#347 – Peter's takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma ｜ Quarterly Podcast Summary #5
Episode Stats
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Summary
In today's episode, we cover interviews I did with Jeff English, Ashley Mason, Sanjay Mehta, Sean Mackey, and Sue Desmond-Hellman. We revisit topics around trauma, therapy, mental and emotional health, insomnia, cognitive behavioral therapy for insomnia and improving sleep, radiology, common misconceptions around it, how radiation is used in not just cancer therapy, but also for treating inflammatory conditions such as arthritis and tendonitis, pain, chronic pain and how to treat them, and how AI is impacting medicine now and possibly in the future.
Transcript
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Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
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I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can access
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the AMA episodes in full, along with a ton of other membership benefits we've created,
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or you can learn more now by going to peteratiyahmd.com forward slash subscribe. So without
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further delay, here's today's sneak peek of the ask me anything episode.
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Welcome to another quarterly podcast summary episode of the drive. In today's quarterly podcast
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summary, I'll discuss what I learned from some of the recent episodes of the drive, focusing on what
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I think were the most important insights, as well as any changes in my behaviors as a result.
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This shouldn't be seen as a replacement for listening to or watching any of the original
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episodes, but this may be a great way to reinforce things that you already saw, or at least point
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you back to an episode you missed. In today's episode, we cover interviews that I did with
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Jeff English, Ashley Mason, Sanjay Mehta, Sean Mackey, and Sue Desmond-Hellman. We revisit topics
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around trauma, therapy, mental and emotional health, insomnia, cognitive behavioral therapy
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for insomnia and improving sleep, radiology, radiophobia, common misconceptions around it,
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how radiation is used in not just cancer therapy, but also for treating inflammatory conditions such
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as arthritis and tendonitis, pain, chronic pain, and how to treat them, and finally, discussions
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around oncology, cancer drug development, and how AI is impacting medicine now and possibly
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in the future. If you're a subscriber and you want to watch the full video of this podcast,
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you can find it on our show notes page. If you're not a subscriber, you can watch the sneak peek
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of the video on our YouTube page. So without further delay, I hope you enjoy this special quarterly
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podcast summary AMA of The Drive. Peter, welcome to another quarterly podcast summary Ask Me Anything
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episode with Peter Attia. How are you doing? Very well. You excited to be here? I am. No place you'd
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rather be? No place I'd rather be. Nothing I'd rather be talking about. Even a race car? Maybe.
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Okay. Well, it's good to know you're still being honest. So today, we're going to cover looking
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back at recent episodes on the podcast. As a reminder for people, these quarterly podcast
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summaries, they are a way for us to talk about and gather insights from you on what you learned
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from previous episodes, where your behavior changed, where you're thinking about things differently,
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but they're not necessarily a replacement for these episodes. What we often find is people kind
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of use this accompanying listening to the episode or even going back and listening to some sections
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again based on these insights. And so for today's episode, we're going to look back at previous ones
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with Jeff English on all things mental, emotional health, trauma, therapy, Ashley Mason, all things
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related to getting better sleep, insomnia, CBTI as it relates to improving sleep. We have Sanjay
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Meta, looking at radiology, radiation, different ways to look at how that can be used to cure cancer,
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and also interestingly, arthritis. We have Sean Mackey, all things related to pain, chronic pain,
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and getting over pain. And then Sue Desmond Hellman, which was an interesting episode,
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kind of looking at her career, but ultimately looking at cancer oncology, drug development,
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and even an interesting segment on AI and medicine. So a lot to talk about,
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a lot of different topics, which I think speaks to who we have on the podcast, which is a variety of
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people, variety of angles. So I think it should be a good one. A lot of different things to chat
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through. Anything you want to say before we get started? No, let's dive in. Perfect. First one,
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Jeff English, all things trauma, mental health, therapy, et cetera. Do you kind of want to walk
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through your insights from that episode? This was an episode I was really looking forward to doing
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as we discuss in the episode. I've obviously known Jeff for many years. I owe him a great debt of
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gratitude. And this is one of those episodes where between the time we recorded it and the time it came
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out is probably eight to 10 weeks. During that period of time, I sent the unedited, just straight
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audio file of it to no fewer than 15 to 20 people. Meaning I couldn't even wait for this episode to
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come out to be sharing it with people. So I think that probably tells you something. I will be
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completely comfortable stating that that will be a record that will last for some time. There's no
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scenario I can think of where I've taken a podcast before it comes out and shared it with so many
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people. I would say that most of the people I shared it with not only found it to be incredibly
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valuable, but actually wanted to sort of engage with Jeff on a professional level after that. So
