So, hello everybody. Thank you so much for being here. I'm Cynthia Stonington, and I am going to be chairing this symposium. Just as a quick check for those in the audience, how many of you have familiarity with evolutionary psychiatry, either through a course or reading? So some, great. Half, so-so, okay. Well, I'm hoping that this will be a lively and interactive and informative session today. So first of all, I'd just like to introduce all of our speakers. Dan Stein is the chair of the Department of Psychiatry at University of Cape Town in South Africa. He has authored and edited over 40 books in neuroscience, philosophy, epidemiology. His latest book is called Problems of Living, which is a masterpiece. Unfortunately, at the last minute, Dan was unable to come because his daughter needed surgery, and he, as a good father, had to be there with her. But the good news is that Randy Nessie will be more than capable of going over, of doing his slides. Randy Nessie is a professor emeritus of psychiatry at University of Michigan, where he was on the faculty for 40 years. He is widely recognized as a founder in the field of evolutionary medicine and evolutionary psychiatry. His books and articles have been cited over 40,000 times. His latest book, Good Reasons for Bad Feelings, is particularly relevant for today's discussion. He also co-wrote the seminal book in evolutionary medicine called Why We Get Sick. He is a distinguished life fellow of the APA and a elected fellow of the American Association of Advancement of Science. Also, we have Dr. Kathy Smith, who is a professor of psychiatry at University of Arizona College of Medicine in Tucson. She is also the Associate Dean of Graduate Medical Education and Associate DIO in the College of Medicine. She completed her residency and training in psychiatry and fellowship in child and adolescent psychiatry at University of Arizona, and has been on the faculty there since 2006. She has specialized training in the assessment and treatment of perinatal mood disorders and in working with transgender and gender non-conforming youth. And Kathy, as she'll tell you about, has found that incorporating evolutionary principles in her work has been incredibly useful, and so we'll be talking more about that later. So my name, I'm Cynthia Stonington. I'm a professor of psychiatry at Mayo Clinic in Arizona with training in neuropsychiatry and neuroimaging and a special interest in resilience and well-being. I'm also, one of my favorite titles is that I'm the Associate Medical Director for the Office of Joy and Well-Being. I was first exposed to evolutionary psychiatry during my residency training at Stanford back in the 1980s by Brant Winograd. And I have really remained interested in the topic since then. By no means am I an expert, but I have been fortunate to know a lot of people who are, and in particular, I think my conversations with Randy has been incredibly illuminating. And over the years, I've found that incorporating these principles of evolutionary psychiatry when talking about patients with their symptoms has been incredibly useful to them. And I think, and I think that my experience has been that this type of psychoeducation and explanatory model reduces a sense of being broken when you have good reasons for bad feelings. Even if those feelings were adaptive for situations in our ancestral environment and not at all useful now, or even if they weren't even adaptive back then, just understanding that, how that came about, is incredibly helpful in beginning to engage people in feeling like it's okay to get treatment. And so, and the other thing is that my, I feel like other, unlike other biological explanations, it's not overly reductionistic. Like, for instance, you have a serotonin deficiency, which is also wrong, but in fact, it really takes advantage of the biopsychosocial model in a much more pluralistic way, but then with explanations that further, I think, engage patients and reduce stigma. So not only does it make it easier for patients to accept treatment when it is needed, it also really prompts clinicians to ask questions in ways that might make them decide that perhaps treatment is not necessary. So, and I think that is also something that we often forget and is very important. So by asking, and we'll be talking about this more, but asking about in what situation a symptom is useful, or why do we keep trying to succeed at an unrealistic goal, for example, it will lead to a wider array of solutions for managing emotional distress. Okay, so our outline today is that we will have, Randy will go over the core principles of evolutionary psychiatry, what it is, what it is not. We'll have a little break with a little fun video that I hope you will enjoy, and then he will also go on to talk about emotional disorders. The second half, we will, Dr. Smith and I and Randy will be discussing some case examples, and then we will break out into small groups to help for practice in terms of using these principles, and then questions and discussion. Okay, so I'm gonna actually escape. Here we go, and Randy, you are up. Thank you so much, Cynthia, and hello, everybody. It's wonderful to see you today. I was so pleased that you mentioned Brent Winograd. I was going to also. Brent is a wonderful psychiatrist in Palo Alto who wrote the very first books on evolution and psychiatry as a professor there, sponsored me for a sabbatical where I wrote the book on why we get sick. If anybody knows Brent, tell him we still love him, and take a look at her books from back 30 years ago when he was thinking about this before many of the rest of us were. I'm going to try to channel Dan Stein, which I think I can do. Just yesterday, I got the proofs from our chapter on Tasman psychiatry, so a lot of these slides are gonna be changed some from the ones that Dan sent, so the problems are all mine. He begins, and these slides are gonna be his, and then we're gonna take a break, and then I'm gonna talk about emotions. So what is this evolutionary psychiatry stuff? Evolutionary medicine is not a special mode of treatment or anything, it's just using the basic science of evolutionary biology to better understand and prevent disease, and evolutionary psychiatry is a sub part of that, using the basic science of evolutionary biology to better understand, prevent, and treat mental disorders. It's all based on this idea, really, from Ernst Mayr and Nico Tinbergen, that everything in biology needs two kinds of explanation. One, about how it works, and the anatomy and physiology and mechanisms and genes. A whole separate kind of explanation is needed about why it is that way, the evolutionary explanation. I didn't know this, at least even until I got on the faculty at Michigan, and it was just a revelation to see that I was only using half of biology. Also, in further work, we came up with this new question, why didn't natural selection do a better job? Why isn't the body better? It could be we could eliminate the wisdom teeth, we could make the bones stronger, improve immune responses, enlarge coronaries, arteries, and of course, that business of a baby's head having to pass through that little narrow ring of bone is ridiculous. And there are good evolutionary reasons why it has not been fixed. So a key to evolutionary medicine in general that deserves a whole hour is listing the evolutionary reasons why natural selection didn't do better. I kept asking these obnoxious questions of my professors in medical school about, so why do genes for nearsightedness stick around, questions like that, and I was told repeatedly, you know, they're mutations, have you heard of mutations? It turns out that, yes, those are important, but there are at least five other reasons. Natural selection can't start fresh, all traits are trade-offs, pathogens evolve too fast. You know, maybe you could ask the AV person if this echo can be done. And here's the biggest one. Natural selection does not shape us for health or longevity or happiness. It increases the prevalence of any gene that increases reproduction. It's a devastating, awful insight. And finally, of most relevance to us in psychiatry is defensive responses. Pain, fever, nausea, vomiting, and anxiety and low mood are there for good reasons. So why isn't the brain or body, why isn't the brain-mind better? It could be better. Natural selection could have shaped the system to down tone everything so we're not so miserable all the time. It could make relationships more cooperative. It could ensure that we don't lose our minds and our memories with age, and it could make us love healthy foods, but it didn't. So the question that people often ask when they start off with evolution and medicine is why does selection shape this disorder? Even amongst pretty sophisticated people, you'll see things like what's the function of