#186 – Does food affect mental health? | Dr. Chris Palmer (Brain Energy)
How might a keto diet transform not only your metabolic health but may also manage symptoms of mental health disorders like depression, anxiety, PTSD, schizophrenia, and more? Dr. Chris Palmer outlines the principles from his book “Brain Energy” with Ben Grynol in this episode and discusses his journey toward the revolutionary idea that might change how we view mental health care moving forward.
Order Brain Energy: https://amazon.com/Brain-Energy-Revolutionary-Understanding-Health/dp/1637741588/ Connect with Chris on Instagram: https://instagram.com/chrispalmermd Connect with Chris on Twitter: https://twitter.com/ChrisPalmerMD Connect with Chris on LinkedIn: https://linkedin.com/in/christopher-palmer-01713032
01:53 — How Chris Palmer started his research for Brain Energy
Chris shares the story of his patient Tom, a 33-year-old man with schizophrenia and bipolar disorder, and how the ketogenic diet changed his life. Originally prescribed to help him lose weight, keto also inspired positive changes in Tom’s mental health, urging Chris to discover the connection between keto and its ties to epilepsy treatment.
So the great news is, I was able to call upon decades of neuroscience research to start to understand what the ketogenic diet is doing to the brain. It changes neurotransmitter systems, decreases brain inflammation, and changes calcium signaling in the brain. It, uh, changes gene expression, changes the gut microbiome. It does all sorts of things that we in psychiatry actually know are highly relevant in people with serious mental illness. And so as soon as I started doing more and more research on the use of the ketogenic diet for epilepsy and neurological disorders, all of the pieces of the puzzle were beginning to fit together.
11:16 — Painting a picture of the mental health crisis through numbers
Chris discusses the statistics of the mental health crisis globally and in the United States, noting how the pandemic dramatically worsened the phenomena.
Mental illness is a growing crisis in the same ways that obesity and diabetes are growing crises. Mental disorders are a growing crisis, and they are now the leading cause of disability in the United States and on the planet. And the disorder that tops the list of disabling diagnoses of all medical diagnoses is depression, plain old bread-and-butter depression. […] The pandemic poured gasoline on an already burning inferno. Prior to the pandemic in about 2017, the World Health Organization estimated there were about one billion people on the planet currently suffering from a mental or substance use disorder. […] Actually, in the United States, the rates are about one in 20, or you know, or no, I’m sorry, one in five people. 20% of the population in any given year will be affected by a mental or substance use disorder. If you look at lifetime prevalence, rates are actually much higher. About 50% of all people in the United States will meet the criteria for a mental disorder at some point or another in their life. […] And so what we know is that mental disorders are actually an escalating and persistent crisis.
18:20 — Discussing the biopsychosocial model and existing research on the roots of mental disorders
Chris expounds on the current scientific research in genetics and risk factors for mental disorders. He reveals that there isn’t a definitive gene that specifically predicts risk for any disorder and that the field still has a lot of work to do to comprehensively understand mental health and its disorders.
Even when we get really granular, like with a specific set of genes, you know, we’ve mapped the human genome, we’ve known about genes for 20 years. Turns out there’s not one gene that converts risk for any one disorder. Believe it or not, there’s not a schizophrenia gene and a depression gene and a bipolar gene, even though everybody thinks there are. We actually know with certainty those don’t exist. And I say that because we’ve had the human genome map for over 20 years. Artificial intelligence has been on the job. Artificial intelligence tells us all the computers. The best scientists tell us, ‘Oh, there aren’t schizophrenia genes.’ There aren’t. Oh, there’s this gene. And it does increase risk for mental disorders, but also in, you know, increases risk for schizophrenia and bipolar and depression. Oh, and epilepsy too. And obesity and mental retardation. Ha, that’s interesting. It increases risk for lots of things, not just the schizophrenia. And so when we look at any of the risk factors, they confer risk for a wide variety of disorders, if not all of the disorders. And that’s where we’re at in the field. It’s this big, complicated mess, is what it is. It’s just a big, complicated puzzle that nobody can figure out.
29:23 — The bidirectional relationship between metabolic and mental health
Considering the thought that mental disorders have strong bidirectional relationships with other mental disorders can pave the path to understanding mental health better moving forward. But it doesn’t stop there: Chris also suggests the possibility of mental disorders sharing a bidirectional relationship with metabolic disorders.
There’s another possibility we need to consider. And the other possibility is that there is something downstream or upstream—however you wanna think about it—I guess upstream from both of those disorders that actually increases the risk of a person developing both of them. And it’s important to think that through because that can help us see the bigger picture about cause and effect. The kind of nutshell is that it turns out that all of the mental disorders have strong bidirectional relationships with all of the other mental disorders, but it doesn’t stop there. They also have strong bidirectional relationships with all the metabolic disorders: obesity, diabetes, and cardiovascular disease.
34:34 — The real power of the mitochondria and the role it plays in fostering mental and metabolic health
Over the past 20 years, research has revealed the true functional power of the mitochondria, allowing Chris to further his research in neuroscience and better understand the connections between mental and metabolic health.
I think one of the things that allowed me to develop this theory is that over the last 20 years, we have groundbreaking, cutting-edge revolutionary research that has taken place on exactly what mitochondria are. And they are so much more than powerhouses of the cell. Yes, they are powerhouses. And without that, we would be dead. They actually do so much more than that. You know, one analogy that I really like: A mitochondrial researcher [said that] if you think of the cell, a human cell is a computer. Most people think of mitochondria as the power cord to that computer because they’re providing the energy. And yes, that’s true. They are like the power cord, but in fact, mitochondria actually are more like the motherboard of that computer. So mitochondria are distributing and allocating resources throughout the cell and throughout the human body. They play a powerful role in numerous functions. And when I, when I began to do this deep dive into the science of mitochondria, knowing what I know as a psychiatrist and a neuroscientist, that’s when like, my mind is just blowing up because I’m like, “Oh my God. This, this is connecting all of the dots of the mental health field.”
44:00 — Medication for mental disorders and their long-term effect on patients’ metabolic health
Chris reveals a revelation in his research suggesting that the metabolic harm caused by medications for mental disorders might not just be side effects at all.
I think the really profound revelations of the brain energy theory are that these metabolic connections are in fact not at all side effects. They represent the direct impact of these medications on the brain and the body, and it is directly related to their ability to suppress symptoms. The challenges that although some of these medications can suppress symptoms in the short run, they may very well be making matters worse in the long run. And I don’t say that lightly. I know how controversial that will be.
The terrifying thing is that we may in fact be prescribing medications that are keeping people chronically ill. And you know, quite honestly, as a psychiatrist who has prescribed these medicines for 27 years now, it’s heartbreaking. It’s heartbreaking to do a deep dive into the science and come to that conclusion. I always knew that the medications were causing metabolic harm, but I, again, for a long time, I just bought the paradigm hook, line, and sinker, that well, these are just side effects. They’re just the price we pay to treat serious disorders. These are serious life-threatening disorders. I’m saving people’s lives by prescribing these medicines. It is heartbreaking to think that maybe I was keeping people ill as a result of those treatment strategies. And I really do feel like the brain energy theory delivers very clear, testable hypotheses, largely supported by the existing evidence that we have. This is not a speculative theory. This is a theory that takes all of the existing research and puts it together in the only logical way possible.
55:14 — Insulin resistance and its impact on mental disorders
Chris shares how insulin resistance can be a risk factor for mental disorders. Listen to the story of Caleb, a young boy diagnosed with multiple mental disorders. Cutting sugar from his diet helped manage his symptoms and empowered him to function well socially and academically.
Within two months [of cutting sugar], Caleb was clearly turning a corner—no more tantrums at school. He actually said, ‘I feel better.’ He didn’t miss the sweets during the school week anymore. And he actually actively noticed like, ‘I’m better, I feel it, I feel better.’ So he actually became an advocate for, ‘I, I need to do my lightbox. I can’t have sweets during the week.’ He like really began to own this treatment as part of his lifestyle and something that he needed to do to control his mood and ability to concentrate. By the next year, Caleb got straight A’s, and then in 2020, Caleb started high school, and that was right in the middle of the pandemic. All the other kids are struggling; all the other kids are stressed and lonely. Caleb was thriving at that point and ended up getting straight A pluses actually.
1:11:10 — Food addiction, stress-eating, and why Chris doesn’t sugarcoat the realities of the ketogenic diet
Chris and Ben talk about how the dopamine hit from stress-eating can eventually lead to food addiction. Chris emphasizes the importance of setting realistic expectations for people who want to try the ketogenic diet, mainly citing the side effects and intense food cravings in the adaptation period.
They are formulated to be addictive even though, you know, the American Psychiatrics Association doesn’t recognize food addiction. You know, the director of the National Institute of Drug Abuse did a lot of research studies are doing that. Some highly processed foods are in fact addictive and use the exact same reward pathways that cocaine addiction and nicotine addiction use. But you know, the food companies kind of admit it. ‘You know, you can’t eat just one.’ I mean, come on. What is that? It means that they are making highly palatable foods. And when you give a highly palatable food to any human being, they are going to be more likely to eat it. If you give a highly palatable food to a human being who is stressed, there is a direct connection there. […] As much as we shame people for that, like, ‘Oh, you’re stress eating.’ We need to just recognize and respect our biology. Our biology is driving us to do that and there’s nothing wrong with our biology, but there are things wrong with the foods that we’re eating, and people can become trapped in a vicious cycle. Once they’re addicted to it, then they start getting stressed because their blood sugars are on a rollercoaster and now they need to eat that food. Not in response to the stress, but the cause of the stress is actually the food that they’re eating, and it’s just a mess. And that’s how people kind of go into metabolic and mental problems.
