Below is a transcript of the interview on overcoming PTSD:
Dr. Hedberg: Well, welcome, everyone to “Functional Medicine Research.” I’m Dr. Hedberg and really looking forward to today’s conversation with Dr. Robert Hedaya. I first heard him speak at the Institute for Functional Medicine last year on PTSD and so I wanted to have him on the show to talk about that. He is a medical doctor. He’s been on the cutting edge of medical practice, psychiatry, and psychopharmacology since 1979. With the publication of his first book, understanding biological psychiatry, in 1996, he pioneered the use of functional medicine in the psychiatric field and he is now pioneering the use of G-guided laser treatment of neuropsychiatric disorders.
Dr. Hedaya is a clinical professor of psychiatry at Georgetown University Medical Center where he’s been awarded the teacher of the year on three occasions while teaching courses on affective disorders, cognitive therapy, and one of my favorite topics, psycho-neuro-immuno-endocrinology. Since 1983, he’s on faculty at the Institute for Functional Medicine, the author of two additional books, “The Antidepressant Survival Guide,” and “Depression: Advancing the Treatment Paradigm,” and he’s the founder of the Center for Whole Psychiatry and Brain Recovery. Dr. Hedaya is an editorial volunteer for Advances in Mind-Body Medicine and Alternative Therapies in Health and Medicine. He’s been featured in local and national media on things like “20/20”, “60 minutes,” “Vogue,” “The New York Times,” and “The Washington Post” on many occasions. And he’s a frequent nationally and internationally recognized speaker. His website is wholepsychiatry.com. Dr. Hedaya, welcome to the show.
Dr. Hedaya: Thank you very much for having me.
Dr. Hedberg: Excellent. So, like I said, I heard you speak at IFM last year and was really interested in your research and studies on PTSD. Why don’t we start by you just talking about how your career evolved from traditional psychiatry into functional medicine and now using some cutting-edge treatments for treatment-resistant depression, dementia, PTSD, chronic fatigue, and technologies like laser?
Dr. Hedaya: Okay. Well, it’s been a long arc and I would say that the main thing is that I always try to follow where the science guides me, what’s the truth that as far as I can best make it out to be. So, rather than being afraid of stepping outside of the box, you know, I just feel it’s my responsibility, as a clinician, helping people to always try to do the right thing, and the right thing for me means doing what the science dictates, and sometimes it’s benched to bedside science. Sometimes, you know, like translational medicine, sometimes you have the studies, but following the principles of biology and physiology and sometimes you have to take a leap because you can’t wait until the studies are there.
So, the way it started for me was, 1983 about, I was treating a woman with panic disorder and she was not really recovering. And panic disorder is pretty easy to treat. Whether you use cognitive behavioral therapy, which I was using, or medications or combination of the two. So, it was about a year and she wasn’t getting better and she paged me, I had a beeper back in those days, on a Saturday night, I was at a wedding and dancing and my beeper went off and looked and there was a number and I went to find the phone booth and called her and she was having a panic attack and I was like, what is going on with her? You know, this should have been over a long time ago.
Anyway, I went into the office early Monday morning to see, look it through her chart, see if I can find any clues. And I saw that the size of her red blood cells in the mean corpuscular volume was a little bit larger than the…a little bit outside the range. The reference range was about 101, the normal range is 80 to 100. I was trained to think, well, it’s just really not that far out of the norm, so ignore it. And to be frank, I didn’t really know what it meant, anyway, so I have ignored it. Well, I did a little research and it turns out that, as you know, is a marker for B12 deficiency, macrocytic anemia, she had a little bit of anemia. So, anyway, I treated her, I did a Schilling’s test to double-check my hunch, treated her with B12 and with the first injection the panic disappeared.
At that point, I was like, “Whoa.” You know, the head is connected to the body by this thing called the neck and I gotta figure out, what else am I missing? You know, because as you may know in psychiatry, there’s a very, very high percentage of people who don’t get well. Now, I think it’s over 60% of psychiatric patients are on at least three medications. So, it wasn’t like that back then, but there was a revolving door phenomenon. So, one thing leads to another and, you know, I’ve learned over the course of years always trying to understand what’s going on. You know, you learn more and more and more and more and before you know it, you know, you’re really…I’m practicing psychiatry and neurology, but also doing immunology, endocrinology, gastroenterology, you know, the whole functional medicine thing.