schizophrenia and what's the function of depression? And that is a very bad question. Diseases are not shaped by natural selection. They do not have advantages. And this is just a mistake that I warn you against early because it's out there. A better question is why has natural selection left us with traits that make us vulnerable to disease? That's the right question. This is a one slide summary of how natural selection shapes behavior. And the key is that it doesn't shape behavior. That brains vary slightly. All those brains there look alike, but of course they're not alike because they slightly different genes make slightly different brains, make slightly different behavior. And whichever brain in that group results in behavior with the most offspring, those genes are going to gradually become more frequent. This again is part of this disturbing insight that natural selection shapes brains that maximize gene transmission, nothing else. So Dan's talk goes on to talk about what an evolutionary explanation, evolutionary psychiatry is not. It's not a treatment method. It sounds like it, but it's not. It's just applying a basic science, just like genetic psychiatry or neurophysiological psychiatry. There's nothing alternative about it. And it's definitely not about improving the species. It's all about improving individual health. And again, why am I emphasizing the errors? Well, it's because our field is right at poised at the moment of fast growth. And if people like you recognize that many in the field are critical and trying to create only hypotheses that are actually testable and tested, I think we're on a good direction. But there's a whole lot of very attractive ideas that spread fast that are just wrong. So this is a challenge we face right now. How can this help in the clinic? I'm gonna pause right here and just note that the challenge we all face today with you, it's like talking about how genetics is useful for psychiatry in an hour, in 1950. I mean, we are so early in this process. Our goal here is to get you interested in all this. And some of you may well be interested in helping to develop this new perspective. Our field has been talking at least for 25 years about we need new directions, we need new approaches, we need new ideas. And here, evolutionary biology has been sitting there as the foundation for animal behavior for 50 years waiting. Dan notes that there are at least three applications, diagnosis, pathogenesis, and treatment. We want diagnosis to have nice crisp categories as if it's a design system. But the reality is that it's a little path in the wilderness, and the crisp differences between things just don't exist. Dan and I worked for a whole year trying to figure out if evolution could improve the DSM. And after that time, we discovered, you know what? It's a pretty good clinical description of what we're seeing. The problem with it is that it doesn't match to our wishes to find specific causes and specific biomarkers for specific disorders. But we can't blame the DSM for that. It's the nature of reality and our own frustration with reality not being as simple as we would like it to be. And Jerry Wakefield, in an article just published this last week, talks about how only evolutionary psychiatry provides a scientifically defensible answer to the fundamental nosological problem of how to separate normal from abnormal. A key point of evolutionary psychiatry is distinguishing symptoms from diagnosis. In the rest of medicine, this is the fundamental. People know that fever, cough, nausea, and vomiting, those aren't the diseases. Those are symptomatic responses. And more sophisticated doctors recognize that these are useful responses shaped by natural selection if they're expressed in the right circumstance. These defenses can cause suffering and impairment themselves. That's why they're regulated to only go off at certain times. Distinguishing symptoms from diseases is the key for making sense of a lot of things in psychiatry. And that'll be my lecture in a couple minutes about emotions. But the key here is that emotions are not disorders unless they're dysregulated. However, normal regulation mechanisms give rise to many useless, painful emotions. Again, wait 10 minutes for more about that. Disease causes, likewise, I'm sure you all share my frustration, and I began my career just as DSM-III was coming in, and we were all confident that these were temporary categories until we identified the specific neuroscience causes that would define the categories better. So here we are, you know, 35 years later, and it hasn't worked. And I don't think we should blame anybody. It's great science that it's created, but we need to recognize that it just hasn't worked. Dan's point is there's no need to argue about which cause is primary. So much effort has gone into that because from an interactive evolutionary point of view, they all interact. An evolutionary framework provides a substantive framework for doing a biopsychosocial model. And finally, for treatment, we'll be doing more of that with Kathy and Cynthia's case study in our discussion. But again, the wish is to have something simple we apply to everybody. The reality is to try to recognize that multiple problems can benefit from multiple kinds of treatments. Dan Stein's written a whole book about philosophy of psychopharmacology with an evolutionary viewpoint. And a main point there is that pharmacology in psychiatry, at least for emotional disorders, is not replenishing or normalizing something. It's just like aspirin or steroids. It's blocking a normal defensive system. And that really changes not only what kind of research we do but how we talk about the efficacy and means that these drugs act on our patients. And it helps them enormously just to recognize, no, this isn't covering over your symptoms, but it's blocking an excessive response just like aspirin can block excessive pain. Likewise for psychotherapy, there's a whole separate talk for another time about how natural selection shaped our capacities for deep relationships and love and prosociality. But there's profound opportunities to apply those principles in psychotherapy. I'm gonna give one minute examples, less than one minute of each of these just to give you the framework. Again, each one of these deserves an hour lecture, but our goal here is to get you interested. So anorexia nervosa, a popular paper says that anorexics run a lot because it's been programmed by natural selection to go running away from an area that has famine to find food in another place and bring it back to your group. This is nonsense. This is, anorexics run because they're trying to lose weight and it's a fatal thing if you're already starving. A better approach is that dieting or often to get a better mate really arouses the famine response and the famine response induces gorging which can't be controlled and it induces excess weight gain because it means you're in an uncertain environment. And that makes people diet even harder leading to the positive feedback cycle that is eating disorders. Orgasm timing is an unfortunate one. You've all noticed, I'm sure, that every textbook about sexual disorders has one for men about why orgasms are often too soon and one for women about why orgasms are often too late or not at all. But none of those books point about, so why? There's a pretty easy explanation and it's not oedipal fear. It is that if a woman ever stops intercourse before the man has his orgasm and ejaculates, no baby is going to come from that. And so natural selection shapes this whole mechanism to maximize reproduction at an enormous cost to mutual satisfaction. So unfortunate. Alcohol use disorder. Some evolutionary psychologists have suggested that people go to bars, get drunk, and therefore they have more babies. Really? No. A better idea is that our learning mechanisms are useful, they're chemically mediated, and we live in modern environments where we can have ready access to distilled alcohol and that grabs those mechanisms and hijacks them. Plus there's a market for such substances and for advertising for them. Schizophrenia is much harder. There have been articles saying that schizophrenics in ancestral populations become shamans and they stay back in camp and have sex while other people are out gathering food. Really? No. But am I being too mean? I don't think so. It's terribly important to get rid of some of the chaff. A better idea is the wrenching transition to the social cultural language niche that makes many of these brain control systems vulnerable. And there's marvelous new data from Lew et al showing that the newer alleles that influence schizophrenia rates reduce schizophrenia while the older alleles increase the risk of schizophrenia. A real good way of testing this hypothesis. Agoraphobia, it's much more career and