Dr. Grammer: “So what people are doing now is essentially exposure therapies, but with MDMA, and instead of requiring, say, months of therapy, they’re seeing benefit in as little as three treatments without the discomfort associated with typical exposure based therapies. So there are studies that are ongoing, it’s really, really exciting and hopefully, that will make treatment of PTSD, quicker, more long lasting, and a lot more comfortable.”

[Life to Live by Grace Mesa (Instrumental Version) begins]

Beyond Depressed is a mental health podcast for people who want to know the science behind emerging treatments and if those treatments are right for them or a loved one. New therapies using psilocybin, magnetic stimulation, ketamine and medical marijuana are bringing people much needed relief. Together, we’ll take a deep dive into depression and how therapy, medications and drugs can help you feel better.

Beyond Depressed is hosted by Dr Geoffrey Grammer. Dr. Grammer is a decorated retired Colonel with the United States Army and is currently serving as the Chief Medical Officer for Greenbrook TMS. He has experience in psychiatry, internal medicine, and behavior neurology.

Disclaimer: The following podcast is for information and educational purposes only and should not be considered official medical advice.

[Life to Live by Grace Mesa (Instrumental Version) ends]

Dr. Grammer 

Welcome back to the podcast. I’m Dr. Geoffrey Grammer. What is PTSD? How do you know if you have PTSD? That’s what we’re going to talk about today. I’m joined again by Joe.

Joe Clements 

Hello.

Dr. Grammer 

So thank you for coming back. So Joe, what is your understanding of what PTSD or Post Traumatic Stress Disorder is?

Joe Clements 

So when you say that two things come to my mind, one is, you know, just given the last 20 years in Iraq and Afghanistan, it is war, PTSD. So soldiers have an intense experience in combat, and then they get home and they hear a loud noise, and they kind of freak out. So that’s one. And then the other is, like a more common PTSD, I guess, where somebody had a bad job or had a bad breakup with somebody, and there are certain triggers that make them really anxious that are related to those things. So that’s, that’s what you know, if you ask me, that’s what comes to my mind.

Dr. Grammer 

Yeah, and I think I think that’s, that’s definitely a good place to start, right. And indeed, because war is traumatic, we most classically associated PTSD with that phenomenon. And indeed, it was after Vietnam, that the idea of PTSD got better crystallized. It’s, it’s had other names in the past, you know, shell shock and battle fatigue, and so forth. But, but now, we’ve sort of defined that as a constellation of symptoms that can occur after a traumatic event. And so you can have PTSD developed from any either direct or indirect trauma, not just war. And indeed, you know…

Joe Clements 

What would be an indirect trauma?

Dr. Grammer 

If you witnessed someone dying, even though you weren’t necessarily at at risk, like a good example is, that’s a little less common, I think that people recognize is, if you have a sick one, that you’re caring for with terminal cancer, right, and you care for them all the way to the end, there can be PTSD phenomenon from that, and things that trigger that like calling out seeing the bed, the smells of the sheets, and things like that can exacerbate or kind of flare, intrusive memories of that.

Joe Clements 

So can you define what’s an intrusive memory?

Dr. Grammer 

Yeah, so with PTSD, we typically think of three broad categories occurring after this trauma. One would be intrusive recollections of that trauma. And that can be in the form of nightmares. That can be flashbacks, where it’s not that someone reminisces about it, but they have this very powerful memory of it that gets triggered by some other stimulus that is out of proportion to what would be appropriate that situation.

Joe Clements 

Okay, would this be an analogy? Because I think everyone’s had this experience. Like you smell something and that smell just reminds you of something from a long time ago?

Dr. Grammer 

So…

Joe Clements 

But is it like that intensity of a sudden of an experience, right, because I think everybody’s had that where there just caught off guard by a certain scent, like it brings back memories it like that intense and sudden of an experience.