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it's one of those podcasts where if it resonates with you, it's really important. You're going to
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share it a lot. Okay. So what was this episode about? I mean, it really was a great episode about
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understanding trauma. And it's such a loaded word that I think it's understandable why people might
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have some skepticism around that. I think the word does get used a little bit too much,
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but Jeff has a great definition for it. And I jotted it down, right? Which is that
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trauma is a moment of perceived helplessness that activates the limbic system. This can be
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a wounding event, a major event, or maybe a series of smaller events. And those typically get referred
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to as big tree and little T traumas. So a big T trauma is something really obvious being the victim
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of a violent crime, for example, and little T traumas are like a thousand paper cuts. A parent that was
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there, but just really wasn't paying attention to their kid. And those can be damaging in different
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ways. So what Jeff talked about was that in trauma, too often people focus on the what happened
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part of the equation, but he thinks that it's more important to focus on the how did I adapt
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part of the equation. And as he talked about it, the sin qua non of trauma is that there is a
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disconnected version of a person that shows up to life relying on maladaptive strategies to replace
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connection with something else. I think that is a remarkably succinct way to explain things.
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And it's not judgmental. It's just saying that something happened, a series of things. There have
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been adaptations. Those adaptations have led to disconnection and maladaptive strategies. This
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could be things that are perceived of as quote unquote bad, like alcohol, drugs, gambling, but it
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could be also things that are perceived of as good, such as work or perfectionism. All of those things
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replace the sense of connection. So this is just an episode that I think you have to go back and listen
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to. But to me, that was the most important takeaway. He spoke about implicit and explicit
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memories. So people can explicitly remember an event and think objectively, as I think about that,
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it didn't really impact me, but implicitly it is impacting them through anxiety or some other type
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of discomfort. He had a great saying, which is if it's hysterical, it's historical. So I think about
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this often when I overreact emotionally, when I calm down, I'm usually asking myself, what was that
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really about? Was it really about the thing that you blew up over? Or was there something deeper
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that this is reminding you of in terms of a vulnerability or something like that?
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Very important distinctions here between guilt and shame. Guilt is about, as he described it,
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making a mistake. Shame is about being a mistake. Some people refer to this as healthy shame and
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unhealthy shame. Again, it's not necessarily one way to think about this. Okay. We talked about the
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trauma tree. I've heard so many different people talk about trauma in so many different ways.
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I still think this is one of the better models. And it's a tree because it has roots and it has
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branches. And the roots are below the ground and the branches are above the ground. And that is a
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metaphor for the fact that the roots or the causes are not necessarily visible, while the adaptations,
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the branches, the branches are indeed visible. So very important to understand in this model that
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intention is not a requirement for the roots of a tree. What do I mean by that? Sometimes the wounding
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events, i.e. the roots, are not intentional. They're not driven by people who are intending to hurt.
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This is, I think, a very important thing for people dealing with trauma to understand,
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because it's very easy to minimize an event that had an impact on you as a child, for example,
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if you believe that the person who was responsible for this wasn't trying to hurt you. And that's
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often the case. So keep that in mind. So what are these? So the five roots are broken down as abuse,
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which can be physical. Typically that is pretty deliberate. Emotional, sexual. Again, obviously these
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are generally quite deliberate. Religious. So there's an example where it might not be with a
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malintent, but of course it has bad outcomes. The next would be abandonment. This can be physical
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abandonment, literally someone being abandoned by a parent, but it could also be emotional. Neglect,
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which is obviously distinct from abandonment in that the care provider is still present,
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but is not paying attention to the child. Enmeshment, which is basically boundary violations,
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emotional incest. This happens when kids have to grow up far too quickly to be emotional caregivers
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or peers with parents typically. And then tragic events. These are pretty obvious, typically not
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subtle. We talk about war. We talk about things of that nature, violent events. Okay. So then we have
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the branches. And again, the branches are the adaptations here. And the important thing to remember
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here, and I think this is really helpful for anybody thinking through this for themselves or for
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others is that adaptations typically work very well for the child that has been wounded. And again,
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I use the word wounded as kind of a broad emotional term. The problem is they tend to become maladaptive
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later in life. He gives a great example of a father who is physically abusing the mother of his child.