anxiety disorders. Freud's idea, avoid sexual opportunities. A lot of people do neuroscience, look at panic disorder in this relationship. Not really. How about just being simple about it and recognizing that repeated experience of panic attacks means you're in a very dangerous environment and you should stay home. And if you go out, you shouldn't go out very far and you should go out with other people. It's not too complicated. So that brings us to emotional disorders. And now we're going to go to Barbara Brinkman. He's a peer reviewed rap artist. I recommend his work in general. I'm gonna let Cynthia pull this up. Says she knows PCs and I'm just a Mac person. Here we go. What are emotions? An evolutionary perspective suggests a simple definition of emotions based on the forces of change. ♪ Lost my friends and pleasures and good feelings ♪ ♪ Bad reasons, creeped out and went on a rampage ♪ ♪ I'm so deep in bad feelings, bad reasons ♪ ♪ Lost my friend and now I'm bleeding, bad feelings ♪ ♪ For good reasons, playing with my kids all night long ♪ ♪ Good feelings, for good reasons ♪ ♪ There's nothing more amazing than the brain of a homocephalic ♪ ♪ Nothing more prone to a craving, appetite ♪ ♪ Calibrated by a thermostat that decides when it's satisfied ♪ ♪ And when it's time to have a slice, homeostatic device ♪ ♪ Temperature regulated by sweating and shivering ♪ ♪ Happiness, misery, anxiety, equanimity ♪ ♪ Situations reliably triggering emotions ♪ ♪ Evolution has one plot, fitness maximization Genetic jump shot, keys to behavior unlock Until something comes along to convert a semi-auto to a bump stock Smoke detector principle, the brain triggered after every snap and twiggle Potential predator attacking, safe assumption When predators are snacking, but when it's panic attacking It gets a bit distracting, the system is adapted to the triggers of the past But the mechanisms jam and the modern mission gaps mismatch A brain open to learning, a system both hominergic The next drug invented, I really hope I'm allergic I know cause I learned it, enjoyment is a fitness key The shape of an opioid gets in between Proxy is a proxy for a natural copy And the brain that signals what kind of action to copy And after addiction comes manic depression Which tends to intervene after a massive rejection When status competition beats you into submission Depression is a mechanism to get you to pivot Just like pain is a mechanism to get you to change position And quickly get your fingers out of the flames With minimal tissue damage sustained I miss my friend, now it's the rationalization of our discontent Lost my friend to pleasure seeking Good feelings, bad reasons Freaked out and went on to deepen Bad feelings, bad reasons Lost my friend and now I'm grieving Bad feelings, for good reasons Playing with my kids all week Good feelings, for good reasons Lost my friend and I'm still feeling the hurt from it I see his face reflected in random surfaces Is he alive or dead? This vivid search image is adaptive When aptly determining where a person is Freak, is it an adaptive feeling that triggers rumination? I could have done something different And if it's fully out of my heads Does it enhance my assessment of risk In the making of future plans? The ache is sharp and intense And no less painful when I'm making it make sense How many weeks get to elapse after a major event? Before the DSM is ready to say I'm depressed Drifting in a daze, contemplating giving up Feeling like a bacteria with flailing cilia Of course it's better to chart random courses Than persist in one direction Into a vortex, so true Organisms do what they're supposed to Act as if fitness enhancement is the only rule Evolution delivers high mood and low mood To assess the relevant situations we go through Persisting in the pursuit of a goal that's not gonna go through Triggers a hopeless feeling of low fuel Even in the produce section of whole foods Infinite calories everywhere, but no juice Just a mobile screen and my hands scrolling the feed Everybody seems happier and more successful than me Until ambition triggers a manic episode I'm about to go platinum with this scientifical flow But no, I'm back on the sofa My daughter's upstairs doing homework My friend is coming over He's on his bipolar, mentin is sober And no longer chasing the ultimate feeling And yes, it helps to know the ultimate reason Lost my friend to pleasure seeking Good feelings, bad reasons Freaked out and went off the deep end Bad feelings, bad reasons Lost my friend and now I'm grieving Bad feelings for good reasons Played with my kids all week Good feelings for good reasons What are emotions? Emotions are specialized states that adjust Physiology, cognition, subjective experience Facial expressions and behavior In ways that increase the ability to meet the adaptive challenges Of situations that have recurred over the evolutionary history Of species Emotions are for our genes, not us Thank you. Sorry the sound wasn't better, but Baba Brinkman is one of the geniuses of our time Go to his website, they're all free You can listen to them and hear the sound better He gave the keynote presentation for the American College of Psychiatry last year And he's someone that you might want to invite to your meeting as well Oh, by the way, he also does the Canterbury Tales This is a guy whose range is extraordinary So now I'm going to, in a less interesting but trying to still be interesting way Talk about emotional disorders in an evolutionary perspective We start with the fact that it's confusing And this is one reason I've dedicated myself to trying to find a different framework Is that I just found, I mean we all find it confusing Why on earth are bad feelings so extraordinarily common? It's like somebody goofed in designing us It's so hard to distinguish normal from abnormal And so many people have multiple disorders Comorbidity is the name of the game for epidemiology It's so disappointing we haven't found specific brain causes We will eventually for some I hope, but it's so sad it hasn't worked And the same genes cause multiple disorders What's that about? It's very different from what we were thinking 30 years ago And the most desperate part is our neuroscience We haven't found better treatments as a result of our basic science Can evolution help? You probably all know this one Anxiety and depression are overwhelming plagues on our species And it's ridiculous the proportion of difficulties that these emotions have The next one is alcohol disorders Modern life causes that one Drug use likewise And only when you get down here are disorders that are neither emotional disorders Nor caused by modern life But it makes you think that maybe natural selection made a big mistake My theme and the theme of this morning's talks are all that Evolutionary biology is a missing basic science for psychiatry All traits need evolutionary explanations There are six reasons as we mentioned before While they're vulnerable, symptoms are not diseases and less dysregulated And this helps in the clinic because it allows respect for emotions While not letting them run over us and assuming that they're always useful And I think most importantly it reframes questions and a patient's self-identity So many of my patients are saying I'm a depressive Or I am a panic disorder patient Or I am a schizophrenic That kind of identity as a patient really constricts people's lives And if they can instead start thinking of I have panic attacks But panic attacks are useful when a lion's chasing me and these are false alarms It really changes their view of their self and their illness It also encourages understanding individuals as individuals Because different people have different reasons for their anxiety and depression And as Cynthia especially is going to point out I think all this provides greater clinical satisfaction from our work So the usual questions in research are why is this person anxious and depressed? That's about why people are different An evolutionary viewpoint instead asks an entirely different questions Why do negative emotions exist at all? Why are they so prevalent? And why are the regulation mechanisms vulnerable to failure because they do also fail? Notice that these are questions about why we are all the same Not why we're different For animal behavior evolution has provided a foundation for 50 years And the fact that it's only now coming to psychiatry Some historians will have to figure out But the basic principle is what the one I've mentioned before Brains are shaped by natural selection to maximize reproduction Now we can ask a different question How does the capacity for each emotion increase fitness? This is a diagram I drew It's kind of imaginary but helpful Pointing out that there are two kinds of situations in which special modes of operation can be useful Threats