- [Zubin] Dr. Rachel Zoffness, the other Dr. Z, UCSF Pain and Health Psychologist and Visiting Professor at Stanford. Welcome back to the show. - [Rachel] Thank you, dude, for having me.
- [Zubin] Snarf! Snarf! - [Rachel] No. - [Zubin] No? - [Rachel] we're not doing ThunderCats today. - [Zubin] No ThunderCats? Oh. - [Rachel] Not today. - [Zubin] Oh, so we're what we're on like episode two of Pain Points now? - [Rachel] Yeah, episode two of Pain Points. - [Zubin] What is Pain Points? We take questions from you guys, from the audience and we answer them best we can with the framework that everything is biopsychosocial.
- [Rachel] Yep. - [Zubin] It's got a biological component, a psychological component, a social component. And in fact, you wrote a book which I got to pitch 'cause this thing is the bomb, "The Pain Management Workbook." And what's great about this is it's actually action items to make you feel better.
- [Rachel] Yeah. - [Zubin] Be better. So thank you for doing that. - [Rachel] I got really mad about the state of pain management in America.
Like I just think we've been mismanaging pain for many decades and that's actually a known entity, it's not my opinion. Even though I have strong opinions about it. You know, we have this opioid epidemic, which people are sick of hearing about, but more importantly, chronic pain is on the rise. So there are things we can do about pain.
And step one is understanding pain. And no one gets taught pain. So I just stuck everything I did in a book, because a lot of it is not affordable for most people. So that's actually why the book was born. I just wanted to make it accessible and affordable to everybody.
- [ Zubin] So people, I've read this book, for people who've actually read it and have given me feedback, it's transformative. - [Rachel] Really? - [Zubin] Yeah, because you're doing something. - [Rachel] Yeah. - [Zubin] It's a workbook. - [Rachel] Right. Yeah. - [Zubin] That's what I love about it. Yeah.
Now, you said something there like, before we get into people's questions, 'cause we're gonna talk about like Omicron, we're gonna talk about depression, we're gonna talk about, hang on... - impostor syndrome. - impostor syndrome, which both you and I suffer from. - [Rachel] I have so many questions for you. - [Zubin] We're gonna have an impostor off.
Like who's the bigger impostor. - [Rachel] Oh great. - [Zubin] Yeah. It's gonna be like that John Travolta movie "Face/Off," where we, you know, peel off the veneer of identity and underneath is just the scathing impostor. - [Rachel] Sounds scary. - [Zubin] It's terrifying. - [Rachel] Yeah.
- [Zubin] I love fear. - [ Rachel] It sounds like Skeletor. (laughs) - [Zubin] No! - [Rachel] I said I wouldn't go there, and then I just did.
- [ Zubin] Oh no, we're not gonna do, we're not gonna do ThunderCats. But we are gonna do He-Man. Dude, Skeletor was the best. Remember, He-Man's sidekick, that weird cat, Battle Cat? So... - [Rachel] Yes! Oh, yeah. It was like a giant- - [Zubin] Huge, like tiger. - [Rachel] Huge mammoth.
- [Zubin] And when it wasn't transformed, when it was just like the standard cat- - [Rachel] Damn, I just opened the He-Man. - Pandora's He-Man box. - I'm so sorry, everybody. - [Zubin] Pandora's He-Man Box sounds like a dirty picture.
So... (laughs) - [Rachel] Oh, man! - [Zubin] So we started on a good foot. So this little cat was a coward. - [Rachel] Oh yeah! And then it like morphs. - [Zubin] It morphs into this battle machine that's ready to fight Skeletor.
- [Rachel] Something happens when you like take me back to '80s cartoons. Like my head sort of explodes. I just haven't thought about it since 1986.
- [Zubin] But yet it's there in your limbic system. - [Rachel] Somewhere. - [Zubin] 'Cause we've been conditioned by watching hours and hours, and hours of this garbage. Yeah. - [Rachel] Yeah, right.
Somewhere in my brain. Can we go back to the listener? (laughs) - [Zubin] Do we have to? I mean, yes. So we were gonna talk about benzodiazepines. - [Rachel] Totally. - [Zubin] Things like Xanax and Valium, and what was it? - [Rachel] Klonopin, Ativan. - [Zubin] Klonopin, and if we have time, we're gonna hit insomnia. - [Rachel] Totally.
And the things we don't get to, we're gonna get to next time. - [Zubin] Yeah, this is a series, right? And I keep thinking, okay, when are we gonna cancel this series when people start saying, "I don't like this anymore"? And I keep getting messages from people saying, "This is the best thing you do so keep doing it." So. - [Rachel] Wow.
- [Zubin] I know. - [Rachel] That's lovely. - [Zubin] And it's because of me, it's not because of you. Let's be honest. - [Rachel] It's definitely because of you. - [Zubin] You write a book, I mean.
I'm gonna pitch the book one more time. Where can you find it? I'll put a link. Amazon. Yes. - [Rachel] It's on Amazon. Yeah, it's cheap. It's pretty cheap. - [Zubin] And it was like, yeah, you just want people to read it. So, and I do too.
So, alright, let's start with Omicron. Now, this is what's amazing. This interview today almost didn't happen because you got the big O, shame! The scarlet letter. - [Rachel] Oh, you don't know.
- [Zubin] The O. - [Rachel] Oh yeah, there are people who still won't see me, just to be clear, including some of my patients, because I tested positive three weeks ago. I'm testing negative now, just to be clear, I don't have symptoms. But I recently had COVID. So yeah, scarlet letter. - [Zubin] The scarlet letter. - [Rachel] the scarlet O.
- [Zubin] Let me just recap your medical history here for people, so they understand. You are fully vaccinated and boosted. - [Rachel] Correct. - [Zubin] You had tested positive for COVID back in 2020. - [Rachel] Correct.
- [Zubin] But we don't know if it was false positive or not 'cause you had no symptoms. - I never had symptoms. - [Zubin] No symptoms. - [Rachel] That's right. - [Zubin] You then started feeling badly, and by the way, so you said some of your patients won't see you because you were three weeks ago tested positive? - [Rachel] People that are just scared. - [Zubin] You show up at my door.
