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- [00:04]
A
Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader and conversation starter on midlife living, hormones and sexuality. Enjoy the show. Hey, everybody. Welcome back to the youe're Not Broken podcast. Talking today with my friend, Dr. Judith Joseph about her amazing book coming out in April called hi Functioning. Overcome your hidden depression and reclaim Joy. Welcome to the podcast.
- [00:31]
B
Oh, thank you for having me.
- [00:33]
A
I forgot we probably met in New York at some menopause thing.
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B
Yep. We were met at, I believe it was like marvelous Mrs. Menopause or something like that. At the World Trade Center.
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A
At the World Trade center, yes.
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B
We were on a panel together.
- [00:47]
A
That was an amazing night. It was super good. So you started out. I just, I like, I'm sorry if you hate the story, but I love it like you are. This is. This is my version of the story. Please expunge. You are an anesthesiologist training in residency. You were going underneath the surgical table to empty the urine bag and you said, what the hell am I doing with my life?
- [01:06]
B
That is accurate.
- [01:07]
A
Do I have that right?
- [01:08]
B
Pee splashing in my face and being cold in the operating room was my like, existential crisis moment.
- [01:15]
A
At least it. At least it happened decently early on and you weren't like 30 years into it or something and you're like, I have been cold for three decades.
- [01:23]
B
That's true. I was two years in and I was like, what am I doing? You know, like, why am I here? Not to say there's anything wrong with anesthesiologists, because a ton of my friends are still anesthesiologists and it's a great feel.
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A
We're all very good friends with all the anesthesiologists and we love them, but
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B
it is not for everyone.
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A
It's not for everybody.
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B
And I think I went into that field because I didn't understand the science of my happiness. I was chasing what other people thought should make me happy. Right. Anesthesiologists make a lot of money. It's a good job. You have good work, life balance. You make a ton of money. But if I were to really understand the science of my happiness at that point in time, I would know. Judith, you are a social person. You like to be around people. You don't like the cold. You don't like waking up that early.
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A
Anesthesiologists have to be there before the surgeons.
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B
It's early, way before to check the machine to make sure the gas is in there, literally, like a mechanic. And you don't get to talk to your patients. You put them to sleep, you keep them alive.
- [02:23]
A
The anesthesiologist I know, they think that's the perk of the job.
- [02:27]
B
That is exactly why I should not have been in that field. I didn't understand the science of my happiness that I was chasing. What other people said would make me happy. And they were wrong.
- [02:38]
A
I love that. So you found. Did you immediately like psychiatry, is it? Or did you just know then? Or how did you switch over to psychiatry?
- [02:46]
B
You know, the match day recently passed and if people knew the pressure that these babies have, like, I call them babies because I work with the medical students at Columbia, and when I go, I'm like, oh my gosh, they look like babies. Cannot believe that this baby is supposed to be choosing the path of their life forever, their destiny. But there's such a big deal when it comes to matching. You know, there are people who want to be anesthesiologists and they can't match into it. So for you to take a spot at a prestigious place like Columbia to then say, oh, two years in, I think I was wrong. That is a big deal. It's not as easy as saying like, oh, you know, I want to switch my major in college. It means that someone else who could have had that spot didn't get it. And the program now has to then find someone to fill the spot. So even if a lot of physicians are really unhappy, they tend to stay. It is a bold move to leave. And at a prestigious organization like that and a prestigious residency, it was like, what am I doing here? But I had to follow my gut. And I remember my parents, they're from the Caribbean, they're immigrants. And when I told them, I said, I think I want to leave this field and I think I want to be a psychiatrist. They were like, you want to work with crazy people? What's wrong with you? You're in a good job. What are you thinking? And I was just like. And to translate that, that's like, what is wrong with you? That is a good job. What are you thinking? Why do you want to work with crazy people?
- [04:12]
A
Your brain's having glitches right now, right?