I think sometimes they sugarcoat keto-adaptation a little too much. ‘You can do it.’ That’s not at all what I say to patients. That’s not even what I say to friends or family who just want to try keto for a diet. I say, ‘It’s gonna be a living hell for two weeks, get ready for it. Let’s prepare for a living hell. You’re gonna feel weak and dizzy and lightheaded, and you’re gonna be having intense cravings, and it’s just gonna feel unbearable, but I will help you get through it.’ […] Every person comes back to me and says, ‘It wasn’t nearly as bad as you made it out to be.’ But setting that expectation makes all the difference in the world.
1:29:05 — It’s not too late to start taking charge of your metabolic health now
Chris shares the story of Mildred, a woman who lived for 53 years with schizophrenia before trying out the ketogenic diet for weight loss. Within months, all her symptoms of schizophrenia went into remission, and she went on to live for 15 years free from the mental suffering she had endured for most of her life.
Within a couple of weeks, not only did she start losing weight, but her hallucinations pretty much went away within a couple of weeks. I will say with a lot of other patients that I work with, it takes a little longer, but she had a powerful effect within months. All her symptoms of schizophrenia were in remission. Within a few more months, she was off all her psychiatric medications and remained in remission. This woman went on to live for another 15 years. Symptom-free. Medication-free. No more mental health professionals. No more suicide attempts, no more psychiatric hospitalizations. She had an entirely new life. And you know, when I last spoke with her, she actually was really happy and actually asked me, almost pleaded with me to please tell her story to as many people as I could. Because she hoped that if her story could even spare one other human being, the living hell that she had to endure for 53 years, that it would be worthwhile.
1:34:11 — Chris touches on the factors that hinder better mental healthcare today and what we can do to advocate for the mentally ill
Chris wants to start a grassroots movement to advocate for the mentally ill through the metabolic theory of mental illness. He ends on a call to action and shares resources that he will personally provide through his book and the upcoming website for Brain Energy.
I am hoping to start the grassroots movement. I really want change. And I think the first step is that we need numbers. We need people. And that means I want you to tell other people, uh, if you are persuaded by the metabolic theory of mental illness, if you see even a tiny sliver of the hope that I see in this for the masses of people who are suffering, I need you to spread the word to tell people about this, whether they buy the book or not. […] My goal is not to sell books. My goal is to sell a theory that can transform human health and mental health for millions and millions of people. […] If you know somebody with a mental illness, I’m not asking you to do it for me. I’m asking you to do it for that person. I’m asking you to do it for the people that you know with mental illness who deserve better lives. That’s why you’re gonna get involved. You’re gonna stand up for those people. You’re gonna stand up for your sons, your daughters, your spouses, your parents, your siblings, your friends, your coworkers, or just the little kid down the block that you see is tormented. You’re gonna stand up for that person, and you’re going to get involved.
Ben Grynol (00:00:06):
When you understand metabolism, when you understand that our current food supply is a lot of non-food. It’s a lot of chemicals, it’s a lot of highly processed food things that are formulated to be addictive, even though the American Psychiatric Association doesn’t recognize food addiction. The director of the National Institute Drug Abuse did a lot of research studies arguing that some highly processed foods are in fact addictive and use the exact same reward pathways that cocaine addiction and nicotine addiction use. But the food companies kind of admit it, you can’t eat just one. I mean, come on, what is that? It means that they are making highly palatable foods and when you give highly palatable food to any human being, they are going to be more likely to eat it. If you give highly palatable food to a human being who is stressed, there is a direct connection there.
I’m Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And this is your front row seat to everything we do. This is a whole new level.
Sometimes the best discoveries are when two unrelated things collide. That was very much the case for Dr. Chris Palmer. Chris Palmer recently wrote a book called, Brain Energy, and it very much addresses this intersection between metabolic health and mental health. What exactly did that look like? Many years ago, Chris was helping one of his patients through mental health interventions that he would typically take. It wasn’t until one day that his patient had unrelated questions about other health considerations and he said, Hey, do you think you could help me? So Chris stepped in and thought, Why not? That led to a pretty meaningful discovery. It wasn’t anything that hadn’t been researched in the world before, but it was somewhat of that light bulb or the aha moment that really kicked things off for Chris to pursue this path of discovery in the cross section between mental health and metabolic health.
In the book, Brain Energy, he addresses all the different things around how diet, lifestyle, sleep, exercise, metabolic health, mitochondrial dysfunction, how all of these things can impact mental illness. Things like schizophrenia, things like bipolar disorder, depression, anxiety, and the list goes on. It was a really meaningful conversation to sit down with Chris and learn more about why he wrote the book, How people can think about mental health and metabolic health. What are things they can do to change mental health considerations for either themselves, their friends, their family, and why it’s such a long journey ahead to get to a point where we’re starting to treat mental illness with metabolic interventions.
Dr. Palmer is a Harvard psychiatrist and researcher and for more than 25 years he’s worked with people who have treatment resistant mental illness using standard treatment. And he’s really been pioneering this use of the medical ketogenic diet in the treatment of psychiatric disorders. He’s developed the first comprehensive theory of what causes mental illness and he’s integrated existing theories and research into one unifying theory. He calls that, the brain energy theory of mental illness. Really the way that he breaks it down is that mental illness is a metabolic disorder of the brain. Anyway, no need to wait. Here’s where we kick things off.
Very excited to dig into this. You’ve got this new book coming out called, Brain Energy, where you discuss the inextricable link between mental health and metabolic health. And you really concretize it down to this simple statement it’s, mental disorders are metabolic disorders of the brain. So it’s something that you’ve been researching for many years prior to this one event, which was a story with a gentleman named Tom. So why don’t we kick it off there because it is really fascinating.
Dr. Chris Palmer (00:04:27):
So Tom’s story really began in 2016, and so Tom had been my patient for about eight years at that point. He was a 33 year old man, was schizo effective disorder, which is a cross between schizophrenia and bipolar disorder. He had hallucinations and delusions every day of his life. He was really paranoid, could barely leave home, was horrible and uncomfortable for him to leave home because he was convinced everybody was out to get him. They were all part of this big conspiracy theory. He had trouble with hygiene. He was a classic person with schizophrenia basically. And he had tried 17 different medications but they failed to work. They did cause him to gain a lot of weight. So weighing 340 pounds, he asked for my help to lose weight and we decided to try the ketogenic diet. Within two weeks not only did he begin losing weight, but I began to notice a dramatic antidepressant effect.
He was making better eye contact, talking more, smiling more. And I thought, well that’s really fascinating. But he was still hallucinating and delusional. And the shocking thing to me was that at about six to eight weeks he spontaneously reported that his longstanding hallucinations were going away and that his paranoid delusions were also going away. He began to realize that they weren’t true and probably never had been. Tom went on to lose now 160 pounds and has kept it off to this day. But he was able to do things that he had never been able to do since the time of his diagnosis. He was able to complete a certificate program, go out in public and not be terrified or paranoid, and he was able to perform improv in front of a live audience and he got better enough that he was able to move out of his father’s home for a period of time. And that really upended everything that I knew as a psychiatrist and started me on a journey.
Ben Grynol (00:06:44):
It really is a fascinating finding or revelation to have because it was so unrelated. The way that you tell this story now and the way that it’s told in the book is that it was unrelated. Hey, I don’t want to go see another doctor. I’ve got this sort of thought of this unrelated thing that I want to mitigate. I want to get in front of it. And so you’re thinking, Sure, I’ll help, I’ll help you out. What were you feeling, the way that you tell the stories, when you first sort of thought… I’ve read research around the idea of ketogenic diets being able to help out with things like epilepsy.
I’ve sort of felt it before, I’ve seen some signs, but that felt like this moment that you thought, I can’t be silent about this to the world anymore. And that seemed to be this deep dive into brain energy. So what were you feeling when as a medical professional, did you feel this internal dilemma of, Do I say something? Is it too wild of an idea? Because it really is a very forward thinking idea to think about diet, lifestyle choices, metabolic health, being able to mitigate serious mental illness.
Dr. Chris Palmer (00:07:54):
Yeah, it’s interesting because at that point I’d been using low carb and keto diets for a long time, but mostly with patients with depression and I actually did not know about the epilepsy literature at that point. I didn’t know that the ketogenic diet was even a treatment for epilepsy. I knew it as a weight loss diet. I had first come across it as the Atkins diet and I also knew that it was really powerful for diabetes. I had used it with both my parents, both of them had type 2 diabetes and I had seen dramatic and remarkable improvement in their symptoms. And with my father in particular, it was nothing short of miraculous for him, for his type 2 diabetes. But this man had schizophrenia and I was like, Wait, this is impossible. I mean, my first reaction was disbelief. I was completely in disbelief.
And the good news is that his father was involved and there was actually another mental health professional, a psychologist who had been seeing him. And I actually had to go to both of them and say, Are you guys seeing what I’m seeing, because I can’t believe what I’m seeing? His schizophrenia symptoms are evaporating and I’ve never seen anything like this. Even with the medication, I’ve never seen anything like this and I didn’t change his meds. He’s on the same meds. This is crazy what. What’s happening? And sure enough, they confirmed it. And that’s when I started doing a deep dive. That’s when I learned that, oh, the ketogenic diet is an epilepsy treatment. Who knew? And why had I never been told that? And that for me was really important as a psychiatrist. And the reason it was so important as a psychiatrist is because we use epilepsy treatments in psychiatry every day in tens of millions of people.