We immediately hug. - [Rachel] Right. Good point. - [Zubin] Because I know that I'm vaccinated, boosted and that you are recovered. - [Rachel] I am recovered.
And I am told, and I want to know this, one of my questions, now that I am recovered, I have heard that you get some immunity after having had it. Is that true? And how long does that last? So I have some immunity to getting it again for like a window. Is that true? - [Zubin] Yes, it is absolutely true. And it's not just, so there've been some studies on this, looking in a particular direction. So the direction of you got infected at some point and then you got vaccinated.
Now, people who've had that particular progression have really good immunity. People who go the other direction also probably have really good immunity. - [Rachel] Great. - [Zubin] And by immunity, there's two aspects of it that people should understand.
One is the neutralizing antibodies that circulate in your blood. - [Rachel] Once you've gotten it. - [Zubin] Once you've gotten it. Those last for probably three months or so.
And they really start to wane. Those are the antibodies that prevent you from getting mild or moderate infection in the first place. So at very high levels, you're pretty safe. That's why in the early days of the vaccine, people were like, oh, 90% effective against even infection. Right? But they wane over time.
Whether it's natural infection or whether it's vaccine. And that's why they talk about boosters 'cause they wanted to bump back up the neutralizing antibodies to reduce the chance of infection. But here's the bigger question. You have a deeper immunity, right? Remember "The Lion, the Witch and the Wardrobe"? - [Rachel] Yeah. I love that book. - [Zubin] Aslan talks about, at the end, he talks about, you know, there's this magic and then there's the deep magic.
- [Rachel] I remember. - [Zubin] That ultimately cracks the stone that he's crucified on. It's like this very powerful thing. That's what memory B and T cell immunity is like.
So you had vaccine-based immunity where the first dose gives you neutralizing antibodies. The second dose really solidifies the memory B and T cells that then live with you so that, it takes a few days to spin them up, but they are the ones that prevent, maybe for as long as your life, we don't know yet, but it's long-term, severe disease. So you got those from your vaccine. And then you got another booster from your natural immunity. - [Rachel] Omicron. - [Zubin] Omicron. - [Rachel] When I got it.
- [Zubin] And Omicron also because you're now immune to multiple parts of the virus, not just the spike protein, you get a broader immunity. And I suspect you're gonna have more resistance to any future variants that come up. Now that doesn't mean go out and get Omicron. Why? Because you experienced it, right? - [Rachel] Yeah. I don't want it again.
And I'm gonna tell everyone what that experience was like. 'Cause I think millions and millions of us are gonna be having this experience if we haven't already. But why does my immunity wane in three months? - [Zubin] Because circulating antibodies, those proteins, that form, that recognize aspects of the virus and bind to them and then trigger other parts of the immune system to kind of sort of gang pile on them, those are designed to wane over time. Because if they didn't, every single virus we get exposed to triggers antibodies, our blood would be slush. It'd be full of protein. - [Rachel] Perfect.
- [Zubin] So they come up when we need them. And then they recede. But the memory source stem cells that produce them, the B and the T cells, the B cells produce the antibodies and the T-cells provide support, they're there for long, long times.
And that's why people like Monica Gandhi and others have said, immunity is our only way through a pandemic. And this immunity is in fact long lasting against severe disease. Which is why people like Paul Offit, who just was on my show, have said, I'm not sure we need boosters for young healthy people, because they already have this deep immunity. Yeah. So back to you. - [Rachel] No, it's just to say, and I suspect a lot of other people have experienced this too. When I got sick, by the way you were saying like my medical history.
I am young. I am fit. I am boosted. I am vaxxed. I exercise all the time for my mental health. I'm like a runner. I'm the slowest runner you've ever met. But, so I got sick. And what I had been hearing was, Omicron is mild.
That word mild is like at the top of everyone's list. It's everywhere. It's on media. It's on Twitter. It's everywhere. Mild, mild. I was so sick that I couldn't get out of bed for something like 12 days, like the fatigue and lethargy.
And I don't want to scare people because at the end of the day, I am told that really, this is what the flu feels like, and sometimes worse. And to be totally transparent, I have never had the flu, somehow. So I don't know what the flu feels like. But to me, mild, I just think we need to like talk about what this word mild means.
To physicians, mild means you're not hospitalized. Mild means you're not on a respirator. Mild means you're not going to die.
- [Zubin] Mild means you're not my problem as a doctor. You're your own problem at home. - [Rachel] See? And that is a major communication breakdown.
And I am all about good communication that makes sense to people like me. So I, and I had also been hearing, in fairness, the common definition of mild among friends and colleagues who were like, "Oh, just a few cold symptoms for few days. And then I was fine." Now, I was knocked on my ass, and I am like an Energizer bunny. You can not knock me down. Like I wake up early, I get a ton of shit on throughout my day.
- [Zubin] You're Battle Cat. (laughs) - [Rachel] I am like He-Man's cat. - [Zubin] Right. Whereas I'm Orko, the weird little ghost guy that would follow him around. - [Rachel] Totally. You're definitely Orko. We can talk more about that. You're definitely Orko. - [Zubin] Orkogenesis.
- [Rachel] Right. Great. But, but when I couldn't get off my couch for like 10 days, I was scared. And I want to be clear about why I was scared. Now, if this was just the flu, I would, anytime before now, I would have been like, oh, this is just what the flu does to you. It knocks you down.
And then in a couple of weeks or whatever, you're fine. You get your energy back, you eat chicken soup, whatever. Because it's COVID, and because we have been hearing in our ears for two years, this effing thing is gonna kill you.
You're gonna get long COVID, you're never gonna be okay again. I was petrified. I'm so annoyed that that happened to me because I am hyper logical. I'm a scientist.
I listened to people like you, and I collect information. And I know logically that being my age, no co-morbidities, blah, blah, blah, chances are very high I'm gonna be fine. And what everyone keeps saying to me is COVID seems to be one of these animals where you just don't know. Like you know everyone has a friend, and I have a patient actually, I have my first long COVID patient, who was like 34 year old, healthy dude, no comorbidities has had long COVID now for like almost two years. - [Zubin] Wow.
