Ep. 343 The Autoimmune Cure: Trauma’s Connection to Autoimmunity with Dr. Sara Gottfried

Today, I am delighted to reconnect with Dr. Sara Gottfried, a board-certified physician practicing evidence-based integrative precision and functional medicine. (She last joined me for Episode 211.) Dr. Gottfried graduated from Harvard and MIT. She is a Clinical Assistant Professor in the Department of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University and the Director of Precision Medicine at the Marcus Institute of Integrative Health. She is also the author of four New York Times best-selling books, including her recent publication, The Autoimmune Cure: Trauma’s Connection to Autoimmunity.

In our discussion today, we discuss the interrelationship between trauma and autoimmunity, highlighting its prevalence, particularly among women. We dive into the impact of trauma, explaining its correlation with autoimmune conditions and demystifying the role of the PINE network (the Psycho Immune Neuro Endocrine system). We explore triggers for perimenopause and menopause, gender differences specific to the changes in immunity and vulnerability in women, the consequences of burnout in various professions, the shortcomings of conventional allopathic methods in addressing mental health and trauma, and immunomodulation, including vitamins, polyphenols, low-dose Naltrexone, and somatic-based therapies. 

With Dr. Gottfried’s invaluable insights into crucial health topics, this episode is a must-listen. Stay tuned for more!

“We must think about the immune changes, nervous system changes, and how your brain doesn’t use glucose the way that it wants to after the age of 40, along with the endocrine changes, and the psychological changes. So we should think about the entire PINE network for our folks going through perimenopause.”

– Dr. Sara Gottfried

IN THIS EPISODE YOU WILL LEARN

• The traumas we experience as children could make us more susceptible to autoimmune conditions later in life.
• How trauma impacts our immune, neurological, and endocrine systems
• Addressing trauma through gut health, heart rate variability, and hormone balance
• Metabolic and immune system changes triggered during perimenopause and menopause can make women more susceptible to autoimmune issues.
• Similar trauma responses  between men in combat and women who experienced sexual assault
• Childhood trauma and how it shapes our direction in life
• The potential benefits of alternative therapies like LSD, MDMA, and Ayahuasca
• How measuring gut health can provide valuable insights for treatment options
• Using low-dose Naltrexone for sleep and immune system modulation
• Somatic therapies and breathwork for stilling the autonomic nervous system and promoting body awareness

Bio: Dr. Sara Gottfried:

Sara Szal Gottfried, MD, is a physician, researcher, author, and educator. She graduated from Harvard Medical School and MIT and completed a residency at UCSF, but is more likely to prescribe a CGM and personalized nutrition plan than the latest pharmaceutical. Dr. Gottfried is a global keynote speaker and the author of four New York Times bestselling books about hormones, nutrition, and health. Her latest book is called THE AUTOIMMUNE CURE (March 2024). She is a Clinical Assistant Professor in the Dept. of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University and Director of Precision Medicine at the Marcus Institute of Integrative Health. She takes care of executives and professional athletes. Her focus is on the interface of mental and physical health, N-of-1 trial design, personalized molecular profiling, use of wearables, and how to leverage these tools to improve health outcomes.

Connect with Cynthia Thurlow

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Connect with Dr. Sara Gottfried

Connect with Dr. Sara Gottfried

• On her website   
• On Instagram

Dr. Gottfried’s new book, The Autoimmune Cure, is available from most bookstores, including Amazon and Barnes and Noble.

Previous Episode Mentioned

Ep. 211 – Addressing the Root Cause of Hormonal Imbalances with Dr. Sara Gottfried

Transcript

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I’m your host, nurse practitioner, Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. 

[00:00:30] Today, I had the honor of reconnecting with Dr. Sara Gottfried. She last joined me on the podcast on Episode 211. She is a board-certified physician, who graduated from Harvard and MIT. She practices evidence-based integrative precision and functional medicine. She is a clinical assistant professor in the Department of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University, and the Director of Precision Medicine at the Marcus Institute of Integrative Health. She has written four New York Times bestselling books and has recently published The Autoimmune Cure. 

[00:01:04] Today, we spoke at great length about the interrelationship between trauma and autoimmunity, understanding that it impacts one in ten worldwide women more than men, the impact of trauma is insidious, pervasive, and corrosive, and predicts autoimmunity that every increase in a particular score, called the ACE score, is associated with a 20% greater likelihood of being hospitalized with an autoimmune condition. The role of the PINE Network, which is the psycho-immune-neuroendocrine system, triggers for perimenopause and menopause, specific to the changes in immunity, the role of gender differences and vulnerability in women, the impact of super autonomous self-sufficiency and burnout rates in not only teachers first responders, but also healthcare providers. The flaws with traditional allopathic approaches to mental health and trauma. The impact of immunomodulation, including vitamins, polyphenols, low-dose naltrexone, and somatic-based therapies. This is a don’t miss episode with the amazing Dr. Gottfried that I know you will find incredibly invaluable. 

[00:02:23] And so really starting the conversation about when we are children and as we are exposed to– And it can be a myriad of things, it could be bullying, it could be a parental divorce, it can be many things that it can impact us, but how does that set us up? And how does that predict for us that we are going to ultimately potentially be much more susceptible to autoimmune conditions, autonomic dysregulation, etc. 