on the right hand side and opportunities on the left hand side And that's why emotions are generally either positive or negative This means that all those arguments for the last 200 years About how many basic emotions are there or should we think about them on dimensions Those are pre-evolutionary views of emotions They're overlapping states that emerge from each other So emotions are universal responses to recurring situations That are regulated by control systems And the very fact that they are regulated by universal control systems Answers the question about whether they're adaptations Because you don't get a control system unless what's being controlled influences fitness So now we ask what about bad feelings? Good feelings obviously seem useful but what about bad feelings? Anxiety is pretty easy or tissue damage is easy, right? Pain is useful to get us to stop damaging the tissues And there are a few unfortunate patients who were born without pain And they're usually dead by early adulthood Threats cause anxiety, that's easy enough to understand We'll give a few more examples But then we get more sophisticated and realize that from an evolutionary viewpoint Losses are very different from failing efforts Losses cause sadness and that is awful for a while and then it goes away Continued efforts in pursuit of an unreachable goal Arouse low mood that disengages wasted effort But that doesn't go away unless you stop that effort or find a different way So again utility of anxiety is obvious, we don't need to spend time on that There are many different kinds of anxiety for different kinds of dangers Obvious enough During heights, people freeze In response to a wild animal, people freeze for a moment And then if it's clear they've been seen, they run like hell So framing anxiety disorders as an excessive useful response is so useful in the clinic And it really transformed my work at the University of Michigan anxiety clinic When I stopped telling people, you have a disorder and you have to accept that it's a mental disorder And they would say, but my heart pounds, can I see a cardiologist? Gradually I started instead saying, you know, it's a useful response that You're having a false alarm in that response And that, you know, trembling is because your muscles are tense And the breathing is because you need to run or Patients said, oh, this makes sense of my symptoms It's just so helpful for them Likewise, they told me, I don't want to take drugs to cover over my symptoms, Dr. Nessie And once I started saying, oh no, don't worry about that Instead I said, you know what, the system shuts the threshold And the sensitivity of anxiety, depending on how dangerous the environment is And the repeated panic attacks you're having are making the inner mind think it's a dangerous environment And making the thing more sensitive and creating a positive feedback We're going to put you on a drug, an antidepressant to stop the panic attacks for a few months And that will re-stabilize the system at the lower level And again, patients say, oh, well, that makes good reason for taking medications The smoke detector principle is probably the single most important contribution here The principle is that when a threat is uncertain, false alarms are worth it If the false alarm is less expensive than not having an alarm A threat might be present You hear a noise in the grass as you're going to get water for your family in the savanna in Africa And all you have is a wooden spear, by the way It's optimal to express panic whenever the probability of the lion being there Is greater than the cost of a panic attack versus the cost of harm If there's no panic attack So how loud does the sound have to be before you flee? Well, it's a hard decision Depends on the cost of panic, call that 100 calories Depends on the cost of no panic, if there's a lion present, that's about 100,000 calories The ratio between those two is 1,000 to 1 And when I first did the calculation, I thought I must have made a mistake Because this means that it's optimum to flee whenever the probability of a lion being present Is greater than 1 in 1,000 And this means that 999 out of 1,000 panic attacks will be perfectly normal, but useless This doesn't just apply to psychiatry and panic attacks This applies to the rest of medicine Because what doctors do mostly is not cure diseases What we do mostly is relieve symptoms by using medications that block normal, detentive, painful responses And we get away with that almost all the time Because natural selection has created redundant mechanisms to protect us And because of the smoke detector principle But it would be wonderful if all of us and if all physicians Were recognizing what they're doing in making these decisions So they're on the lookout for that 1 in 1,000 time Big implications for psychopharm This means, in my opinion, it's fine to block useless responses So long as you're thinking about it and not just doing it willy-nilly The function of depression is much harder, doesn't seem useful at all Oh, but wait, that's the wrong question Depression doesn't have a function, it's not an adaptation itself What we're really talking about is low mood Low mood is a trait we all have in response to certain situations And the right question is, in what situation is low mood useful? That's the best question In what situations do they increase fitness? And the global summary is There are propitious situations in which a small effort gives you a big payoff In those situations, a lot of initiative and risk-taking is worth it Pretty girl smiles at you from across the room, who knows? An unproficient situation, low mood avoids risks and saves wasted effort And unfortunately, there are still situations like that in all of our lives In fact, every day to some extent And it's wasted effort if you keep on trying to do something that isn't working So there's lots of papers about evolution and depression Most of them posit that it has a specific function It's to protect you when you have an infection It's to protect you after you have lost a status battle It's to have a need for help These are all useful partial explanations for how depression helps Or low mood, I should say But a better way of looking at this is not to ask what's the function Instead, ask what's the situation Matthew Keller, a former graduate student of mine Who's now the head of behavioral genetics, University of Colorado Boulder Took on a challenging project of asking If different kinds of situation cause different symptoms of depression And it was quite clear, there are three studies on this now That social losses cause crime, pain and desire for support While failed efforts cause anhedonia, fatigue and pessimism I mean, saying that depression is just one thing Is like saying that an upper respiratory infection is all one thing Yeah, it kind of is But just, you have a runny nose when there's virus here And you have a sore throat when there's virus here And you have a cough when there's virus here And natural selection is pretty good About putting the defenses in play where they're needed It does the same for depression This is work by Echo Freed, now in Amsterdam And he was at Michigan with us for a time He's analyzed some specific symptoms of depression individually Most of them, when we study depression We total up the number of symptoms a person has And his research points out how unscientific that is We're losing most of the information First of all, he's pointed out that the symptoms in the DSM That I find in depression have no more centrality To the overall network of depression than other symptoms They were just chosen almost out of a hat So the conclusion of this is Please pay attention to specific symptoms And don't rely on some simple sum score Because that loses a lot of valuable information Notice that this is proposing a medical approach If psychiatry wants to be more like the rest of medicine And it should The first thing we need to do is distinguish symptoms from diseases And look for what's causing them Instead of automatically assuming That the regulation mechanism is defective Sometimes the regulation mechanism is defective This is a quick slide that I think will not... You can review the different areas in life The way a behavioral ecologist does, S-O-C-I-A-L I think I'll skip this because we're running short of time Are we? No, you're fine We're okay? Didn't mean to strangle you So this is a simple mnemonic to use I mean, there's six kind of resources That behavioral ecologists look for And this, I think, is in your online thing If you'd like to download a copy But there's six resources that all animals are striving for Social status and friends Occupation, it's like a role in the group Relatives, offspring Income and food and resources Abilities, appearance and personal resources and health And