So we use medications like Depakote, Tegretol, Lamictal, Topamax, Neurontin or Gabapentin, Valium, Klonopin, Xanax, all of those are anti-seizure medicines. But most people who’ve heard of them actually have heard of them because of their use in mental health. And as I said, we use them in tens of millions of people. Turns out the ketogenic diet can stop seizures even when those pills don’t stop seizures. And that became very intriguing to me because I’m like, wait, if this diet can actually stop seizures when all of those medicines fail to, maybe it’s doing something like that to Tom’s brain and that’s why Tom is getting so much better.
So the great news is that I was able to call upon decades of neuroscience research to start to understand what the ketogenic diet is doing to the brain. It changes neurotransmitter systems, decreases brain inflammation, changes calcium signaling in the brain, it changes gene expression, changes the gut microbiome. It does all sorts of things that we in psychiatry actually know are highly relevant in people with serious mental illness. And so as soon as I started doing more and more research on the use of the ketogenic diet for epilepsy and neurological disorders, all of the pieces of the puzzle were beginning to fit together.
Ben Grynol (00:11:24):
The interesting thing that you highlight too is the conclusion of the book isn’t go eat a ketogenic diet and everything changes. It’s very much not that. There’s so much deep science and even the way that you seal man your own argument saying, there are other diets, there are certain things that objectively are going to lead to metabolic dysfunction, mitochondrial dysfunction. And you go on how that ties into mental disorders and that’s the interesting thing is that it’s not just, we’ll get into correlations does not equal causation, because it’s such a fun thing to talk about in general in the world, but it’s not, the conclusion is not, go eat keto and everything changes. It’s an input to get this other output. I love the way you started off the book though, and you talked about very much from the first page of the book, this stance of vulnerability where you said, Hey, when I started my career, I felt very much like a fraud because you get the question, what causes mental illness?
And you start talking about all of these things, but everyone feels a sense of instead of just saying, we don’t really know, we know that there are all of these underlying factors. This was idea with Tom seemed to be this first foray into thinking through how important diet lifestyle, we’ll generalize it as metabolic health, but metabolic health is as an input positive or great metabolic health to positive mental health. So it was one of those moments where the link became very clear when thinking through that. So would be great to get into the size and scale of the problem though. So defining more around how big is mental health as far as a consideration for the number of people that it affects globally and then from an economic impact, what do you see as far as those numbers go?
Dr. Chris Palmer (00:13:27):
So for people who don’t know, mental illness is a growing crisis in the same ways that obesity and diabetes are growing crises. Mental disorders are a growing crisis and they are now the leading cause of disability on the planet, the leading cause of disability in the United States and on the planet. And that the disorder that tops the list of disabling diagnoses of all medical diagnoses is depression, plain old bread and butter depression. And it’s not because those people aren’t getting treatment, those people are getting treatment. They are trying antidepressant after antidepressant, they are in psychotherapy for years or decades. They are trying shock therapy, they’re trying transcranial magnetic stimulation. They’re getting ketamine injections, they’re trying psychedelics. They are thinking happy, positive thoughts. They’re doing everything in their power to not be disabled and to not be miserable. And yet depression is the leading cause of disability on the planet.
The other mental disorders, if you look at the percentage of people who are disabled based on diagnosis, I think everybody knows schizophrenia is much, much worse than depression. Bipolar disorder also is, substance use disorders can be obsessive, compulsive disorder can be. So the global statistics are really hard to measure right now because of the pandemic. The pandemic poured gasoline on an already burning inferno, really. Prior to the pandemic in about 2017, the World Health Organization estimated there were about one billion people on the planet currently suffering from a mental or substance use disorder and that’s about 13% of the population or so. In the United States, the rates are higher and they’ve been higher for many, many decades actually. The United States, the rates are about one in five people, 20% of the population in any given year will be affected by a mental or substance use disorder.
If you look at lifetime prevalence rates are actually much higher. About 50% of all people in the United States will meet criteria for a mental disorder at some point or another in their life. But as I said, the pandemic has actually made everything worse. At the peak of the pandemic, so the CDC was actually actively and aggressively tracking rates of mental disorders during the pandemic. And at the peak, which was in 2020, at one point they were doing representative household surveys of like 1000 or 2000 people just trying to get a sense for what is happening in the population. And at one point, about 40% of all Americans, a representative sample of all Americans, reported that they were currently suffering from symptoms of depression, anxiety, PTSD, or a substance use disorder. I think the more alarming statistic was that they asked participants in the last 30 days, have you seriously considered killing yourself?
And 11% of respondents said yes. And when we look at the younger age group, they didn’t interview people younger than 18. So the youngest age group was 18 to 24. And among that group, that statistic was 25%. One in four young adults said they had seriously considered killing themselves in the last 30 days. The rates have come down a little bit from that peak, but they are not back to the baseline rates. And so what we know is that mental disorders are actually an escalating and persistent crisis. They are a crisis right now, in terms of dollars, it’s hard to estimate with the pandemic again. And the Biden administration actually just pledged billions more dollars toward mental health. So I’m sure that will change the statistics, in a couple of years we’ll look back and have better data. But prior to the pandemic, the estimates were that by 2030, mental disorders would cost the global economy about $6 trillion a year. And those costs include direct care services, disability, productivity losses at work and other societal costs.
Ben Grynol (00:18:38):
It’s alarming. And where it’s really eyeopening is there were a number of places where you talked about children and adolescence. There’s one stat that you brought up that was around the rates of depression in children between 12 to 17. And over the course of, I guess it was between 2006 to 2017, depression had gone up by 68%. It’s alarming because, we’ll get into the biopsychosocial model in a second because that’s an interesting way of thinking about mental health being an output to a number of inputs. But children are developing and that’s where it starts to really become clear that there are many inputs that are contributing to this. It’s not just things like technology. It’s not just environmental. It’s not just, we can go on and on. You start to say, Wow, what is happening at a societal level? What are we doing that is causing these increased rates of mental illness that’s increasing at an increasing rate? And the only other thing that’s increasing at an increasing rate is the metabolic health crisis. And so you go, that’s interesting. But why don’t we get into the idea of this, mental health is very much an output to many different inputs. So 1977, Dr. George Engel developed the bio psychosocial model. So what exactly is the model?
Dr. Chris Palmer (00:20:02):
So right now, if you actually ask the best neuroscientists and psychiatrists, what actually causes mental illness, what causes schizophrenia? What causes major depression? What causes anxiety disorders? What causes alcoholism? The real answer is, no one knows. All we know are risk factors. And the risk factors get lumped into what we call this biopsychosocial model, which says that there are biological, psychological and social factors that all come together to result in different mental disorders in different people. And seemingly there are unlimited numbers of combinations of factors. And so we know that genetics, neurotransmitters, hormones, play a role, those are some of the biological factors. Psychological factors are like, your parents messed you up when you were a kid, or you got bullied and teased and you have really low self- esteem. Those start to get into the psychological and social factor. The bullying and teasing might be a social factor, other social factors can be poverty, homelessness, abuse, neglect, those types of issues.
And the real answer is, so a lot of people think that, well, abuse and neglect that causes PTSD, but that doesn’t have anything to do with schizophrenia. In fact, that is incorrect, that kind of assertion. So it turns out that the bio psychosocial risk factors confer risk for all mental disorders pretty much across the board. The only exceptions would be the neurodevelopmental disorders that begin in infancy or at a very young age, or people come out of the womb with a neurodevelopmental disorder, that those disorders, everybody kind of knows, well, the person was born this way. That’s not bullying and teasing. They never even had an opportunity to be bullied and teased. So that would be the one caveat is that neurodevelopmental disorders, we put them in a bucket of their own. All of those risk factors confer risk for all the mental disorders. So for example, trauma and neglect in childhood, as I said, most people think PTSD, but guess what else? Depression. Well, that makes sense. Anxiety. Oh, that makes sense. Alcoholism. Oh yeah, I can see that. Bipolar, schizophrenia.
Really? Yeah, really. Trauma and neglect confer risk for psychotic disorders, which include bipolar and schizophrenia. Even when we get really granular with a specific set of genes, we’ve mapped the human genome, we’ve known about genes for 20 years. Turns out there’s not one gene that confers risk for any one disorder. Believe it or not, there’s not a schizophrenia gene and a depression gene and a bipolar gene, even though everybody thinks there are. We actually know with certainty those don’t exist. And I say that because we’ve had the human genome map for over 20 years. Artificial intelligence has been on the job. Artificial intelligence tells us, all the computers, the best scientists tell us, Oh, there aren’t schizophrenia genes. Oh, there’s this gene.
And it does increase risk for mental disorders, but also in increases risk for schizophrenia and bipolar and depression and epilepsy too and obesity and mental retardation, huh, that’s interesting. It increases risk for lots of things, not just the schizophrenia. And so when we look at any of the risk factors, they confer risk for a wide variety of disorders, if not all of the disorders. And that’s where we’re at in the field. And so it’s this big complicated mess is what it is. It’s just a big complicated puzzle that nobody can figure out.
Ben Grynol (00:24:19):
What is it that you think is a reason that lifestyle factors, lifestyle choices like diet, sleep, exercise, just overall metabolic health, why do you think it’s been overlooked for so long and there’s been so much focus on the psychosocial model, always trying to find that correlation? Well, it was this, it’s exactly what you highlighted. This is the result for that. When really the foundation that you uncovered, it’s all so far upstream. Why do you think so many people overlooked it for so long?