Dr. Sara Gottfried: [00:02:46] I’m glad you raised this point about your training in Inner City Baltimore. So, I grew up not far from there, in Maryland. I had a similar experience where I would work at San Francisco General Hospital, and I felt being homeless, being a street worker, a sex worker, there were these traumas that I sensed as being incredibly distressing and disruptive to physiology. But my experience at home growing up, the marriage that I was in, there are all of these other small “t” traumas. I think Gabor Maté may have said that originally that past dysregulation. And in many ways, it’s not the trauma, it’s the way that it lives on in your system that really matters. So that living on in your system is what you’re asking about. And it’s so curious to me, because we all know about the stress response system. We all know about the hypothalamic-pituitary-adrenal axis. 

[00:03:48] And when you start to look at the data on trauma, and you think about how people with trauma, large “T” or small “t”, have mental health issues. They have post-traumatic stress disorder, anxiety, depression, disordered eating, obsessive-compulsive disorder, attention deficit disorder, that’s important, but it’s a small part of the bigger picture of dysregulation. And the parts of the body that are the most sensitive to it, the most vulnerable, are what I think of as the PINE network. So that’s your psychology ‘P,’ your immune system ‘I,’ your neurological system ‘N,’ and your endocrine system ‘E.’ And so, PINE is easier for me to remember than psychoneuroimmunology or some of the other terms that are used. 

[00:04:38] And when you look at the way that people respond to overwhelming and distressing events, often there’s a vulnerability with one system or another. I feel like my vulnerability might be with all of the above, with the entire PINE network, and that may not map so much to the amount of trauma in my life, but just the way my makeup is. I think it’s important to point out that I don’t feel like a victim about this. I feel like these things happened through me and for me and not to me, and that’s another really critical part that maybe we’ll get into a little bit later. But when you look at the immune system, when you look at the neurological system, when you look at the endocrine system, I think of particular biomarkers. I think of with the immune system, do you have autoimmunity? Do you have a dysregulated immune response? Maybe you had COVID and you’ve got kind of this ongoing process of responding to spike protein, which is now thought of as an autoimmune condition, non-classical.

[00:05:40] And in my case, I had anti-nuclear antibodies, so I had positive anti-nuclear antibodies, they recognized this about six years ago. So, if you think of the cells in your body and the nucleus and the cells of your body, I was making antibodies against this really fundamental part of my body. So, we’ve got trillions of cells and my immune system was attacking the nucleus of my cells. My antinuclear antibodies are now negative, so we can talk a little bit about that process. But then if you shift to the neurological system, I was someone who just always had a low heart rate variability, which is that measure of once again balance or homeostasis in a particular system that responds to stress, toxic stress, and trauma. And so, I’ve had to do a lot of work and N of 1 experiments to address that, to improve my heart rate variability. 

[00:06:41] And then with the endocrine system, the books that I’ve written are mostly about hormones. And here there are certain hormones that are especially vulnerable, such as cortisol, that means stress hormone. Upstream from that, corticotropin releasing hormone, which is directly toxic to the permeability of your gut, integrity, and can lead to increased intestinal permeability, so called leaky gut. And it can also lead to problems with insulin and glucose, which I also have. I’ve had prediabetes. It can affect sex hormones less directly, but progesterone, estrogen, testosterone, DHEA. So, when we think of the impact of these traumas, large “T” and small “t”, I really think it’s helpful to consider the PINE network. And also, to consider how’s your PINE network functioning? Do you have some dysregulation? Are there ways that your body is not in a state of balance that needs to be addressed?

Cynthia Thurlow: [00:07:37] Yeah, it’s interesting to me because I think about all these compensatory ways that as we navigate childhood into young adulthood or years where we’re establishing ourselves within our career, maybe getting married, having children. And I think for women in particular, we’re just so largely disconnected from our bodies. We’re kind of trained. You mentioned in the book about being a physician, and forget about going to the bathroom, forget about eating when you need to, forget about sleeping when you need to, and that’s not per se unique to just healthcare providers, but so many occupations that we just subjugate our needs in order to get the job done. And for many people, focusing in on school or focusing in on our purpose or our occupation allows us to deflect attention to the inner work which is so much harder. I always say it’s easy for me to get up and go to the gym or go for a walk, it’s a whole lot harder when I have to do the inner work, and I think this is something that likely resonates with listeners, that growing awareness of– It’s like this little scratch and the acknowledgment that you know that work needs to be done.

[00:08:43] And more often than not, these autoimmune conditions and as you appropriately mentioned, when you were going through your training, which was likely around the time I was going through my own training, there was a lot less. The laundry list of autoimmune conditions was much shorter than they are now. And so, for all these things, like, I never made the connection that after being treated for Lyme with six weeks appropriately of antibiotics for which I’m grateful, because in 1995, most people probably seeing a lot of bullseye rashes, and I had one, I then developed psoriasis, but even my healthcare providers never said, “Oh, by the way, you’ve now developed psoriasis, because the antibiotics that address the Lyme appropriately have now created leaky gut. And, oh, by the way, this is what you now have.” And sometimes these skin manifestations can be the very first sign that something is kind of brewing underneath the surface. 

[00:09:32] In the book, you talk quite a bit about specific autoimmune conditions that show up as skin related. And I’m kind of like looking through my notes realizing I’m looking for this one area where you were talking specifically about psoriasis and eczema and things like this that can be harbingers of specific types of trauma and internal duress that’s being manifested in our skin. And for me, that was very affirming. I think for many people, we’re diagnosed with one, maybe two, maybe three autoimmune conditions, and then maybe the light bulb goes on that we need to look a little bit more deeply, we need to be a little bit more conscientious. Maybe there’s this internal work that needs to be done, and yet that’s the hardest work. And as you appropriately said, traumas happen in many ways for us, I’m stronger because of what I went through. I view my family compassionately. There’s no shame or judgment from my part. But I think for many people, it’s getting to the point where you can reflect objectively and compassionately at yourself and what you’ve survived and grown up within. 