- [04:15]
B
But I remember when I was a fourth year medical student, I did a rotation in South Africa and I lived on an orphanage and I was working with these young girls and they were age 8 to 12, and I was leading a group of a trauma informed group with my Fellow medical student, Dr. Gerson at the Time. And she was going to psychiatry. And she was like, can you lead this trauma informed group with me? I was like, oh, well, okay, I'll be there. You know, like, I don't really know what I'm doing, but, oh, my gosh, that changed my life. I was hearing stories from these little girls who had no parents because they lost their parents to aids, had nothing, but they still had hope. And, like, hearing them pour their souls out and, like, me telling them about how I grew up with very little too, and if I can be a doctor, you can. And we cried together. I was like, why didn't I go to psychiatry? I was like, so jealous of Ruth. I was like, ruth, I wish I was going to psychiatry. This is powerful. And she was like, it's never too late, Judith. You know, famous last words. And then when I was an anesthesiology resident, I called up all my friends who were psychiatrists, my friend Kristenecht Cornell. And I was like, I need to switch things up because I'm unhappy, and I think I want to be a psychiatrist. And I never look back. I got the one spot at a psych residency at Columbia because there was a resident who was moving to the west coast, and I'm still friends with that resident who moved away. But I got that spot. And I was lucky because the residence director, she wanted someone who could do a lines because she was doing suicide research with fmris. There were a bunch of surgeons who are lining up for the spot. And I got it because she was like, I need someone who could do a lines. And I'm like, yes, anesthesia dude for the win. And I got this thought, I don't
- [05:59]
A
remember learning about trauma in medical school. And to me, I'm like, was I just young? Did I not care? Like, I don't remember. And in all fairness, I made it through fricking urology residency without fully understanding the complete anatomy of the clitoris. So, like, right, here we are. But I'm like, I don't remember learning about trauma, let alone, like, trauma informed. To me, that was a word that probably just came out a couple of years ago. So for people who don't understand what that means, can you explain that to them?
- [06:28]
B
You know, trauma is something that if you don't acknowledge it, it can seep up in so many different ways in your life. It can show up in your relationships. Because how you see yourself and how you interact in the world is often shaped by traumatic experiences and trauma. By definition, if you want to use the clinical term in the DSM 5, they usually are referring to things like assault or combat or something near death that happened to you or you witnessed it. However, if someone comes to your office, to my office, and they're telling me that they went through this breakup and the person was belittling them emotionally, breaking them down verbally, that, you know, they. It ended in divorce and they ended up with very little money and they had to move from their home, I can't tell them that that's not a trauma. I can't say, well, actually, According to the DSM 5, you got to be in, like, combat. And I'll say, of course I believe you. Of course that's painful. That was psychologically and emotionally shaping the way that you view yourself and the way that you interact in the world. So that is a trauma. So it may not be a big T trauma, but it's definitely a trauma that needs to be acknowledged. So the whole idea of trauma informed care is relatively new. And I did adult psychiatry and child psychiatry fellowship after. In child psychiatry, we were taught about trauma so heavily, but I didn't really learn that much about trauma in adult residency. And I think it's because we focus so much in medicine on fixing things that seem like crises, like schizophrenia. If you're psychotic and you're seeing things and that leads you to become violent, then that's a crisis. If you're manic and you're spending all your money and having reckless sex and using drugs, that's a crisis. If you're depressed and you're hopeless and you're suicidal, that's a crisis. Right. So things that are chronically wearing on you, like a trauma that's unresolved, those don't really get taught up front. Yes, we learn about ptsd, but the emphasis is not there. But in child psychiatry fellowship, we learn about trauma from day one. Why? Because a child who shows up to the classroom and is hitting people and acting out, we're not gonna just automatically assume that that child has adhd. We're gonna wonder if there's someone at home hurting them. Are they neglected? Is this their language for asking for help? How do we set up the classroom so that they have less issues with focusing, so that they feel less triggered by loud noises? How do we make sure they're supported so that if they are feeling as if they fight or flight, there's a room for them to leave? How do we set up the environment so it's not having sense that will trigger them because it reminds them of a attachment figure that hurt them? You know, and that's trauma informed care. Understanding how traumas shape the person's experience and how they view themselves in the world and in medicine. This is very important, especially in your field where you're working with parts that are very sensitive, that may trigger unprocessed pain. When you're seeing a physician who doesn't understand that you had an assault in your past, or if it's possible that you were in a relationship where someone ridiculed your parts and made you feel ashamed for not wanting to have sex, if you're with a provider, a professional who is not trauma informed, and they're just like, okay, give me this tool and let's get in there. And isn't talking with you, isn't seeing where you are physiologically or mentally or psychologically in that moment, then they can be adding to your trauma. And they're doing so unknowingly because they're not trauma informed.
- [10:10]
A
Yeah, I mean, the more I learn about it, the more I'm like, oh, the medical system traumatizes. My big rally is the 10 minute doctor visit. I'm like, these are good people who care greatly, who want to help, who do not have the space for what it requires to actually talk and deal with all of that. It's like, we gotta get the pap smear done. You're here for the pap smear. We don't have the tools to be mindful of that. I know they just did a big trauma informed thing at the recent Ishwish conference, and I wasn't there. I was in Australia. But I heard it was incredibly powerful to be like, how traumatizing the field of gynecology is to humans who need to go through it for healthcare.
