredibly complex and these medications are so rudimentary, like you’re just taking a systemic medication that goes everywhere and that is often why these sort of lower tech interventions like exercise or sleep are so powerful because they target the brain and even more nuanced ways than we can with just like, giving you from 25 milligrams to 50 milligrams or whatever.

One of the things I find myself saying a lot is that these negative habits that we fall into we focus on them as like, this is a bug of the brain. Like my brain’s broken. It’s not working correctly. When in fact, no, that’s a feature of the brain. Your brain is working exactly as it’s supposed to.

It’s just, uh, in this specific instance, like creating a problem because why do we overthink things? Well, because we have this really powerful prefrontal cortex that’s really good at imagining things that could go wrong. That is an amazing feature of the prefrontal cortex that it evolved to do.

Well, there’s not really a way to design it where we like think through things where we don’t, occasionally, sometimes overthink things because if we’re saying No, I should never overthink things, then you will much more likely to under think things and act impulsively and make stupid decisions.

So if you’re gonna say that you don’t want to under think things. Then some of the time you’re going to overthink things, but it’s not a binary thing, you always overthinking. It is a good trait that you have that you sometimes over utilize, or it’s a tendency that just gets stuck a little bit more.

And my favorite example, it’s like, how can we have this problem or pattern if there’s not something wrong with the brain? And so I like to use this analogy of a microphone and a speaker because it’s a simple feedback.

It’s a simple circuit that’s kind of mirrors some of their circuits in the brain. And when a microphone is connected to a speaker, if the volume on the speaker is turned up a little too high, Or the microphone is very sensitive and you’re yelling into it a little too loudly, then it leads to this screeching feedback.

Everyone is like that’s not how it’s supposed to sound. It’s this objective problem that we can recognize. And yet, nothing is wrong with The speaker. Nothing is wrong with the microphone. Both of them are working exactly as they are supposed to and the solution is just sometimes like you just need to turn down the volume a little bit on the speaker or even sometimes just will recognize that you have a really sensitive microphone.

And instead of being like, Oh my God, why do I have this stupid sensitive microphone that, you know, well, I have a sensitive microphone, so maybe I should stop shouting into it. And there are certain aspects of our brain like that are regulated by our genetics or early experiences that influence the development of key emotional circuits.

And some people have brains that are more emotionally reactive. Okay, well, if that’s you, then yeah, you are more likely to get stuck in this pattern. But like overthinking isn’t a problem with thinking per se, it’s that you are using this good habit that you have of thinking and that good habit helps reduce the reactivity.

Of your stress and anxiety and you do it because it helps you feel less anxious. It’s just doesn’t solve the anxiety. And that’s why, yeah, you can take medication to reduce the anxiety. And that would sort of turn down the volume on the speaker. And then you wouldn’t feel the need to engage in this habit so much.

We can take cognitive therapy approaches and just, recognize how these thoughts are triggering habits, or you could just get a better night’s sleep or socialize with your friends more, or just like go for a run every day. And that will also, turn down the reactivity of this circuit, which one should you specifically do?

I can’t answer that question, but nobody else can either. But you are in a very good position to help figure out that answer because you are the one who can say, yeah, you know what? I’d never exercise. I could exercise more. Okay, well then do it. Did that solve the problem? Great. Did it not solve the problem?

Okay, then try some of these other things. But we know that exercise, for example, is very helpful in reducing stress. And we can have a guidelines like, most people exercise this much, but science can’t tell you for you specifically at this point in your life, exactly how much exercise do you need and when and how to do it to function optimally.

We can say, yeah, you need, probably should exercise more and eat healthy and sleep better. But that’s a challenging thing for psychiatrists to tell people. But if someone is like, hey, what are the things that I can do? That’s a different question. Whether it’s the person asking themselves versus a psychiatrist telling them, hey, you need to do this whole list of things.

Why don’t we do what we should do?

Bruce: I’m glad you mentioned running because I wanted to talk about motivation And you also mentioned how understanding neuroscience can help with motivation via Being educated on how these things are work.

However, I know doctors are some of the worst patients And so just knowing something doesn’t necessarily equate to doing it And I’m sure for Alex Korb You have some sort of bad habits at times too that you work on despite knowing all the things you should be doing what kinds of things trip you up on a day to day basis and do you draw from your own workbook

Alex: I do. I mean, I look at my phone too much or like I don’t exercise or like I sit, you know, in front of the computer too much. I don’t always eat the things that I want and in some ways it’s harder for me because I’m like, I wrote a book. I shouldn’t be these things. I should know all of these things.