- [Rachel] Yeah. I don't want to scare people. But that's the thing that's happening. We know that that's happening. But long COVID is a biopsychosocial recipe just like every everything else. And I don't want to go down that rabbit hole right now, but there's things going on with him, of course, in his biopsychosocial recipe that are maintaining the fatigue and the lethargy and the brain fog.
But just to say, because I know that that's an option and because I've been receiving all of this panicked information about it from the media, it wasn't a casual cold for me. And it sure as shit did not feel mild. - [Zubin] That, okay. Okay, this is worth really diving into. You were incepted to some degree by the overall biopsychosocial.
So the social component of it, whether it's the media, whether it's hearing about it constantly, whether it's the social component of hearing from your own patients, hey, this is what my experience was. And how will you roll the dice? Even when you're young and healthy, some people end up in ICU with ARDS and stiff lungs and the post ICU syndrome and all these things that we've talked about on my show. Okay, so all of that syrup. Turns out, this happens with flu too. Like how much of chronic fatigue syndrome, how much of fibromyalgia, how much of these syndromes are long flu? Are long Epstein-Barr virus? Are long mono? We don't know because we haven't studied it properly.
And so when you think of flu, like I've had mono, I've had flu before, I've been out for two weeks like you, unable to get out of bed, full-on like just feel like I'm hit by a truck. And then for a few months afterwards, I'm not right. - [Rachel] I've heard that. - [Zubin] Exactly.
And so if I had had the same symptoms like you with COVID with all this milieu I would have felt like you did, "Oh my God, like, do I need to go to the hospital?" And you know, this manifests in a way psychologically, but it manifests also in a logistic way. So now the hospitals are full of people that think they're dying, that wouldn't normally go to the hospital, and look, you do want to go with COVID because, again, this is one of those things we're still learning about. But the idea that we've created this anxiety contagion. And so your point to messaging, when we say mild, that is very deceptive, yeah.
- [Rachel] Right. It's so deceptive, and then when you get the symptoms that you're actually supposed to get, because, by the by, this is a virus. So you get the symptoms you're supposed to get with a virus like this, which is like the fatigue, the lethargy, the brain fog, the head cold. Because you've been told it's mild, you're like, well, crap, do I have a not mild version? And does this bode poorly for me? And not for nothing. You know, a lot of people have heard the word placebo.
And the word placebo is a little bit more complex than really what we've been told. Placebo is not just a sugar pill. Placebo is language also. So if someone says, as you did to me, "You're going to be fine. This is what's expected. You're going to be fine."
Language matters a lot to the brain and to your physiology. So my brain heard that message and it internalized it. And, thank God, that I have friends like you and other people who said that to me. And I believed that.
Nocebo is the opposite. And many people have not heard the word nocebo. Nocebo is language that conveys that you are effed. And by the way, I had a dear friend, who is a physician, who does obviously not know about nocebo. And on day 10 or so, I was feeling worse.
Like literally I felt like I had been hit by a train, and I couldn't move, which is scary for me. And like, and I texted her, and I was like, "Is this normal?" And she said, "Oh man, like day 10 that's when people go to the hospital." - [Zubin] Oh dear Lord. - [Rachel] Right.
- [Zubin] Nocebo effect. - [Rachel] You got it. And I felt the adrenaline in my bloodstream. I felt the cortisol. Guess what cortisol does to your immune system, by the way? - [Zubin] It suppresses it. - [Rachel] It tanks your immune system! So when you have a virus, cortisol, by the way, is a stress hormone that your body produces when you're feeling stressed out or anxious.
- [Zubin] Also called... Actually, no, nevermind. Keep going. - [Rachel] Yeah. - [Zubin] Yeah. - [Rachel] But so when you get a nocebic message, which has a message of danger, your body produces adrenaline and cortisol, which, ta-ta-ta-da, suppresses your immune system.
So if you're already sick, chances are high you're actually gonna get sicker and not recover. So I got so angry, I muted her. Like I didn't tell her this, but I like muted all of her incoming text messages. She was like, day 10, that's like emergency day, that's when everyone comes in and they can't breathe, and blood oxygen is low.
And I was like, I actually wrote, "Don't say anything else." And then I just silenced her. And I reached out to my other people who I knew were not gonna give me catastrophic messages.
So that's my piece of advice number one. If you get COVID, and a lot of us are going to, maybe all of us will, make sure to filter the incoming input that's coming into your ears. Do not solicit input from people who are highly anxious about COVID. Mute them. Mute them.
Don't call them. Don't ask them for advice. If they are catastrophic or anxious about COVID, they're going to have a nocebic effect on your health. So listen to people who are good, reputable sources of information, like Zubin or whomever you're getting your information from, who have facts and who are gonna state facts, but are not gonna state facts in a panicky, sort of negative information nocebic way that's gonna trigger your cortisol immune suppressing system. You want the opposite.
Does that make sense the way I said that? - [Zubin] (laughs) I don't think anybody's talking about this honestly. - Okay, let's talk about it. - [Zubin] This is crucial. Like what you just said, and listen, listen, you like, you've been through the ringer. And you know, by the way, you look great.
- [Rachel] Oh thanks. Oh great. - [Zubin] You're high-energy Jeb. Whereas I'm sleepy Joe. - [Rachel] This is just adrenaline, I'm just nervous. - [Zubin] Pure adrenaline, right.
Yeah. Which is good. Again, yeah, we're gonna get your cortisol spike. You're gonna get a secondary infection and pneumonia. I'm nocebofizng you. - [Rachel] Don't! - [Zubin] Can you feel it? - [Rachel] Don't nocebofize me. - [Zubin] Do you feel it? - I don't want you to.
- [Zubin] What you said about- - [Rachel] You're fired. - [Zubin] Listening to the catastrophizers. So it is a poisonous input in that sense. - [Rachel] Correct. - [Zubin] And people think words don't matter and so on, but we are social creatures.
So they do matter. And they do affect our overall health. They do affect our standing, and our mental status, and the biopsychosocial aspects of any disease, which is 100% of all diseases.
So this is partially why I do what I do actually, during the pandemic. - [Rachel] Yeah, that's right. - [Zubin] I have been accused by many people of underplaying aspects of this thing, and downplaying severity and using words like mild and things like that in certain contexts. But the messages I get from people are: thank you for calming me down. I was living in fear. I'm so much happier.