- [10:52]
B
Yeah, even a waiting area. I just consulted for this nonprofit that deals with refugees. And you know, I was trying to. They were showing me the waiting area and I was like, okay, we need to change some things here. Because this area, you know, imagine someone coming from God knows what situation, they're entering this waiting area and there's trash on the side and there's this like, window that looks as if someone could come in any moment. You got to think about these things differently. Even a waiting area can be traumatizing. Right. So trauma informed care is something that is relatively new, but it's important. And thankfully, a lot of schools are learning this, A lot of prison or correctional institutes are learning about this, because many people who appear agitated or violent or scary are actually traumatized. So they're projecting that onto you. And without you understanding what they're going through, then you're just adding to the problem. You're just making it worse and making their symptoms worse. And that's why it's important to use software language, to use certain language to sit with a patient, not stand to meet them at their level. If it's a child, you know, to make sure your hands are visible, because when your hands aren't, people think something's up to not use heavy smells when you go into a room because that scent can trigger a past experience for that person.
- [12:16]
A
Is it true that complex PTSD is a different thing than war combat ptsd? Can you expand on those?
- [12:24]
B
Yeah. So PTSD is a condition that is well studied because the VA hospital has created so many studies and rating skills. In fact, for my PTSD studies, I have to be trained by someone on the team of Frank Weathers. I was lucky enough to be trained by Frank Weathers, who created the CAHPS5. But typically you don't see these odd things that you would typically see in something like a psychosis. Right. Typically what you see with PTSD is avoidance. So this is when you don't want to deal with things that are painful or triggering, like people, places or situations. Hypervigilance, where you have like an arousal when you're triggered by these things, things like flashbacks or nightmares which are re experiencing these things and these cognitive symptoms, like feeling depressed, feeling shame and blame, not remembering what happened. So these are the four buckets. And then there are things that are like dissociative properties, like feeling as if you're not part of your body or feeling as if you're not part of a situation. And when you look at these assessments, there are like 30 plus symptoms of PTSD. When I ever say that to people, they're like, really? I thought it was just flashbacks. And he's like, no, that shame that you feel, that blame that you feel, that's actually a symptom. Oh, really? That's why I don't feel worthy of love. That's why I keep. And that risk taking that you do, like speeding and using drugs and having sex with people that you normally wouldn't, that's called risk taking behavior. That's part of it. And they're like, because it's counterintuitive. Why would I put myself in a situation where I could be traumatized? That's a part of ptsd. Right. So if you knew about this and how complicated PTSD was, you wouldn't be so quick to write people off as not having It. But then there are people who have had a series of traumas. Think about the child who has been in multiple foster homes, who tried to attach, but that person that they attached to hurt them. And then they went to another home and they just really have a really difficult time coping. And so instead of verbalizing their pain, they may act out and they may appear as if they're agitated, having symptoms that look like psychosis because they're constantly having dissociative experiences, even at times looking as if they're two people. Something called dissociative identity disorder. So you have all these other types of trauma responses that are more complicated because the person never had a chance to recover. They went from one trauma to the other to the other. And so that's why there is this bucket of PTSD kind of conditions, otherwise unspecified, or because we just haven't been able to pinpoint all of these other types of experiences that people have. But it doesn't mean it's not real. It doesn't mean it doesn't exist. Dissociative identity disorder used to be called multiple personality disorder. And when people started reporting cases, these doctors were shamed, they were ripped apart. But now we know that this is real. Just because something isn't a classification today doesn't mean it won't be one day. And these are areas that we need to study more because there's just so much diversity in terms of how they're represented. And if you think about the age groups and the different cultural representations, that makes it even more difficult too.
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A
Yes. Let alone you're in a female body.
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B
Yes.
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A
I'm hearing a lot more about bipolar and the role of trauma in people's history of bipolar.
- [15:38]
B
Anyone who's had a history of erratic or like labile mood, you really want to rule out trauma. I'm always thinking about trauma, especially with people who are like labeled with these. Schizophrenia, bipolar, I see it a lot and I want to make sure that. Were you having a flashback when someone said you were being erratic? Were you having a dissociative experience? Were you feeling out of your body? So when they were like, hey, are you okay? You were actually not psychotic, or when you were engaging in risk taking behaviors like drinking or speeding and all these things, drug use, is this a trauma response? Because again, that's one of the symptoms of a possible trauma response. Right. And so if people don't know trauma, if they don't understand ptsd, you're going to get a lot of wrong diagnoses. And it's possible to have both. It is possible to have bipolar disorder and ptsd. It is possible to have a bipolar disorder and adhd. The thing I hear a lot, Kelly, from people who follow me on socials is, is ADHD a trauma response? And I say, no, it is not. ADHD is a childhood condition. It is very, very common. It's neurological. It responds very, very well to stimulants, you know, and organizational skills. But it is not the same as trauma. Can you have ADHD and trauma? Yes, because if you imagine a kid who's hyperactive, who doesn't pay attention, who's running around and who's living in a home where the parents are just not, you know, they don't have those skills to be patient, sometimes they're going to get hit. Right. Sometimes they're going to be the one who gets, you know, bullied in the classroom, who gets neglected. Right. So that may put you at risk for trauma. So you can't have both. But they are not the same.