And then that, in the last 2 or 3 years, really since in 2009, I reversed my first case of dementia and in the last 3 or 4 years, I have been treating a lot of neurodegenerative disorders using functional medicine and using other technologies now like hyperbaric oxygen or light treatments to the brain, etc. So it’s been a long path but basically, I follow…The principle is that I would say is you have to follow where the science takes you and what the logic of the process is and not really be so worried about sticking with, you know, the traditional approaches because that’s what the evidence base shows because the evidence base is skewed. We know it’s skewed by the pharmaceutical companies. We know it is…and that’s not to say medication is bad, but it’s certainly skewed. And we know that there are limitations on who’s gonna do what studies if there’s not a profit in it. So, now, this idea of evidence-based medicine is nice in theory, but in practice, it has its limitations. So, you have to use logic and common sense. And that’s really the main idea.
Dr. Hedberg: Let’s dig into PTSD because this is an area of your expertise and I think a lot of practitioners and people as well may look at PTSD as a single event, you know, say a car accident or sexual trauma, something like that. But there can also be ongoing issues, say, with a parent, or teacher, you know, loved one, things like that. Can you talk a little bit about how you define PTSD and the variables involved in trauma that’s not just a single adverse event?
Dr. Hedaya: Yeah, sure. So, PTSD really, there’s a trauma, the actual post-traumatic stress disorder actually is a repetitive assault on the mind, on the body, the spirit, and this repetition of re-experiencing the trauma over and over again as if it were really happening at this point in time leads to very, very serious consequences in the body. I mean, it’s really a whole mind, body, soul event. And, you know, the studies are very clear that PTSD is not a psychological problem per se. It’s actually a whole-body problem. It affects…I think there are four studies that show that gastrointestinal ulcers are associated with PTSD, there’s type two diabetes is associated with PTSD, there’s certainly earlier mortality. Seven out of 10 studies show that there’s a 29% increased risk of mortality. Inflammatory markers are up in PTSD, like interleukin 6, 1-beta CRP. Telomere length, which is associated with biological aging, kind of a marker of biological aging, in all of the studies that we’ve done, six studies, consistently show that people with PTSD have shortened telomeres. So, PTSD puts the person at risk for many, many disorders and it needs to be conceptualized as such. And so, to me, the body is under siege continuously and repetitively in PTSD.
Dr. Hedberg: And childhood trauma, adverse childhood experiences, the ACE scores and things like that, is that going to make the patient’s PTSD more severe as an adult? The more childhood trauma they have, the more severe the PTSD as an adult or is that highly variable depending on the patient?
Dr. Hedaya: Well, it’s a vulnerability factor. So, if you take a hundred people who have had childhood trauma and there is to some degree, a dose-response, right? The more trauma you’ve had, the more vulnerable you are. But it is overlaid on other factors. So, how much support does the person have? What’s the genetic makeup of the person, you know, the child? There are a variety of genes, which I talked about at the presentation that you were at, but we can think of them as resilience genes. That’s the NR3C1, FKBP5, corticotropin-releasing hormone-binding protein, and corticotropin-releasing hormone receptor 1 and 2. These are all associated with the risk for PTSD. And so, if a person has, a child has a high compliment of these variants in these genes, then essentially what it is, is that their stress response, their resilience to stress is reduced, and they have increased risk for PTSD, for immunological problems, for depression, and even suicide. So, it’s really a combination of factors that are at play.
Dr. Hedberg: One of the things that was most interesting to me in your presentation was the slides on the specific changes in the brain that happen from PTSD, limbic system, the prefrontal cortex, and other areas. So, basically, what you were saying is that these changes in the brain occur and it begins to inhibit the patient’s ability to make rational decisions and be logical and things like that. Can you talk a little bit more about those changes in the brain and how it affects rational decision making?