love and sex And I find that when I go through this list In a gentle way with my patients and say How are things going in each of these areas Half the time something comes out that never came out From my regular history And from asking them what stresses have you been under Getting kind of specific about What they're trying to do in each area And how it's going Gives you a quite deep sense for this person as an individual Which is the foundation for trying to understand their emotions And now we come to a key part Wrapping up here Most bad feelings we have are useless But they come from normal mechanisms This is a thesis that really deserves a paper and a lot of research Because it seems so obvious that If you're having bad low mood or anxiety And it's not useful in that instance It must mean that the regulation mechanism is broken And that we need to find the cause in the brain But if you think about it from an evolutionary viewpoint There are at least four reasons for Normal mechanisms giving rise to useless emotions First is smoke detector principle False alarms are necessary in an optimal system Second is that we're all in novel environments That's... Imagine putting a hunter-gatherer Wait, we're all hunter-gatherers In that environment and ask him to sit all day I mean really There are all kinds of things in modern environments That make our emotions very maladaptive in modern times Then there's this big principle we keep returning back to That the system is not shaped for our health, happiness or welfare It's shaped for maximizing gene transmission And therefore we spend so much of our lives With painful feelings about sexual competition And losses and jealousy and sex itself These things are not benefiting us They're benefiting our genes And the last is especially interesting for depression and anxiety The mechanisms that regulate the thresholds for these emotions Self-adjust according to the situation So for instance If you repeatedly go to your watering hole And there's a lion there three nights in a row You'd better have a more sensitive system To go off more easily the next night Likewise for depression You all have heard about kindling The fact that if you have one episode of depression It makes future episodes more likely A lot of work has been done on the brain mechanisms Often presuming that they're defects And they could be On the other hand If you repeatedly try to do something And fail and have depressive episodes It may be an indication that you're in an environment Where more low mood is useful In response to those smaller cues This gives you a completely different approach To try to look at recurrent depression How do antidepressants work? We'd like to think that they normalize something But if low mood is a useful response Almost certainly what antidepressants are doing Is disrupting the normal system that regulates the expression Just the way aspirin reduces pain And I'll point out With about the same efficacy And the same amount of side effects In all these cases we're fighting An expression that natural selection has shaped And we can be helpful But we need to recognize that's what we're doing So the conclusions from all of this Are that evolution provides a really useful biological framework For a medical approach to emotional disorders It also makes the practice of psychiatry more scientific More interesting and more effective And finally Research on how natural selection shaped Emotional regulation systems Will be crucial for finding new treatments For emotional disorders For those interested These are resources The middle volume is from the Cambridge University Press And the Royal College of Psychiatry group That's been developing And I have 2,500 members In their evolutionary interest group And we need to do something more like that in this country There's a website that may or may not come up For evolutionarypsychiatry.org It's actually a subpage on mine Where if you're interested you can sign up To get information about upcoming events And newsletters that are of interest Thank you very much Applause Thank you We'll have lots of time for questions and discussions, so just so you know. Oops. Sorry. There we go. Sorry. All right. Hey, good morning everyone. Well, we're going to transition now to give just a few cases of how we think about this when we're taking care of patients. And then, as we said at the beginning, we'll go into some small groups with a little worksheet and a case and let you sort of talk through that on your own. So I want to start with this case that I'll just read and summarize very quickly for you. This is Sophia. She's a 34-year-old woman, G3P1, status post an uncomplicated vaginal delivery eight weeks ago of a healthy infant boy who was born at 37 weeks gestation. She's currently breastfeeding, but has been having worsening depressed mood, increased crying, poor sleep, increased guilt, poor appetite, low energy, loss of interest, and it's been happening for over two weeks. No signs or symptoms of mania, hypomania, psychosis, suicidal ideation, no thoughts of hurting her baby, but she's been unable to get out of bed to do anything other than care for her baby, and she's not able to take care of her own needs. She's had one other major depressive episode when she was going through infertility treatment and was treated with an SSRI at that time with remission of her symptoms. So we could sort of just stop there, right, and treat her with an SSRI. She certainly is meeting criteria for that, right, for a recurrent episode, but I like to get back to Randy's question, which, and think about this more broadly with her, is there's something I'm missing, something about her that she might be trying to do or feels like, you know, she is giving up on even if she's not succeeding. And if I think and keep that perspective in mind to get beyond just the symptoms and take more of a careful history, in this case, you know, in your social history or with the social tool that Randy has talked about before, in this case, I learn a whole lot more. So for Sophia specifically, she also, when we talked more, was having a lot of guilt related to lack of enjoyment of her baby. This is very typical for women who've experienced or gone through infertility treatment. They've gone through a whole lot of effort and a lot has happened to make, you know, be able to have a child. And then when you start to feel bad about that situation, there's a lot of guilt that goes along with that. Baby wasn't sleeping through the night and so, of course, Sophia isn't sleeping very much and was interpreting the crying baby as feeling abandoned and feeling unloved. And she was also exclusively caring for the child even though she did have a partner at home. But as I talked about these things with her, you know, there's this overall feeling of just I'm failing at this, right? I'm not, I don't know how to do this and I'm not doing it well. And this is where I find like bringing in that evolutionary perspective is most useful because I can really understand her experience, but I can talk about other interventions beyond just medications that make sense for her and doesn't reinforce that feeling of failure, right? And so these are common things. I mean, I don't have to go into these too, too in depth, but these will be very common things I talk about with women who are postpartum. I talk a lot about the biology of infant sleep, why babies cry and talk about ways to maximize sleep. Sleep is probably one of the biggest interventions we do when we're working with postpartum moms. And I don't want to just say, oh, let's talk about just sleep interventions, right? Because in some ways that just reinforces the idea that we were doing it wrong in the first place. But if I explain why we have to do some of these things, it's so much more helpful. So for example, right, we mentioned a little bit at the beginning, this, the obstetrical dilemma, right? That babies are born very early because we've evolved these very gigantic heads and we also stand up and our arms are free to manipulate the world. We also have these really narrow hips. And so babies are born early, right? And at great cost, right, significant morbidity and mortality for childbirth. So babies are born early and they're very neurologically immature and they just need to sleep a lot. And so I talk about what the normal architecture of sleep is in infants and, you know, waiting to get to six or eight weeks before babies start to consolidate their sleep. And we talk about the Moreau reflex, if you remember that primitive reflex that babies have, right? So when babies are sleeping on their backs, you'll see them sort of reach out for the world, right? In an effort to hold onto something if they have a sense of falling. What is one thing that we did about, you know, 30, 20 years ago, 25, 30 years ago was