Dr. Chris Palmer (00:24:50):
We’ve been looking at the complexity of the brain to try to understand what causes these disorders. So that’s first and foremost, is that researchers, for very good reason, for obvious reasons, have assumed that schizophrenia must be a disorder of the brain. Depression has to be a disorder of the brain, bipolar, even alcoholism. That’s the only organ researchers are studying. They’re not studying the pancreas, they’re not looking at fat cells. The gut microbiome is the hot topic lately, and they’ve started looking at the gut, but that’s in its infancy in terms of the gut brain connection. But for the most part, researchers have focused on the brain and the complexity of the brain to try to understand mental illness. Again, good. It made sense. It was logical. It was the obvious place to look. But the shocking thing to most people is that the conclusion is…
PART 1 OF 4 ENDS [00:26:04]
Dr. Chris Palmer (00:26:02):
The thing to most people is that the conclusion is that mental disorders are all over the map. So if we look at a group of people all with major depression and we scan their brains, there are no consistent findings. If we look at a group of people with schizophrenia and we scan their brains, there are no consistent findings. The findings are all over the place. What we call this is heterogeneity. They’re heterogeneous findings. So some people can have abnormalities in metabolism in some regions, but this person with the exact same diagnosis might have abnormalities in metabolism and a different brain region compared to healthy controls. And so that’s part of it. And then we’ve had these signals for decades, literally 80 years. And we’ve had the clinical evidence for 200 years at least. That there are these connections between what we call metabolic problems and mental disorders.
So we’ve known since the 1800s that diabetes and mental illness have strong connections. And their bidirectional, meaning people with diabetes are more likely to get mental illness, serious ones, bipolar, schizophrenia, and depression. But people with those disorders are more likely to develop diabetes. So that’s been known since the 1800s. And that research continues to show that those connections persist to this day. So that’s fairly well documented and established as fact. The beginning of the 1940s, we had all this metabolic research. Researchers studying schizophrenia actually took blood from people’s veins and found that they had abnormalities in lactate metabolism. So you guys here at levels, you know about lactate. Lactate is a kind of metabolic kind of marker. It’s a marker of metabolic stress. If you really exercise and push yourself, then you’re going to have higher levels of lactate. Well schizophrenics who are just rested can have higher levels of lactate.
And that was discovered in the 1940s. And in fact in the 1980s, researchers were injecting lactate into people who have panic disorder. And lo and behold, when they did that, it would induce a panic attack in most of the patients. And it wasn’t just the needle injection because when they injected saline, nothing happened. Injecting lactate into a vein of somebody with panic disorder can precipitate a panic attack.
So what does lactate have to do with a mental disorder? Mental disorders are chemical imbalances in your brain, neurotransmitters. They don’t have nothing to do with lactate. Well, in fact, again, this in many ways my theory is nothing new. My theory builds on decades and decades of research, but the challenge has been, metabolism is really complicated. We’re still trying to figure it out. And the brain is even more complicated, some would say. It really can’t be because metabolism is the whole body. And so the brain has to be subsumed under that. But the brain is just fricking complicated. There’s just no way around it. And there’s so much we still don’t know about the brain. And so you put those two fields together and it’s like, “Well it’s just a mess. It’s just, it’s overwhelming. There’s no way anybody can figure this out.” Lots of researchers are just waiting on better computers because better computers will have the computing power to figure this puzzle out.
And that’s where the field has been. And I am really hoping that my book will change all of that and just bring clarity, a big picture clarity to the issues.
Ben Grynol (00:30:21):
The brain, I mean it’s so complex and you highlighted the one stat around it’s roughly 2% of body mass but represents roughly 20% of the energy used in a resting state. And so you’re thinking, “How much fuel does this need?” And if your, we’ll get into mitochondria, but if your energy factories of the body are not working well, what do you think is happening in the brain? To touch on the bidirectional relationships, correlation does not equal causation. But there are some really interesting things that you brought up around the idea, the bidirectional relationship when we start to think about schizophrenia and diabetes and diabetes as it relates to depression and talking through some of those bidirectional relationships. So why don’t we get into some of those metrics? Because they really are alarming when you start to think one doesn’t cause the other, but which came before which, we don’t know. What we know is they are very much bidirectional.
Dr. Chris Palmer (00:31:20):
I think the really important take home point about a bidirectional relationship is that when we see correlations between two variables, A and B, most people assume it’s cause and effect. And people get really overly simplistic. Children who watch a lot of screen, they have a lot of screen time, are more likely to have ADHD. So they go, Does the screen time cause ADHD or does ADHD cause kids to sit around and look at screens all day? So that’s an example of correlations and people are thinking cause and effect. And that’s usually where people stop is it’s cause and effect.
It’s like people who eat a lot of sugar might have higher glucose levels and they think it’s a very clear linear relationship, eating a lot of sugar results in increased blood glucose levels. But in fact, so you see two variables that have bidirectional relationships. Meaning if I look at a group of people with, I’ll make this real, if I look at a group of people with depression, they’re more likely to have a substance use disorder like alcoholism. But if I look at a group of alcoholics, they’re more likely to have depression.
People get into just ridiculous debates. So depression must cause alcoholism. And that’s the self-medication hypothesis that’s out there. Quite prominent. People become alcoholic because they’re self-medicating, they were probably depressed their whole life. And alcohol is the only thing that made them feel better and that’s why they drank. Other people go the other direction. No, it’s the alcohol. Alcohol’s making them depressed. The alcoholism comes first and then depression. That’s the way it goes. But there’s another possibility we need to consider. And the other possibility is that there is something downstream or upstream, however you want to think about it, I guess upstream from both of those disorders, that actually increases the risk of a person developing both of them. And it’s important to think that through because that can help us see the bigger picture about cause and effect. And the kind of nutshell is that it turns out that all of the mental disorders have strong bidirectional relationships with all of the other mental disorders, but it doesn’t stop there.
They also have strong bidirectional relationships with all of the metabolic disorders, obesity, diabetes, cardiovascular disease. And I throw in some neurological disorders like epilepsy and Alzheimer’s disease. And it sounds crazy, it sounds overwhelming. And that’s why I really kind of take my time in the book to walk people, to step people through one by one and at least in what I hope is a measured way to help them really get it. Looking at a variety of different types of studies, epidemiological studies and others, but even some basic science studies that all support the same conclusions. And when we see these strong bidirectional relationships, it suggests that there is some common factor or pathway upstream from all of these different disorders that might be playing a role in the etiology of these disorders.
Ben Grynol (00:35:05):
Some of the metrics are just, they’re shocking to read. I mean frankly, schizophrenia, people who are schizophrenic are three times more likely to develop diabetes. People with diabetes are two to three times more likely to develop depression. People with depression are 60% more likely to develop diabetes. You start to look at all of these relationships and you see this and you go, “I can see some patterns here as far as the impact that poor metabolic health can have on mental disorders.” And it’s taking those data points into account is really important for thinking through the framing of how do we get to this point anyway? How do we get to the point where we’ve got poor metabolic health? You bring up really what is the foundation of all of this? How do we get to this point? And it’s energy production. So you talk immensely about mitochondrial dysfunction. So why don’t we dive into that. Framing, what exactly is mitochondria, how can we think about them as being these energy factories of the body and why it’s so important to have great mitochondrial function in the body, how that relates to mental health.
Dr. Chris Palmer (00:36:22):
So for me, that was the epiphany and that was the journey that I got led kind of to, and honestly it was quite mind blowing. So most people who’ve heard of mitochondria know them as the powerhouse of the cell. And that’s what most people learn in school biology, whether it’s middle school, high school, or even college, powerhouses of the cell. That’s what they do. And what that means is that they take food and oxygen and turn it into ATP, which is the energy currency of the cell. And yes, there is no doubt mitochondria are the powerhouses of the cell. They make the majority of energy in the human body and that is a critically important task. And if you poison mitochondria, people can die very quickly.
But I think one of the things that allowed me to develop this theory is that over the last 20 years we have groundbreaking, cutting-edge, revolutionary research that has taken place on exactly what mitochondria are and they are so much more than powerhouses of the cell. Yes, they are powerhouses and without that we would be dead. They actually do so much more than that. One analogy that’s really, I like, a mitochondrial researcher said this kind of said, “If you think of the cell, a human cell as a computer, most people think of mitochondria as the power cord to that computer because they’re providing the energy. And yes, that’s true, they are like the power cord, but in fact mitochondria are actually more like the motherboard of that computer. So mitochondria are distributing and allocating resources throughout the cell and throughout the human body. They play a powerful role in numerous functions.”
And when I began to do this deep dive into the science mitochondria, knowing what I know as a psychiatrist and a neuroscientist, that’s when my mind is just blowing up because I’m like, “Oh my god, this is connecting all of the dots of the mental health field.” So mitochondria play powerful and direct roles in neurotransmitter production and regulation. They play a direct role in the production and regulation of critical hormones like cortisol, estrogen, testosterone, progesterone. They turn inflammation on and off in the human body. Mitochondria are the single most powerful factor that control epigenetics. And some researchers suggest that they probably control at least 60% of the human genome. They play a powerful role in metabolism and they actually sense glucose. Everybody loves glucose and sugar and insulin. Guess what? Mitochondria are the things that are sensing glucose levels. They are the single factor that controls whether insulin gets released from the pancreatic beta cells or not. Mitochondria and their reactive oxygen species are the determining factor of the release of insulin. So I know a lot of people in the metabolic health community love to focus on sugar and insulin and mitochondria are right there doing that too. But they play powerful roles and very direct roles in all of these things. And once we understand that the beautiful thing is not only can we understand mental health and in fact all mental disorders, but it puts it together with why are there these strong relationships between mental disorders and type two diabetes? Why there are strong relationships between mental disorders and cardiovascular disease and premature aging and premature mortality. Why? And as soon as you understand the metabolic and mitochondrial connections, everything makes sense.
