Bonus: In Conversation with Dr. Rachel Yehuda

conversations ever. Could you begin by telling me how you ended up studying trauma and its effects At the beginning, yes, it was a little bit of an accident. Um. I was a graduate student in the late nineteen eighties and I was studying the effects of stress on beIN development. I was doing so in laboratory RAPS. I was a student of neuroscience, and I found the idea that stress

can affect brain development really very fascinating. But I did not find RAPS very fascinating, and I really the whole time I was in graduate school wondered if there would be any way that I could possibly pivot towards working with people, and I ended up meeting somebody in my graduate school who was very interested in studying psychosis proneness, which is really the idea of being able to look to see if college students are at risk for the

later development of mental illness. And he had developed a screening tool. But this was the emerging era of biological psychiatry, and so we met casually one time, and I was a student of neuroscides. He said, I wonder if there is a test that could be used to biologically validate my UM questionnaire. And I looked in the literature and I found that indeed, people were starting to talk about UM risk for developing psychosis in terms of a biological

alteration in a in an enzyme called monoamine oxidase. And so I thought to myself, I wonder if this could be measured, and learned that it can be measured in plate lists. So it was so organic. I said to him, you know what, I bet I could figure out how to measure this enzyme in plate lits. And my advisor wasn't that happy about this whole new development, but I promised him I would finish my dissertation in the rats um. And this is such a challenge for me to figure

this out. But I did figure it out, and we did find UM that the enzyme levels were associated with his test. And after that, I just really wanted to do clinical work and it wasn't necessarily important for me

to do it in trauma. About what happened was this professor's name was Dr William Addell, moved to Yale and UM asked me to come with him, and I ended up doing a post doctoral fellowship at Yale Medical School UM starting looking for people that knew about this enzyme, monoman oxidase, and ending up at the v A UM at the West Haven v A where UM somebody had actually done work with this enzyme but had now moved towards studying post traumatic stress disorder. And I thought that

was magnificent. I hadn't heard of it before, but I've been studying the effects of stress in rats for so long that I thought, oh, this is perfect. So how long had post traumatic stress disorder had a name and been been something that was in maybe not the popular lexicon but the medical Yeah, that's a really good question.

It had only been a diagnosis for seven years by the time that I began my post doc um which is seven and PTSD was first described in the d s M three in Night, so there was very little known about the disorder. That disorder itself was kind of controversial when it first came out, and in fact, my mentors at Yale that I ended up working with, doctors Earl Giller and Dr John Mason Um had just published what was the first biologic study in PTSD, and they

showed very counterintuitive findings. One paper they published showed that adrenaline levels were higher in Vietnam veterans compared to other veterans with other psychiatric conditions. But another paper that they published showed that levels of the stress hormone cortisol or lower in Vietnam veterans with post traumatic stress disorder compared the patients with depression and schizophrenia and other conditions. And this lower cortisol level than a stress disorder had everybody

really baffled. And when I heard about it had just been published, it had me baffled because everybody knew that stress related conditions were associated with elevated stress hormone levels, and against the backdrop of the fact that people were having a hard time in the field of psychiatry wrapping their heads around post traumatic stress disorder. You know, this was sort of an inconvenient truth in a way, because it would have been better had the initial study found

high stress formal levels. Then you could say, see, I told you they still are under stress. But this seemed to be a very challenging initial observation. So the first study that I ever did in the field of PTSD was to try to replicate this observation, and I was astonished when I actually found the same thing, low cortisal levels in combat Vietnam veterans with PTSD compared to combat veterans without PTSD. And what did you make of that? I mean, what what? And over time? What have you

made of that? It must be you know, I'm not a scientist. It must be so sort of provocative in a way as a scientist when you know the results are there and they're irrefutable, and yet they're not. They're frustrating because they're complicated or confusing or not not what was expected or creates I guess, create new challenges. Yeah, so irrefutable is a big word, because um, no stud

these a refutable. What what people like me do when when we do a study is we try very hard to minimize the kind of confounds that might contribute to having false results UM. And so you always wonder when you do a study, is this really right? Did I minimize all the things that could contribute to something that might give me a distorted readout? And so what most