I went and got vaccinated. I'm okay. I was a recluse in my house. Or, I panicked because this happened.
And so there is a responsibility, I think, for people who do science communication, including physicians and others, and psychologists, to speak knowing these effects, not to ever be inauthentic. So never to lie. Never try to manipulate. But to say, you know that's actually true and how do we say it matters.
- [Rachel] Right, so mild with Omicron means just to be, and you correct me, it means you are very, very unlikely to get so sick that you have to go to the hospital. You are extremely unlikely to die from it, unless you have some pretty complex comorbidities. And it's a small percentage of people who are being hospitalized and who are dying from Omicron. Is that correct? - [Zubin] That is what my definition of mild is.
- [Rachel] And, did I interrupt you? - [Zubin] No. - [Rachel] I feel like I did, I'm so sorry. - [Zubin] But, you know, if you did, the audience is thanking you because I'll just talk for hours and I'll say nothing. - [Rachel] I want you to, that's why we're here. Okay. But part two is if you're just a regular layperson like me and you get Omicron, if your definition of mild is like, I'm gonna sneeze a few times and maybe have a runny nose, and then I'm gonna be done, that is true, that that's happening for a lot of people.
Like a lot of my friends are like, "What's happening to you? I was just sick for two days and now I'm fine." And I'm like, "I don't know what's happening to me. I don't know." But for a lot of people, because I put this on Twitter and I got like dozens and dozens of messages from other healthcare providers and physicians and everyone else, saying, yeah, this mild shit is not accurate as far as my definition of mild. And I have been sick for three weeks, and I had actually a couple of people email me and say, the fatigue and lethargy has a long tail. I kept hearing long tail. - [Zubin] Yeah, yeah.
- [Rachel] The fatigue and lethargy has a long tail. So when the head cold and the sniffling and whatever goes away, you still might experience some fatigue and lethargy. So like full transparency. I do not sleep late. I have been sleeping til like 10 and 11 in the morning.
And now, this is like day 21 for me or something ridiculous, and I'm fine. No more symptoms, testing negative, all good. But the fatigue and lethargy seemed to have a long tail. - [Zubin] So I'm gonna validate you even more. - [Rachel] Oh, great! - [Zubin] So I just did a show called "TRIGGERnometry" with a couple of British comedians who have this podcast. - [Rachel] I saw, yeah.
- [Zubin] So they never were vaccinated, but they got naturally infected back in 2020. So they thought they were okay, and they were from a severe disease standpoint. But they both came down with what was presumably Omicron. It kicked their ass.
So they did a podcast about what it was like days of just terrible pain, night sweats, isolation. It made their underlying mental predispositions worse. So one of them has anxiety. He said he was just wracked with anxiety.
- [Rachel] Of course. - [Zubin] And he went to their A&E, which is their ER, And it was just a shitshow of panic. And so, and these are hyper rational, if anything, they're on the more the antithesis side of the COVID spectrum, saying, you know, we're, overblowing this, like we need to live our lives, and more libertarian. And they were like, no, but this thing is, you call it mild, it ain't right.
- [Rachel] That's right. - [Zubin] Yeah. And this is the thing. So influenza, the reason I get a flu shot every year and the reason I think this is why I argue for young people should still get vaccinated even though it's not absolutely necessary. You still, if you can reduce your chances of having a flu-like syndrome for two weeks, that's a good thing. And the vaccines do do that.
Now, even with boosters, it breaks through, it happens. It depends on your inoculum. It depends on your genetics. Now, the last thing I want to say about that piece of it, because you brought it up and we have to be real, this is something where you're threading a needle, because long COVID. - [Rachel] Oh yeah, this.
- [Zubin] So you have symptoms for so many days now, you know, and we define long COVID is so many weeks of the symptoms lasting, and those symptoms could be anything. It could be loss of taste. It could be, the definitions are tricky. But it is completely normal to have residual symptoms. Like you said, the long tail for a long time. - [Rachel] Yeah, any illness.
- [Zubin] For any illness, any viral illness, any bacterial illness, it happens. And some of it is, remember, some of it is deconditioning too, from being in bed for so long. 'Cause it does happen. You're used to a certain level of activity and then you don't get it. - [Rachel] Muscle atrophy.
- [Zubin] Absolutely. - [Rachel] You're not eating as much. - [Zubin] There's autophagy, you're eating yourself, you know, like. - [Rachel] Yeah. - [Zubin] And so all this stuff happens. And so it's important when we tell people, oh, you know, it's important to note these symptoms could last, but it doesn't mean that you're permanently damaged. - [Rachel] And it doesn't mean it's long COVID.
- [Zubin] That's right! - [Rachel] That's so important. And it's just making me realize, like, we don't have this catastrophic name for long flu, or long pneumonia. Like my friend last night on the phone, we do like a weekly Zoom. She said, yeah, when I had pneumonia, I had lingering symptoms for three months, and no one panicked about that and they didn't give it a scary, big name. So like maybe there's a little bit of catastrophizing around the tail, the long tail. - [Zubin] The long tail.
Now, there is long COVID. - Of course, long COVID. - [Zubin] We're not diminishing that. But you're absolutely right. - [Rachel] But when do we call it that? And should we normalize that your symptoms might last a couple of months? Just normalizing that experience so that people don't think they have long COVID, if they don't. - [Zubin] Yeah, yeah. - [Rachel] Because, yes, long COVID is real. And there's this period in between, this like interstitial period, which is like, well, I'm recovered, but I still have some symptoms.
Do I have long COVID now? - [Zubin] Right, right. - [Rachel] Which is sort of where I was. I was like, oh my God! - [Zubin] Totally. Why wouldn't you? - [Rachel] Exactly. - [Zubin] In this current milieu, you're normal to feel that way, right? Now, one thing in your book, you do a lot of sort of CBT, cognitive behavioral therapy, type stuff.
And you mention a few trigger words here that are from that space, catastrophize. - [Rachel] Yeah, you got it. - [Zubin] That's one of them, right? It's a cognitive distortion where we see the worst possible outcome and focus on it, knowing that, in fact, that's only one of many outcomes, and it's probably unlikely. There are others, right? Like, overgeneralization.