- [17:27]
A
I think the other thing with adhd, tell me if you think about this differently is like, because ADHD is so trending right now. I was reading an article on, like, the people who say they have ADHD versus if they were properly assessed for what's actually going on. Some of those behaviors might actually be other things.
- [17:44]
B
Absolutely. You know, one of the common things in ADHD is a lack of focus. Well, you know what else has a lack of focus going through? Perimenopause. You know what else has a lack of focus? Depression. It's actually one of the symptoms. Anxiety can cause a lack of focusing. Trauma can cause that. Schizophrenia can. So if you're just going solely on one symptom and you're not looking at the full picture, you know, a way to know whether or not you have ADHD or not is look at your childhood. Because it is, by definition a childhood condition that continues into adulthood if you're an adult. And so look at things such as the inattentive parts of adhd. Like, were you careless with mistakes? Were you forgetful? Were you that kid that always left the bag at home or at school? You know, was your desk often messy when people were talking to you? Were you, like, zoning out? Or you're like, huh, say that again. Those are, like, the focus or inattentive parts of adhd. But then there's the hyperactivity symptoms of it. Were you someone who was, like, twirling your hair a lot? Were you someone who was, like, tapping their feet? Was it hard for you to wait in line. Was it like, oh, my gosh, I felt like there was like ants on my pants just waiting in line. Was it hard for you to, like, not say things before you know, the question was done? So you're blurting out the answer. Were you constantly interrupting people? Like, these are the hyperactive things in adhd and there's adulthood symptoms that go into it. There's a whole adult checklist. So if you didn't have it as a child before the age of 12, then most likely it's not ADHD. And if it didn't impair your functioning in two settings like home and school, then probably not ADHD. But there are things that can mimic it. If you have, again, perimenopause. I see this a lot. A lot of women come in, they're like, I think I have adhd, but they have brain fog. And I'm like, so when did your symptoms start? Oh, like my late 30s or 44. Yeah, I don't think that's ADHD. Now, ADHD can worsen as you go through perimenopause and menopause, that is for certain. But, like, it doesn't start in midlife.
- [19:40]
A
Yeah, good to know. Let's talk about perfectionism as a trauma response.
- [19:45]
B
Yes. So you know I told you about the 30 symptoms of trauma. One of those is avoidance. Well, when you classically think about avoidance, you think, I don't want to think about the person who hurt me or the situation. I just don't want to deal with it. But a trauma response in people who are high functioning is busying yourself. So when you're still, you feel restless, when you're not busy, you feel empty. So you just do, do, do. And you see this in people who are doing multiple things at work, and then when they're at home, they can't sit still. They're doing something for their kids, they're doing things on the weekend, they're taking on an extra project, and they know deep down they shouldn't be, but they just can't sit still. They're running from something and they haven't taken the time to process or even reflect on their trauma. That is an avoidance. And it's a form of avoidance that does not get acknowledged enough.
- [20:39]
A
Well, I think our society rewards it. And you talk about that in your book of like, our society is like, perfect. And then you can, you know what you can do? You can get a LinkedIn account, you can get a TikTok account, you can start blogging over on Substack, you can start A podcast. You can write a couple of books. You can open a new clinic. You could do another research paper. Like, there's so much to do. Society rewards this.
- [21:00]
B
Well, you know how you said we don't learn about trauma in medical school? I think a lot of healthcare professionals are traumatized. I mean, when I think about. Because I did anesthesiology first, and at that time, they didn't combine the whole four years into one thing. We would do internal medicine for a year and then go into anesthesia. So my first year of internal medicine, I just remember my code, and I was in a code, and it was so traumatizing. I mean, I don't even want to talk about it. But, you know, no one pulled me aside and said, how do you feel about that? That was a terrible code. It was awful. And to see someone, you know, pass away in such a terrible way in front of your eyes, under your hands. I think so many healthcare professionals are traumatized. I think we don't acknowledge trauma because we are taught in a very, like, militarized way to just move on. We are in the trenches.