Dr. Grammer 

Yeah. And actually…  But more negative probably. Well, smells can actually trigger – can be one of the things that triggers that intrusive recollections. And part of the reason is, our smell system or factory system actually is tied to memories. So that’s why like, if you grew up and someone cooks the same holiday Thanksgiving dinner, like if you smell that same smell of like cooked, I don’t know, Turkey or whatever, it’ll bring back not just the memory of it, but it’s almost like the emotional valence you had from those. Right? So olfactory in particular, is very good at eliciting, that more crystallized memory of something, including the emotions that come with it. So yeah, you get these intrusive recollections. Nightmares are a real brutal one, but even a car backfiring on the street and some soldier may, you know, not just kind of duck down and be like, Oh, someone’s shooting but they may actually suddenly remember being in a circumstance where they witnessed a shooting or being shot at. Another part to it is this idea of hyper vigilance where the fight or flight reaction gets super twitchy, if you will. So tapping someone on the shoulder, for example, could result in a startle response, like oh my gosh, and for some people, and this is I think a lot of people don’t realize this, irritability is part of hyper vigilance. Right? Because you’re in that fight mode. Right? And so a lot of people will become irritable to everyone around them when they have PTSD, and they don’t know why. And they actually feel remorse for, you know, having difficulty controlling that.

Joe Clements 

So irritability is just kind of like a low grade aggression?

Dr. Grammer 

Yeah. Yeah. All the time being like, you know, what are you talking, you know, and just temperamental if you will, and then the third thing is avoidance of things that reminds you of that trauma. And that can actually be avoidance of a lot of stuff. And you know, we typically would think of it like, you don’t want to watch horror movies if you’ve been through war, you don’t want to read a story about a sexual assault if you’ve been sexually assaulted. But the other thing that happens is people can actually withdraw from the world around them. Try to get into that safe space, if you will. So you’re avoiding anything that might kind of trigger you, to get into that protective little corner where like no one’s gonna be able to surprise you or anything. And as you can imagine, that can be very problematic from a functional perspective.

Joe Clements 

So side question on this, what is the thinking about how this process developed in the brain? Because it seemed like humans probably evolved in a very dangerous environment, where bad things probably happened pretty often. What causes the brain to respond so strongly to things that, you know, sexual abuse, things like that aside, but war has been a part of humanity, forever, people accidental death forever, things like that forever? Why does the brain have such a tough time with it?

Dr. Grammer 

Well, it’s adaptive in an unsafe environment. So I think the listeners know, I’ve done a couple of tours to Iraq and one to Afghanistan. And a good example is, if you were the rear vehicle in a convoy, they would have a gunner. And they would have this sort of escalation in use of force that they would have to follow as part of the rules of engagement. So if a vehicle is coming up upon you, you have to do like a visual verbal warning, a shot in the air, a shot in the engine block, and a shot at the driver, right? And the decisions to get through that have to happen in a split second. And so you need to be able to go from zero to 100, lethality, like instantaneously. But if someone’s being a jerk at you at a bar, okay? In this society, you can’t have that same zero to 100 lethality. So what was adaptive overseas in a combat zone suddenly becomes maladaptive in a lawful, safe environment. So likewise, if you were a cave person, and you had to go hunting, you’re battling food with like tigers and bears and stuff like that, yeah, you need to be on guard, you need to be twitchy, you need to have that zero 100 lethality. But now that we go to the grocery store, and we pick stuff that’s been prepared for us, and so forth, you don’t need that same thing. So I think some people think that some of this is almost a maladaption to the safety and security of our predictable, modern lawful society.

Joe Clements 

Interesting. So what may have been good 10,000 years ago, what works in a warzone, still creeps through in modern society, you might experience a tragic, accidental death, you might see something bad happen. But the issue is like you really don’t live in an environment where that’s very likely to happen repeatedly for most people.

Dr. Grammer 

Right? And I think when it starts to cause problems with your functioning within society, within your job, and within your family, like that’s the problem.

Joe Clements 

What are the because I’m gonna guess this is like most of the issues, we’ve talked about, what else is on that checklist of criteria that have to be met before it’s actual PTSD Versus just like, you know, we use it as a slang term?