Dr. Sara Gottfried: [00:10:39] Yeah. Well, Cynthia, I love talking to you. Meeting you a couple weeks ago in New York was such a highlight for me because you’re a deep and wise thinker about the challenges that we’re facing at this point in our lives. And there’s all these compensatory ways that our body deals with. Things like Lyme disease and a lot of them backfire. Sometimes you get antibiotics for one thing and it leads to disruption of the microbiome, it leads to dysbiosis, it leads to increased intestinal permeability as you mentioned, and so the body is magnificent, and there are ways in which it can get derailed. And my experience is that that seems to happen much more often in women than it does in men, that the balance, the homeostasis, the delicacy of it is greater in women, and maybe the opportunity as a result of that. 

[00:11:31] So there’re so many things I want to respond to there, and I’ll just pick a few. One is, the title of this book is The Autoimmune Cure. And in some ways, I wish that people understood not to wait until they’ve got an autoimmune disease. So, psoriasis, as you mentioned, is one of those autoimmune diseases. It’s where you get plaques and kind of these changes that can occur different places on your body, your scalp, your hands, your other parts. And we know that people have autoimmunity, they’ve got this dysregulated immune response that can last for seven to 14 years before they get diagnosed with an autoimmune disease. And those are the people I especially want to be talking to, because we know, based on–

[00:12:18] I was just talking last week to Mark Hyman about his work with Function Health. And he’s shown and he’s talked about this publicly, that in the 100,000 plus people that have done blood work with Function Health, that 30% have positive anti-nuclear antibodies, 30% have autoimmunity, 12% have antibodies against their thyroid that can lead to Hashimoto’s thyroiditis. So, this is not something that affects only the 24 to 50 million people in the US. It’s something that’s affecting a much larger group of people. And I think, especially post pandemic, we’re seeing more of this. Women, once again, are disproportionately affected, we can talk about why that is. But the state of compensation and the way that it backfires, I think is really critical. And you just described beautifully with Lyme disease, I’m glad you got treated so early with your rash, and a lot of people don’t. And that can lead to dysregulation of the immune system. 

[00:13:21] And what Alessio Fasano, the Pediatric Gastroenterology at Massachusetts General Hospital talks about is the three-legged stool that’s required to develop autoimmunity, and that is genetic predisposition together with increased intestinal permeability, so called leaky gut, and then a trigger. So that trigger could be, maybe in your case, Lyme disease antibiotics, it could be toxic stress, it could be adverse childhood experiences which we know increase the risk of autoimmune disease, it could be a divorce, it could be infection, it could be pregnancy, postpartum, perimenopause, a big hormonal shift, so there’s lots of different triggers. What I think is important to mention is that, yeah, you can’t do much about your genetics. You can’t change the way that your genes are expressed, but the opportunity here is with the leaky gut and with the way that you respond to triggers, that’s the empowering part of this message. 

Cynthia Thurlow: [00:14:22] Yeah. I think that’s so important that people don’t walk away feeling like they’re powerless. I think for anyone that’s listening to this podcast, understanding that there’s great information, obviously, in the information, as well as your book, which does a really beautiful job of tying all this together, what is it about middle age, perimenopause, menopause that makes us much more susceptible to autoimmunity? Because I cannot tell you how many women, I have worked with that have said, “I was kind of plugging along until 45, and then the wheels fell off the bus, and now I’m trying to pick up the pieces, put myself back together, and try to navigate this next stage in my life.” What is it about that’s so unique to perimenopause in particular that makes us much more susceptible to this? 

Dr. Sara Gottfried: [00:15:09] You just described exactly what we’re trying to elicit when we’re talking to clients and patients about their story. So, I’m always listening for the trigger. I’m listening for, “I was fine until–” And as you said, “I was 45 and the wheels came off.” So, what we know is that perimenopause is so much bigger than just hormonal change. We tend to think of it as sort of initially loss of progesterone. You’ve got ovarian aging and then loss of estradiol, and then menopause, your final menstrual period, but you got to widen the lens here, because there are immune and metabolic changes that are a critical part of what’s happening in perimenopause. So, if you just look at the different parts of the immune system. We know that innate immunity, adaptive immunity changes pretty dramatically. And one of the ways that this got my attention was that– And I’m going to be careful to kind of stay in the middle of the road here. During the pandemic as I was taking care of people with telehealth, it was the women in perimenopause. It was the women who were 40 to 55 who were having the most adverse reactions to vaccines and less so to COVID infection. And overall, women were doing better in terms of survival compared to men, because we’ve got this more reactive immune system, but especially in response to vaccines, many more vaccine injuries, many more problems in response to vaccines compared to my male patients. Did you see that too?

Cynthia Thurlow: [00:16:39] I did quite a bit and I don’t know if I’ve spoken about this personally on the podcast, but I did get vaccinated and bled for six months. And my functional medicine doc finally said, I think this is– Because I’m seeing so much of this interruption between the hypothalamus-pituitary-ovarian axis in both menopausal and perimenopausal women that I’m fairly certain. And I even had autoimmune markers like my ANA skyrocketed with no other proclivity for how that could have happened, so, yes, definitely, personally and professionally. 

Dr. Sara Gottfried: [00:17:12] I understand the desire to kind of keep things simple, to think about perimenopause, “Okay, estrogen, progesterone, yeah. Let me consider whether I need bioidentical hormone therapy,” but we really want to be looking broader. We want to be thinking about the immune changes, the nervous system changes, the way that your brain just doesn’t use glucose, the way that it wants to after the age of 40, along with the endocrine changes and the psychological changes. So, we want to be thinking about the entire PINE network for our folks that are going through perimenopause. 