- [Rachel] Do you see me beaming with pride over here? I'm like beaming with pride! I'm so impressed! - [Zubin] Ah, you know, that's why we're a great duo, two Dr. Zs are better than one. - [Rachel] Dude, I was so impressed. That was summarized so perfectly.
- [Zubin] Oh, thank you. - [Rachel] Yeah. - [Zubin] And I learned from your book, I read your book. People should get her book. The overgeneralization, black and white thinking. These are all aspects that we can catch in ourselves.
- [Rachel] Yes. - [Zubin] That we can also catch it in media. We can catch it in communications.
We can catch it in writing styles of op-eds where, you know, you almost sometimes imagine that the person writing the op-ed is experiencing these cognitive distortions and is projecting them into the page, which is now projecting them into the world, which is now creating a biopsychosocial crisis. - [Rachel] So let's now normalize. When you get COVID, it's very likely and also normal that your brain is gonna feed you a lot of BS, distorted, anxious thoughts.
Because we have all been ingesting nocebic, scary information about COVID for two years now from the sensationalist media, that's putting up the word COVID in like red and yellow with dangerous fangs, you know. So naturally and normally, if and when you get COVID, if you feel terrified, that is normal and your brain is gonna feed you a lot of catastrophic, scary thoughts that are gonna tell you, like my brain was telling me, that this is gonna be long COVID and it's never gonna go away. And the chances are high that that's not true. And it's very important to catch those thoughts, and wrangle them, and talk back to them. Otherwise, they will perpetuate that spike in cortisol that might mess with your immune system. So we want to catch the cognitive component of COVID too.
- [Zubin] Yes. I think that's very well said. - [Rachel] Okay, great. - [Zubin] Very well said. - [Zubin] So, yeah.
I'm glad we had that discussion. - [Rachel] I know, me too. That's not where I expected this to go, but that was so helpful for me.
- [Zubin] For me too. - [Rachel] Yeah, so helpful. - [Zubin] Because as somebody who's communicating about this, but, you know, people are suffering, they're suffering. This is massive suffering. - That's exactly right. - [Zubin] And the goal is to relieve suffering as much as we can. - That is exactly right.
- [Zubin] So, good. Anything else on Omicron you wanted to talk about? - [Rachel] Just one thing. Where are we on time? Just out of curiosity. - [Zubin] Don't even worry about it. Time is not a problem. - [Rachel] Alright, fine. Just one thing.
- [Zubin] Time is a concept that humans create. In reality, it's the eternal now, so. - [Rachel] Wow. I feel like my head explodes when you talk about that. One thing that I learned about Omicron is that because it's being marketed as mild, there are a subset of people who, I don't know if this is still happening, who are trying to get it on purpose.
- [Zubin] Yeah, please don't do that. - [Rachel] Can I? I have a story. Brief story? - [Zubin] Yes. - [Rachel] Dear friend named Ben, when I was in San Diego getting my PhD and he made us dinner every Sunday night with a bunch of friends, and we called it our Sunday night family dinner. And one thing that we often did was we played Scrabble. - [Zubin] Nerds.
- [Rachel] That was not a normal game of Scrabble. You can judge me if you want, it wasn't my idea. It was perverted Scrabble. - [Zubin] Oh! - [Rachel] Yeah, that's true.
And the rules, it's not my idea! But it was really fun and really funny. - [Zubin] You like, taint. Right. - [Rachel] Exactly. And the rules were, you had to make a word that was like ridiculous and perverted, and you had to define it.
And it had to be an accurate definition. So one word that I learned, this is coming full circle, I promise. One word that I learned is bugchaser.
- [Zubin] Bugchaser? - [Rachel] Bugchaser. - [Zubin] I've never heard that term. - [Rachel] I had never heard it either. And it blew my mind, and then I went and looked it up. And it's a psychological phenomenon that occurred probably multiple times, but the context in which I learned it was with the AIDS epidemic, right. There were a subset of people who were so overcome with anxiety and paralysis about getting HIV and AIDS that they deliberately would find infected partners and have sex with them to get it over with.
So they didn't have to be anxious about it anymore. And you see where I'm going with this? - [Zubin] Yes. - [Rachel] There's a lot of people who have been anxious about getting COVID for two years and/or just want to get it over with.
And by the way, when I finally got it, very much, I was like, thank God. I want to just get, let me just get this thing over with, get the immunity and move on with my life. I'm just so over it.
Like everybody, we're just tired of it. - [Zubin] Yeah. Normal, very normal. - [Rachel] Right, but there are people who are going out of their way- - [Zubin] To try to go to an Omicron party- - [Rachel] Bugchasing. - [Zubin] Yeah, bugchasing. - [Rachel] And one of my colleagues, a pediatrician, said to me, oh, we see that a lot with chickenpox. - [Zubin] Yes we do! - [Rachel] 'Cause you want your kids to get it and get it over with. - [Zubin] So, so funny, I just interviewed Paul Offit and he mentioned the same exact scenario, the chickenpox parties.
Before vaccine, you do want your kids to get chickenpox because it's much more dangerous to get it as an adult. For us, we would rather get Omicron when we're young and healthy than when we're 80 and whatever. The thing is we have a vaccine. And when the varicella vaccine came out for chickenpox, people were still having chickenpox parties.
Now, you're subjecting your child to a risk, as small as it is, of hemorrhagic varicella, or encephalitis, or pneumonia that can be fatal. In the pre-vaccine era, up to 10,000 kids were hospitalized every year with chickenpox related complications. So what we're saying with Omicron is I know the desire to do that. It's normal desire.
You're not a bad person for wanting to go out and get omicrox. But don't. And it doesn't mean you have to hide or do any of that, but don't go out of your way. And if you're gonna make that statement, like, "Oh, I want to get Omicron," I hope you're vaccinated. - [Rachel] Oh yeah. - [Zubin] Because, again, the vaccines aren't perfect.
That's why we are still careful. It doesn't mean you have to triple mask and do all that if you don't want to, but it's just about understanding risk. So going out and getting Omicron, don't advise it.