Dr. Grammer 

Yeah. So I think a lot of people talk about having some mild trauma, like, Oh, my traffic was really bad today. And I don’t even want to drive tomorrow. It’s like post traumatic stress. And I think it’s become a vernacular, and that can be good and bad. On one hand, I think it normalizes the phenomenon of PTSD. On the other hand, it dilutes out the severity of the illness,

Joe Clements 

Are those on the same spectrum of thing?

Dr. Grammer 

Well.

Joe Clements 

Or are they just actually very different things qualitatively?

Dr. Grammer 

That’s a great question. And I think it depends on the individual, I do think life has trauma associated with it. And that trauma does shape our expectations of the present and the future. But the real defining criteria is when it becomes problematic when it is causing you to function less well or experience a significant degree of distress. So I think a good example is well, let me back up a little bit. So absolutely, there’s sort of like a normal variant for trauma. If you’re walking down a dark alley, in the middle of the night, your threat vigilance is going to be higher, right? But if you’re walking down a busy city street, you don’t want that threat vigilance to be so high that you can’t focus on where you’re supposed to go, you can’t relax, you can’t be in the moment. So it’s all a matter of degrees. And I think there’s certainly spectrums of severity for PTSD. What’s interesting is, and this is an important point, I think, we have these criteria for PTSD, but it probably is quite inadequate. Because what someone who grows up with a history of like physical or sexual abuse experiences what someone who has a singular sexual assault at some age, or someone with a life threatening motor vehicle accident or soldier who’s been deployed overseas, what each of them is going to go through is gonna be a little different. And yet we use the same diagnosis to describe all of them. So when you look at literature like this, it can be really problematic because you can’t take a study from say a civilian trauma, like an automobile, or sorry, a plane wreck, and the people who go clean that up often the rescuers of a plane crash will have PTSD. You can’t necessarily extrapolate that to the warfighter, right? And so we haven’t gotten to a place yet where we’ve really kind of divvied up the different sub classifications of PTSD. But the way that I think about it is, there’s sort of some salient features to most PTSD that has different degrees within these categories. So one is the existential trauma. If you experience something that should not have happened to you, you’re mugged on the way home and get your wallet stolen, get beat up, right? How you see the world going forward is going to change. Right? Because suddenly something happened to you, you did nothing wrong, you didn’t deserve this, it should have been safe, and you got hurt. So then how do you approach the rest of life? Why do these things happen? Where’s the justice? And you can imagine even in war, it gets worse, right? Why did the good guy live and the… or sorry, the good guy and the bad guy live, and so forth. I mean, there can be horrible things that happen in combat that just defy kind of the logical rules that we’re used to. A second part to PTSD, I think is there are changes in the brain. And when we look at people with PTSD and look at their brains, there’s volumetric changes being the size of different areas can change over time, there’s endocrine changes, meaning levels of cortisol can fluctuate over time. And that can actually we think, lead to some of the neurologic phenomenon that promotes this intrusive recollection, kind of circular thought, or the hyper vigilance to a degree because it gets triggered. And then third part kind of goes back to the hyper vigilance. And that’s the autonomic instability. And there’s a lot more research going to this now, because we can measure something called heart rate variability, which measures the beat to beat variability between different heartbeats. And normally, that will fluctuate, when we breathe. When we breathe in, it actually will increase the amount of blood flow into the heart, the heart will typically slow down as a response. But when your adrenaline is constantly up, it actually narrows that beat to beat variability. So whether you’re breathing in or not, your heart’s kind of always a little bit ramped up and so it beats at that same amount. So it decreases beat to beat variability. That’s a sign of like an overly active fight or flight response. And that can be an issue for some people where they just get triggered way too happy. And I think for each person with PTSD, there’s various levels of severity within each of those categories. And unfortunately, that does potentially dictate how they should be treated. So with PTSD in particular, and kind of more than a lot of other psychiatric illnesses, I do think that the treatment needs to be individualized to that individual’s trauma and manifestations of the disease rather than here’s the one pill we get for PTSD get better.

Joe Clements 

So what are the standard treatments for PTSD?