Ben Grynol (00:41:08):
When you think about brain efficiency, brain effectiveness, a single neuron using 4.7 billion molecules of ATP every second. I mean the numbers are, they’re just hard to fathom as a human. You’re like, “That just sounds like a lot. Because it is a lot.” What you know is that if your mitochondria are producing ATP but they’re not functioning well, that’s directly connected with the brain, when you start to think about that. There’s also the idea… So we talked about energy production, but let’s talk about the other side of mitochondria. When talking through the idea of eliminating old and damaged cells, why it’s so important. And I know you talked about mitophagy and autophagy and why this is also important to have well-functioning mitochondria in the body.
Dr. Chris Palmer (00:41:59):
So there are a few processes. So the two big ones that some people have heard of, I think people in your audience have probably heard of autophagy. And there’s actually another process called apoptosis. So autophagy is usually not necessarily the death of an entire cell, instead it is taking old damaged cell parts, proteins, misfolded proteins, old proteins, other waste molecules. It’s recycling them, managing those recycled products. Some of those products just get reused for energy or building blocks to create new proteins. But some of them need to be managed appropriately. The easiest way to think of autophagy is a hoarder’s house. Autophagy is cleaning up that house and it’s not indiscriminate cleaning. It’s not just we’re going to burn the whole house down and start fresh and it’s not, we’re going to throw away all of the useful furniture in that hoarder’s house.
We’re going to keep what the person actually needs and requires, but we’re got to get rid of all the junk and we’re going to get rid of it, recycle it, clean house and things will actually be healthier and more efficient if we do that. Apoptosis is a different process in which cells become old, dysfunctional and they pass a point of no return in which they need to be killed. They die. And turns out both processes, autophagy and apoptosis, mitochondria play a direct and important role in both of them.
So mitochondria are the central regulators of apoptosis. For a long time, researchers thought it was the human genome, but in fact it doesn’t come from the nucleus. That signal comes from mitochondria and autophagy is a process that gets stimulated in particular during fasting states or if somebody’s on a ketogenic diet, you’re actually mimicking the fasting state. And one of the more powerful regulators of that process, I mean there’s always baseline autophagy going on because otherwise we would just accumulate with waste products and pass away. So there’s always a baseline amount going on, but you can really put autophagy into hyperdrive through fasting and fasting mimicking diets and mitochondria play a direct role in creating the signals that start that process.
Ben Grynol (00:44:52):
The interesting thing around mitochondrial dysfunction, and this is really the dichotomy with what it sounds like, the dichotomy with psychiatry right now, there is a time and a place which you state for prescribing medication. It’s not to say let’s not do it at all. There are things like seizures where you said medication can help. That is true. If a person seizes for too long, they’ll pass away. But the challenge is that, and this is the dichotomy, is you prescribe medication, but then that can lead to in some cases mitochondrial impairment. And so you’re sitting there going, oh, you’re trying to weigh out what to do. And I’d imagine as a medical professional that that’s always one of these things that you’re trying to think about the cost and the benefit of whether you prescribe or how you can mitigate in different ways with things like a metabolic program.
Dr. Chris Palmer (00:45:49):
Yeah. So the mental health field and anybody who has ever taken a psychiatric medication, at least most of them, certainly not all of them, stimulants like Ritalin and Adderall actually, if anything, have been used for weight loss. Stimulants have been used for decades for weight loss and they actually speed up metabolism and they increase mitochondrial function, they increase the production of energy and heat and that helps people burn calories. So there aren’t any kind of across the board themes for psychiatric medications, but there are classes of psychiatric medications, in particular the antipsychotics and some of the mood stabilizers, but also some of the antidepressants and other types of meds that we know with certainty impair metabolism. And we know with certainty in per mitochondrial function. And for the most part these were just thought to be side effects. It’s just the price we pay and because psychiatric disorders are sometimes dangerous and life-threatening disorders, these are the pills that seem to work any good clinician knows.
And I don’t know any good… I don’t know any clinicians who feel good about the fact that we’re causing metabolic harm. I don’t think anybody does. I have met a couple of what I would call clueless clinicians who think, “Well if they just ate less and exercised more, they wouldn’t be gaining so much weight.” And I’m like, ” That is really heartless and cruel and naive and actually stupid of you to say.” Because anybody who takes these pills gains weight essentially. I mean, it is an extraordinarily rare human being who can take some of those pills and not gain weight. So it’s unfair to put all the blame on patient. But we’ve known this. But again, it’s just assumed these are side effects and metabolism that has nothing to do with mental illness and diabetes, that’s really not, even though we’ve kind of known since 1800s, well, but these are just side effects of the meds that has nothing to do with the actual effect of the medication on the brain.
Because the brain isn’t where diabetes is. Diabetes is in the pancreas, and anybody who actually knows metabolism now actually knows, no actually it’s not all located in the pancreas. The brain actually is playing a role in sensing glucose levels and controlling glucose levels and actually playing a role in the secretion of insulin from the pancreas. So believe it or not, the human body is really interconnected and that includes the brain. The brain is actually really integral in that interconnection. I think the really profound revelations of the brain energy theory are that these metabolic connections are in fact not at all side effects. They represent the direct impact of these medications on the brain and the body, and it is directly related to their ability to suppress symptoms.
The challenge is that although some of these medications can suppress symptoms in the short run, they may very well be making matters worse in the long run. And I don’t say that lightly. I know how controversial that will be. I also just want to say, if anybody listening is taking a psychiatric medication, please, please, please, please do not stop your medication on your own. Do not try to taper yourself off your medication on your own. I can tell you with certainty that I have seen patients manic, psychotic, suicidal, severely depressed, many of them hospitalized, some of them arrested, some dead because they took it upon themselves to stop their medications.
So once you’ve been on these medications, I’m sorry, you are in a difficult position now and it is not, you cannot just easily get off them. So please do not stop them on your own. Please don’t try to taper them on your own. Please work with a competent healthcare provider who knows what they’re doing and can help you safely get off them if you decide that that might be something you want to attempt to do. But you also have to have a treatment plan in place. Because simply getting off medications may not be an effective treatment plan.
It’s kind of like if somebody gained a hundred pounds from the medications, simply getting them off the meds doesn’t make them automatically lose that a hundred pounds. They have to put other treatments or strategies in place. And I’m particularly interested not in people’s weight, although I can help people lose tremendous amounts of weight. I’m interested in brain function and brain symptoms that impair and disable people. And so it needs to be done safely and it needs to be done responsibly. The terrifying thing is that we may in fact be prescribing medications that are keeping people chronically ill. And quite honestly, as a psychiatrist who has prescribed these medicines for 27 years now, it’s heartbreaking. It’s heartbreaking to do a deep dive into the science and come to that.
PART 2 OF 4 ENDS [00:52:04]
Dr. Chris Palmer (00:52:02):
… to do a deep dive into the science and come to that conclusion. I always knew that the medications were causing metabolic harm. But I, again, for a long time I just bought the paradigm hook, line and sinker that, “Well, these are just side effects. They’re just the price we pay to treat serious disorders. These are serious life-threatening disorders. I’m saving people’s lives by prescribing these medicines.” It is heartbreaking to think that maybe I was keeping people ill as a result of those treatment strategies. I really do feel like the brain energy theory delivers very clear, testable hypotheses, largely supported by the existing evidence that we have. This is not a speculative theory. This is a theory that takes all of the existing research and puts it together in the only logical way possible.
Do we need more research to really fully test this theory? Yeah, we do. Do we need more research to fully test what treatment strategies will really help people fully recover and remain recovered for life? Yeah, we do. But the path to those clinical trials, those research studies is obvious now. It is obvious. The path to helping people heal and recover from depression and anxiety, but also OCD, schizophrenia and bipolar disorder becomes clear now. I genuinely believe we can put those illnesses into remission and help people recover.
Ben Grynol (00:53:59):
One of the things that really stuck with me was the model that you brought up around why it’s so hard to diagnose mental disorders? That being this marriage of signs and symptoms.
So a syndrome is made up of signs and symptoms. It was so simple and so easy to understand. It was something that I thought, “Hey, you can just extrapolate this outside of this psychiatric field into all of healthcare.” So signs being objective measures, and that’s very much what we’re focused on is this idea of when you see data, you can start to make meaningful change.
The challenge is that in any healthcare field, especially in the psychiatric field, you diagnose based on symptoms. So symptoms being subjective, “Hey Chris, I feel this way.” Well, you can’t argue against that. You can’t say, “No, you don’t. You don’t feel that way.” Right? So we end up having to mitigate with treatment based on these symptoms, but we don’t necessarily have clear signs all the time. And the more that healthcare can get to a point where we can start to see patterns proactively as far upstream to look at the signs, it allows us to start to link things together and say, “Oh, I can see the pattern here.”
We know how to treat things better, but without that it becomes very, very challenging. So that model alone was so clear and it’s something that I have thought about time and time again of how important it is when we start to think about how we can change healthcare long term across the board.