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And whenever this happened, the child would run into his bedroom out of fear because dad is getting
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violent, he's hurting mom. But one day the child's fear that his mother was going to be hurt was so
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great that he ran into the bathroom and pretended that he was sick as a way to distract the father.
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So the father screams at the mother and says, ah, look what you're doing. Your hysterical whining has
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made your son sick. And this temporary distraction actually prevented his father from injuring the
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mother. So that was an amazing adaption. That child basically learned that he could be deceptive
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and manipulative and it actually worked. It was a really good adaptation and it probably will serve
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that child well for some time. The problem is it will not serve that child well as an adult.
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He describes these adaptations as old friends that serve you well, but lose their utility and become
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destructive as you age. And so again, what are these four branches? These four branches are
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codependency, which he calls an outer reach for inner security. Addictive patterns. Again,
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these are the most obvious in some ways. So substances, but also work, process, obsession,
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things of that nature. Attachment issues where the common thread is sort of insecurity. So there's
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kind of an anxious attachment, avoidant attachment, disorganized attachments. He goes into these in
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details. And then just kind of a bucket for all other maladaptive strategies here. And I'm sure people
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can think of many examples. So I think I've learned a lot over the past seven or eight years on this,
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but I think Jeff sums it up so well. And I've seen this over and over in myself, in my patients,
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when you're working through trauma, or if you're on the fence about whether or not you should work
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through trauma, it's worth remembering. You're either going to deal with it or it's going to deal
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with you. These things cannot be buried. They're going to always, like a whack-a-mole thing,
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always show up at some point. And you can't play whack-a-mole indefinitely. The first step,
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I think, is just accepting that that's the case and that there's a better way to be. And that these
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coping strategies, while incredibly valuable, are probably not helping you. That you may indeed be
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passing on maladaptive behaviors to your kids if you're a parent. And dealing with something that he
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describes as putting the adaptive child out of the driver's seat and into the back of the car.
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So those are probably some of the important things I would take from that episode. I don't think that
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this summary even remotely serves as a substitute for listening to that. So if you missed that episode
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and anything I said even remotely piques your curiosity, I think you've got to go back to it.
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Aside from the insights, are there any behaviors that you changed? Maybe from your relationship with
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Jeff even prior to this? Or even that behaviors that after people listening to Jeff could start
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to apply in their own life if they're trying to kind of figure this out for themselves?
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To practice, we've talked about this on other podcasts, but practicing or understanding what
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your practice looks like to expand your distress tolerance window. I write about this quite a bit
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in the final chapter of Outlive. But it's sort of knowing the things that you do that give you a
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greater operating window. So for example, for many people, meditation is a great tool to increase
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the probability of responding as opposed to reacting when something happens. Learning the language of I
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statements. Basically taking ownership for what you think, what you feel, what you do. Working through
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this triad that he describes as the triangle of vulnerability. So sadness, shame, and fear. And trying to be
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curious about where you are on that triangle and being more responsive to your own emotional
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vocabulary around these things. Noticing what your coping skills are. Again, I talk and often joke about
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some of mine that still exist to this day. E-shopping is an enormous coping skill for stress. I just can't
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stop buying stupid things online when I am stressed out. I feel fortunate. In some ways, I'm really glad that
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it's not drinking too much alcohol, but it's still a distraction. Even if the worst thing it does is
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set me back a few dollars, it's preventing me from connecting. And it's preventing me from
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accepting and dealing with what it is that's happening. I think there are other things, but I
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think those would be a great place to sort of start. And obviously, we talk about so much more in this
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episode. Someone who, let's say, has listened to the episode and are listening to us and they're like,
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this is something that I've maybe been ignoring in my own life or pushed aside and decided up to this
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point not to deal with it. I know you also have patients who are like that. And so when you're
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talking to people and trying to encourage them to take the first step and to figure out this journey
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for themselves, any advice you have for those people just in case they're on the other end
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listening here? I just can't say enough about it. It's one of the things I enjoy talking about with
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patients more than anything, because even though patients come to our practice because they want
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to improve their lifespan, they also care about healthspan. And it's easy to forget that emotional
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health is a piece of healthspan. And I think when a person is sort of caught in the vicious cycle of
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what's often the response to and the adaptation to traumatic events, not necessarily exclusively as
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children, but often as children, they're not living this connected life that Jeff talks about.