Dr. Grammer 

So there are two drugs that are currently FDA cleared for the treatment of PTSD. Those are Sertraline, which is Zoloft, and Paroxetine, which is Paxil. There are other drugs which have also shown efficacy but don’t have FDA approval. Venlafaxine, for example, would be one particularly at doses like 150 milligrams or less.

Joe Clements 

So we talked about this in the antidepressant episode, but the antidepressants also have anti anxiety effects. Is it the anti anxiety property that’s helping mitigate the impacts of the PTSD?

Dr. Grammer 

So I think the common thread in this is it’s serotonergic, related. And we do know that serotonin can impact both mood and anxiety and regulate an area of the brain called the limbic system. And when you increase the amount of serotonin being communicated between the nerves, it tends to quiet down some of the overactive areas of that limbic system, and bring down the tenor of anxiety, whether it’s triggered by memory or environment or what have you. So yes, I think there’s some overlap there. But unfortunately, for a lot of PTSD, a med is not going to fix it all. And indeed, though, Paroxetine, and Sertraline got FDA approval, there have been other studies that kind of throw some water on the enthusiasm of how well they work. And they can help diminish all three spectrums of the hyper vigilance intrusive recollections and avoidance that we talked about. But it’s not nearly as robust as we would hope. So, practice guidelines and even my own opinion, would recommend that psychotherapy, particularly certain forms of psychotherapy, also be part of a comprehensive treatment plan. It’s going to be hard to get better from Post Traumatic Stress Disorder without some form of psychotherapy to help navigate through that.

Joe Clements 

And what are the effective types of psychotherapy for PTSD?

Dr. Grammer 

So most of the types that have been shown to be effective have some form of what we call exposure therapy. So our bodies are kind of wired to eventually begin to ignore a sensory stimulus that is in our environment, because otherwise if we maintain attention to that, we can’t focus on what we’re trying to focus on. So if you are afraid of heights, for example, and I put you into a glass box, and then, you know, suspended 30 feet off the ground, and kept you there for a few hours, your fear of heights would actually begin to diminish. And so with PTSD, there are different ways to do this, whether it’s with EMDR, which is the eye movement, you know, sort of rapid desensitization or exposure Just good old fashioned script based exposure therapy, or even something called cognitive reprocessing therapy all have different variations of this exposure. And I – there are different theories of how this works. But one of the better ones that I’ve kind of read about and kind of seen is this idea of reprocessing. So when we bring a memory into conscious thought, when it gets restored as a memory, we almost kind of bring it out of the memory, fiddle with it, and then restore it. If you can take away some of the anxiety from that memory, it gets restored with less emotional valence. So what these exposure therapies will try to do is get you to bring up the trauma, but maintain a low level of anxiety, so that when it does get re encoded, it brings less of that emotional valence with it.

Joe Clements 

So this is kind of the equivalent of if you watch a horror movie one time, everything that pops out to you is scary. If you watch the horror movie 15 times, by the eighth or ninth time you’ve watched it, you know exactly what’s coming, and it has less emotional impact. You’re still aware that a ghost popped out, you know, and drug someone under the bed. But it doesn’t have the same thing. It’s not a surprise, your emotional response to it is decreasing at every exposure.

Dr. Grammer 

Yeah, or roller coaster ride. Another good metaphor, you go on it once and are like holy cow that was awful. You go on and again, you’re like, okay.

Joe Clements 

So why does it take thera… So if the problem with the intrusive memory is the memory pops up, that would mean that the person is experiencing that memory hundreds or maybe even 1000s of times? Why outside of a therapeutic situation does it… Why doesn’t the emotional valence lower on its own?

Dr. Grammer 

Because you gotta disconnect the anxiety from it. So if you have an intrusive recollection, you’re bringing anxiety with it, a lot of people will often feel a level of distress. And then when that gets reprocessed, it goes back with that emotional distress and anxiety. So it really is sort of an exercise that’s done over time in a therapeutic environment where you’re teaching someone, whether it’s mindfulness or what have you, or repetitive grounding, or whatever technique you want to use to kind of help bring that anxiety down, that allows for it to be reprocessed with less.