Cynthia Thurlow: [00:17:44] I think it’s so helpful to be thinking broadly as opposed to just focusing narrowly, which in many instances, is the way that kind of traditional allopathic medicine can look at these problems and these concerns. Something that I thought was really interesting was looking at the research, and you do such a beautiful job weaving this into the book itself, talking about how there’s not enough research done on women, certainly not in this area. There’s a lack of gender representation. But what I found interesting was that when you were looking at men in combat versus women with sexual assault, they behave similarly after these traumatic events. The hyperarousal, the reexperiencing, the avoidance, the numbing. And is there anything that helps explain this? Because seemingly they seem so diametrically opposed. Obviously, great insults on both sides. I think this was looking at men that had fought in Vietnam, and my dad is a Vietnam vet, but their experiences with later developing PTSD were very similar, despite very different traumatic experiences. 

Dr. Sara Gottfried: [00:18:46] I would say we’re still at the learning to crawl stage in terms of understanding some of the sex differences in the way that those who are assigned female at birth, those that are assigned male at birth, respond to traumatic events. We do know that if you take a more modern picture with military service, that men and women exposed to the same trauma, women have higher rates of post-traumatic stress disorder. So, there’s a vulnerability that women have– And I sometimes will say that being female is just a health hazard, at least in the culture that we live in. And there’s so much evidence of that, this is just one line of evidence. 

[00:19:25] In terms of sexual assault versus military service and progression to post-traumatic stress disorder. Once again, I want to broaden this because I had partial PTSD, there’s a few reasons for that, but I see a lot of patients who are not classic PTSD. They don’t meet all criteria, but they’ve got partial or subthreshold PTSD. And this is another place where I really want our listeners to consider whether that might be true for them. Hyperarousal, maybe reexperiencing some traumas, kind of going over conversations or fights, conflicts that you had, this physiology kind of the way that your biology gets disturbed by the reexperiencing. So, we know that women are exposed to sexual violence at much higher rates than men. And it’s appalling to me when I look at the numbers. And I’ve got two daughters, one’s 19, the other’s 24, and it just breaks my heart to see how high the rates are, especially among teenage women, college age women, but really women of all ages. So, yes, the women are exposed more to sexual violence, men are exposed more to physical violence, and it’s important to see that the end result, kind of the final common pathway, is actually pretty similar between the two, although women have higher rates of it in response to a particular exposure.

Cynthia Thurlow: [00:20:48] Yeah, it’s really interesting. And I think as I have children that are now teenagers, one going off to college and having conversations. Obviously they’re male, but having conversations with them, that the exposures to things that will happen in college, just being aware and cognizant of where they are in parties, what they’re doing, being aware of one another, I think is so important. 

[00:21:10] And I found, as I was considering what we would talk about today, because there’s so much information here, a plethora of information to discuss, but what is so important about trauma is understanding that a lot of the behavioral mechanisms that I know you and I share, ways that we worked around our traumas achievement was something that in my house, if I achieved, I was left alone and I wasn’t involved in a lot of the verbal and physical things that happened at home. But in many ways, these hyperindependence, the autonomy, the achievement is highly valued in these dysfunctional families as it makes a child or adult easier to manage when they have little to no needs, that hit me so hard, it made so much sense, but I’m sure there are many people listening that understand that’s how you survive that experience. And many people go many different directions. But that was how I kind of had that experience. And I think in many ways, it probably drove me into healthcare, helping others, serving others was something that was very heart centered. 

[00:22:17] But what I found really interesting, in addition to this super autonomous self-sufficiency, which is a new term for me, was that understanding that healthcare providers and teachers have some of this highest rates of burnout. And yeah, we know we’ve come out of this pandemic. We’ve talked around the pandemic a little bit, but understanding that the degree of burnout. So, you have individuals that have very likely headed into career paths that serve their soul and in many ways are healing them as a byproduct of this achievement orientation, but they’re also the highest rates of burnout and yet many of us probably don’t understand that the people that are serving others in many ways are the ones at greatest risk for this continued dysregulation of their autonomic nervous system, of their PINE system, if you will.

Dr. Sara Gottfried: [00:22:57] Such a critical point. And yes, it feels like there’s a way that childhood trauma can shape you in this direction. And it sounds like your experience is similar to my experience in that I learned how to over function. I learned how to achieve and succeed academically. I tried to achieve athletically, but that didn’t go so well. And it maps to so many future behaviors and career choices, so you’re absolutely right. Nurses, physicians, other healthcare workers, first responders, teachers, we’re the ones with the highest rates of burnout. And I think much of it relates to over functioning. And how much of that then connects to adverse childhood experiences or maybe trauma as an adult, it’s a little hard to tease that apart, but over functioning was a huge part of my story. And I didn’t even recognize it until I would say, maybe my 30s, when I was having kids. And that’s when I first recognized that my cortisol was a hot mess. So, my stress hormones were really– My pattern was that they were really high, and this is classic for women who are in healthcare. So really high cortisol, and not just by a little bit, but like two to threefold higher than the upper limit of normal. And so, I could work with that. I found ways to improve it. I became a certified yoga teacher, started meditating every single morning. I took supplements that helped me with my cortisol. But then I would get bent out of shape pretty easily because I wasn’t resolving the trauma signature that was in my body.