people do is think I better retreat the study. And since the results really were so counterintuitive, but by this time it was the second finding, because I was replicating a finding already. But still the results are so counterintuitive that I thought I had to replicate them. And then I wondered if there had been something special about Vietnam veterans who were at the v a UM that might

not be prototypic of other kinds of trauma survivors. And for my replication I chose to study Holocaust survivors UM because I thought, well, you know, Holocaust survivors have also suffered extreme trauma. I grew up in a Jewish community where there were a lot of Holocaust survivors, and to me, they seemed initially like they might be different from Vietnam veterans who were at the v a UM. But that

was a false first impression. But in any event, I thought, look, I'm going to go and find out if cortisol levels are lower in Holocaust survivors and adrenaline levels are higher also in Holocaust survivors within without PTSD, And in kind of putting that study together, UM, I learned that first of all, yes, we were able to replicate the finding of lower cortisol levels and increased levels of adrenaline in

Holocaust survivors PTSD. But the thing that gave me the biggest jolt was how many Holocaust survivors had PTSD even fifty years after the Holocaust, and how infrequently this has been talked about, how they didn't have a name for it, how they hadn't sought treatment for it, and how how many of them were people that I had grown up with and never suspected we're suffering. We'll be right back.

I think it would be so helpful um to listeners, even though it's really so basic for you to actually define PTSD in regard to its symptoms, because I know it can take on many different shapes and forms, but it is it is diagnosable in terms of symptoms as well as in terms of the science of the cortisol levels.

It's a it's a good point PTSD, as as it was defined then, was a condition that occurs following exposure to an extremely traumatic event, generally a life threatening event UM and at that time there were three symptom clusters

associated with PTSD. There are now four, but they are UM having intrusive distressing recollections of the trauma, either because um, you get reminded of what happened, or just out of the blue, you know, you're just minding your own business and you have an intrusive recollection of something horrible, or the memory comes to you in the form of a nightmare. And one of the things that happens when you do get triggered or you do have a memory, is you

become very, very distressed. So it's easy enough to ask people about whether they have UM distressing recollections of a trauma that they've been exposed to you. And the second category of symptoms have to do with avoidance. That is that trauma survivors with PTSD tried desperately to do whatever they can do to not think about the trauma or

not get triggered by the trauma. And this involves not dealing with people that might remind them of what happened or going to places where the trauma occurred, and it could be a real barrier in therapy because if you have an illness or condition where you one of the symptoms is that you want to avoid thinking about what happened. You're reluctant to talk about what happened, and healing from trauma often involves that. But you can ask people about

their avoidance behavior. And the third UM symptom cluster with hyper arousal, and these are the real physiological symptoms that are probably a function of the higher address all levels.

But there's a difficulty sleeping and difficulty concentrating UM. There's something we call hyper vigilance, which is scanning the environment just sort of sort of being in a new place and feeling like it might be unsafe, looking for the exits, making sure that um, you know where the doors are UM, and having a startle response um uh to loud noises. One of the one of the hyperreusal symptoms are also

being very irritable and angry. And this is something that many trauma survivors just cannot understand why they're so irritable and why little things make them so angry. But it's part of a physiological complex, and now in the d s M five there's a new symptom cluster that is really reflecting changes in mood and changes in cognition, which simply means that you think about the world differently. You just don't see the world the same way as a

result of trauma as you used to see it. And for people who have been exposed to trauma early on, so it's really confusing because they don't remember there before. They just know that they don't feel safe and that the world is a dangerous place and that you can't trust strangers, or they may feel that they are incompetent to deal with what life has to offer them. And the mood disturbances are such that you feel pretty sad

most of the time, sometimes anxious, sometimes hopeless. In that sense, um PTSD can often be confused with depression, or sometimes it just can co occur with it. It's so interesting too and complex that the person suffering may and I guess that goes to the fourth cluster, may not actually consciously be able to identify what the source of the suffering is. That there's a kind of dissociative way of

sort of distancing avoiding. Does that make sense? Completely and that and that that's what I found in the Holocaust survivor is that they knew they were distressed. They thought it was their lot in life. Um. They never gave their own symptoms that much consideration because they were, after all, the survivors, and compared to the fact that so many people had died. Um, they didn't even feel perhaps entitled