 But it really comes down to simply being aware when we’re like, why do I do this? Often when we ask, why do we do this? It’s not actually a curiosity. It’s a criticism veiled as a question. Like, we’re just criticizing ourselves. So the question would be like, why are you criticizing yourself? Ah, because it helps you feel more in control.

Over the situation and one of the fundamental underlying Answers for why is it that we sometimes do things we don’t want to do is because different parts of your brain Want to do different things because they evolved for different purposes so the habit circuit in the brain the dorsal striatum that tries to get you to do whatever Has been most deeply ingrained or whatever you’ve been practicing for the last 20 years the Prefrontal cortex the analytical part.

It’s like hey, yeah, we could do that. But like that has led us to here and Where we don’t want to be so maybe we should try doing it differently But then when even you try to do something differently That’s going off and against your habits. And then the impulsive circuit or the reward circuit is like, Oh, hey, look, there’s a cookie.

And somewhere in that conversation, your actions get determined. And whenever you are stressed out, the activation of the amygdala system that biases that conversation away. From your thoughtful, rational prefrontal cortex and towards these habits and impulses. And anytime you’re stuck, often what we do is we criticize ourselves into trying to change, but like that criticism is just a habit that doesn’t actually Solve the underlying stress of what we’re doing and we’re trying to stress ourselves and we just keep staying stuck in the same pattern.

So one of the biggest keys is simply to recognize that process is happening. That sometimes we’re like, why aren’t I more motivated to do X? Well, it means you might actually be really motivated. It’s just that other parts of your brain are really motivated to not do that. And those parts of your brain are trying to help you in some way.

And if you can just acknowledge like, Thank you habit circuit for trying to protect me from frustration or stress or whatever like I appreciate you like if you think hey Maybe going for a run would solve my depression. Your habit circuit is gonna be like that’s probably not gonna work. It’s helping you avoid the frustration that might come from your unreasonable expectations that like doing this one little five minute run is going to solve everything.

And so it’s trying to protect you. And this is where we can realize and have a more nuanced relationship with ourselves. It’s trying to help me. I disagree with it, but I can still say, Oh, thank you. And acknowledge that it’s there. Just like as a kid, when you’re leaving your house and your mom is like, put on a sweatshirt, you’ll get cold.

 You might be like, Oh, no, I’m gonna be fine. You can still appreciate your mom trying to help you. Often, though, we experience is like, Ah, she’s just nagging me or whatever. And so we have these brain circuits. And we often experience them as like my brain or my emotions or my habits are holding me back.

When really, if you had a deeper understanding, you would say, Oh the most of the time they are very beneficial.

Convince your mind

Bruce: I appreciate that answer because it almost sounds obvious when a patient will say, I want to get a new job. But in the process, over the last 20 minutes, they already described to me why they fear getting that new job, or they don’t want to get a new job, but they don’t see it right away.

they’re like, why am I not motivated to do any interviews? maybe because you don’t want to do any interviews, there’s many parts of your brain that actually don’t want to do that. So my question to you is, can we trick ourselves in a way? Because I know there are individuals who often feel imposter syndrome, who are highly talented, skilled individuals and they might believe that in some level, but there’s also this other voice inside their head, which it sounds like is also coming into effect with motivation too.

How might a neuroscientist suggest to an individual to convince or trick your mind to thinking something?

I remember watching Dr. Phil show I think it was Tony Robbins would come up with these posture or power positions then proven to actually not be true.

Alex: Well, so just one thing about the power poses is like, right, it’s not true. You can’t just trick your body into like, no, I’m not upset. I’m happy. Or like, I’m not afraid. I’m confident that isn’t true. And in some ways, if we can end up gaslighting ourselves, sort of like to try and Which is in fact like what people with depression do all the time.

They like pretend that they’re happy. That doesn’t just make them happy. What it does do, what the research shows, both with the facial expressions and posture, is it can amplify or reduce your experience of an emotion that you already are feeling. So if you’re happy and you smile, that just turns up the volume.

On your experience of happiness, if you’re feeling sad and you just slump away and listen to sad music and have a sad posture, it enhance your experience of sadness.