[00:24:35] I have a sister who’s a teacher. She teaches in elementary school, and she’s got a similar story. I mean, especially post pandemic, she works with a really diverse population in Oregon, and she’s got a lot of trauma among the kids that she’s takng care of, and she’s got a really big classroom. She’s a public school teacher. It’s a lot to manage. I also volunteer with a nonprofit that is bringing ketamine-assisted therapy to first responders. And you look at firefighters as an example, and the amount of trauma that they’re managing, especially with the crisis, the climate crisis that we have right now, there are ways that we’re more vulnerable and more dysregulated than ever before. And so, starting to recognize that dysregulation, starting to understand your own exposure to trauma, maybe knowing what your adverse childhood experiences score is, that’s a really good place to start. 

[00:25:31] And then starting to look at the ways that you over function. For me, fixing my cortisol would get me like two steps forward and then one step back, it didn’t really solve the problem. Supplements, even some of the behaviors that we know are good, would only get me so far. And I had to really address the trauma in my tissues, kind of the issues in my tissues in a different way, a novel way to start to see differences in my downstream behavior, differences in who I am in the world, differences in the way that I serve so that I could start to function instead of over functioning. 

Cynthia Thurlow: [00:26:07] Yeah. Thank you for your transparency, because I think it makes things so much more relatable when we’re able to share about our own experiences. I think whether it’s people that work in high-risk OB or dealing with obstetrical, fgnecologic emergencies, the ER. I think for many of us, we gravitate towards, we like the thrill of that stress, and maybe that serves us well in our 20s and 30s and then as we’re getting older, we’re like, “Okay, I don’t think I need quite that much stress in my life. I need to find other ways to be stimulated.” And I think it would be remiss if we didn’t address some of the kind of flaws with the traditional allopathic model as it pertains to trauma. And you do such a beautiful job talking about this much of traditional allopathic medicine. And let me be clear, there’s clearly for urgent, emergent needs. Allopathic medicine really does a great job, but for trauma therapy, chronic, stable conditions, preventative care, sometimes we need a little bit more support, and we’re very pharmaceutically driven, and so, it’s my understanding that the traditional pills or pharmaceuticals are not really particularly adept at addressing trauma. And so perhaps kind of talking about it there, you talk about the top down, the bottom-up kind of approaches to care. What are some of the more traditional ways of addressing trauma? And what are some of the new emerging science around MDMA? Things that I think are really fascinating, but other ways that we can look at addressing this in a proactive manner. 

Dr. Sara Gottfried: [00:27:45] The short version is that the standard of care for post-traumatic stress disorder has an efficacy of about 30%. So, 70% of people with PTSD get treated with the standard of care. And that includes sometimes selective serotonin reuptake inhibitors. There’s three that are FDA approved for PTSD, and usually talk therapy, increasingly more trauma informed therapy. But the standard of care and an efficacy of 30% I find to be appalling. These novel treatments and this is what really got my attention. Five plus years ago, these novel treatments, like you mentioned, MDMA-assisted therapy for PTSD are more than double as effective. So that’s what really got my attention. It got me to want to look at trauma and ways to immunomodulate and other ways of modulating the PINE network. 

[00:28:41] But this is a really important thing to understand, and I appreciate that you’re not throwing the conventional medicine that you and I trained in under the bus, because we don’t want to do that. I love my conventional colleagues. I trained along with them. They’re essential for acute problems. And yet, when you take a chronic health condition like post-traumatic stress disorder or one of the 45 chronic health conditions associated with higher adverse childhood experiences scores, modern medicine just doesn’t do a very good job. 

[00:29:17] So, this efficacy that we see with talk therapy, why is that? Why is it that it doesn’t work very well? And why wasn’t I informed when I started it in my 20s. I was in my medical training, I had an episode of depression, and I started talk therapy. And I feel like if I was told at that time that my trauma was predicting my risk of depression, that talk therapy would in some ways reinforce and kind of get me to reexperience a lot of my trauma without actually healing it, and that there was a different part of the brain where the healing happened and the talk therapy didn’t really talk to that part of the brain, if I had known that, I wouldn’t have spent weekly, very expensive time going to talk therapy. So these more novel treatments are really interesting. And it’s not just that we need MDMA-assisted therapy for people who’ve got post-traumatic stress disorder. 

[00:30:12] When we start to look at some of these novel treatments, many of which are ancient and are used by indigenous practitioners, they definitely have a role in terms of helping us with regulation, helping us with the signature of trauma, helping us with posttraumatic stress disorder. So, there’s now two phase three randomized trials that are published by MAPS and the collaborators that they worked with. Looking at MDMA-assisted therapy in people with post-traumatic stress disorder, the first one showed that with two to three sessions of MDMA-assisted therapy, together with preparation and integration, those two to three sessions led to two-thirds of subjects no longer meeting criteria for PTSD. So, I saw that and I just felt like, “Okay, we’ve got to pay attention to this.” 

[00:31:06] And I read it as a person who’s been utterly square all of my life. So, I didn’t smoke pot in high school or college. I didn’t take any psychedelic medicines. It wasn’t until I was 50 and I started to look at this data, and I felt like, “Oh, there’s something here.” And then there were some criticisms of that first phase three trial was mostly a white population, people with severe PTSD. So, then a second trial was published showing that with moderate to severe PTSD and with 50% non-white population, that 71% no longer met criteria for PTSD. So, there’s an opportunity here that we have to be paying attention to. 

Cynthia Thurlow: [00:31:47] Yeah, it’s really exciting. Ironically, just by pure happenstance on Netflix, Michael Pollan has a documentary looking at LSD, MDMA, ayahuasca, peyote, and I’ve been watching it just out of pure curiosity. And I was saying to my husband, I had no idea how in the 1960s/into the early 70s that there was ongoing research with these kinds of therapies. And out of an abundance of fear or ignorance or a multiplicity of other things that occurred, these were all shelved and put largely as Schedule 1 drugs, there’s no therapeutic benefit. I find it very exciting that the proper utilization of these drug therapies have the ability to help so many people. And I think that’s incredibly encouraging. 