- [21:53]
A
You're a professional, and you've been taught how to get through this. Well, I think part of medical training is the dehumanization of us to the point of, you're not thirsty, you don't need to pee, you don't need to
- [22:04]
B
sleep, and you're punished if you say, I'm fazed by that. Like, I don't think I could do that. It's like, what? You're punished? You're, like, shamed? You're considered weak?
- [22:15]
A
Totally. Totally. I bet you if somebody did that research, it would be a.99% of healthcare professionals have been traumatized. I did. After coaching training, I coached female surgeons for a while with a friend, and that was the point where I was like, oh, we're all traumatized. And I'm like, we're just starting to talk about that. I was talking to another coach who coaches physicians, and I'm like, you realize they're all traumatized. And she was like, what? And I'm like, oh, you better realize pretty quick that we're all very traumatized. And I don't say that for anybody, you know, who's listening, who isn't a surgeon. I'm not saying this to put down doctors. I'm saying this to extend immense compassion to the people who are tasked with helping other people. Their training is traumatizing.
- [23:02]
B
It is. They're traumatized. And the worst thing you can do to someone who's traumatized is to invalidate them and then to make them feel unsafe. In fact, in trauma informed care, the number one thing you do after the trauma is you tell them it's not their fault. You make them feel safe, so you take them out of the situation and you give them a routine. But what do we do to our healthcare professionals? We blame them. We do morbidity and mortality rounds. We air their mistakes in front of the entire department. So we're blaming them, we're telling them it's their fault.
- [23:34]
A
It wouldn't have happened if you had done something different.
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B
Totally. We blame them. And then do we make them feel safe? No, we don't remove them from the situation. We put them right back there. Who is taking the next call? Right. And then rather than a routine like you know what to expect, expect, you don't know what you're expecting. You're right back in the trenches. We are a highly traumatized industry and it's no wonder that we don't recognize trauma in others because we gaslight ourselves, we invalidate our own trauma.
- [24:03]
A
Well, I think even in the, you know, for credentialing, for like state licensure and all, it's like people lie about having had needed to get help. Like you don't admit that you need help at all. A recent article came out about death by suicide and the risk for female physicians. And it's a crazy multiplier more than the general population.
- [24:27]
B
Yeah, I just took my medical, you know, take your boards again every 10 years for the psychiatry and medical students. Like if, if you did the poll, the residents, one in 10 are thinking about suicide. What is happening here? Yet if they are told to go get help, they have to report it. In some states that's only recently being challenged. So imagine you're a young student, you sacrificed your entire youth. Some of them are in such debt like I was. And then you're told that if you're sad or depressed and you're feeling hopeless, if you report it, you may not be able to work. Well, who's going to report that? They got to pay their bills. Why would they do that? So of course they're going to continue gaslighting. They're not going to invalidate. And so people who are not healed, who have not processed their trauma, are now treating patients. And when they see trauma in their patients, they're like, well, everyone goes through this, so I'm not going to. Why would I take the time? We're all traumatized. They're not saying this on a Conscious level. But it's like, well, everyone has pain. Whereas if you process your trauma and you're healed or you're in the healing process, you're gonna notice when someone is tense, you're gonna notice when someone is hurt. You're gonna notice when someone needs that extra care because you've processed your own. And you're gonna be there in the way that you need to for that patient. But the unhealed are trying to be the healers.
- [25:50]
A
Well, I think as people are healing, they're leaving the medical system.
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B
Drop the mic.
- [25:59]
A
Maybe speaking from personal experience, but it's like you realize I cannot play a part in this anymore. I cannot see 25 people a day. I cannot continue to have them say all they want is more time with me and me not be able to do that. And you get to the point where you're like, it's not actually good for me to have to process 25 people a day, write notes, do prescriptions, do all the follow up phone calls. Your body needs a break at some point. And I see so many people in get sick. And I remember being like, I want to leave this on my own terms, not because I got sick.
- [26:36]
B
Well, you're the one of the lucky and brave ones.
- [26:39]
A
Oh, it takes bravery for. It was like leaving anesthesia residency is like, you got to rock a boat to do it.
- [26:45]
B
Yeah. And like, what you're told is that you're in a safe position. You have it. You're in a hospital, you're in a healthcare system, it's safe, you know what to expect. And because you've been in this situation where you're told it's scary if you leave, you'll be ruined. If you leave, you just kind of get stuck and you're just like, well, I don't. You know, humans don't like the unknown. We don't like the uncertain. Right.
- [27:06]
A
Well, then there's safety in the trauma that you know. Like, I do know what my day is going to be like. It might be shitty and stressful, but I know what it's going to be like.