Dr. Hedaya: Yeah, sure. I mean, I think it’s interesting. So, a simple way of putting this, this is very simple, okay, is that you can think of the brain as like an ice cream cone, that’s the analogy I use with my patients. So, the cone itself is the brainstem, you know, that controls your respiration, your temperature, your heart rate, etc., basic functions that keep you alive. The first scoop of the ice cream cone is your emotional brain. And the emotional brain controls your emotion, your rewards, your fear, your aggression, sexual desire, and drive. And then the last scoop would be your thinking brain, which we refer to often as the frontal cortex, or the very front of that is the prefrontal cortex, which is really what people talk about most of the time.
So, basically what happens is with the repetition of stress in PTSD, there’s a remodeling of the brain. And so, in a simple way, what happens is the limbic brain, the emotional brain, gets overactivated repeatedly and the thinking brain actually is inhibited because the thinking brain and emotional brain actually are…they reciprocally inhibit each other, meaning it’s like a seesaw. If the thinking brain is more active, the emotional brain is quieted. If the emotional brain is more active, the thinking brain is quieted. And so, if someone is perceiving, you know, that they’re under stress all the time, say due to PTSD, right, and they’re not in control of that, that’s just arising from within, then what happens is the neural connections between these two broad areas actually change in structure.
And so, the prefrontal cortex actually does shrink, the neurons actually shrink. And that is mediated by a lot of things such as the glucocorticoids, meaning cortisol can be too high or there can be inflammation so you might have NMDA receptors being activated. You might have cytokines from inflammation coming from the gut or from other areas. The endocannabinoid receptors are involved in that. That’s very simplistic, but whatever it is, whatever the mechanism is, there’s actually a remodeling in these areas. So, the prefrontal cortex itself is shrinking but the amygdala, one part of the emotional brain that is involved in fear sensing, the valence of a situation is a dangerous situation to me, the amygdala actually increases in size. The density of the neuronal spines increase.
So, you’re really having a remodeling of the brain. Now, the brain is always remodeling, right? If you learn to play the piano and you practice a lot, you’re remodeling your brain. So, that’s good news because if you can deal with the PTSD and start working on activating your thinking brain and reducing the PTSD response, you know, and reducing the things that are stressing your system in all areas in functional medicine matrix, then you can remodel your brain towards health as well.
Dr. Hedberg: Excellent. So, I got to thinking about some specific scenarios that I wanted to run by you and it’s in regards to people who are in chronic pain and the decision to have a surgery. So, hypothetically, let’s say someone has had a surgery for pain, it’s very traumatic. They had a lot of pain prior to the surgery and the surgery just doesn’t really work. In fact, it makes them a little bit worse and the doctor or the surgeon recommends another surgery and the patient decides to move forward with that because, you know, they trust their doctor. And that appears to be the best option for them at the time, at least from a conventional medical perspective.
So, if they’re traumatized and they lack the ability to make rational decisions about having another surgery, that’s probably just gonna make them worse, doesn’t someone need to step in and help make this decision for them? I mean, as doctors, we’re taught that we can’t make decisions for people. We can only present them with all the best available information and then they make the decisions themselves. But if they’re traumatized and their brain has changed, should they really be making these types of decisions on their own? And it’s a big decision because it could potentially make them worse. What are your thoughts on scenarios like that and a practitioner actually stepping in and saying, “No, don’t have this right now, let’s wait.” What do you think about that?
Dr. Hedaya: That’s a wonderful question because it’s kind of a scenario we come up against in many ways as clinicians. And so, the way I would approach is this. I would say, first of all, you really wanna educate the patient and explain your thinking, and second of all, you really wanna get someone else involved, a family member, and explain your thinking and have facts. So, for example, I’m not sure why the first surgery was traumatic exactly. Can you say why it was traumatic or is it a more general question and not a specific situation?
Dr. Hedberg: Well, yeah, I mean, there are some specific situations, for example, with pelvic pain and surgeries in that area can be very traumatic for some individuals, both men and women.
Dr. Hedaya: The trauma being what? What’s the nature of the trauma, having been cut in that area or what’s the…?
Dr. Hedberg: Right. Yeah, being cut in that area.