started sleeping infants on their backs, right? Because of this concern about sudden infant death syndrome. But when babies are being slept on their stomachs, they don't Moreau and they sleep through the, you know, night or at least a few more hours. But now we sleep babies on their backs. They Moreau, they wake, they're overtired, they're exhausted, and they cry. So this is all a lot of discussion that I can give to women that I find is really helpful. And then I sort of address that group effort, right, that we really did care for kids in a large group in a village because it's hard and it's a lot of work. So I will hear, and maybe you do too, from women all the time, like my husband or my partner, you know, works and he has to go back to work and I'm at home and I don't want to ask him to help and they're, often we're more separated from our families. So we don't have all of that natural support. But women will feel like they have to do it all, right? Like I have to get back to work in six weeks and I have to clean my house and make gourmet foods and take care of my baby and all of that good stuff. So helping normalize all of that, because this was really how we were meant to raise families, helps them make space and have conversations about who can help and support the family if we are separated from those, who we don't feel so bad asking to help. So that was my case I wanted to talk about, and I will give this over to you. Thanks, Kathy. So I'm just going to present a very quick case, this time for all of us, it's because in my role as the, like I said, the medical director of the Office of Joy and Wellbeing, I hear a lot about burnout, and I'm just, and so I'm going to just suggest that we can even think about using this evolutionary framework as we try to solve our problems with burnout. So this is a case that I hear frequently. This physician has been seeing many complex patients daily with little time to do more than adjust or renew meds and document in the electronic health record. No longer seeing colleagues as much and having those sort of just casual interactions because they're doing a lot of telepsychiatry. Chair is concerned that the practice revenue is too low and it's inefficient for psychiatrists to be doing psychotherapy. Becoming more and more demoralized and exhausted, increasingly less productive, and feeling like he is failing at both work and at home. Does that sound at all familiar? Yeah? So, thinking about this, what, one could just say, well, I'm feeling burned out and I need to kind of get rid of those feelings, right? Or you can just ask, is there anything useful about these feelings, right? So, getting back to Randy's question, is there something big you are trying to do that you can't give up on even though it seems like you will never succeed? Think about that case. What is this physician trying to do, oops, sorry, going the wrong way, and what are all the impacts of this work life? Think about what are the other things, and then can you even take a review of social assistance in this case? Thinking about what's happening, in terms of this person's status, in terms of their occupational roles, what is the most valued role, are they trying to achieve something that they're not actually given the permission to do? What's happening to their family, what's happening, you know, what is going on? And I think it's important to recognize, you know, that there's always trade-offs with all of these things that we're trying to achieve, and so it never is perfect, and so we do have to recognize that. So asking that question, thinking about all of that, I think what happens is that we start to realize that we are actually trying to persist in potentially an impossible situation if we want to have it all, right? And so it really forces us to think about those gaps between what I have, what I want, and what I expect. And this is, by definition, again, going to generate bad feelings, right, when you have a mismatch between what you want, what you expect, and what you have, right? So how do we kind of, so addressing that solution then depends on sort of navigating those gaps, and how can we resolve those gaps? So one way to think about this, this is just some examples, and you may have some other ideas, but I think it's useful to really think about maybe it tells us, boy, you know, if you have the ability, and maybe you're not in a position of leadership and you don't have this ability, but if you are, maybe it means we need to restructure our practice because this is not something that's sustainable, right? Maybe it helps us realize that, you know, technology is really great, but if we fill in the time we saved on that technology with more stuff, without giving space for those critical things that we need as humans, right, that what is our basic needs, which has to be, I mean, social connections, evolutionary are critical, having, and when we're having that low mood or that feeling of failure at any point, you know, a very adaptive response is to take a pause and sort of think about what else can we do or give ourselves space. So this tells us we really do need to structure into our day a pause. We really need to really find ways to use technology to our advantage, but also structure in opportunities for social connections one way or another. And we also need to think about, you know, of course, if you're really persisting at trying to do a job where it's at odds with what you think you're, you know, you're trained to do, like, for instance, you know, taking that time to listen to patients and connect with them on that level. Anyway, that's just an example. So at this point, so I just kind of give you a couple examples how we've been thinking about it. At this point, we want to now take a moment and actually, should we have it first of all, I'd like to take just a moment and maybe ask, yeah, we'll do an exercise giving you an example of a case that'll be written, Kathy has it, and I'd like you to see if you can utilize this principle, this framework in talking through that case. So Kathy's going to give a round, and maybe Kathy, do you want to speak up? Yeah, yeah, yeah. So I have about 50 copies, so if you want to form those into, like, four or five, four or so, and then we'll have them for everyone. Like, if you were going to go, like, two months or a semester, and there's a couple of those, would you be there? This case literally was a patient I saw last week, and I think it's a very useful way to, if you just take a moment, look through the case, and then talk with each other about how you might use an evolutionary framework to help talk to this patient about the case. Sure. Oh, my goodness. There you go. For y'all? Okay. There you go. Okay. So we should probably give them, what, five minutes, or how long? No. 1030. Oh, we're too new. Oh, good. So we've got four minutes. Oh, good. Do you want to give an example of how long? Yeah. Oh, sure. Take about 10 minutes, and then we'll have time for questions. Do you want to maybe circulate? She's just smiling. Okay. Okay, just another minute or two, another minute or two and we'll ask for any comments. I'm going to go to 11.30 now. Oh, that's 11.38. I'll get ready. I'm not sure that he will. All right, everyone. It's wonderful to hear so much discussion. That's great. It's my favorite part, listening to the rumbling of conversation. We're going to go ahead and have you talk a little bit, if you want to, about some of the conversation you were having. Anybody want to sort of share anything that came up about how you would talk about this with a patient? And if you want to, you can come up to the microphone. And if you want to yell out from there, I can repeat it in the microphone, because we are recording. All right. So what did you think? Any comments? Hold the microphone up close. OK, microphone up close. What our group seemed to focus on was how useful this type of a framework can be to help the patient and the therapist to destigmatize what's happening. My work a lot is with seasonal depression, and so I've been doing this for a long time, trying to explain how your reactions are really very appropriate. It's just you're living in the wrong environment. These reactions don't serve you very well here. And it seemed to be the same thing here, that if you can reframe these symptoms as something that is a signal gone awry, and then the person can then help to look at it from a less anxiety-provoking framework that doesn't make them feel bad about their symptoms. It seemed very useful. We're actually quite excited about the framework. Oh, that's great. Indeed. Indeed. Yes, I think that's something we reflect on a lot, too, is the value it has in destigmatizing and sort of managing some of the guilt that folks can have about feelings. Thank you. I have a question that I was considering even