- [Rachel] That's so good. Just want us to knock out- - [Zubin] I'm glad you're alive. - [Rachel] Thank you. I am also glad I'm alive. - [Zubin] Yeah, 'cause it would have sucked for the show if I were just talking to myself. - [Rachel] Okay, Zub.
- [Zubin] (laughs) Okay, Rach. - [Rachel] Oh, no, I hate when someone say that. - [Zubin] You're gonna Zub me, I'm gonna Rach you. - [Rachel] That's fair. I was telling Zubin that I get messages sometimes from people I've never met, who Rach me.
Like, "Hey, Rach." - [Zubin] I get that too. - [Rachel] Hey, Zub. - [Zubin] I'm like, you're a little too familiar. I don't know I sound like Trump, hey, you're being a little too familiar. That doesn't sound like Trump at all. Depression. - Sounded like The Godfather.
- [Zubin] It did. - [Rachel] Can we talk about depression? - [Zubin] Ya. - [Rachel] It's ubiquitous in the United States. I mean everywhere. And especially during the pandemic.
- [Zubin] Raise your hand if you've ever been depressed. Raise your hand if you've been diagnosed with major depression. - [Rachel] I have not. - [Zubin] I have not. So it's a spectrum. - [Rachel] So here's the interesting thing about depression. There is a book out there called "Saving Normal."
Have you read "Saving Normal"? I'm gonna give it to you. - [Zubin] I've heard about this, yes. I haven't read it though. - [Rachel] "Saving Normal," it's a fascinating book that goes into how arbitrary truly our definitions of normal and abnormal really are, and how the definition of depression and the criteria in the book we call the DSM, which defines criteria, is influenced by many, many, many things, including Big Pharma.
That is absolutely a true story. And "Saving Normal" was written by one of the gentlemen who helped write the DSM. And he goes into how these definitions came to be.
And for anyone who is interested in health or mental health, you will be utterly astonished to learn that this thing we call major depressive disorder is quite arbitrary. There's not a lot of science in our current definition of illness, mental illness, what is normal and what is abnormal is always changing. And we have to be very careful when we talk about disease and labeling people who have been diagnosed with this thing, depression, as mentally ill. Now, I want to be clear that I am not saying that depression is not a mental illness. Of course, it's real. Yes. I am not saying that.
But I want to talk about the definitions. First of all, the other issue and then you can maybe get to our questions. The other issue with depression is that we have all been sold this completely BS idea that depression is a purely biomedical thing. And by that I mean people who are depressed and go to their doctor get told, "It's not your fault. Your brain is just broken.
But it's not your fault. It's a flaw in chemistry, not a flaw in character." That, when I lived in Manhattan, when I was getting my master's degree at Columbia, I would look out my window every day, and on this big building in like 12-foot letters, I'm not joking, put up by a Big Pharma company, "Depression is not a flaw in character. It's just a flaw in chemistry." It's a brilliant message because here's what it does.
It takes the onus off of you. Like, oh, it's not your fault. But it does place the onus squarely and directly on your dysfunctional broken brain. Now, that is a big lie. And I want to make sure I'm saying this clearly. People with depression, you are not broken.
You are not broken. That is a big lie that you have been sold. Is depression real? Yes. Is it debilitating for many people? Yes. Are there treatments out there that work? 100%.
neurotransmitters are involved in depression. neurotransmitters are those chemicals that live in your brain and regulate mood and sleep and appetite and all those delightful things. But those are not the only component of depression. You have something to say, I know you do. I can see it in your face. - [Zubin] No, I'm just, I'm vibing with this so much.
I have a lot of thoughts. Keep going. - [Rachel] Okay, well, what I wanted, what I was thinking was I want to hear all of your thoughts. Do you want to read some of the questions we got about depression or no? - [Zubin] Absolutely.
And before and before I do, I want to say one thing. So what you're describing is a reductionism. - [Rachel] Correct. - [Zubin] And it is actually in service of Big Pharma's interests, which are to sell pills. - [Rachel] Correct.
- [Zubin] I like the de-stigmatizing component that it's not your fault, but in reality, nothing is your fault because we are what we are. But that doesn't mean you don't take responsibility for making yourself better. And so the reductionism is a fascinating piece. There's a guy named Iain McGilchrist, who's a psychiatrist, neuroscientist in Great Britain.
Who's written a book called "The Master and His Emissary." And it is about the right brain and the left brain. Not the pop psychology nonsense, like I'm a right brain, kind of creative. And I'm a left brain scientist. It turns out that's not what they do. That's not what they do at all.
But what is felt to be the case is that the right brain sees the world in a holistic, connected, relational way. And the left brain actually evolved as the right brain's servant, as its emissary. Because what it does is it reduces wholes into little parts and grasps at them and tries to drill down and make sense in a reductionist way. He argues in the book that as human societies progress, they start to fail because we go from a right brain-left brain balance, where it's true, the master right brain and his emissary are working in concert to see things holistically and work together, to a left brain dominant society, where we reduce everything to its bureaucratic lowest common denominator. And I think that's what we're seeing with depression treatment.
And thinking about it, well, it's just a chemical imbalance. - [Rachel] Right. - [Zubin] Yeah. Doesn't help anyone. - [Rachel] Right. - [Zubin] And then you have this huge bureaucracy in medicine that manages the chemical imbalance with a rubber stamp. Here's some Prozac here, some Paxil, here's whatever, not even looking at the biopsychosocial holistic part of the whole thing.
- [Rachel] And we're gonna talk about what that means, depression being biopsychosocial. 'Cause that was actually the question we got. - [Zubin] That's perfect. So let's start with the first question then.
"I've been on and off anti-depressants for 25 years. Every psychiatrist tells me meds work. Why aren't I better?" Harold M. via Twitter.
- [Rachel] Will you read the next one also? - [Zubin] And, "My depression ebbs and flows, and I've been on meds for more than a decade. Help me understand depression with your biopsychosocial magic. Please," says Danny. - [Rachel] Right. So just so I want to be clear what this biomedical model of health is. This is what is predominant in medical schools, and the biomedical model of health focuses on just biology. Will you say as a former med student, 'cause I did not go to med school, what a biomedical model of health looks like a little bit? - [Zubin] A biomedical model of health reduces the sort of four quadrants of human existence to one quadrant, which is it.