Dr. Hedaya: Yeah. So, I would say, so if you’re dealing…you’re saying, basically, this is a patient, say, who is kind of a little not thinking thoroughly through this. Right? They’re just hoping desperately for a quick solution because they have so much pain. They were traumatized. The surgeon is saying, “No, we’ll go in and we’ll do this again.” Right? I guess what I would wanna be armed with is facts and I would present the facts to the patient and to the family. And the facts might include something like, you know, “Look, your CRP is high. You have a lot of inflammatory signals coming from your gut.” You know, “The neurotransmitters from your gut are changing your brain and we know that a significant portion of pain is in the brain. It doesn’t mean you’re not having pain in your body also, but we know some of it is in the brain. And guess what, we also looked at your genetics and we see that you are prone to having inflammation or you have problems in those stress resilience genes that I was talking about, NR3C1, etc., and maybe you wanna do something like a SPECT scan to look at how the brain is functioning and whether the pain is coming from the brain, or QEEG and see if the pain circuitry is activated.
In other words, really have facts to back up your argument. And then I would say strongly if I felt the facts were, you know, there, “This is my medical opinion.” Obviously, you’re not gonna be in control. You can’t declare the person incompetent because they’re not really gonna fit the definition of incompetent. But I would say…I’m not shy when I have a clear opinion. I feel it’s my responsibility to be very clear about what my opinion is and what the pros and cons of things are. What I would do if it were me or my family member, I usually couch it that way. And if I’m not sure, then I’m not sure, you know? But I’m not shy because I feel that’s my responsibility to the patient to be very clear.
Dr. Hedberg: Right, right. I’m really glad to hear you say that because, you know, a lot of patients just, they don’t have all the information or they’re severely traumatized and they’re confused. And if you can give them a strong opinion based on facts and your medical opinion, I think that could save someone from a lot of lifelong pain, just stepping in and doing that.
Dr. Hedaya: Yeah. You know, the other thing is, I find that education is so powerful. So, I’m sitting with people, I’ll pull out a slide deck that I’ve done or I will, you know, draw on a whiteboard or I will show them examples. I mean, I try to explain to them the physiology or the processes. You know, they don’t know what’s going on in my mind, you know, what I’m thinking about. I’m thinking about four or five things. They don’t know that. So, I have to take the time to stop and actually give them the science as I know it and people find that to be comforting. And then the other thing is, you know, surgery, unless it’s emergency surgery, you know, nothing wrong with delaying surgery, you know, to at least get the body in a better position to heal. Right? So, yeah. So, I think that’s the general approach I would take, you know.
Dr. Hedberg: Excellent. So, let’s talk a little bit more about that. Your approaches, what you do in your practice. So, what are your main approaches to brain and mind-based disorders in your practice?
Dr. Hedaya: So, you know, I kind of divide what I do into two things. I call it the brain and the terrain. So, the first thing I deal with is the terrain. You know, what’s the physiology? You know, what are the things outside of the brain that are affecting the brain? So, that could be anything from the psychological or the social or spiritual isolation or lifestyle habits, right? And then…or circumstances, or, you know, religious affiliation, or non-affiliation, or job loss, right? All that psycho, social, spiritual stuff. That has to be taken into account. And then I look at the functional medicine matrix or I look at digestion. I look at nutrition. I look at immune function core, infections and inflammation. I look at detoxification factors or toxicity factors, whether it be mold or heavy metals or organo-toxins. I look at mitochondrial function to the degree that we can by looking at mitochondrial, biochemical markers and genetics to some degree.
And then I will look at all of the hormones because in psychiatry and neurology, certainly in psychiatry, there’s not one hormonal disorder that cannot present with psychiatric problems. If you go to a textbook of endocrinology, look up any disorder, you’re going to see symptoms that are psychiatric and oftentimes neurological symptoms as well, but certainly psychiatric. So, I look at, very thoroughly, all the hormones and I do spend a lot of time on genetics because the genetics are vulnerability factors. So, what I do is I look at genetics and then I correlate the genetics with the history and with the biochemical data that I get. And so just because you have a variant in some of your genes doesn’t mean they’re causing any problem because there are many factors from the gene, you know, to what’s actually going on. There are other genes that modify, there’s methylation, there’s acetylation, there’s RNA production, there’s protein folding, there’s many, many steps along the way. So, you can’t just look at a gene and say, “Oh, you got a problem.” You have to correlate it with the data that you have. And so that’s kind of what I do.