Joe Clements 

Does this tie into this psychological concept of integration, that that traumatic event is… you haven’t fully processed it or work through it yet and so it kind of exists as this separate piece of your experience of life and of the world that kind of jumps out at you, you push it back, jumps out at you again, and then by processing it through and taking away the emotional valence it becomes integrated to like any other memory or any other part of your life.

Dr. Grammer 

Yeah, I think that’s a good point because trying to make sense of the nonsensical is, is hard and that can create this sense of sort of existential crisis. You know, it is for the warfighter, for example, it is hard to go overseas and see things and experience things that shouldn’t happen. And then to come back here and rejoin what is for the most part, a calm, peaceful, lawful society with a predictability about it. And then say, well, why do these things happen in the world? Right? And how do I, how do I live in this without feeling like I’m disrespecting the sacrifice of others to feel like I’m not, and beginning to sort of exponentially navigate through that I think is important. And this is where the listeners out there, I think it’s really important that you find a good therapist with specific training and trauma based therapies. Because there are some people who say, well, oh, I, you know, at school I learned about exposure therapy, so we’re gonna write a script, you’re gonna read it for me, we’re going to practice some deep breathing while you do it. And we’re gonna do this every time. But if if somebody watched their buddy bleed out five feet from them, but they couldn’t get to him because they were under direct fire, they still have to work through that they still have to forgive themselves for being in an impossible situation. Or let’s even say it’s worse, someone makes a mistake. And they’re not paying attention to the road, and they slammed a car into another car and fatally injure the other person. They’re gonna have to figure out how to move forward from that and you can’t just do this exposure script. So I agree with you. I think a good wise therapist is not only going to help someone attenuate some of those things, but say, how do you make sense of your life going forward in a way that integrates this experience to reestablish sort of the integrity of who you are and how you see yourself in the universe?

Joe Clements 

So that’s the therapeutic part. So we’ve discussed pretty routinely at this point in the podcast, there’s talk therapy, this would be this exposure therapy is not exactly talk therapy but its a… What do you call that category of therapies where there’s no medication or anything involved? Psy?

Dr. Grammer 

Psychotherapy.

Joe Clements 

Psychotherapy?

Dr. Grammer 

Yeah.

Joe Clements 

So we discussed the medication options, what else is available? Is there anything emerging for PTSD treatment?

Dr. Grammer 

Yeah. And I think there are some cool things out there like one is virtual reality based therapy. So again, I’ll use the military just and I want to be very clear, there are a lot of people out there with non military related post traumatic stress disorder.

Joe Clements 

This is a easier, cleaner example to go by, though it’s much harder to use an example of somebody who’s been molested as a child for 10 years, and… the military examples cleaner, people get it.

Dr. Grammer 

Yeah. And I think, like, candidly, it’s been in like more movies and stuff like that so people can resonate with that. So I’m using that example. And so one thing would be a virtual reality based. So there’s a research ongoing, and there are some providers who provide essentially Call of Duty using the kind of VR glasses and they use these kind of cannons that sit on the base, and they actually hold this rifle that then gets tracked in real time. And they’ll recreate they’ll actually design the traumatic event and have the person kind of play through that over and over again. So those are exciting. So but all this is how do we best facilitate this exposure based therapy? Because for a lot of people, when you bring up that memory, it can be very, it can be very uncomfortable. And a lot of people will actually drop out of exposure based therapies because they can’t tolerate it. So yeah, it’s evidence based. And yeah, like the Veterans Administration kind of recommends that as kind of a first line. But for a lot of people, like I can’t do it. And I’ve seen patients all the time come to me and say, I saw good therapist, they were training me through this, but it was just too uncomfortable. So one of the neat things that’s out there kind of sticking with this idea of things that had previously been used recreationally in our being revisited as potential therapeutic modalities would be MDMA, or ecstasy, or Molly. And so that’s actually pretty exciting stuff. So one of the things that MDMA does, is it will quiet down the anxiety area of the brain called the amygdala. And so typically, when we bring a memory with us into the conscious thought, and conscious mind, the amygdala will activate and manifest that anxiety. But you can accelerate the reprocessing without the anxiety if you just shut off the amygdala. And that’s what ecstasy does. One of the reasons why it’s been used as a party drug is because it eliminates this sense of any kind of worry, and people are completely at peace with their environment. Right? In addition, it may help with things like oxytocin, which it helps us with. And that’s the same thing that gets released when women breastfeed, but people have studied that as well.