to complain about the symptoms that they did have. And certainly there wasn't this idea that anyone could do anything for them. Um. As one woman put it to me, what is somebody going to do take back the Holocaust? Make it like I didn't go through what I went through. So there there really was this feeling that they were as marked as the tattoo on their arm, that this is something that they were going to just have to

live with. Um. And they didn't think about it as a cluster of symptoms that might be able to be treated, or that even the things that they now thought as a result of the trauma might be revisited or contemplated or discussed in therapy so that you could get a different idea about them, which is actually one of the main purposes of psychotherapy. So to me, it was just striking to see what something looks like when you don't

deal with it for so long. Now, of course, many Holocaust survivors had primary care doctors, and many primary care doctors saw the anxiety and prescribe things for insomnia and for anxiety. But that's not really the same thing as naming something that happened as a result of a terrible traumatic experience, and maybe even something that UM might not need to exist in its current form. If you can work yourself around what has happened and what it means,

some of those symptoms will go away. I mean that that's so much what the you know, thematic material of this podcast has been over the course of four seasons, UM, because you know, we talk about my you know, my guests, and I talked about secrets, all different kinds of secrets. I mean that the tagline is the secrets that are kept from us, the secrets we keep from others, and the secrets we keep from ourselves. And UM, I find most poignant and distressing in a way the secrets we

keep from ourselves. But there's you know, where they're like if I were going to draw a Van diagram, like where there is the intersection between secrecy and silence, UM, silence and shame UM the places where those three sort of states intersect. And you know, you're you're talking about UM studying the Holocaust survivors in Cleveland, where you grew up, and and I remember that that is when you came

across my radar for the first time. UM was when I was deep, deep, deep into the research and the experience of having discovered a family secret that was so deep and so powerful that I could never have actually consciously imagined it, which was that I was the family secret that my dad had not been my biological father. And I had never consciously entertained that thought consciously being

you know the key word. And and I had grown up in New Jersey, in a neighborhood that was filled with Holocaust survivors, and I felt like I knew the people you were talking about. And for the most part, because I you know, I can't say it to the person. But wouldn't have sought therapy. I mean, it would have been like the last thing that they would have And they very often didn't speak of it UM or it would leak out sideways, or they wouldn't speak of it

with their children or there. You know, it was like you shouldn't know from that, and so they carried it. But carrying something without speaking it has such a profound cost, which I think is what I've been learning in a way as a student of all this um for the last number of years, is what the cost of that is.

It doesn't go away because you wanted to. It doesn't go away because you wanted to, And keeping and not using your words to talk about it doesn't mean you're not conveying the narrative in some nonverbal way, and that I think is a lot of the information that we do get sometimes from our parents is nonverbal. I mean we internalize the information even if it isn't spoken in words.

Um So, but that trilogy of silence, change, secrecy, I think is something that really unites many trauma survivors because I think you're exactly right about those three aspects of the problem. And also, when you seek treatment UM you have to feel in some way that you're entitled to it,

which many trauma survivors don't. And in fact that many trauma survivors end up in therapy because someone that they live with or someone that they love tells them that they should go to therapy because they're not able to tolerate some of the manifestations of trauma UM that either they do or don't recognize as manifestations of trauma. But sometimes trauma survivors go for therapy without even understanding that they're there to process the trauma UM, which is very

interesting but is not at all unusual. No, that doesn't that doesn't surprise me. I but why the sense of undeserving or and I'm sure that there are many different reasons for different individuals. But is it because um, because it's really a sense of minimizing the trauma or kind of erasing the trauma, or is it the shame or sort of shame based feeling of like I don't deserve to feel better or I don't deserve to be better.