Dr. Chris Palmer (00:55:34):
Yeah. No, I love that. I think that the metabolic theory of mental illness, again, based on existing studies that have already been done. This theory gives us so many opportunities to intervene and prevent potentially lifelong chronic mental disorders.
To just make that clear and concrete maybe for the listeners. So there was one longitudinal study, 5,000 kids followed from the ages of one to 24. The kids with the highest levels of insulin resistance beginning at age nine were five times more likely, that’s 500% more likely, to be at risk for a psychotic disorder by the time they turned 24. They were three times more likely to already be diagnosed with bipolar disorder or schizophrenia. So insulin resistance beginning at age nine confers a highly elevated risk for the development of a chronic psychotic disorder.
I think as all of your listeners on this podcast know, insulin resistance is something we can measure. The researchers did, but a lot of you people… “You people are all measuring your insulin resistant. You’ve got your continuous glucose monitors on, you’re tracking insulin levels. You’re tracking all sorts of stuff.” So you know what it is.
We could slap one of these on a kid sometime and see what level of insulin resistance does this child have and we could intervene. We can do things with diet, exercise, and other lifestyle strategies to address insulin resistance. Now, I actually think insulin resistance… It is a biomarker of extraordinarily complicated metabolic and mitochondrial things happening in the human body. Some people think of insulin resistance as you eat too much sugar and then you have insulin resistance. I don’t see it as such a simple construct. Yes, if somebody gorges on sugar all the time, they probably will develop some insulin resistance. But that’s not the only cause of insulin resistance. Trauma causes insulin resistance.
If your mother was starving or grossly underweight while she was pregnant with you, that puts you at risk for insulin resistance. You didn’t do anything wrong. It has nothing to do with your diet. It has to do with your fetal programming by your mother based on her environmental circumstances.
The only way the brain energy theory works is that we have to think more completely and in a more complex way about what is metabolism and what does it mean to have a metabolic problem. Because only then can we start to understand mental disorders, but I actually think this theory is extraordinarily useful to people who want to lose weight. I think this theory is going to be extraordinarily powerful to people who want to prevent a heart attack or to people who want to better control their diabetes. Because for all of those people, if you’re a low carb enthusiast like I am, make no mistake, I’m not the enemy here. I am a low carb enthusiast, a keto enthusiast. Some might even call me a keto quack. I’m with you. Low carb and keto are not the cure-all for everything in the human species. They just are not. We need to be more sophisticated than that.
We need to be clear that trauma, neglect, epigenetic and genetic factors are playing a role. Hormonal factors are playing a role. Inflammation from things that you cannot control. You might have gotten an infection. You might have chronic Lyme disease. You might have long COVID, which the latest research suggests is a chronic infection for some people. Their bodies are not clearing the virus. That is not diet. That doesn’t have anything to do with carbohydrates, but it will cause insulin resistance and it will cause mental problems potentially, and it will cause metabolic health problems. I think when we think more comprehensively in those ways, we can actually fully address human health in more effective ways.
Ben Grynol (01:01:05):
You touch on adolescence and that’s a really important one. There is a section in the book where you brought up ACE scores. There’s so much research out there, you hear it all the time where a child that comes from an environment or that’s surrounded by certain conditions that are adverse in some way, shape or form. It could be physical abuse, it could be substance abuse, it could be bullying, the list goes on. It’s really easy for us to rationalize it as a society and go, “Well, yeah, that makes sense. I can see a link between having poor mental health and having high ACE score.” But when you tied it back to kids with high ACE scores also have a 25 to 52% higher probability of either being obese or having diabetes. Those are the things that you go, “Yeah, but that’s a metabolic disorder.” Right? And you look at all of these things.
Now, we can extrapolate it many different ways. Was it their diet growing up and whatever it might be? But in general, when we start to bucket these things out, you go, “Wow,” around the points you brought up for kids that have higher rates of insulin resistance and how that can lead to higher rates of bipolar disorder, higher rates of schizophrenia. It’s alarming. It really is, it’s saddening. Especially as a parent you think of all these things that you try to mitigate, you try to get in front of them.
There’s one story that you brought up in the book that was so relatable for so many reasons around Caleb. So, I would love to dig into it because it’s something that I think so many parents can go, “Wait, that’s like I do that, but I don’t give my child a bad upbringing, but am I contributing to these factors?” So, it would be wonderful to hear that story.
Dr. Chris Palmer (01:02:57):
Caleb was a kid, a young boy, growing up in an upper middle class family. He had a reasonably good life, but he had a strong family history of all sorts of mental disorders, bipolar disorder, depression, substance use disorders, psychotic disorders, suicide attempts. So most people would say, “Well, oh, that’s not good.”
From a young age he was diagnosed with ADHD, parents initially wanted to try to avoid medications so he got psychotherapy. His parents were working with the school. They tried all sorts of different strategies to try to help him, but none of those worked. At some point, they decided to try stimulant medication, which is the standard treatment for ADHD and for a few days it actually worked great. Caleb was able to focus better and everybody noticed an improvement. Parents and teachers all noticed significant dramatic improvement overnight with the use of a stimulant, but within a week or two, he couldn’t sleep.
They tried different stimulant preparations, long-acting, short-acting, lower and higher doses, different times of the day. They really tried to figure out how to make this work and nothing was working. Then the psychiatrist was like, “Well, let’s put you on a sleep medicine on top of your stimulant to make sure that you do sleep.” That’s where the parents said they’d already been tinkering with this stimulant and nothing was really working.
So in some ways he was able to focus, but in other ways things were getting worse because of the insomnia. So he was getting more irritable and having some tantrums and other problems. So the parents actually said, “No, we’re we’re not interested in adding more pills. We will stop the offending pill and figure out what to do.”
Caleb did not get better with just stopping that stimulant. His symptoms persisted and evolved. So now he starts developing mood symptoms. He’s getting depressed. He’s throwing tantrums in school, he’s getting disciplined frequently and starts actually threatening suicide. He actually threatened to kill people at school. I don’t think anybody took it seriously. But you know, you can’t say you’re going to kill somebody at school. That doesn’t go over well with anyone. And would actually jab himself with a pencil sometimes, not necessarily breaking his skin, but people were alarmed and just appropriately concerned.
At some point, the psychiatrist who was working with them and the school began insisting that Caleb take a mood stabilizer. They didn’t even go to antidepressant, they went right to mood stabilizer because of Caleb’s family history. The parents said, “No way,” and instead wanted to try a metabolic treatment strategy.
We ended up trying two things. So one was that Caleb was eating a ton of sugar. School sucked for him. There was no doubt about school sucked. When he came home, he was almost in tears and parents just felt terrible about this. His parents were just like, “Oh my God, it’s heartbreaking to see our son struggle and suffer so much.” So he would want a treat at the end of school day. You know, “I want a treat.” So the parents were like, “Okay, go ahead, have ice cream, cookies, whatever. We’ll we’ll stock the kitchen with treats for you.”
Then he would have dinner, a decent, reasonable dinner, and then he wanted dessert after dinner. So another ice cream or another cookie or candy bar or whatever and parents went along with it because it just seemed like the nice thing to do. It really did. Caleb was so, he was just struggling so much.
So we looked at that pattern. I talked with them about insulin resistance and how it might be playing a role in bipolar disorder and depression in some kids and that there’s really low-hanging fruit. I didn’t go right for the ketogenic diet. I [inaudible 01:08:00] really low-hanging fruit, “Could we get rid of the sugar at least during the school week?”
I didn’t want to be heartless. I didn’t want to say like, “All the time. Weekends he can still have dessert, but could we get rid of the sugar during the school week? Let’s just try that and see.” Caleb was not thrilled about it, but he recognized that he was not doing well. He knew he was suffering. He knew he was struggling in school and he also knew all these people were trying to make him go on more pills and he was very reluctant to want to go on pills because he remembered the stimulants and how they made him not sleep and he didn’t want to be in that situation again.
So he was very invested in if there’s a way to control this without pills, I am open to that. So that was the hard sell. The easy sell was that I also introduced a light box, light therapy. So one of the things that we know about people with bipolar disorder, and I’m just operating under the assumption. Clearly he has depression, clearly he has ADHD, that is the perfect setup for what we call bipolar disorder. He’s also got this strong family history of bipolar. So it’s just like, “Okay, I’m treating this kid as though he’s got bipolar disorder, but I’m using metabolic approaches.” So we’ve got actually really good data that sleep regulation is critical for the control of mood disorders and bipolar disorder in particular, and light exposure first thing in the morning is a really powerful way to control circadian rhythms and sleep.
We ended up introducing a light box first thing in the morning. He was on video games anyway, and so we had the parents put the light box right in front of the video games that he was playing anyway. Within two months Caleb was clearly turning a corner, no more tantrums at school. He actually said, “I feel better.” He didn’t miss the sweets during the school week anymore. And he actually actively noticed, like, “I’m better. I feel it, I feel better.” So he actually became an advocate for, “I need to do my light box. I can’t have sweets during the week.” He really began to own this treatment as part of his lifestyle and something that he needed to do to control his mood and ability to concentrate.
By the next year, Caleb got straight A’s. Then in 2020, Caleb started high school and that was right in the middle of the pandemic. All the other kids were struggling, all the other kids are stressed and lonely. Caleb was thriving at that point and ended up getting straight A+’s actually, and the new high school was like, “Why the hell is this kid on an IEP? He’s the top student in his classes. Who the hell put him on an IEP?” Individualized Education Plan, for those who don’t know. It’s like a Special Ed kind of a thing. The school said, “He doesn’t need it anymore.” And he continues to thrive and continues to essentially follow the same treatment plan to this day.