[00:32:37] From my perspective, when you look at there’s so much money in pharmaceuticals, I think some of the things you quote in the book, that Pfizer makes $267 billion worth of profits off of one drug. Eli Lilly makes $334 billion from Zyprexa, that it just made me realize that there’s so much money in pushing pharmaceuticals, but yet we now have these alternatives that, for many individuals, may be life altering for them. Those are possibilities that are emerging, which I think is so exciting. When we’re looking at evaluating a patient for these types of therapies or looking at dysregulation in their physiology, I know you’ve touched on some of the hormones when we’re looking at things like wearables, doing imaging, looking at sleep studies as an example. I think for a lot of us that have Oura Rings, one of the most common questions I receive from women is how do I improve my deep sleep? And you talk about this in the book, in particular, looking at gut health. But what are some of the diagnostics and some of the emerging treatment modalities that you’re excited about? Things that you feel like are very helpful for you as a clinician when you’re working with your patients to be able to provide them the answers they need and deserve to be able to move forward in treatment.

Dr. Sara Gottfried: [00:33:48] I practice precision medicine, so diagnostics are a huge part of the work that I do. And I think you start with measuring trauma. You start with looking at adverse childhood experiences. And the good thing is the ACE questionnaire, adverse childhood experiences is available in the public domain. And if you want to see one that I put together on my website, just to make it super easy, you can just Google Sara Gottfried ACE score and take your score. So, I think knowing what your childhood exposure was, it’s not a perfect test, but it’s highly validated. I think that’s where you start.

[00:34:24] And then you want to look at, okay, what’s the signature of that trauma that you were exposed to? And that includes looking at things like some basic immune tests. If we go through the PINE network, I would put trauma under the psychology, at least initially. And for the immune system, a lot of the testing that we do hasn’t changed in 40 to 50 years, which I think is appalling. But it’s things like doing a complete blood count with a differential and looking at your neutrophil to lymphocyte ratio, NLR. This is a way of looking at inflammatory tone, like how much you’re inflamed. And with my Oura Ring, I was noticing that it’s a little harder for me to get my ring off my finger after spending a weekend in Los Angeles, and that’s how I know that I’m inflamed, because normally this just slips right off my finger. So, I’ve got some puffiness, some inflammation in my fingers. 

[00:35:19] So inflammation is one of those signs that we’re looking for, chronic inflammation related to the immune system. You can also look at things like high sensitivity C-reactive protein. You can look at the erythrocyte sedimentation rate, ESR. And then when you think about inflammation, where is it coming from? 70% of the immune system is in your gut. So, when I see inflammation, I want to look at the gut, I want to do stool testing. This is more advanced, but things like, I use the longevity gut biotest. I use a lot of different labs in terms of looking for dysbiosis, increased intestinal permeability. There’s certain bacteria that are more associated with developing autoimmunity, and so knowing that about your gut can be helpful. And then with the neurological system and heart rate variability, I think that’s so valuable to track. 

[00:36:03] And for some people, just having that composite score that you get with an Oura Ring or a Garmin or a WHOOP can be really helpful, because then you can do N of 1 experiments and see what’s helpful. Things like, “Oh, if I have a shot of tequila, my HRV goes down by half. If I get my magnesium and I don’t have a shot of tequila, my HRV goes up pretty significantly.” So doing those kinds of experiments, I think can be really helpful. 

[00:36:32] And then the “E” part of the PINE system, I like to do a DUTCH Plus in pretty much every patient that I see. So, I’m looking at cortisol, you can do salivary cortisol, you can do dried urine. I like the DUTCH Plus because it gives me a picture in both men and women of what’s going on with cortisol at four or five points during the day, including the middle of the night if insomnia is an issue, which affects twice as many women as men. And then it also tells me about the metabolites, metabolite of cortisol, c. And it tells me about metabolites of other sex hormones, including estrogens and the androgens, and a little bit of organic acid testing. So those are some of the diagnostics that I like to use. 

[00:37:12] And then you mentioned deep sleep. When I started to really look at the microbiome maybe 15 years ago, and I started to address my own microbiome issues, I had a loss of diversity related to antibiotic usage. As I started to do gut rehab, I noticed that my deep sleep more than doubled. So, I aim for deep sleep of about 2 hours when I’m on my game, which during a book launch is not [Cynthia laughs] every night, but I was amazed that gut function maps so directly to deep sleep. And that’s something I really challenge our listeners to consider and track if they’re looking at sleep metrics. 

Cynthia Thurlow: [00:37:51] I think it’s so important because almost always women will say, and we get a lot of questions on social media. My team gets a lot of questions and they’ll say, “I get an hour of deep sleep.” And I always say, “You need to work on that.” And so, for many individuals, they aren’t sleeping enough. They’re not in a cold dark room. As you mentioned, they’re waking at night. I do find and I’m curious to know if this is what you see with your patients as well. But women in menopause that are in HRT generally tend to have better sleep scores, better HRV, that has certainly been my clinical experience, but I find that deep sleep is the challenge that many women in particular experience. 