Joe Clements 

Sex, hugging, physical contact has released it… petting your dog,

Dr. Grammer 

Bingo, exactly. And so it may increase this empathic connectedness to others, which can be a huge problem with PTSD where people feel out of touch out of space and misunderstood by others, right? So what people are doing now is essentially exposure therapies, but with MDMA, and instead of requiring, say, months of therapy, they’re seeing benefit in as little as three treatments without the discomfort associated with typical exposure based therapies. So there are studies that are ongoing, it’s really, really exciting and hopefully, that will make treatment of PTSD, quicker, more long lasting, and a lot more comfortable.

Joe Clements 

So let me kind of see if I have the mechanics, right that the amygdala, if I’m recalling is the one of the things that’s firing at you, when you’re watching cable news, you’re on social media, it’s that burst of negative emotion anxiety. I know in a lot of social science research, that’s what’s at play when you’re mean tweeting on Twitter as the amygdala is being fired up. In a party situation, it’s useful to calm the amygdala down because your social interactions are likely to be much kinder, much less conflict based, much more cooperative. If you add the oxytocin element, you’re likely to make friends quicker, which is why people do this drug at parties. And if you can shut that down for a period of time, while you’re recalling painful or difficult memories, you can then process that memory without the painful or difficult aspects associated to it. And then condition your brain not to have this over the top response every time it surfaces.

Dr. Grammer 

Yeah, because again, when you bring that memory out, and then you restore it when it’s done being manipulated in your conscious thought it goes back without the emotional valence with it. So kind of like your olfactory thing you mentioned before. When we store memories, we will often store it with other valances whether it’s sensory valence, or emotional valence. And so and that’s the way our brains are designed. So when you shut off the amygdala, you’re taking out the emotional valence from the memory. So the next time it’s recalled it no longer has that anxiety response with it.

Joe Clements 

So are there other drugs that are similar to that? So you mentioned, you know, we talked about anti depressants having an anti anxiety effect. Would that also be the case then with memories when you’re on an anti… or is that the theory behind say, like Zoloft or what was the other one you had said? Paxil.

Dr. Grammer 

Paxil? Yeah.

Joe Clements 

Is that when you reduce that anxiety response in the amygdala, you can then just process through more memories, you can have memories that don’t make you feel sad or feel negative emotion neurotic emotions.

Dr. Grammer 

I think probably, there’s a more basal modulation of that anxiety and fear that comes with the antidepressant. So it’s not so much that you’re having that same mechanism where you’re then bringing it up and then restoring less anxiety, but it’s just kind of taking the thermostat overall, and turning it down a little bit. And particularly serotonergic agents, they can be associated with an overall sense of calm. If you look at couples that fight and you give them Prozac, for example, Fluoxetine, there may be actually less animosity in a couple that they’re both taking it regardless of whether or not they’re depressed. So there may be a part of this, where it helps just kind of placate the severity of uncomfortable feelings of anxiety and rage.

Joe Clements 

So diving deeper into the memory piece, and this is a little bit down a rabbit hole, does the, if you take away the emotional valence of a memory are then you also less likely to recall as quickly other related memories with the same negative emotion tied to them. So let’s say you have PTSD from perhaps multiple events, and they chain against each other. So you remember one thing in Iraq, that recalls a thing from another deployment that recalls a third? If you’re able to break the emotional valence on one does that then prevent the other two from being chained up to it?

Dr. Grammer 

Yeah, I don’t know that anyone’s going to give you a real clear answer on that yet. I think it’s… poly trauma certainly is a problem. And we do know, the more traumas you have the more…

Joe Clements 

There’s a word for it – poly trauma?

Dr. Grammer 

Yeah yeah.