- [27:14]
B
Yes. And there is that trauma bond. Some doctors feel guilty leaving the troops behind. It becomes a very toxic relationship. So it takes these discussions, like what we're having right now, knowing that you're not alone, when you know that it's not you, and that's happening to a lot of people, it gives you that comfort. And then that you stop blaming yourself. You realize it's the system, it's a situation that happened to you. It's not your fault and you can do something about it. And that's why one of the demographics I try to focus in my work is healthcare professionals. I think a lot of us have high functioning depression, we have the symptoms of depression. But if you look at the DSM at the bottom of the checklist, we're not broken down, we're over functioning, we're doing research, we are teaching students, we're
- [27:59]
A
in the top tax bracket, my friend. How dare you say there's something wrong with me?
- [28:03]
B
Right? Yes. We don't meet criteria, we haven't lost functioning. And the second bucket of distress, we don't acknowledge our distress. In order to meet criteria for clinical depression, you have to have these symptoms and also either have lost functioning or be distressed. But if you're in a culture where you're not acknowledging it and you're just going through the emotions and you're feeling meh, blah, anhedonia, then you're not gonna meet criteria. So why are we waiting for people to break down? Why are we waiting for them to be in crisis to do something about it? Let's give them the tools now before they break down. And like you're in menopause medicine, there is this renaissance happening in longevity medicine where we're saying let's stop the cancer, let's prevent it before it happens, let's stop the heart attack before it happened, let's stop the hip from being broken before it happens with hrt and let's prevent these poor health outcomes. Where is that excitement for mental health? I'm waiting for it to happen. So we should not wait for people to break down. Let us prevent the clinical depression, let's prevent the substance use, let's prevent the suicide, let's not wait for that box to be checked. Let's just start investing in joy today. And we know that doctors who have joy make less mistakes. People who have joy in their lives, they stay in the workplace, they have better relationships, they have better health outcomes. So let's actually invest in joy. As cheesy as it sounds, let's not wait for the crisis to happen.
- [29:26]
A
I love that. I think the gene theory in medicine has really hurt many things, but I think mental health, because what we were taught was that you, I'm sorry, you're a result of your genetics. It's what the gene, the hand you were dealt. And so we think mental illness is just, you're genetically disposed to depression, you're genetically disposed, blah, blah, you got that from your parents and there's. You lose the agency. And you also lose the fact that your environment matters in how your brain's functioning. And you lose all this power of like, no, no. Joy is not just like a bonus level in a video game of like. It's an essential key component to keeping the brain health. And when you think about it like that, it changes it.
- [30:11]
B
Yeah. And you know, if it were as simple as genetics, then we would just all be on an antidepressant and be happy. Go lucky. Right. If it was just as simple as one chemical that boop. But it's not the case. And there's really great research coming out. I believe it's at Stanford. They're trying to subtype different depressions. You know, people who are really slow moving, people who are cognitively stuck, people who have more anhedonia. And we do this, write up medical students. We get the biopsychosocial in our literal first year of training. So why are we not allowing people to learn about all the components that take away from their happiness? That's why I say know the science of your happiness. Because if you know that biologically you're at risk, you're going to do certain things differently if you know that socially at risk, because you're like in a situation that's really difficult at work or at home, or you're engaging in activities that are not adding to your happiness or taking away or psychologically, let's say you have past trauma or ADHD or other psychological factors. If you know the science of your happiness, then you're not going to be doing what someone else is doing. You're going to focus on what works for you. So let's arm people with this because this is the information they need so they have more joy and they have better outcomes in life. I love it.
- [31:22]
A
When did the light bulb go off? So high functioning depression. Let's define it. But my other question is like, you're creating the field of this. What was the light bulb to be like? This is a thing. This is real. Even though it's not in the literature. Like, tell me that journey.