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And I can just share from personal experience that being disconnected versus being connected is all
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the difference in living. And it's not like you flip a switch and everything is fine. It's a process.
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It's a journey, of course. But I've never met a person who's addressed their negative adaptations
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and come out on the other side and said, I wish I didn't do that.
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So this is a question we get asked a decent amount to the website. So it's here as well.
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You in the book of Openly Talk podcast that you went to two centers to kind of like do in-depth
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work on this. Oftentimes people just ask, hey, what are those called? So they can look them up as well.
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Obviously these aren't the only two, but do you just want to state those where if people are looking
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for a first place to start, two that you found beneficial for you?
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Yeah. The first place was called the Bridge to Recovery. I went there in 2017. That's actually
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where I met Jeff English. We talk about that a lot in the podcast. The second place I went
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in 2020 was called PCS, Psychological Counseling Services. And I would recommend both of those
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places very, very highly. And I think PCS focuses on more than just trauma, but it's very trauma
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focused. The Bridge is really a trauma-based residential program. And again, I'm sure there
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are others out there that are maybe equally wonderful. I know that for many people, obviously
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I've encouraged a number of people to go to these locations and many have. Everyone acknowledges as I
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did upfront, like, are you kidding me? How about I just keep working with my therapist for an hour,
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or twice a month? That can work, but sometimes it doesn't. And sometimes you actually need to
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I was going to have you give this metaphor because you've talked about it before, but I think it clicks
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with people, which is the idea if you want to learn a language, one hour a week tutoring in a class is
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good, but sometimes moving to that country and being forced into that is how you're going to learn
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Last question on this, just because I need to do it. And there's probably people wondering,
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have you ever bought anything in one of those shopping stints? And you've thought a week later,
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like, oh, this was actually awesome. I'm glad I did. And if so, what was the best thing that came
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I mean, truthfully, and this is obviously just terrible rationalization. I think most things I
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buy in my eShopaholic bursts, I'm pretty happy with them. Not all of them. I have bought
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some really stupid things. And what I tend to do is give them away so that I don't see them again,
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which is actually counterproductive because I should keep more of those things as a reminder
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of my bad behavior. In other words, I should surround myself with more of the consequences
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That's a great answer. Spoken like a true shopaholic in that.
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Actually, yeah, actually, these things are all really awesome. And at the end of the day,
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Right. It's this horrible selection bias. I keep the things that are awesome. I give away the things
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Yes. So does that mean anyone who's ever gotten a gift from you should think that this is actually
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Peter getting rid of stuff that he doesn't want? Or it doesn't quite work that way?
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Doesn't quite work that way. I give away much more than just my non-awesome stuff.
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Yes. Okay. That's good. Good to know. Moving on, Ashley Mason. This was a great episode on
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sleep, insomnia, CBTI, how to improve your sleep. Very, very interesting. I know we talked about
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already wanting her to come back for part two because we didn't even get through near everything
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we were hoping to do. So do you want to start with walking through your biggest takeaways,
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Yeah. Boy, Ashley is a force of nature. We had sketched out a lot of things we were going to
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talk about, but we never got out of insomnia and CBTI because I felt like it was just too
00:20:17.780
important to stay there and gather all that information. So yes, definitely we'll have to
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have Ashley back. So I learned a lot. Honestly, what I came away with is thinking that, okay, I feel like
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I almost know enough to help people through part of the CBTI playbook without even having to refer out to
00:20:35.900
CBTI. And I think that the takeaway from this episode should be that you can do a lot of CBTI on your
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own, which is not to say you shouldn't reach out to a practitioner if you're struggling, but the good
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news is so much of the heavy lifting was covered here. So first of all, let's just start with the
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semantics, right? So insomnia must persist for months. It must interfere with life and it must cause
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distress. This isn't just a few nights of bad rest. So we don't want to over pathologize this.