before the vignette we worked on, is how you would look at shame, and how do we reformulate shame? I mean, anxiety, fear, panic, depression seems not too difficult to reframe in terms of the evolutionary point of view, but how would guilt and shame? Randy? They both think I have something to say about this. So natural selection shaped all of these amazingly pro-social emotions for us, guilt, shame, and the like. And one of the reasons evolutionary approaches to mental health in humans haven't taken off, I think, is because people imagine that it encourages selfish behavior or selfish genes or something. But in fact, if you look at how natural selection shapes us, it shapes us to do whatever makes us preferred partners, because the people who get the preferred partners do better in life, and not just sexual partners, either. So we are all so sensitive to what other people think about us. And for my work with social anxiety patients, it's been so useful to help point out to them, you know what? Thank goodness you're sensitive. There are people with the opposite problem, and they have a much worse problem than being too socially sensitive. So shame is one of this suite of negative emotions that's helpful for cooperation. And I think the other piece of that, again, is, you know, shame is something a lot of times arises when you have the thought that I'm broken, something's wrong with me, as opposed to, you know, other things. And so it really helps to reframe that in a way that it's not that I'm broken. I'm in this situation where I'm being, you know, where I'm having this response, and it's useless. But it's not that I'm broken. We can figure out a way to fix that regulatory mechanism. So I think it takes us away from that feeling, which is very, very common, and goes along with shame, that, you know, that sense of there's something deeply wrong with me. Hello. My name is Ravi Chandra. I'm a psychiatrist and writer here in San Francisco. And I think you all seem like very warm people, and probably people in the audience. So this will probably be an obvious thing. I think we all talked about the smoke detector and so forth, as you've discussed in the case. But this can also come across, this framework. It could come across, and I think you have to stage this, because it can come across as westernized and individualized and intellectualized. So the first job, of course, is empathy and validation. And the patient is having a pair, a couple's problem as well. And recognizing the pair bond is the survival bond, comes out of Holocaust research. So to really restore connection and empathy and validation for these natural fears, which I'm sure you would do in clinical practice, is very important. Thank you so much for that comment. I couldn't agree with you more. One of the papers that we're actually working on right now is how to kind of use this, using actually the idea of cultural, kind of asking patients about what their explanatory models are and how they understand their symptoms and whatnot. And there is a way, I think, very usefully to interweave, to frame this, and to help validate the patient's understanding of what's going on in an iterative process and in a way that makes them feel actually even more understood. But I very much appreciate that comment. Thank you. Yeah, and if I can, I'll just follow up, too, because I also am very sensitive to that and thoughtful about it. And so I do sort of think about how or when I want to incorporate this, and often I have thought about making sure there's an alliance and a rapport. The other thought that comes to mind for me is, as a child psychiatrist, is the language that I use, too. So even when I'm talking with my younger patients, my adolescent patients, about some of these things, when we're talking about ADHD, for example, which kids can find really helpful, being really cognizant of educational level and all of those other variables. So thank you for that. And I'm going to chime in, too, because this is so important. I've been reluctant to talk about the SOCIAL system because if you just do it crudely, it can be very harmful. How are things going? Calling attention to places in people's lives that aren't working very well without sensitivity is just devastating. So I think everything we're talking about today explains or justifies even more clinical training about trying to be sensitive and gentle. But on the other hand, it's so much better than, you've got this diagnosis, take this drug. We're way beyond that. Yes, so one of the things that I came across is there are so many explanations that can be given through an evolutionary point of view. So how do we come to one or two explanations? For example, even in the disease definition, there is biostatical theory. There is a selected effects theory. In this suicide, it's anger or aggression turned inwards. Some people say that that's the evolutionary advantage because instead of killing so many people, you are just killing yourself. So that's something that I see. Even in this case, this fear could be conceptualized in so many ways, especially when it happened after COVID. And I actually have seen so many patients like that. So sometimes I give them the example of deers who are too cautious about themselves. I couldn't hear that, so could you take it? So yeah, the question is, I mean, there's almost countless explanations that you can come up with that may or may not be right, maybe, if I understand that correctly. There's a big concern that you're just basically coming up with a just-so story. And that may not be as useful as something that really there's some basis in reality for. So I think it's a super important question. And so, I don't know. Brandy, I think you're the best to answer that. Couldn't agree more. And Gould and Lewontin made this critique years ago. But they didn't say anything about how to do it. They just said, don't do it. And that set back animal behavior research by a good decade. I think now we have pretty good criteria in general for trying to understand how natural selection shapes a particular behavioral tendency. And those things need to be applied in psychiatry. And a group of us are trying to work on that. And you heard from all of my hesitancy about recommending everything in evolutionary psychiatry, because some of it's wacko. I think it's necessary to be slow. And it's going to take years to get this straight. And the only thing I would add to that, too, from an education point of view as a previous program director, is really remembering that all of these different conceptual models are important. We were talking recently of how when you look at the list that's included of cognition and psychodynamic and these different ways to think about things, the solution is not in the sort of master list, right? So making sure that it's in there. And I think I would just add that it's okay, even when, forgive me, you can disagree, but even I'll often just say, like, this is a hypothesis or these are things to think about. Just keeping it in context like that is still helpful with, you know, in living in some of the uncertainty of how do we make all of these different ways of thinking about our patients relevant. And you don't need to use the E word because half of our patients get frightened by E or Darwin word. You can just talk about, you know, the usefulness. Yeah, indeed. Hi. My name is Tom Rudiger, and I was an evolutionary biologist before I went into psychiatry, so I'm obsessed with this. Several things come to mind. Maybe the most important thing is you do a wonderful job of relating phylogeny to adult errors, and you even mentioned the obstetrical dilemma, which condemns us to two years of complete dependency on someone else, and therein lies the risk of developmental derailment. So it's so much of a shame, you know, low self-esteem, you know, blaming yourself for everything. All of that grows out of childhood adversity, which we are vulnerable to more than any other species because of this long time that parents have to get it right, and they don't know what they're doing. You know, and as far as just those stories are concerned, you know, that drives me crazy when people say that. Daly and Wilson set up testable hypotheses based on human nature from an evolutionary perspective. You know, in a newborn nursery, ask the mother and her family and the father and his family who the baby looks like and what are they going to say, and making predictions about that without a theory is impossible, but the female, of course, says they look just like the father because they don't want the father to abandon, and the father says, I don't know who they look like because he doesn't want to get cuckolded, and so, you know, it all makes sense. I mean, there are testable hypotheses. Anyway, I just wanted to, the ontogeny, the phylogeny leading to