Ben Grynol (01:11:40):
The thing that we do, I think, as a society, to give Rob Lustig a hat tip, he talks all about sugar is love. We think we’re doing a favor. We think we’re doing something positive for a child. Or if you’re a grandparent and you’re doing it for grandchildren, it’s, “I’m going to give sugar.” Because you don’t want to be thought of as the bad person, that, “Oh, it’s deprivation.” We’re not. As we learn more, we’re not doing anyone any favors. You said it directly, Caleb felt better and noticed it.
These are all things where it’s almost like, “Why are we,” not to be too hyperbolic about it, “But why are we poisoning with certain things?” We give highly processed food to kids because we think it’s, “Oh, they’re kids, they should have treats.” We give things that are extremely high in sugar and it doesn’t mean that we should be so prescriptive that kids have a, we’ll call it, a difficult relationship with food. They’re learning too. We want them to understand what whole food is, what processed food is so they can these decisions.
But there’s one thing that’s for sure, if you give your kid only highly processed food the outcome is going to be metabolic dysfunction, long term, full stop. And what you brought up in the book is a direct link to mental health. So we’re not doing our children any favors by surrounding them with conditions that they aren’t really in control of when they’re that young.
Dr. Chris Palmer (01:13:09):
We’re not. I think most people don’t at all understand or appreciate, even clinicians don’t understand and appreciate these connections with mental health. Most people think that the processed food and sugar is all about weight.
And “We’re a fat-shaming society and we’re getting beyond that and we don’t want to be fat-shaming people. Kids have a high metabolism anyway. They can eat that stuff. They can eat that stuff and burn it off. I’ll just have them go run around the house a little bit or go play baseball or whatever and that’ll help them burn off those calories. So it’s a win-win. I, as a parent, give them treats. They like me and love me for giving them treats and they’re burning off their calories.”
I think that really is the way a lot of people see it and think about it. And when you understand metabolism, when you understand that our current food supply is a lot of non-food. It’s a lot of chemicals. It’s a lot of highly processed food things that are formulated to be addictive. They are formulated to be addictive. Even though the American Psychiatric Association doesn’t recognize food addiction, the director of the National Institute on Drug Abuse did a lot of research studies arguing that some highly processed foods are in fact addictive and use the exact same reward pathways that cocaine addiction and nicotine addiction use.
But the food companies kind of admit it. You know, “You can’t eat just one.” I mean, come on, what is that? It means that they are making highly palatable foods. When you give a highly palatable food to any human being, they are going to be more likely to eat it. If you give a highly palatable food to a human being who is stressed, there is a direct connection there.
The reason the parents wanted to give Caleb that food is because they knew it would decrease his stress response in the moment. And it did. When people are highly stressed, they have intense cravings for that food. So if his parents had just willy-nilly decided to deprive him of it without a clear rationale, without a clear plan, without clear objectives of, this is what we’re trying to measure, Caleb would’ve experienced that as just cruelty or deprivation. Because again, when any of us are stressed, we crave highly palatable and high calorie foods. That is in our biology. It is in our biology. I think that it’s probably an evolutionary adaptive strategy for when humans were stressed in other ways. Like stress can be starvation or war or famine or abuse. And if you’re in any of those situations and you see some food around, you should probably take the opportunity to eat it because you might not have another opportunity in the next few days.
So when animals are highly stressed and food is right in front of them, they are going to eat it. I imagine, as much as we shame people for that like, “Oh, you’re stress eating.” We need to just recognize and respect our biology. Our biology is driving us to do that.
There’s nothing wrong with our biology. But there are things wrong with the foods that we’re eating. And people can become trapped in a vicious cycle. Once they’re addicted to it, then they start getting stressed because their blood sugars are on a rollercoaster and now they need to eat that food in response to the stress, but the cause of the stress is actually the food that they’re eating and it’s just a mess. That’s how people kind of go into metabolic and mental problems.
Ben Grynol (01:17:43):
We’re very much irrational creatures of the dopamine factory that exists inside of us to keep hitting that button and just keep going, going, going because it feels really good. Feeling those reward pathways, it just feels good in the moment and we hyperbolically discount long-term outcomes with short-term-
PART 3 OF 4 ENDS [01:18:04]
Ben Grynol (01:18:03):
Hyperbolically discount long-term outcomes with short-term gains, I need this now. When you think about that and behavior change, there’s one line that you brought up that is, well, it’s a motivation problem. And you frame it as, it’s not. There is not a motivation problem. It’s a metabolic one, and that being this idea around the economic impact you highlighted around by 2030, $6 trillion in economic impact based on treating mental disorders. When you think about it from a productivity standpoint, people want to get to work. People want to live very average lives. People want to feel good. How do you think about long-term behavior change knowing that we are these creatures of hitting that dopamine button over and over and over again?
Dr. Chris Palmer (01:18:54):
It’s a question that I get asked a lot. And other researchers, clinicians, patients, will often say, “Chris, yeah, we get the science. I listened to your lecture, or I saw you give a talk, or whatever. And the science is compelling. You make a really good case. But how the hell are you going to get somebody to do a diet?” We have an obesity epidemic. Nobody can do a diet. And you’re working with seriously mentally ill people who are further impaired, and they’re impaired in terms of motivation, they’re taking medications that increase their appetite. It’s a double whammy for them because we’re giving them medications that are making them crave sweets even more than they probably did before those medications.
And so most people get really hopeless about this, or pessimistic about, humans like the dopamine reward and you’re never going to get them to overcome it. I think one of the reasons I have been so successful at getting people to do these may in fact be because I do work with people who are suffering. And suffering is a powerful motivator. And if somebody’s just a little bit overweight, it doesn’t physically hurt them to be a little overweight. It may not even emotionally or psychologically hurt them. It might. I mean, yeah, there’s fat shaming, or maybe you really want to go out with that hot boy, or girl, or man or woman, whatever, and they don’t look at you because you’re a little overweight. And yeah, some will say, “Oh, that’s suffering,” but that’s not the kind of suffering I deal with.
I deal with people who are tortured by their symptoms, who are depressed, who have no self esteem, regardless of what they look like. I deal with people who are tormented by hallucinations and delusions, or addiction. And those people desperately want to make those symptoms stop. And so when I talk with them about metabolic treatments, it’s more than diet. For some, it’s exercise. For some, it is diet. For some, it’s sleep regulation. And for some, it’s getting off substances that are harming their metabolism. So there are lots of different metabolic treatments. But when I talk with them about a comprehensive metabolic treatment strategy and I give them accurate and actionable information, which includes all of the downsides, and I think that’s one of the things, even when I talk to other low carb or keto clinicians, I think sometimes they sugar coat keto adaptation a little too much.
You can do it, that’s not at all what I say to patients. That’s not even what I say to friends or family who just want to try keto for a diet. I say, “It’s going to be a living hell for two weeks. Get ready for it. Let’s prepare for a living hell. You’re going to feel weak and dizzy and lightheaded. And you’re going to be having intense cravings. And it’s just going to feel unbearable, but I will help you get through it. We will come up with strategies. I have gotten schizophrenic patients to do it. You can do it too.” That’s my approach almost across the board, pretty much I think 100%. I’m still 100% across the board. Every person comes back to me and says, “It wasn’t nearly as bad as you made it out to be.”
But setting that expectation makes all the difference in the world because if you tell them this is a really easy diet to do, you can do it, I feel great on keto, and you fail to tell them about what keto adaptation was like for you, as soon as they experience discomfort, or dizziness, or weakness, or intense cravings, they freak out and they think something horrible has gone wrong, and that they’re not getting this euphoria that you speak of. They’re instead, they’re having a serious bad reaction and all those vegans who were saying that keto is dangerous were right. And oh, my God, you’re killing me. You’re killing me with this keto diet. So I set the stage, I set the stage for this is how you’re going to do it. This is what’s going to happen. These are the strategies you’re going to use to get through it. And then if they fall off the wagon, I’m right there. I’m not frustrated. I’m not exasperated. I actually am expecting it. I am expecting nobody is perfect, and certainly not the patients I work with. They’re going to give it a shot and probably fall off the wagon at some point. They’re going to go out with friends, and those friends are going to push all sorts of food in front of them. And they’re not going to have the willpower, they’re not going to have the strategies. They’re not going to have the assertiveness that they need to be able to resist. And they’re going to give in and eat it, and then they’re going to come back in and they’re not going to be in ketosis because I might be measuring that.
And then we’ll talk about, “Well, what’s going on? You’re not in ketosis, and I thought you were onto this plan. Are you still wanting to do the plan? Do you not want to do the plan?” I always give them the out. I always give them the out. You don’t have to do this if you don’t want to. But I really do believe it might help you feel better and change your life. And are you interested in that still? And almost universally it’s, “Well, yeah, of course I am.” And you’ve tried 30 pills already. You really think number 31 is going to be the magic pill, really? Because I don’t, I’m a psychiatrist, I prescribe these all the time. I don’t think 31 is going to be the magic pill for you. Instead, I think we need a whole new approach, an entirely new approach.