- [31:39]
B
You've been to my lab. So you see, I use very thick rating scales to quantify things because in order for a patient to be in a research study, they have to meet these criteria. It's very rigid. And I was seeing so many people who I would go through the checklist and when it came to functioning, no, I'm not breaking down, actually, I'm doing more. I'm killing it. And it's like, oh, well, I'm So sorry, you don't meet criteria. And I'm like, I'm seeing this a lot. And I was actually experiencing this in my life. I was at my desk giving a talk to this big health system, and I was supposed to be giving them tools to heal and to cope. And halfway through the talk, I just felt like, so, like, blah. And I'm like, I feel numb, I feel anhedonic. I'm like, wait, do I have anhedonia? The thing that I study that I, like, do checklists for. I cannot believe it snuck up on me. I'm like, wait a second, I think I'm depressed. And I just remember sitting at my desk, like, how did this happen? And I was like, if this happened to me and I study this and I treat this and I work with patients all day, how many people does this happen to? It can't just be me. And I've taught this course at NYU for the past 12 years where I teach doctors how to give press interviews. So if there's this big outbreak, how do you talk to the public and without scaring them and using this big long word and having them running for the hills, right? And the doctors after 2020 were asking me to help them with socials because they were like, no one's watching the news anymore. They're not really doing radio interviews. Teach us social media. So I had to learn socials to teach them socials. And I thought, let me test the waters and let me put what I see in my practice out there on a social media video. And that video was seen over 20 million times around the world on high functioning depression. And I was just like, what? So this is not just me and people in my practice. This is a thing. This is real. And then I was like, oh, let me do some videos on Anadonia again. People are like, that's what I'm feeling, you know? So I thought, well, what an opportunity to bridge the research world with the real world. Use this as a tool to educate and to see what's happening. And I thought, I have this lab. Yes, I can continue doing the research that is the classic research in schizophrenia, adhd, dementia, postpartum depression. But wouldn't it be cool if I wrote a protocol and try to figure out what it was that people with high functioning depression actually experience and whether or not they're risk factors. So I wrote the protocol, submitted to the IRB, and we enrolled 120 patients. And the paper was published this year. And I think it's important because when people see their experience Reflected in the work, validated in the research. It tells them that there's nothing wrong with them, that this happens, this is real. Other people experience this too, and it gives them hope. Because if they see themselves in the research, they know that maybe there's something to do about it. If we understand what's causing it, maybe we know how to cope with it. So that's why I think research is so important. Not just to, like, seem smart and like brainy, but because it validates what people are going through. If you see that what you're going through is in other individuals and it's being studied and taken seriously and people are curious about it, that gives you hope. That's why research is so important.
- [34:59]
A
Oh, I love that. I love that. What has been your colleague's opinion about this? Are they, Are they like, yes, obviously we see this all the time. Are they like, what are you doing coming up with something new? I don't think it's real. Like, what's been the energy behind these discoveries?
- [35:16]
B
Well, initially when I was talking about it, they were like, oh, that's not real. We have to use the DSM to classify things. Like, we can't just focus on everyone. And I was like, why don't you guys focus on the ones that are breaking down and I'll take the rest, you know, like, how about I focus on people so they don't break down? How about that? And they were like, oh, it's not a real thing. But then when I did the study and I published the research, they were like, wow, I wish I thought of that. They're like, oh my gosh, it makes sense because I see way more people who are like high functioning depressed than people who are broken. I was like, that's what I was trying to tell you. I would try to tell you this for years. Like, there are way more people who have the depressive symptoms who are functioning or over functioning than those who are broken down. So we need to help everyone.
- [36:01]
A
Why are the high functioning people coming to see you? Because I would assume that they don't know they're depressed. Of course they don't know. It's called high functioning depression because you, like, you literally just put it out in the world. Like, why are they seeking care in the first place if they're not below functioning?
- [36:18]
B
Usually it's anhedonia. It's like a. I feel stuck, there's something off. I'm not excited in life. And when I use my anhedonia rating skills, they're like, oh my gosh that's it. That's what I'm feeling. But the term anhedonia is not used in medical settings, in clinical care, in the literature. It's all over research. It's literally in like every single protocol. But in the real world, it's not used. Why? Because doctors and therapists and healthcare professionals are focusing on the things that are like, glaring. Like if someone's crying and not getting out of bed, that's what they're focusing on. They're not focusing on a lack of joy and pleasure and interest. They're like, well, that's not emergency, right?
- [36:59]
A
Yeah, yeah, yeah.
- [37:00]
B
I can't, I can't code for that. Yeah, I can't bill for that. But that's what, why people tend to come to see me. They're like, if something's off, I just don't feel excited about things. I feel stuck. And then I'm like. There's a term called anhedonia. It's when things that used to give you pleasure and joy and interest, they just don't light you up anymore, you know? Take this quiz. It's a rating scale. There's an old one called the Shops that's used in research this Nath Hamilton, but I adapted it and modified it to include more modern experiences. Because if you look at the shots, they're like things like, you know, drinking tea and looking at, oh, we don't really do that here.
- [37:34]
A
Do you take your pony for a walk?