One of the problems that people run into is thinking that their negative emotions are something that you need to get rid of instead of realizing like, no, your negative emotions are tools that your brain is using to try and help you like anger. That’s your brain trying to help you to take action. Or like sadness. Well, that’s your brain trying to help you accept the things you can’t control. Because there’s some things you can’t control and we can either keep banging our heads against the same wall trying to control them or just accept that we don’t have control.

And the key is really something that I’ve taken a long time to figure out, but this is essentially what now I coach people through. That really all you need is clarity on two things. What is important to you? By contrast, what’s less important to you, and what you have control over, and by contrast, what your limitations are, what you don’t have control over.

And things that are important to us, that we potentially don’t have control over, activate the emotional circuitry in the brain and the stress response. They create strong emotions. What should we do with those emotions? Well, crucially, it depends, ah, is the thing that’s triggering the emotion actually important to me or what part of it is important to me?

Like, people are coming over to my house and my house is a mess and that’s creating a lot of anxiety. Okay is the sock on the floor, is that actually the important thing? Like, no, it’s my relationship with these people. That’s important. So, I don’t have enough time to answer the door and clean up. That creates anxiety and stress. What should I do with it? I should answer the door and be kind to my friend because that’s actually the piece that’s most important to me. And that’s controllable. And so I can take action on that, whereas cleaning up the socks, I can also take action on that but that’s actually not as important.

And so it still creates emotions, but that piece of emotions that’s less important. The only thing to do with that is just experience it Or like, promise, hey, next time I’ll clean up sooner. Or, reframe it instead of focusing on, I can’t be nice to my friend and clean up at the same time.

But I can focus on the thing that’s more important to me. And so, when we have that clarity, It allows us to focus on the important things in our lives that we actually have control over instead of constantly getting distracted by the things that are unimportant or uncontrollable or both. And based on our experiences and our habits and our culture and what our parents have taught us, we often make mistakes about things where we believe that something is controllable when it’s not actually, or we believe that something is more important, like making money than it actually is and therapy can help you sort through that or just experience and reflection can help you sort it.

Through that, but one of the simplest tools that I believe people, most smart, successful people need to use more of is self compassion, which is to recognize, yeah, there are some things you don’t have control over. You might have a lot of important things that you want to do, but you can’t do all of them right now.

And that creates doubt and fear. The only thing to do useful to do with that doubt and fear is to be like, Okay, well, I can at least work towards the thing that’s most important to me right now and then be compassionate towards myself. Like, hey, it sucks. It’s okay that you can’t do everything right now, or that you’re not comfortable with it.

Humor and comedy in medicine

Bruce: I want to talk about a pretty fun topic, one that I know you have an interest in. And that’s of using humor and comedy in medicine. I know from experience, I’m also interested in laughing. Who’s not? I like watching comedy and things of that nature. But I noticed when I go through a depressive episode, my sense of humor is probably the first thing to go.

And it’s really hard to work your way, through a depressive episode using humor kind of intentionally to, as a treatment modality. It’s more or less a metric of whether or not I’m doing well or not.

 What is the data there show? What does the research show in terms of how humor can be used as a form of medicine?

Bruce: Everybody always talks about it. Like laughter is the best form of medicine, but we don’t ever have stand up comedians in hospital systems.

Alex: but there are a lot of depressed stand up comedians. I sort of say it’s a joke, except like, yeah, because those people Figure it out. I can’t control the crap going on in my life, but like, I can, make a joke about it and create it and turn it into art and also laugh at myself and that is a extremely powerful coping mechanism.

Just the framing of your question just reminds me that one of the problems with psychiatry is when we try and think of what’s the one treatment that’s going to solve it all? There’s not one treatment that’s going to solve it.

There’s many different little things that you can do. Like, I talked to a group of psychiatrists about the power of gratitude. And one of them was like, okay, so there are double blind studies comparing the effectiveness of gratitude versus antidepressant medications. That’s not helpful. Like, you could just take five minutes to write down, you know, write a thank you letter to someone.

Like, it does increase the effective. Right. So one of the problems with laughter is that people will then take their negative emotions, say, No, not supposed to feel this. I should feel happy and I’ll laugh.