And so that gives you at least a flavor of how you overcome that dopamine addiction, how you overcome those societal pressures, how you overcome just human nature. And I usually paint a picture. I almost always tell people, especially if they’re doing a low carb or keto diet and they really like sweets, I always tell them, “You have to give me three months, three months of really sticking to it.” And then, and only then will we assess two things. We will assess: Is this diet working for the symptoms that we outlined that we want it to work for? So usually in my case, it’s I’m trying to treat mental symptoms, so depression, anxiety, bipolar, schizophrenia, whatever. We’re going to look at: Is this diet working for you? The second thing we’re going to assess is: Is this diet sustainable, at least for a couple years? And I always let them know I don’t want you to answer either of those questions prior to three months. And the reason is because some patients will say at the six week mark, some patients will experience dramatic improvement in their mental symptoms. But they will still be having intense cravings for bread, or ice cream, or other sweets that they can’t have on the diet. And they will still be thinking life is going to be really miserable without those foods. What’s the point in living if I can’t socialize with people, if I can’t celebrate holidays with people? I’m going to be this social outcast who has to eat a weird diet, and I’m craving those foods, and I really desperately want those foods.
The shocking thing is that for the majority of people, if they can get through three months of it, that goes away. All of it goes away. And they start to realize, wow, I feel so good. And now that I see people eating that ice cream, it reminds me of how shitty I used to feel. I don’t think I need that anymore. I don’t want to eat that. Or actually, the more likely scenario is they go ahead, at the four month mark, they go ahead and try pizza and ice cream because they’re feeling so great. They figure, well, I’m good now. I don’t need this diet anymore. They eat that, and then they wake up the next morning feeling like crap. And the patients I deal with, they might wake up hallucinating again, or they might wake up feeling severely depressed again and suicidal again. And that is one of the most powerful motivators for the people I work with because then they see a clear and direct effect of food on their mental health.
Ben Grynol (01:29:10):
Long-term behavior change, it takes such commitment. And one thing we’re very, very good at doing is giving up on things. Right? As humans, we’re good at giving up on ourselves. That’s very much a mindset thing. We’re also really good in some cases at giving up on others. And I think there’s no better example than the story around Mildred that you highlighted. It seems like something that it’s just too far gone. This is impossible. Highlighting that story was one of the most eye opening parts of the book when I read that, so would love to dig into that story.
Dr. Chris Palmer (01:29:49):
So this woman’s story is particularly powerful because some people think, most people think schizophrenia is a chronic lifelong disorder. A lot of people, and even neuroscientists think if you’ve had schizophrenia for decades, it’s too late. It’s too late for you. So this woman was diagnosed with schizophrenia when she was 17 years old. And she had daily hallucinations and delusions. Over ensuing decades, she tried numerous antipsychotic and mood stabilizing medications, but they did not stop her symptoms. She was gaining tons of weight. She had a guarding and a pack team, which means the people who came into her home to help her with grocery shopping, or paying her bills, or other things.
And this woman was miserable. Between the ages of 68 and 70, she tried to kill herself at least six times and was hospitalized for those suicide attempts. At the age of 70, so she’s now 53 years with schizophrenia, the age of 70, she’s referred to Duke University, where Dr. Eric Westman was using ketogenic diet as a weight loss tool, and she was referred for weight loss, and that’s all Dr. Westman was treating, weight loss. And within a couple of weeks, not only did she start losing weight, but her hallucinations pretty much went away within a couple weeks. I will say, a lot of other patients that I work with, it takes a little longer, but she had a powerful effect. Within months, all her symptoms of schizophrenia were in remission. Within a few more months, she was off all her psychiatric medications and remained in remission.
This woman went on to live for another 15 years, symptom free, medication free, no more mental health professionals, no more suicide attempts, no more psychiatric hospitalizations. She had an entirely new life. And when I last spoke with her, she actually was really happy and actually asked me, almost pleaded with me, to please tell her story to as many people as I could because she hoped that if her story could even spare one other human being the living hell that she had to endure for 53 years, that it would be worthwhile. So very sadly, this had not happened at the time that I wrote the book, but very tragically, this woman passed away this past January of COVID pneumonia at the age of 85, which is actually a longer than average life for a person with schizophrenia.
Ben Grynol (01:33:07):
Such a powerful story, and it’s a reminder that she lived for such a prolonged period of time after making this change. You think, “Well, I’m in the tail end of my health span and my lifespan, being 70 years old.” People don’t know, once you get to an older age, they might not know how many years they have left because things can change. She lived for 15 years. It’s just an incredible story to think that if she had a life that was very different than the life that she knew. So thinking how we can make these changes, whether it’s with friends, whether it’s with family, but things are in more of our control than we think when we start to think about metabolic impact and how we can make changes to make positive mental health changes.
So in thinking through, there’s two last things to touch on, so one of them is around: Why is it so hard from … There are very much macro conditions. There’s government, there’s academia. There’s the medical field as a whole. But when then thinking through, I guess what’s the biggest challenge when you think about why implementing something, the brain health model, implementing this changes, it just still feels like there’s more of a movement that needs to be done, when you think through these challenges, what is the largest one that we face?
Dr. Chris Palmer (01:34:41):
I think the biggest challenge in the mental health field is the stigma of mental illness. Society for centuries has just wanted to discard the mentally ill. They are considered subhuman by many. They are considered criminals. In fact, the US prison system is the largest provider of mental health services in the United States. Homeless shelters are filled with the mentally ill. Lots of mentally ill people are disabled or living less than optimal lives. They stay at home. They don’t go out. They don’t have as many friends as other people. That stigma makes people not really care about them, not really care about providing resources for them, treatment for them. The tragedy is that when we pair it with the gross ineffectiveness of the current mental health treatments, that just serves to further change and stigmatize and humiliate the mentally ill.
So we put them on pills that are not effective long-term, and we know that based on all of the controlled trials that we have, all of them. There are no trials showing that we can put even 50% of patients with any diagnosis, depression, anxiety, any diagnosis, there are no studies showing that we can put even 50% into full and lasting remission for years, not one study shows us that. And so our treatments if we really do a hard and kind of realistic assessment, our treatments are failing these people, so it’s hard to get worked up about marching in the streets for ineffective treatments that make people feel like crap and make them fat and diabetic, and they don’t work anyway. Who wants to march in the streets for that?
And back to the stigma, and it’s just the mentally ill anyway, they’re defective. They’re weak. Those are the biggest barriers that we have. And I am 100% convinced that nothing will change if we do not get a grassroots movement, if people don’t join me and others demanding change, demanding treatment programs that use metabolic strategies to help people fully heal and recover from their mental disorders, if we don’t get insurance companies to start paying for this, if we don’t get government and others to start funding research for this, nothing’s going to change. And the status quo will remain, and mental disorders will continue to skyrocket. And we’ll probably take on a larger and larger portion of disability throughout the world. Now I really honestly am aware of that pessimism, and I am begging people to join us because I’ve devoted my career to this work. I know these people deserve respect. I know these people deserve better lives. And so I desperately want people to join this movement.
Ben Grynol (01:38:56):
So if people want to make change, those around them, friends, family, what are some tactical things, what are small things that they can do, aside from read the book of course, follow you on Twitter, make sure that people are part of this movement? What are small things that they can do as far as tactics to make this change, to educate others about it, to do things for those around them to make this positive impact?
Dr. Chris Palmer (01:39:27):
The biggest thing is that I am hoping to create a home at brainenergy.com. So I’m going to encourage people to go to a website, brainenergy.com. By November 15th, there will be a free self assessment, help people assess their mental health and their metabolic health with some objective markers that I think might be really useful. So that will give people an assessment. I’m not giving you a treatment plan. I’m giving you an … I cannot treat the world’s population based on some small computer algorithm, but it will help inform people about, here are some areas you might think about changing, might help you determine whether you’ve got insulin resistance or not, might help you think about blood pressure, your weight, and other things, but also, your mental health, a lot of mental health things.
And it will give you some ideas about, here are some things that you might want to work on. You can take that to, if you’re struggling yourself, or if you know somebody who’s struggling, help encourage them to do that. Take that, friends, family, other metabolic mental health podcasts, listen for strategies. How can I improve my insulin resistance? How can I improve my blood pressure? What can I do to get stronger, fitter? What can I do to add some meaning and purpose in my life? You could take that assessment to your healthcare provider, whether it’s your general practitioner, whether it’s a mental health provider. But also, at brainenergy.com, I am hoping to start the grassroots movement. I really want change.
And I think the first step is that we need numbers. We need people. And that means I want you to tell other people. If you are persuaded by the metabolic theory of mental illness, if you see even a tiny sliver of the hope that I see in this for the masses of people who are suffering, I need you to spread the word, to tell people about this. Whether they buy the book or not, I really kind of don’t care. My publisher will kill me for saying that. My goal is not to sell books. My goal is to sell a theory that can transform human health, mental health, for millions and millions of people. And that means people need to have this knowledge. They need to know why and how, why does this work this way, so that you can talk with healthcare providers in a competent, knowledgeable way. But also, what are some strategies that I can use? What are some problem areas that I might identify?
And then I want to advocate for change. I want insurance companies covering this. I want government funding this. And that means we need numbers. If we get millions of people, I know that sounds audacious and grandiose, and maybe it won’t happen, maybe nobody cares, and maybe nobody believes me. That’s fine. You don’t believe me, go ahead. Go figure it out. You come up with better plans, please. But for the people who do believe me, trust me. Nobody else is going to do this. Nobody’s going to do it for you.
If you know somebody with a mental illness, I’m not asking you to do it for me. I’m asking you to do it for that person. I’m asking you to do it for the people that you know with mental illness who deserve better lives. That’s why you’re going to get involved. You’re going to stand up for those people. You’re going to stand up for your sons, your daughters, your spouses, your parents, your siblings, your friends, your coworkers, or just the little kid down the block that you see as tormented. You’re going to stand up for that person and you’re going to get involved.