So the body, its chemicals, its functions, it's a left brain approach. It's saying, let me not look at a whole, but let me just look at the parts, and by fixing parts, by moving parts, we will fix the whole. - [Rachel] Right. - [Zubin] Yeah. - [Rachel] That's right.
So what you and I have been talking about for a while now is this idea, which is more like fact, which is that health is always more complex than just that, human beings are more than just body parts. Right? We're more than just chemicals and organs. So there's the bio domain of health. It's this three-part thing. There's bio, which is our biology. Then there's psych, which is like thoughts and emotions, and behaviors, and memories and trauma.
And then their social or sociological, which is like the everything else bubble, right? Socioeconomic status and access to care, and race and ethnicity, and- - [Zubin] Cultural issues. - [Rachel] Family and culture and context and your larger environment, right? So it's all these things always working together in a complex interplay. - [Zubin] Which, by the way, you can reduce in the spirit of reductionism in the biomedical model. You can reduce to I, we and its.
So the bio is its, the we is the social, technological stuff, and the I is the internal state. - [Rachel] Great. Great. What I want everyone to know is that while bio is a very important part of depression, of course, and the bio of depression is like genetics and it's hormones and it's immune functioning. And it's like sleep and diet and exercise, and it's sex. So females more than males are prone to depression for a million reasons. We can go into the social component of that.
And it's also like time of year and the amount of sunlight you get. Like winter tends to be a trigger. So all the bio things, like neurotransmitters hormones, those genetics, all real. There is no gene for depression.
Tan-ta-ta-da! There is no gene for depression. There's no depression gene. So I have patients come to me and say, "My mom has depression. So I'm screwed." If my mom has a gene for depression, I am going to be depressed. Talk about nocebo. Right, so we want to be careful. And by the way, yes, it has shown that depression can run in families.
But let's talk about that for a second. Can you think of other reasons why, if a parent is depressed and a child grows up in that home, why that child might end up feeling depressed other than it was passed down by a gene? - [Zubin] Well, we are social creatures. Children are particularly empathic. They're picking up on the signals of the parents.
There may be abuse and other cyclic actions that are triggered by the depression. And I'll say this in the spirit of true integration, there's cultural stuff, social stuff, the way the child then behaves as someone who has some stigma of that, how they're treated socially, can feed back into that. And then I think that's all in the setting of maybe there are multiple genetic pieces that collude to put you at slightly higher risk, that then is fulfilled by your environment. - [Rachel] Wow. Do we give out gold stars on this show? - [Zubin] If so- - [Rachel] Can we get those next time? - [Zubin] I can get half of one. - [Rachel] And then we can wear them on our forehead.
- [Zubin] That's a good idea. Maybe we could get a little device that just goes chi-ching! I wanted to do that multiple times when you were talking. Yes, yes, yes. (laughs) - [Rachel] Awesome. Great. That was beautifully said. So yes, there are a number of genes it is hypothesized that might contribute.
And it is never, ever, ever genetics alone. It is never, ever, ever brain chemistry alone. That's not how it works.
Again, depression lives in the middle of this biopsychosocial recipe. Like exactly what you just said. So we already did the bio. Let's talk about the psych for a minute. The psychological contributors to depression include the thoughts you have in your head. So when I see people who are depressed, they think things like this is never going to get better.
I am broken. Nobody loves me. My life is meaningless. There's no purpose. Now, if you're thinking thoughts like that, how do you think you're gonna feel? I literally just ate the microphone.
'cause I got so excited. - [Zubin] Rogan is always asking people- - [Rachel] Eat the microphone. Yeah, I kinda just ingested it, yeah.
- [Zubin] So what you described are those cognitive, thoughts, keep going. - [Rachel] Cognitive components of depression feed this cycle of depression, because it's always all the things. And guess what? Here's a fact. Thoughts affect physiology. So yes, if you are hooked up to a machine, by the way, this is called biofeedback, which gives you feedback about your biological processes. If you're hooked up to a machine, and you're thinking catastrophic, terrifying or depressing negative thoughts, the machine that is reading biological processes will show you that there are changes in heart rate, changes in body temperature, changes in muscle tension and blood flow.
And even blood oxygen. The things that change when you think a thought are physiological. So I just want to prove to everyone that depression is biopsychosocial. So we have thoughts.
Thing two in the psych bubble, our emotions. So if you are feeling stressed or overwhelmed or anxious, or having lots of sad feelings, or you're feeling very angry, emotions are also gonna feed into the depressive cycle. As everyone knows, when you're really anxious and really stressed out, it's hard to be in a good mood. So emotions are always perpetuating the cycle also. We have self-esteem in the psych bubble too.
If you imagine, like, if you're struggling with low self-esteem that can contribute to a depression recipe. - [Zubin] So, oh man, this is like a three hour show in itself. It's so good. I wish... Oh, so, okay, okay, okay. Just a couple of things before you go on. So thoughts contributing to depression, that's easy to wrap your head around, because you can say, okay, these catastrophizing, these identity issues around self-esteem, absolutely, because that's a story.
It's another thought complex. We tell about ourselves "I'm worthless," and these are distortions too. Because I did this, I'm forever this. - [Rachel] Right. - [Zubin] All these kinds of ways of saying. What's interesting is the emotion piece.
So this is where I'm gonna put the blame squarely, again, on thought. I think thinking, and it's a Zen saying, thinking is the disease of the human mind, and this is why emotion, raw emotion can come up. But what it does is it triggers a thought cascade, a story cascade, an identity cascade, a self-esteem cascade. And that feeds back and actually reinforces the emotion through resistance. It's like, no, no, no, I shouldn't be feeling this. This anger is bad. I'm a bad person.
Then the stories, and then the depression is worse. So yeah, so anyway, sorry not to interrupt, but that's something that just came to me that actually accepting raw emotion as it is and letting it be is a very hard thing for humans to do. 'Cause we tell stories about it. Yeah.