[00:38:35] My husband falls asleep and stays asleep and has no issues, and he’s a couple of years older than me. But I found for myself the deep sleep as I’ve been working on my gut, but also my hydration status has a huge impact on the amount of deep sleep that I get. I aim like you for 2 hours. If I get less than that, there’s usually a reason, it could sometimes be whatever I ate or drank, maybe I ate too close to bedtime, maybe there’s a little bit of prevailing stress that I’m not acknowledging that’s going on. Now, something that I think is exciting and you mentioned this in the book are certain treatment options, and so something that I probably haven’t spoken about on the podcast with any frequency is low-dose naltrexone as being one of these therapies. And this is something that I’ve actually taken. It’s probably been the one thing that’s helped get my thyroid properly regulated. I had about three years where it wasn’t particularly therapeutic. But let’s talk about what makes low-dose naltrexone so different than some other modalities, and how it can beneficial in kind of quieting the immune response in the body. 

Dr. Sara Gottfried: [00:39:33] Well, I might need to riff with you on this one, because I prescribe it, and I feel like, as a scientist, I don’t know that we really understand what it is that it’s doing. So, it’s affecting a number of the signaling pathways in the brain and also in the immune system. So, naltrexone is used at higher doses for a number of indications. It’s used for opioid use disorder. And increasingly, I’m seeing it, at least out here in the Bay Area, used for dissociation. So, I talk in the book about my own functional dissociation. It was part of a trauma response. I would just go cognitive, kind of hypercognitive to deal with problems and just ignore my body from the waist down. And so, naltrexone at higher doses, like 50 to 100 mg can be helpful for dissociation.

[00:40:24] At lower doses, so I typically start around 1.5 mg, sometimes in people who are highly sensitive, even lower, and I build up to 4.5 to 5 mg. It’s remarkable how much it can affect the immune system. The mechanism of it, you might know a little bit better than me. I’ve looked at the science on this and it’s not quite where I would like it to be. I feel like we don’t have randomized trials. We’ve got mostly empiric information and small studies showing that it’s beneficial in autoimmune disease. But I use it quite a bit in mostly Hashimoto’s. I’ve got patients with type 1 diabetes, psoriasis, rheumatoid arthritis. Those are the ones in whom I’m using it. So, what about you? You might know the mechanism a little better than me. 

Cynthia Thurlow: [00:41:09] No, I mean, it’s funny, I had this conversation with my functional medicine doc, and he said, “Cynthia, we don’t fully understand or appreciate how it works in low doses.” He said, “But what I will tell you is that when it works, it works beautifully. And sometimes I can’t explain why it doesn’t work.” I think the irony is I recently had a new medical provider and I had to go over my medication list, and the nurse I was talking to, looked at me, and she didn’t catch that I said, “low-dose naltrexone.” And she said, “Oh, I didn’t realize you were in recovery.” And I said, “No, no, no.” I said, “I’m taking this for my–” Because in many instances, it’s used for different reasons. This is more one of those off label quieting the immune response. I too kind of look at it as it’s been a blessing for me. But I understand that it hasn’t consistently been consistent with other individuals. But I know that it’s been helpful, certainly in my circumstances. What are some of the other assisted therapies that you like to talk to your patients about? Things like these polyphenol rich compounds that can be of benefit, dietary changes. I know I always say, it all starts with food, and the same applies to this overactivation of the PINE, dealing with trauma, etc., there’s certainly benefits to fighting inflammation in the body. What are some of your favorite kind of polyphenols that you utilize with your patients? 

Dr. Sara Gottfried: [00:42:26] Yeah, I’ve got a food first philosophy as well. And the day after I met you in New York, I saw one of my clients the next day who’s been having some gut issues, kind of some early signs of an autoimmune process. And so, we put her on an elimination diet. And a well-constructed elimination diet is incredibly effective when you’re someone who’s reacting to your environment, especially the foods that you’re eating. So that’s, of course, gluten and dairy, and usually nightshades, nuts and seeds, which a lot of people don’t want to give up. But the moment that she gave up these foods, within 24 hours, she felt better, her gut symptoms resolved. And so, I see that quite a bit. 

[00:43:13] So, you asked about polyphenols, and part of what we’re talking about here is immunomodulators. That’s kind of a fancy term for things. There’s more than 50,000 molecules in the foods that we eat, and many of them can have these beneficial effects on the immune system. We know, for instance, getting five to seven colors of the rainbow each day with the food that you eat, that’s one of the best things you can do for the immune system. So, with polyphenols, with the things that the pigments and foods that make fruits and vegetables so colorful, they can really help in terms of the immune system. I had a period of time where I was really working on Akkermansia in my patient population. So, I had a lot of professional athletes and executives and just kind of everyday folk who would do a stool test, and they had no Akkermansia. And Akkermansia is important for a lot of different functions. We’re still in the early stages of understanding these individual bacteria and what they do in the body. But the things that Akkermansia really loves are cranberries and pomegranates. 

[00:44:21] And so with my NBA players, I would start making smoothies with these particular ingredients. And over time, you can see some improvements in terms of gut health and reduced inflammation and better immune functioning. So, there’s ways to make that easier. I also have a patient who’s in the book, his name is Larry, who had Crohn’s disease. So, one of the inflammatory bowel diseases, autoimmune disease. And before I met him, he had to have a segment of his colon removed. He had colonic Crohn’s. And one of the things he did afterwards, he had a high sensitivity c-reactive protein that was in 20s, so lot of chronic inflammation in his body. And he decided through his work at University of California, San Diego, that he was going to start making a polyphenol rich smoothie and drink it every day. 

[00:45:13] And so, Larry goes a little bit overboard. He’s one of the fathers of supercomputers, but he would go to the farmers market, he’d get a pinch of this, a pinch of that. He’d get about 57 different species of fruits and vegetables and then make a smoothie out of it and freeze it and then drink four to six ounces a day. So, you don’t have to do 57 species, that’s probably overkill. But those polyphenols have completely transformed his microbiome. He’s been in remission now for, let’s see, eight years. And so, polyphenols can really make the difference in terms of immunomodulation.