So, that’s the terrain. That usually takes, depending on how quick people are, that’ll take me a few months, anywhere from three to five or six months to deal with for most people. And then once the terrain is straightened out then I will look at the brain itself, usually the QEEG, MRI, Neuroreader to look at specific brain regions, whatever it is that I need to do. And then if there’s still stuff going on inside the brain, which oftentimes there is, the functional medicine helps people feel a lot better. It’s pretty remarkable, but I find when I look in the brain in a functional way using the QEEG, I’m surprised often at the dysfunctions that are still there. Then people are…you know, the brain is working hard to compensate often for other things. It could be a brain injury that, you know, somebody had, they didn’t know they had or, you know, axonal injury from a car accident or rotational injury or thalamocortical disconnection, you know, the variety of things. So, that’s the second half of what we do is you look at that and then based on what we see, we will work on what’s going on inside the brain.
Dr. Hedberg: So, the QEEG guided laser is something that you’re using and neurofeedback as well, hyperbarics. What exactly are you looking for and how does the QEEG guided laser work?
Dr. Hedaya: Well, so, you know, the idea is that if you look at QEEGs and you learn how to read them, you see that…the dysregulations that you’ll see in…Different neurons fire at different frequencies. So, some neurons are firing at 1 Hertz or 1 cycle per second, some are 2 cycles per second, some are 30 cycles per second, right? So, it goes from 1 to 40 or 50 or 60 but I’m looking at the neurons that fire 1 to 30 times per second as different populations. And the ones that fire at, say, one to four are the delta, we call it delta, those are the neurons that are firing from the deeper parts of the brain. Really, you could even think of it as your unconscious. It’s very deep parts of the brain and they’re slow firing, slow rhythm. You get to the five to eight or nine, you’re in the theta range and those come more from the, I’m gonna call that the subconscious. Not the unconscious but the subconscious. So, these are areas that are, you know, maybe in the limbic area, in the emotional brain or deeper in the thalamic area. The thalamus is a kind of a sensory integration area.
And then we look at the neurons that fire roughly 10 to 12 cycles per second known as the alpha frequency. Alpha is like your day-to-day thinking, you know, I’m gonna go to the grocery store and I’m gonna pick up some groceries and I’m gonna do this and I’m gonna…you know, just your day-to-day thinking. And then we move from there into the beta frequencies, which are, you know, 13 to 30. Some people break it into two or three categories, which is involved with higher-order thinking, more complex thinking also associated with anxiety.
So, with QEEG, you can look at all these populations and each of these populations in different circuits in the brain, on the surface of the brain and see how well connected they are. Sometimes different areas of the brain are not talking to each other very well. Sometimes they’re screaming at each other and overcompensating. So, you have to really kind of figure out what’s the source or sources of the problem? You know, where, in the brain, is it? Is it diffuse, is it specific? Was it from the traumatic brain injury? You know, what is it? And then based on that, you can design a treatment to correct the problem using, you know, a number of modalities.
Dr. Hedberg: Excellent. So, let’s talk a little bit about social isolation. I wanna get your opinion on this. There’s more and more studies coming out on loneliness and social isolation and how these affect inflammatory cytokines, stress hormones, the brain, things like that. And I’m interested in your opinion on how social media could be amplifying social isolation because obviously, people are connecting more and more on social media and not in person. So, can you talk a little bit about the social isolation, loneliness, and potential social media dynamics?
Dr. Hedaya: Yeah, so I mean, you know, I would say that broadly speaking, there’s an atomization of society, meaning we’re being atomized, we’re being turned into isolated single atoms so that our connection to each other, even though it still exists, is less and less apparent. And so, it’s so clear, you know, if you actually go back to biblical times if you read the Bible, but I’m sure even forever and, you know, what’s one of the worst things that a person can do or can be done to a person is to shun them, to separate them from the tribe, to, you know, cut them off from their community or from their family, you know, that actually can kill a person. So, you know, that’s the power of isolation, shunning, cutting off, etc.