Joe Clements 

Okay.

Dr. Grammer 

The more traumas you have, the more likely you are to develop PTSD. And you see that with deployments all the time, people will be fine the first two, and its the third that gets them more. If you have a history of childhood trauma, you may get through that, okay, but then you get deployed overseas, and then everything gets reactivated all at once. Pandemic is a great example of this. So the pandemic is horrible when it comes to exacerbating PTSD, because you now have an unseen threat that’s constantly around you that you can’t completely mitigate. That’s there all the time. Right? And so that’s going to increase that threat vigilance, that’s going to resonate with any kind of trauma you’ve had in the past where you felt vulnerable and unable to protect yourself…

Joe Clements 

 And people’s physical proximity to you is perceived as a threat. Yeah.

Dr. Grammer 

Yeah, yeah absolutely. So if you quiet one, does it help quiet the others? I think that’s an interesting thought. I don’t know that anyone could definitively tell you that yet. But it does make sense. And we do know that if you began to treat PTSD, holistically like that, then whether it’s a singular trauma or poly trauma doesn’t have to be so compartmentalized, right? You may get a synergy of benefit. And part of the reason for that is, you know, one of the ideas of PTSD is that there’s a generalizability of the stimulus that creates that intrusive recollection or kind of recurrence of the memory. And the more you can bring that down and get rid of it. So some forms of exposure therapy, go back and try to clarify what you went through. So it’s burning rubber, for example, from a tire that caught fire or something. So anything that smells burnt, may do that. Well, you want people to understand that no, this was a burning tire from your automobile accident on this date, and not all burning rubber. And you’re clarifying that. So I think anything that can help someone better crystallize, and integrate that memory as a circumscribed event, rather than a holistic phenomenon in their life has a chance of overall improving any kind of trauma they’ve had in the past.

Joe Clements 

So this is an area where the brain being a pattern matching machine that actually works against you, because it’s patterning all burned after that one specific burn tire, for example.

Dr. Grammer 

Yeah, I think one way that people have described PTSD is it’s a deficit in forgetting.

Joe Clements 

Interesting.

Dr. Grammer 

Yeah, you just you can’t move past it. You get stuck in the past.

Joe Clements 

I was gonna one last question on that. Is there is there truth to this idea of collective PTSD? So you mentioned the pandemic, for generationally for me, like, I don’t know, everybody in my high school, watch 911 happened live on repeat for an entire day. Is there this idea that potentially millions of people could be traumatized at one point and you could have millions of people with PTSD walking around from from one mediated event? Not an experienced event?

Dr. Grammer 

Yeah. So you can have vicarious traumatization, right, where you witness something where people die, people get hurt, people are even at threat of dying. And that is traumatic for you. One easy place you see that is in caregiver fatigue, right. So we’ll take the pandemic again. You have healthcare providers, who see people every day of their career, not do well and do well but the volume and the senselessness of the deaths from COVID-19 has just finally overwhelmed them until you have an entire kind of population of health care workers now that are struggling with how to make sense of that all.

Joe Clements 

Mhm.

Dr. Grammer 

Right? You know, World War Two, there certainly were large swathes of the planet that were impacted by the war, either directly or indirectly, that is going to change how they see the world and how comfortable they’re in it, then there’s also a very intriguing thing that has a lot more work to be described. But oddly enough, there is a bit of a genetic sort of passing of this trauma. And that’s some really kind of interesting and sort of mind twisting research where if you look at Holocaust survivors and descendants of that, then their incidence of PTSD may actually be higher, even though they were never directly affected by the Holocaust. And we don’t, we don’t entirely understand this kind of genetic memory. But I do think that the consequence of population based trauma may actually precipitate down. And this again, controversial, so I’m sure they’re people…

Joe Clements 

Well, I think I’ve I’ve heard of a study where something similar is replicated in lab rats, teaching a lab rat to be afraid of something also ended up being passed down to its offspring that had never been exposed to that negative stimulus.