[00:45:48] And there’s other immunomodulators too. We talked about low-dose naltrexone. There’s vitamin D, there’s curcumin. A lot of these act on the inflammasome, kind of this inflammatory process that occurs in the body to help to decrease the amount of inflammation, to get the immune system to settle down, to not be so dysregulated, and it can be really effective. And I would also put psychedelic medicine in that category. Healing states of consciousness can be immunomodulatory. And you don’t have to take MDMA or do ayahuasca or microdose on psilocybin, you can do it with breathwork, you can do it with orgasm, there’s lots of ways to enter healing states of consciousness. 

Cynthia Thurlow: [00:46:27] I think it’s so important for people to know that there are many options. It is not just food based. It is not just medication based. I find somatic therapies really fascinating. I find breath work really exciting. I went down a rabbit hole and was reading more into this holotropic breathwork, trying to locate someone in my area. We kind of end the conversation talking about these somaticized therapies and how they can be very instrumental in quieting the autonomic nervous system, helping us get into a state where we are more body aware with the sensations, and then also in this more peaceful state. And this holotrophic breathwork in particular. And I challenge listeners to go check this out because I found it very interesting. It’s definitely something that I will be looking into, but how important this breath work really is? It’s not just box breathing, which I’m a huge fan of, but there’s more to it, this hyperventilatory state that can be very beneficial. 

Dr. Sara Gottfried: [00:47:25] That’s right. So, holotrophic breath work is super interesting. I went to American Academy of Antiaging Medicine conference about three years ago, and they had a dome where they were teaching this form of breathwork. And I went in, a total skeptic, I had been in Las Vegas for about three days, and after three days in Las Vegas, I’m highly sensitive. I’m just kind of climbing the walls because of casinos and noise and smoking and all these things that you’re exposed to. So, I walk in there, I’ve got a low-grade headache, I’m not sleeping well, and I’m like, I don’t know about this. Inside of 20 minutes, my entire matrix was changed, and so I can’t totally explain it. I mean, yes, my heart rate variability went up. Yes, I was able to do some deep abdominal breathing. There’s specific changes that occur with holotropic breathing that are salient and helpful for the body, but that started me toward doing holotropic breathwork four times a week for several years. 

[00:48:28] So, you mentioned also somatic therapy. And the idea here is your sense of embodiment. Are you someone– like, I used to be where you’re kind of up here most of the time, that’s how you interact with the world. I call it kind of going upstairs and staying upstairs, or are you someone who’s really integrating and has a sense of the signals that your body is sending. So those are the signals, as you described, that we learn to ignore as part of being a nurse, as part of being a physician. In your training to become a nurse practitioner, we’re taught to ignore a lot of those signals. And so sometimes it takes a particular effort to learn how to be fully embodied. And that’s where somatic therapy can be so helpful. And there’s a lot of different flavors of this. 

[00:49:14] I like Hakomi, and I’ve gone through the level one certification of Hakomi. It’s considered to be somatic, mindfulness-based self-exploration and self-experimentation. There’s also somatic experiencing. There’s EMDR, there’s the neuro-emotional technique, something that we study at Thomas Jefferson University quite a bit. So, I think that these ways of working can be really critical. And one of my teachers that I’ve worked with for years, with breathwork, talks about how we make our own medicine when we’re in that healing state of consciousness. So that 20 minutes of holotrophic breathing, you’re making your own medicine, like what you most need personally to heal and to feel embodied and to notice these fluctuations that occur in your body that you might sort of steamroll through, or at least you were taught to do that. So, it’s really a different way of being. When you look at embodiment as a virtue, as something that we really want, it changes everything. 

Cynthia Thurlow: [00:50:18] Absolutely. And I think for so many of us that are on this journey, because it really is a journey of life, helping to figure out what we need at that stage in our lives. And this is certainly the stage for myself, where very transparently these are things that I need to be doing. This is the kind of work that’s the next step for me to continue with my healing journey. Dr. Gottfried, please let listeners know how to connect with you on social media, how to get access to your amazing new book, how to work with you, because I know that you’re still working on the East and West Coast, how to work with you if they would like to become a patient of yours. 

Dr. Sara Gottfried: [00:50:51] The best place to get the book is wherever books are sold. So, Amazon, Barnes & Noble, your local independent bookseller. The place that I hang out on social media is mostly Instagram. I’ve got daughters, so they are trying to get me to get back on TikTok and like rebrand, or I don’t even know what I’m supposed to do over there, but I might do that sometime in the next few weeks. And then my website is saragottfriedmd.com. That’s where kind of the mothership, it’s where a lot of this is housed, including the ACE score, if people want to take that. So that’s where I hang out. And are you on TikTok? I should hang out with you on TikTok. 

Cynthia Thurlow: [00:51:27] Yes, you should. I am there. But I generally let my team post because I feel like trying to navigate multiple platforms is challenging. And I acknowledge that colleagues of ours are blowing up on TikTok because they’re there, but you’ve to really– It’s like a consistency piece that I just feel like I haven’t hit my stride yet. I feel a sense of obligation and so I keep telling my team, if I’m going to be active on there, it’s going to have to be you all at least getting things started so that I’m there consistently.

Dr. Sara Gottfried: [00:51:59] Yeah. So, hang out with Cynthia and I on Instagram. That’s where we are most of the time. 

Cynthia Thurlow: [00:52:04] Yeah. Thank you so much. 

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