00:21:05.180
So we're really trying to focus on a meaningful reduction in sleep. CBTI or cognitive behavioral
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therapy for insomnia is one of the most effective tools for addressing serious insomnia. 50 to 60
00:21:18.440
people who utilize this achieve a complete remission and 70% show improvement. So there are lots of
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contributing factors to the development of insomnia. So you have predisposing factors like genetic
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past experiences. You have precipitating factors such as a life crisis, divorce, enormous stressful
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experiences at work. And then you have perpetuating factors or coping strategies like what you do when
00:21:50.220
you are in this state of insomnia. Now CBTI only focuses on the latter. It does not concern itself with
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what your predisposing factors are. It doesn't even care what the precipitating factor is and doesn't try
00:22:04.040
to stratify people based on those things. It basically says, you're here, you're having
00:22:08.620
significant insomnia, what are you doing to cope with it? And how do we address that? So in that
00:22:14.160
sense, the treatment is independent of the first two. Of course, I should just say this before we go on,
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you do need to address any sleep pathology like restless leg syndrome or sleep apnea before engaging in
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is. So you have to rule out that kind of stuff. Okay. So CBTI is really about addressing this triangle
00:22:32.880
of thoughts to feelings to behaviors. So picture a triangle, thoughts, feelings, behaviors, where each
00:22:39.940
one is influencing the next. And the discussion with Ashley was really a great way to kind of go through
00:22:46.540
all of the behavioral changes to mitigate insomnia, which fall under the themes that are, I think,
00:22:52.940
bucketed as sleep hygiene, stimulus control, time in bed restriction, cognitive techniques,
00:23:00.660
and relaxation techniques. So let's just talk about each of these. Sleep hygiene is something that
00:23:06.300
listeners of this podcast are very familiar with. These include things like keeping the room
00:23:11.240
temperature cold in the mid sixties, even if you need to wear socks, keeping the room as dark as
00:23:17.460
possible and using an eye mask if that's necessary. It means not drinking too much fluid,
00:23:22.720
after dinner to reduce the probability that you need to get up and pee at night. This means
00:23:28.240
addressing prostate issues. If you're a male, things of that nature. It means getting rid of
00:23:33.340
down comforters and heavy blankets, which disrupt the circadian temperature rhythm. Remember when we're
00:23:38.280
in bed, we're supposed to get into bed and rapidly begin a process of cooling to get into our deepest
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sleep before we begin to warm a couple of hours before we wake up. She said anything with duvet in it
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should be banned. So basically anything that's going to keep too much heat in is a bad idea.
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Okay. What's stimulus control? Stimulus control means limiting the bed to only two things,
00:24:02.460
sleep and sex. Everything else happens somewhere else. That means no phone. That means no reading.
00:24:08.620
And while those are obvious, the other thing she made a really clear point about was no worrying.
00:24:14.020
Now you might say, well, who sets out to worry in bed? But what she really means by that,
00:24:18.400
and I think this is very important, is that you don't want to spend time laying in bed awake.
00:24:25.500
So if you're laying in bed and you're awake, especially if you're worrying, you need to get
00:24:30.840
out of bed and do something else. So she talks about people who suffer from insomnia. One of the
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important things you have to do is get them out of bed for 20 to 30 minutes to do something really
00:24:41.740
low key. She had a funny description of get out of bed and do something that you would be embarrassed
00:24:47.640
if your colleagues at work saw you doing it. In other words, don't get out of bed at three in
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the morning to go and work for 30 minutes. Get out of bed for 30 minutes to read a trashy magazine or
00:25:00.080
watch some silly sitcom, but something that's not really activating and allow yourself to get a little
00:25:06.140
bit sleepy and then come back to bed. By the way, not long after the podcast with Ashley, and I rarely
00:25:12.660
experience insomnia, but I went through a couple of days when I was being jolted up at two or three
00:25:18.920
in the morning and could not get back to sleep. And my inclination was sort of to sit there and just
00:25:24.280
fight it and fight it and fight it. And finally on the third night, I was like, why am I not just
00:25:29.360
doing what Ashley said? So as soon as it happened, I got up, went out to the couch in the family room,
00:25:34.780
threw down an episode of Silicon Valley, which as you know, you and I talk about this all the time,
00:25:39.660
one of the greatest shows of all time, and then just went back in and went to bed. So that's an
00:25:43.420
example of something that's super low key that allowed me to get back into it. The next one here
00:25:48.840
is really, really hard for people to wrap their head around sometime, but it's called time in bed
00:25:53.900
restriction. Previously, people referred to this as sleep restriction, which the name of that is
00:25:58.920
obvious. So why would you do such a thing? Well, the problem is for many people with insomnia,
00:26:03.320
they're actually spending too much time in bed and their sleep efficiency is really low.