And that can actually make the problem worse because the issue is like your negative emotions exist for a reason. Like, stop trying to ignore the fact that you have negative emotions because unless you allow yourself to acknowledge them, they’re gonna keep coming back.

but you can find moments of humor just like, when you keep doing something that you don’t want to do. You could either yell at yourself, sure, like that’s probably not helpful. Or You could just laugh at yourself. Like, I know I have a great life, and I just don’t feel like getting out of bed in the morning. It’s just that laughter doesn’t have all the same negative consequences.

Bruce: can that be improved upon? Can like somebody get trained on doing that? Or is there a set point where it’s ingrained in your temperament or your personality?

Alex: I think it’s some of both, that some people have an easier time of laughing. The problem with those people, is that if we go back to what I was talking about before, the important things and the controllable things, there might be something that’s super important to you that you’re scared about.

And if you have a habit of laughing, then maybe, Oh, that’s fine. I can’t do it. But no for you specifically, like you’re over relying on your habit of laughing and that’s kind of just making you avoid or give up this thing that no, you should actually take action on to change.

Whereas other people have the opposite problem. They keep trying to change something that they can’t actually change and they’d be better off laughing at themselves about it.

Because laughter is extremely helpful with acceptance. It helps us accept things. Just like sadness. Like, you can’t fly. There a point in your life where you thought you could. You were three years old. You jumped off a chair. You got really sad and frustrated. And then guess what? You accepted it. Because the sadness helped you accept this thing you can’t control. And it is not bothered you at all since then, because you accepted it, because it was actually something you couldn’t control.

You can laughter also helps us accept things that we can’t control. It’s just that we want to make sure the things that we are accepting, that we can’t control, are actually out of our control. And so the tool of acceptance, which mindfulness can help us with, is an extremely powerful tool. You just need to use it for the right things.

Or you’ll, be like, Oh, I guess I can’t do anything about it. And so like, laughter is extremely helpful with that and humor. But you just need to use it in the right way. And, having an expert guidance, through therapy or a coach, or just reflecting on yourself can help you start to notice, Oh yeah, I am like laughing at myself when I should be, taking more committed action.

Bruce: I feel like I could talk to you all day. These are really interesting topics, kind of really making me think about my practice and how we explain neuroscience to patients and how we utilize different modalities of treatment.

Alex: hope it doesn’t make you overthink it.

Accept what we feel

Bruce: Well if it does, I’m going to come back to you and figure out a fix for that too.

Alex: Well it’s not that you don’t need to fix it. It’s really these, I mean, I’m sort of joking here, but it’s really these binary things of when I need to, this is bad, I need to change it. This is good, I need to do more of it. There’s nothing. That is always bad or always good. These emotions that you have, these habits that you have, they’re extremely important tools that your brain evolved, but it’s how you use the tools and at what time in what way that determines whether they’re useful to you.

So thinking is a very useful tool. Just like a hammer is a useful tool. It only becomes a problem When you use that really useful tool too much or in the wrong way. So don’t get mad at yourself for having a hammer or realize that that’s a separate tool. But like, oh, I’m grateful that I have this hammer.

I just recognize, ah, this specific moment in time, given what is important to me and what I actually have control over right now. It’s not actually helping me so I can be grateful that I have it. I’m put it back in my tool belt and then use a different tool or if I’m frustrated that I’m not sure what tool to use , well, that frustration that’s trying to help me motivate me to do something about it.

And I’m angry that I and stress that I don’t know what to do. Well, that stress that’s trying to help me and basically treat yourself with more compassion, not So that you can just give up or lower your standards, but so you can hold yourself accountable to the things that you actually have control over that are important to you, and for everything else that you can just accept or let go of.

And it’s a process to figure that out.

Bruce: Well, thank you so much. I appreciate it.

Alex: Yeah, thanks for having me, and if, people want to learn more, I have some, actually a free guide on overthinking on my website that they can download.

Bruce: That’s it for this episode. I’d appreciate it if you please like and share this podcast with your colleagues. It’d be especially helpful for us. If you’d like, please leave us a rating on your favorite podcatcher. If you’re a clinician, I developed a course on how to start a private practice. And for patients, I’ve also developed a course on acceptance and commitment therapy and cognitive behavioral based therapy lessons for treating and helping anxiety.

You can find all these on our website as well. as well as the show notes and resources for each episode. Thank you so much, and I’ll see you in the next episode.