the ontogeny, I think, is a real important aspect of your presentation that would enrich it, I think, but I think it's absolutely wonderful, and thank you for being our guru. So, thank you so much for that. We might mention at this point that for those people who do have a special interest in this area and might want to do research or teaching, some of us will go to lunch afterwards, and we have room for a few other people at a table, so come up afterwards immediately, and we'll try to coordinate that, but thank you so much for your comments. Great. Hi, I'm Andrew Choco. I'm a psychiatrist here in San Francisco. The echo is terrible from up here because the speakers are pointed that way, so we're going to ask everyone to talk as slowly and clearly as possible. Thank you. So, my name is Andrew. Is that better? Yeah. And one of the things that I love the evolutionary biology perspective, and, I mean, admittedly, I'm just approaching it as a layperson, but one of the initial conversations I always have with my patients is I start with, do you know why you have a brain? And you have a brain because you move, right? Nonliving things don't have a brain. Living things that don't move have no brain. Once a creature starts to move with any purpose, as opposed to like chemotaxis and whatnot, it develops a nervous system to control that movement, and as that movement becomes more and more complicated, our brain becomes more and more complicated. And so really using that as a basis to get them to encourage them to go out and move and exercise and improve their brain function is stuff they can do to kind of feel better and think better, and that's one of the things I share with the group, and it really helps put things in perspective for, like, feeling better. Thank you. That's really interesting. I hadn't thought about it that way, so I appreciate the comment. Actually, I can't take credit for it either. I heard it in a TED talk, and this is after residency. It was Daniel Wolpert, who is a – he calls himself a – I know Daniel Wolpert. He's a movement chauvinist is what he calls himself, and it's a great talk where he talks about how we develop movement. And so I just was like, wow, I hadn't thought about it that way either, and it really puts things in perspective. That's great. Thanks. Hi. This is really fantastic. Thank you. I've been using this framework more or less and giving briefings to people with it, and the one question I had, and you alluded to it a minute ago, was the E-word because some people, they feel like you're sort of threatening their religious beliefs maybe. So I was just wondering how you would work – you would present it with, you know, neutral language or whatever. Thanks. Yeah. I hardly ever use the E-word when we're talking with patients. I simply talk about, you know what, can you think with me about whether the different symptoms that you're having with your panic attack might be useful in some circumstance? And the patient says, well, I sweat. I say, well, that would make you slippery, wouldn't it, and make you cool so you can run fast. My muscles get tight. And so you just go through things with them and let them figure out. It's kind of a gentle, quick interpretation where they figure out for themselves that there are useful aspects to this. For depression, it's harder. For depression, I ask more general questions about, you know, are there circumstances in which it might be useful to put less energy into things? And people very quickly come to the conclusion that, yeah, now that you mention it, might you be in one of those situations? Not having to mention how these systems came to be at all. Randy, this might be a good time to ask. We were chatting yesterday, and I just think it's really interesting about, you know, I was asking, is there – so how can we use evolutionary theory to find better drugs? And he told me this story that relates to what you just said, and I want you to just share that. So one of the great challenges for all of us in life is to figure out when to give up on things, right? When to give up on things. And I think it's not simple. And I would hate for anyone to go away from here thinking that Dr. Nessie says if you're not making progress towards a goal, you should just give up, because no, that's not right. So we use this when we try to find new drugs, right? What's the standard way for trying to identify a new drug that might be useful for depression? It's to put a rat in a beaker of water and see how long it swims if it has a potential antidepressant versus placebo. And consistently, drugs that turn out to be good antidepressants lead rats to swim longer. As for those rats that don't swim as long, you kind of get the idea that they drown, right? Does anybody know the trick about this? There are 300 papers published every day about what's called the poor salt test. This is a standard test. What actually happens with those rats who don't keep swimming? They float with the nose just above water. What happens to the rats that get the antidepressant drug? They're more likely to drown because they are putting up with excess energy. And I'm going to just wrap up. It's such a delicate matter. I mean, how we fail and when we decide to quit, it requires long conversations. You can't just, oh, why don't you quit your marriage or your job? Or you've got to keep trying because it's just depression. I mean, patients wouldn't be in our offices unless it was a real desperate dilemma, and it's our job to listen to them and to try to help them work through what their options might be and accept the difficulties of real life. Hi there. My name's Damon Parsons. I'm a psychiatrist over from the UK. My question is about how do you feel the advent of the internet and the ability for people to have this information at the click of a finger? It has affected or will have an effect when we look at psychiatry in terms of an evolutionary psychiatry lens because even going back to the vinaigrette, the health anxiety that this gentleman was facing would obviously be different than someone experiencing health anxiety 20 years ago, at the very minimum, because now this person can research their symptoms, they can find information about their symptoms, or they can find misinformation about their symptoms, which is, I guess, when we talk about these anxieties in an evolutionary context, there's never been that immediate access to information before. So do you think it will have an effect? What effect do you think it will have? It's incredibly important, and it's a reality, right? In fact, this patient is a real patient I literally saw last week, and I asked him, you know, I sort of asked him, what do you think is going to be helpful? And he came up on his own. Number one thing, first thing he said, I'm going to have to stop looking on the internet. Dr. Google actually is not my friend right now. And so he, you know, we talked about that, and we talked about why, but he was able to recognize that. And so, yes, it is a challenge, and getting people to realize that just being exposed to triggers and information sometimes isn't always what it's cracked up to be. So, yes, and it creates another wrinkle and another thing that we have to deal with, but it's a reality, right? It's a reality of our world. And sometimes it's a good thing, not so bad. The only thing I would add, too, is I'm always, as a child psychiatrist, so aware of how much time my patients spend online. So there's the misinformation and the amount of information, but there's also being exposed to information you're not yet developmentally ready to learn about or hear about. And that's the other challenge that I have. And then what's happening is then kids are experiencing this in isolation, right? So if something bad happened to your village, there was a tsunami, and everybody had the experience, you could also heal together and rebuild together and share that experience. But now kids are being exposed to really scary things that they can't understand, but we don't know it. And so the adults in their lives can't help guide them through that. And that's one of the things that I will talk a lot about with families. I mean, we want to set limits, yada, yada, but that's a different issue. But for me, it's much more about knowing what they're being exposed to and then making sure there's room and space for kids to talk about that. So it's noon, so I'm afraid we're going to have to stop with the questions. But anybody who would like to chat more or come to lunch, please come up here and we can talk some more. Thank you all so much. Thanks for being here.

evolutionary psychiatry

mental health

Cynthia Stonington

Randy Nesse

Kathy Smith

evolutionary biology

perinatal mood disorders

LGBTQ+ youth

depression

anxiety

emotional defenses

treatment approaches

patient-clinician communication