I think a lot of it is shame based UM, certainly depending on the trauma of a lot of people that are exposed to sexual violence or sexual trauma, particularly early on, are convinced that they somehow provoked it, and they feel very ashamed about that. And even if they don't feel that they provoked it, many people feel very ashamed that they couldn't stop it. UM. And I heard this also from Holocaust survivors, just the they could really do nothing, and yet there was the shame of being

so degraded and so humiliated by the circumstance. So I think that that shame is connected to feeling undeserving in some way. And it's very complicated for combat veterans. We talked now a lot about moral injury and people being very ashamed of some of the things that might have happened in combat. So again, combat is an pretty uncontrollable situation most of it, and um, people are going to

often second guess themselves. Even after nine eleven, so many people talked about what they could have done, what they didn't do. Kind of a lot of recriminations of running down the stairs instead of helping other people down the stairs. Anywhere you go in a traumatic situation, there's room to second guess yourself. We refer to it in the field

as the basis of developing negative cognition. So you start to wonder why you didn't do this, that or the other thing, and then you develop an answer for that, Well, it must be I'm a bad person, it must be I'm incompetent, alright, So it feeds into the same thing. The reality is that when you're under a fight or flight response, you're not really thinking that much. Your body is doing what it is evolutionarily designed to do, which

is save those genes that they can be cassed. And so you don't go into an entire analysis of what should I be doing at this moment. You just do it at this moment what your genes are programmed to help you do, which is survived by any means necessary. We'll be back in a moment with more family secrets.

Are certain people's genes programmed more toward one of those evolutionary responses In other words, I mean I recently came to be aware that you know that the freeze response is part of that like it's it's and so it's like this trio of I came to realize it because I'm a freezer. I'm not a fighter, I'm not a flear I'm a freezer. I go into like just I'm going to be as still as possible and maybe this will pass. UM. I'm just wondering whether that's is that

genetic or is that circumstantial. It's probably got features of both. Um, but sometimes the body makes different decisions based on what's happening, So freeze might be exactly the right response under some circumstances. Don't move over, else something bad will happen. Sometimes fleeing is the best and wisest response, and sometimes fighting is. You know, So I think that I actually think that we might have I think we have the capacity to

do all of those things under different circumstances. But that you make the best choice you can given how you size up a situation at the moment. So I think that that I think we all do that when when a trauma occurs when you're younger, it's probably the most adaptive thing to just freeze through it, because you're not going to be able to fight, and maybe you're not even going to be able to flee, So just breathe

through this and let's see where it goes. Do you think some of that then becomes learned and ingrained, so that if when we were younger we learned that freezing was what was going in too get us out of this, or or or be the best recourse, maybe we've become more freezers as adults, or or any of the any of the responses. Maybe maybe we did flee or maybe we did fight, or is it as you say that, it really does depend on the circumstances. No, no, no,

that's exactly right. I mean one of the most important things that happens when you're in a situation of extreme stress is that the body's release of stress hormones, among other things, helps you remember what has happened, presumably for the purpose of allowing you to have a better response

next time. So, yes, our responses to trauma very much depend on what has happened to us before that moment, which is why when you're responding to a trauma in the here and now, if you're also responding to a

lot of things that have happened in the past. And this is why we start to get a lot of individual differences in the way people respond to events, because so much of what you're doing in the moment, Sure it's biologically conserved and your program to save yourself, but a lot of the decision making about how to respond to trauma does have to do not only with what happened in the past, but what the outcomes of those

decisions were. That makes so much sense. So let's go back for a moment to Cleveland and the Holocaust survivors. And was this the beginning of your exploration of or sort of identification of epigenetics in the intergenerational effects of trauma. Oh no, no, no, no, that didn't happen for a really long time. Interesting. Yeah, no, no, no, I didn't know the word every genetics when I first started studying Holocaust survivors. It wasn't a word that was used in

neuroscience or matl health or psychiatry. And it wasn't even a concept that was available to me, which is what makes the whole story so much more um interesting, because what I was thinking to myself, Well, what happened was

we study, we did a study on Holocaust survivors. We were able to replicate the hormonal findings, which to me meant this is real and worth pursuing because I got to find out what is it that is resulting in lower cordisol levels and people that have had a trauma so long ago and now have PTSD, Like, what's that about? But the other thing was, you know, there's a whole population here of Holocaust survivors that there's an unmet mental

health need. And when I went back to New York and I started my first job as an assistant professor around Sinai in New York. I was dis gusting this. With my chairman, I said, I really wish that we could we could create a clinic for Holocaust survivors, and he said, do it, and so I did it. UM. What I found was that it was it was the children of Holocaust survivors that began calling, and so I

didn't know what to make of that. UM. Some of my best friends are children of Holocaust survivors, and they didn't seem that different from me. UM. But again, things are very different when you look deeper than on the surface. UM. But these adult children of Holocaust survivors were really claiming to be casualties of the Holocaust, and certainly casualties of