- [Rachel] Agree. And I thought, yeah, that was very helpful connection. Because I think what you and I really want to do is just connect all the things. We have this false divide between brain and body, but actually the truth of it is that all the things are connected all the time. - [Zubin] Yes. Body-mind-environment,
it's all one thing, yeah. - [Rachel] Correct. Right. So we've got our bio bubble. We've got our psych bubble. And just to say, also in the psych bubble of this biopsychosocial model of depression, is behavior, coping behavior. So how you act when you have depression is going to affect the cycle of depression. So what I mean by that is when we are depressed, sometimes we naturally and normally isolate, stop moving, stop going outside, stop exercising, stop seeing friends.
You know, we hole up and become hermits. We sleep all day. And guess what? That kind of coping you bet your ass is gonna make you feel more depressed because now you have no life. You're not seeing your friends. You're not going out. Sunlight, by the way, we are diurnal animals.
Sunlight is critically important for serotonin, which is the neurochemical that crashes in depression. We need to be moving our bodies because exercise stimulates this neurotransmitter called serotonin that is implicated in depression. And in fact, the medications that we dispense for depression raise levels of serotonin.
So coping behaviors, the behaviors we choose to engage in can also either tank our serotonin or raise our serotonin. So even though depression is fighting you and telling you to stay home and stay on your couch and not see anyone, the most critical part of treatment, in my very humble opinion, is fighting it, getting off your couch, making plans, standing outside in the sun, making sure you're connected with your community, finding ways to move your body. So coping also changes depression and that lives in this psych bubble. - [Zubin] Absolutely. Well, one thing I'll even add, I don't know how valid this is, but it seems to be valid.
There's a kind of self-soothing that we've learned as young kids that we, it used to be like you reach out with certain actions and behaviors to your parents to get soothed. Like I'm suffering. Let me show you how I'm suffering, and the parent soothes you and then you calm down. But as we get older, we internalize some of those processes. So in our mind, we start to go, "God, I'm suffering so much. I'm so old. I'm so sad.
I can't get out of bed. I won't get out of bed." And there's a kind of an internal self-soothing algorithm where we think, okay, this is gonna make us feel better by really just wallowing in this. So you don't get out of bed, you don't move.
You know, by moving, by getting out of bed, it's almost like admitting, oh, maybe the suffering isn't as bad. Maybe I won't get soothed in this way. And I wonder if there's a conditioning there that sometimes it's good to make explicit, I don't know. It's just something that kind of comes to me sometimes.
- [Rachel] So I think that's actually really true. And it does feel like soothing, except that it's a trap. - [Zubin] It's a trap! - [Rachel] Right. - [Zubin] That's the thing.
The point is it's a trap. It's quicksand. It's something we learned as kids, but it doesn't work when it's internal. - [Rachel] Right, and also that kind of self-soothing is great and fine, like nurture yourself, take time to rest and eat good food, and then break the cycle. - [Zubin] That's right. It's a different type of self-soothing.
- [Rachel] It's very critical to break. And I want to get to part three because, you know, otherwise we will do seven hours on the biosocial which would be fascinating. - [Zubin] Which is fine. - [Rachel] But so then there's the psychosocial bubble or the social bubble of depression. And that really is everything else. So socioeconomic status.
And we can talk about what happened during COVID, where people lost jobs and lost homes, and there was food insecurity, and what that does to your mood. And social isolation, human beings are social animals. In the presence of other people our brains produce chemicals that make us feel good. Serotonin, I keep mentioning serotonin because that's an antidepressant. So in the presence of other people, your brain produces serotonin. It also produces dopamine, which is this reward chemical that makes you feel good.
It also produces oxytocin, which makes you feel connected to other people, makes you feel warm and fuzzy. - [Zubin] I produce man milk when I release oxytocin. - [Rachel] And some of Zubin's breasts produce man milk, which is very impressive. Your brain also produces endorphins when you're with other people, which is a natural painkiller and an endogenous painkiller. So in the presence of others, your brain literally makes you feel good to encourage you to engage in social behavior. Guess what happens when you're isolated? Like the last two years.
- [Zubin] All of this, all got sucked away. - [Rachel] All the chemicals crash and you feel worse. So if you have depression and you're socially isolated, COVID has probably been real bad for you.
Because we've also lost our normal coping strategies and our support systems. Like for some people it's church, and for some people it's Thursday night, you know, board games and whoever, whatever it is, - [Zubin] Perverted Scrabble. - [Rachel] Maybe it's perverted Scrabble at Ben's house where he's making you homemade ice cream. And like, I really miss those evenings, I'll just say.
But in this social bubble, there's also like parents and family dysfunction and a lot of stuff that happened during COVID too was an increase in abuse and domestic violence. And, you know, relationships are toxic as we all know. So there's a lot of things that live in this social bubble. Like, as you know, your relationships affect your mood. There's also, we're not talking about grief and loss and death.
Like I have a dear family member who lost her daughter to a terrible accident in a hospital. And she was diagnosed with depression. By the way, that's grief and mourning and loss. And they put her on SSRIs which are a medication for depression, and surprising to no one, they didn't make her feel better because it's not that her brain is broken, it's not that it's a flaw in chemistry. It's that when you lose a child, it is a terrible, terrible trauma. And there's a lot of ways of treating that.
And by the way, I want to make clear, I am not anti-medication. I have heard from many people that antidepressants have been very helpful for them, but what I am pro and what I want to promote is that it's never just one thing. It's never just the bio. If you really want to treat depression, you have to go after the whole biopsychosocial recipe. You want to look at the bio. Yes, of course you do. And you want to look at the psych.
You want to look at the thoughts, and the memories, and the other emotions besides sadness that are happening for you. And your coping behaviors, what you're doing and whether or not it's working. And you want to look in the social bubble, what's going on in my environment that is perpetuating my depression? Do I have toxic relationships? Is there abuse? Is there poverty? Is there racism? What is happening in my larger context that might be messing with my mood and what can I do about it? So I hope that makes sense that the actual real treatment for depression, the actual real treatment is not and never will be just a pill. That is not the treatment for depression. It is a biopsychosocial illness that requires a biopsychosocial treatment.
And that is true 100% of the time. And I actually recently got into a fight with a physician at Stanford who has a website that I think is horrible. And if you search f
2022-02-02