How does it affect you? Well, in reality, we’re all connected even though we think we’re separate individuals, we are all connected. So, you know, my brain right now is connected to your brain and my brain is connected to the people who are listening, etc. So, it’s all connected, you know, that’s without question, right? So, if you’re breaking the connection, then how can an entity survive, you know, without the resources and connectivity of the others? You know, it’s just a fundamental principle. You know, hopefully, I’ve made it clear, it’s so fundamental. And this is why a religious practice is very important. I say religion incorporating spirituality, but as part of a group because not only do you want to connect to the greater consciousness, which is the spiritual, but you want to do it with likeminded people in a constructive way, in a way that is life-affirming and supportive and, you know, directly to higher and better purposes.
So, you know, some people have bad families or abusive families or, you know, and they just can’t get it from the family. They gotta get it somewhere else if they’re gonna build a healthy network. That’s very, very important. Studies show over and over that a person who is isolated, lonely has vulnerability for psychological problems and medical problems and shortened lifespan and, you know, heart disease and, you know, etc. So, when it comes to social media, you know, I think what I see…and I’m not an expert on that because I’m in the older generation and I don’t do the Facebook thing, you know, with my email, I do what I have to do. But I think what I’m seeing in younger people is that even people who are dating, they try to date by texting. I’m struck, I’m blown away.
You know, we’ve all seen that, people, a group of teenagers sitting around all in the same room or location. They’re not looking at each other, they’re not talking to each other, they’re texting. So, I am concerned that that’s part of the reason we’re seeing so much suicide. Not just the social media, but it’s really the atomization of society where we’re becoming isolated. You know, everything is becoming kinda, I like the word atomized because it’s, you know, nondescript, you know, you try to call a company and what do you do? You don’t get to talk to a human being, that’s for sure. You know, you’re just…you know, they do whatever they have to do so they don’t have to talk to you. We’re all experiencing that, everybody.
So, the answer to that is that you have to recognize this and you have to go out of your way to develop healthy, supportive networks and you have to control not only the food that comes into your mouth, but you have to control the media that comes into your mind. The messages that come into your mind are very, very, very important because the energy that you allow into your mind and into your life will actually change the actual nature of your life. Energy creates matter. You look at physics, everything is energy. Everything is energy. Matter is just slowed down energy. So, it’s all about energy. So, your psychological energy, the media that you allow in is as important as the food you take in.
And, you know, my feeling is that we need to be educating people about this. Young people need to be educated, etc. And parents really need to lead. Parents are afraid to lead their children in this. They need to lead their children and teach their children. And, you know, a child who doesn’t have a parent in charge is a child who’s anxious, scared, and out of control. Whether it turns into OCD, or substance abuse, or poor grades, or ADD, whatever you wanna call it, parents must lead, they must lead. And they should lead based on time-tested traditional values, you know, is what they need to lead with. You know, responsibility, discipline, you know, determining what your purpose is in the world and working hard to bring the world to a better place. I think that’s what we need.
Dr. Hedberg: Well said. Well, this has been really educational, Dr. Hedaya. How would you like people to find you? I mentioned your website earlier, so let’s mention that again, and if there’s anything else you want to mention about your practice, you know, if you’re taking on new patients, things like that, just please let us know.
Dr. Hedaya: Yeah. No, the best way to reach me is really through my website. It’s wholepsychiatry.com, like Whole Foods with a W, wholepsychiatry.com. There’s a contact form. There’s a lot of resources on the website. I have videos, lectures, it’s like, I don’t know, 200, 300-page website. A lot of good information there. And, you know, I think that what I would say is that what I do is precision medicine, it’s very, very precise. It’s very detailed. It’s extremely thorough. I just spent six hours with a new patient last week. And so, it’s not, you know, come in, get your pill, walk out, you know, 30 minutes. This is for people who really wanna drill down and are very motivated and determined to improve their health, their wellbeing so that they can be a force for good in the world. And that’s what we like to do.
Dr. Hedberg: Excellent. Right. So, Dr. Hedaya’s website is wholepsychiatry.com. Thank you for coming on. And there will be a full transcript of this on drhedberg.com. So, to all the listeners, just search for PTSD or Dr. Hedaya and this interview and transcript will come up. So, take care, everyone. Thanks for listening. This is Dr. Hedberg and I’ll talk to you next time.