Dr. Grammer 

Absolutely. And there’s a biologic mechanism of epigenetics, which is like a whole nother hour, where the way that we kind of unfold our genetic material and encode stuff may allow for something like that to occur. So it’s not in so much that you’re changing your genetic code, but what you’re changing is way that code is expressed,

Joe Clements 

Like the apps that are operating so to speak, in the genetic system.

Dr. Grammer 

Yeah, yeah, exactly.

Joe Clements 

Is there thinking that in the future, PTSD and other things like this may be treated through gene therapy?

Dr. Grammer 

That is not something I’ve heard a lot of work on, or about, I think, gene therapy in general, what I think is gonna happen with gene therapy, honestly, is we’re gonna see that a lot more for things like genetically acquired diseases, like cystic fibrosis is one area where like, that’s like, super cool stuff, right? Then we’re going to start to see that unfold in cancer, I think the thing with PTSD that makes it so hard is kind of like depression. There are multiple variables that lead to the manifestation of the disease. So there’s not some single gene locus that says, a ha, this is the PTSD gene. And that’s one of these reasons why it’s not a silver bullet, there’s no like target, we say this is what went wrong, as opposed to an abnormality in division of cells that then leads to cancer.

Joe Clements 

This goes back to your orchestra example where the orchestra playing the right sheet of music is, you know, it’s the same sound no matter what, but there’s almost an infinite number of ways the orchestra can can go bad and play the wrong music.

Dr. Grammer 

Yeah.

Joe Clements 

Because the woodwind section goes awry, or the percussion section goes awry.

Dr. Grammer 

So, before, I know, we’re getting close on time here, but before we end, I do want to kind of make a plea out there to all the listeners. PTSD can be extremely debilitating for patients, for the family of patients with PTSD for friends. And a lot of people suffer in silence, a lot of people feel like no one is going to understand their plight, they weren’t there, they didn’t experience it. And there is help, that can be available to you, and you don’t have to suffer. You do want to find somebody who does have training in taking care of people with PTSD. That is not always an established competency of every single program that’s out there, right? So you need to talk to somebody who’s been doing this, or was trained in it. And while it can be uncomfortable to start, you can come out the other side, a whole lot more comfortable, a whole lot more peaceful. What you don’t want to do is drift down that path of increasing isolation, and maladaptive behaviors like substance use, or aggression or criminal activity or what have you. I cannot tell you how many people how many patients I’ve seen who come to me after they’ve left a trail of tragedies that are a consequence of their trauma, and then patching that all back together becomes a lot more complex. So please reach out for help.

Joe Clements 

So is that why the substance abuse becomes a problem for people with PTSD?

Dr. Grammer 

Yeah, I mean, a lot of folks will tell you at night like they don’t want to dream, they don’t want to think about it when all the stimuli goes away, and they start lying in a dark room at night. And so they will drink themselves to unconsciousness, but that has real kind of psychological and physiologic consequences that are unhealthy.

Joe Clements 

So last couple of questions to close out. And I’m going to guess I know the answer to this. You probably cannot treat yourself with street Molly, for your PTSD.

Dr. Grammer 

So there’s a good reason why and I know I’ve talked several times about don’t use street drugs. Molly is particularly dangerous, okay. Getting pure pharmaceutical grade Molly is almost impossible right now. It is very likely to be cut with another substance like methamphetamine and fentanyl. And that, candidly can kill you don’t do it, you also shouldn’t do that without the construct of the therapy that we just talked about. The training for this stuff does not come from like an afternoon seminar like they… people go to school for a long time to learn how to do this. And so you’re going to want to do this with where you know the exact dosing that you get in a controlled setting with a therapist who’s been trained specifically how to do this not on your own with your buddy, who’s a nice person.

Joe Clements 

That seems to be the rule for a lot of the treatments we’ve discussed.

Dr. Grammer 

Agreed. Agreed. So any other questions?

Joe Clements 

No, I think we’re good.

Dr. Grammer 

All right. Well, again, Joe, always appreciate you coming onto the podcast here. To all of our listeners, thank you so much for tuning in. I think the last podcast we have coming up for this season is going to be for medicinal uses of marijuana. So stay tuned for that.

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