00:26:08.500
They're spending a lot of time in bed because they're tired because they're not sleeping and
00:26:13.580
it becomes a vicious cycle. Now, anybody who's used a wearable for sleep or uses anything that
00:26:19.640
measures sleep probably notices a calculation that gets spit out called sleep efficiency.
00:26:24.840
Sleep efficiency is time sleeping divided by time in bed. You want to be able to hit at least 85%
00:26:31.640
here. I should say you want to be able to hit about 85% here. So to be clear, if you're
00:26:36.300
hitting 95%, you're not giving yourself enough time in bed is almost assuredly the case. And if
00:26:43.500
you're hitting 75%, you're probably spending too much time in bed. So to restrict time in bed,
00:26:50.320
you want to first understand your typical time of sleep with a sleep diary. And then you add a 30
00:26:56.580
minute buffer to get your target time in bed. So you can also determine the ideal wake up time
00:27:01.260
and base your time in bed off this wake up time. So getting your wake up time right is key. This is
00:27:08.340
the thing that you want to be fixed. And then your bedtime starts to take care of itself as you build
00:27:15.300
up sleep pressure over time. You've probably heard me talk about this on the podcast before. The more
00:27:21.020
consistent your wake up time is, even on weekends, the easier it is to control sleep hygiene. The term of
00:27:28.840
people who let their sleep schedules move on weekends and they sleep in a lot later, which is
00:27:34.440
understandable, right? Like if you work Monday through Friday and you're getting up at five in
00:27:37.680
the morning, it is a real tempting on the weekends to sleep till eight or nine o'clock. The problem is
00:27:43.040
that process of social jet lag is devastating for your circadian rhythm. So she describes focusing on
00:27:50.240
process S, which is sleep pressure to standardize what she calls process C or circadian rhythm.
00:27:58.100
And we talked a little bit about sleep trackers. She does not recommend using them if you're
00:28:02.640
struggling with insomnia. And I couldn't agree more from our own practice. One of the first things we do
00:28:07.900
when people are struggling with sleep is we get them to take their sleep trackers and at best put them
00:28:13.840
away. At worst, throw them out. Once this kind of gets in your head, it becomes a brutal cycle.
00:28:19.140
So you don't need this to fix the problem. Cognitive techniques. I found this to be very
00:28:24.160
interesting. Schedule time for worrying. Again, for many people, the waking up part then triggers
00:28:31.880
the set of ruminating thoughts. Insomnia sometimes arises from not processing information enough during
00:28:38.320
the daytime and spending too much time in bed ruminating. So she has her patients schedule worry time
00:28:45.340
by intentionally putting something on the calendar where they literally write down all the things
00:28:51.260
that they are worried about. And they might have 20 minutes a day to do that. And then they don't
00:28:56.980
have to feel the need to process this at night. So you think about the things that you would normally
00:29:01.740
think about laying awake in bed, and all of a sudden it gets a lot better. She does something called
00:29:06.540
tracking the degree of belief, which means asking yourself, how much do I believe this is true?
00:29:11.840
True. So a lot of times people will find the things that seem absolutely certain in the evening may
00:29:17.940
turn out to be kind of unlikely during the day. They just feel more certain of it before bed, which
00:29:22.980
increases worrying. So again, these are some of the techniques. I won't go through all the other
00:29:28.040
stuff. There's some stuff she talks about on relaxation, which I think is helpful. And she also
00:29:32.900
talked about A-B testing other things that are probably less effective. She wasn't a huge proponent
00:29:38.160
of blocking out blue light, but she said it's always worth trying. If wearing red light or blue
00:29:44.840
light glasses in the evening helps, she's like, by all means, great. Give it a shot. Obviously
00:29:50.660
experimenting on timing of caffeine, medication, supplements, all great, but her view is just
00:29:56.680
test those things out. So yeah, I would say those are kind of the big things.
00:30:00.620
And Peter, remind me, did she talk about anything on like sleep supplements, sleep prescription
00:30:07.560
drugs that people should think about potentially use if they're going through this?
00:30:30.620
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