the way they were raised in their homes. So we started clinical programming for both Holocaust survivors and offspring, and we continued to do biologic work to try to figure out, you know, what exactly is going on with this very unusual hormonal us bonds, which, by the way, many offspring showed as well the evidence of the low cortisol levels

and um the high adrenaline levels. And we kept at it until we figured out that at least four adult children of Holocaust survivors, many of the biological and clinical features that we were observing that looked like a traumatic stress response actually occurred when one of the parents had post traumatic stress disorder, and that a few years later even learned that there were kind of different effects if the mother was traumatized or if the father was traumatized.

We started to just go deeper and deeper. Now every genetics came along in kind of like maybe two thousand and four or something like that, there was a paper that was published by actually a very good friend and colleague of mine, Dr Michael Meaney, and he was studying again laboratory rats, but he was studying um parenting. Interestingly enough, he thought he started out thinking he was going to

study maternal um stress. And what happens when you remove a mother rat from the cage where her little babies are right and you handle the animals, you return the mother back. Um. It's a stressful thing for the mother.

It's probably a little stressful for the babies. UM. But what the mother starts to do after being removed from the home cage for fifteen minutes is she starts looking and grooming her pups, and what Dr Meni and his UM group noticed was that there was a lot of variation in how much licking and grooming there was, and eventually they realized that the licking and grooming of the pups by the mother h was really having a profound

effect on the way that offspring the baby wrath as adults. Right, um developed different kinds of stress responses and cognitive responses as adults, and so they came up with this wonderful theory of early developmental programming and really understanding that the kind of mothering that you receive may have a profound impact. And they started measuring this with stress hormones even in the rats that as they became adults, which for fortunately

for rats it just takes a few months um. But they began to see that they were the first really to apply epigenetics to this question, and they began to see that in the hippocampus of these rats that had been exposed to differences in maternal care, they found differences. Epigenetic differences is on a stress related gene, and it just happened to be the gene that is the receptor

for cortisol, which is called the global cordicord receptor. So when I read this, I was just all over it and I actually called Michael Mini and said, I think this work might apply to Holocaust offspring. At the time, I thought maybe the Holocaust offspring for the way they were because of parenting. That's certainly what I thought in the early two thousands, right, and um, so I asked him to help me figure out how to do ety

genetic measures. Um. We didn't have brains available to us, but we decided we could measure the same part of the gene in blood and indeed we began looking at every genetic changes and then what we saw was that there were different that that direction of change in offspring, in Holocaust offspring was different depending on whether the mother or the father had PTSD, And so we we knew

that this couldn't just be parenting. We knew that there had to be a bigger story here, UM that would explain a different epigenetic finding right in Holocaust offspring based

on parental gender. And that's when we started to really explore epigenetic changes, looking at the contribution of in uterine stress or perhaps thinking about the fact that some of the changes might be UM might have been present preconception and might have been transmitted through sperm or egg, And that's when, you know, we began to really connect the epigenetic findings with the concept of every genetic inheritance. So, yeah, that that was a journey that really took a long

time and began. And that began with the fact that those that those offspring of of the of the generation of survivors were the ones who who reached out. Yeah, we studied them. We found that, sure enough, there was more anxiety and depression and PTSD in those offspring than in Jewish very similarly demographically similar comparison people and UM.

And then we chased the hormonal findings and by then, you know, we were just we just got lucky because by then molecular neuroscience had given us all kinds of tools to be able to look inside the cell and look on the d NA, so we couldn't do this work.

Even though in the early nineties when I first encountered this, I knew that it wasn't exactly genetics that was explaining this, but I thought it was more than just being raised in the environments that offspring were raised in, because there was so much diversity in the homes of you know, some parents talked all about the Holocaust all the time and some didn't say a word, and so there was I felt there had to be more, and indeed there

seems to be more. We'll be back tomorrow with part two of my conversation with Dr Rachel Yehuda, and please keep in mind that Season five of Family Secrets will drop on April one with ten all new episodes. For more podcasts for my Heart Radio, visit the i Heart Radio app, Apple podcast, or wherever you listen to your favorite shows.