- [37:39]
B
So I wanted it to be like more like real world pleasures. And then, you know, people are like, you know, I don't enjoy that. I. I didn't even think about that. I just, I just got so busy, I didn't realize I don't enjoy very much anymore. And I'm like, well, that's anhedonia. That's that unsettling feeling. And there's something called affect labeling. It's when, if you can identify the emotion, if you can identify the experience, then that in itself is therapeutic. Because humans don't like the uncertain. They don't like the unknown. So if they don't know what they're feeling, if they're like, what is? I just don't. That creates anxiety. So when you can name it and you're like, oh, that's what that is, that's what anhedonia. Then it's like, well, now what do I do about it? You know? So I call it the jade deficiency, the joy deficiency. I laid out this methodology in my book the 5 Vs to help you tap into joy. Every Day. Because if you think about it, when people come to my practice in the private practice, they'll say, I just want to be happy. Dr. Judith. And I'm like, in the research practice, we're just trying to eradicate your depression. We're adding up points. And so I want people to think about it differently. In research, you rarely see the word happy on your scales. You'll see things like, when you took a nap, did you feel rested? When you saw a loved one, did you feel connected? When you ate your food, did you savor it? Did it satisfy you? When you were intimate, did you enjoy that? Was it pleasurable? These are all the points of joy that make up happiness in research. But in the real world, people are like, I just want to be happy. And you ask them, what is happy? Happy is when I get that career, you know, when I finally get a partner, when I finally have the home. It's an idea. So I try to train people to think about it differently. Happiness is this idea, this ideal. Joy is that experience every day. So if you can try to increase the amount of points of joy every day, overall, you'll be happier. Because you could say, today, well, I'm going to, like, sit and eat my meal and taste the flavors, and that's a point of joy. And then tomorrow, maybe I'll get two points. Maybe tomorrow I'll see a friend and really, like, connect with them and listen to their funny story and laugh. Well, that's another point of joy versus I just want to be happy. Well, you may never get that idea of happiness. That may never happen for you. But joy, joy is within our reach. Every single one of us has the capacity for joy. It is in our DNA. We just forgot how to access it. So that shift can be so powerful for people.
- [40:01]
A
I think in the sexual health realm, women come in. Men too. But women come in and they say, I don't have sexual desire. They go through the motions. Sex might not be good for a myriad of reasons, but they're not enjoying anything else about life either. Like, they're just going. So I'm like, sex doesn't exist in a bubble. If nothing's bringing you pleasure or joy, why would this one thing be the one thing, right? And thinking about, like, pleasure, being, being able to appreciate it everywhere. And I think, you know, the sex med people use the word pleasure. You use the word joy. I think we're saying the same thing.
- [40:36]
B
It's the same thing. And one of the points of joy on the scales that we use is, are you Stressed, intense. Not necessarily think of stress as being related to joy, but it is because if you are relaxed, it's easier to feel joyful. And with sex, if you're stressed out, if you're in a demanding job, if you have like, don't even have a second to yourself, you can't even like take a pee break at work, who's going to want to have sex if you're that stressed out? If you're thinking about finances, you know, if you don't know how you're going to pay the, the bill, the mortgage, and you don't have to send your kid to school, who's going to want to have sex? So I think for people, people really need to think about joy and the in terms of these basic human experiences. And if you can try to decrease the amount of stress, then maybe pleasure in the bedroom will be more accessible. I use this acronym, sex, like S is like the setting, right? If you're stressed, if that setting is not set up properly for you to really have pleasure, if you're like having the physiological, like heat, the hot flashes, that that room is not cool, the setting has to be right. You know, if you have your laptop in the bedroom a half an hour before you're about to get it on, your brain is still at work and you want the bottom half of you to be in the bedroom, it's just not going to work, right? If the room isn't set up in a way that is sensual, there's clothes everywhere and like it's messy and cluttery. That's the setting is off. And then the E in sex is emotional connection. Sex does not start in the bedroom. You know this, it starts outside. It's like, did you say hello to your partner? Did you make eye contact? Did you rub the small of their back? Did you check in to see how they were doing earlier this week? Did you have like a chuckle together? Did you joke around that emotional connection? Do you, do you know what each other even likes? That is where sex starts. Not in the bedroom. We put so much pressure on the bedroom. And then the X part of sex is the toxicity. If the relationship is toxic, how are you going to have good sex? How's it going to work? You know, like it's the mind, body, it's connected. You know, if you're engaging in like lots of wine, that toxin is going to make it hard to get it on. If you're smoking, you know, if you're not eating healthy foods, things don't work that well, you know, There if you have again, poor work, life, balance, it's just not going to work. So all of these things make up pleasure. But we always think about, well, I just have to have the right partner, he's got to have the right bills and he's got to have the right amount of money. He's got to look the right way and all this. No, no, no, no, no. It's the basics. It's the simple things that make sex good. It's not what you see in the pornos. It's literally the basic parts of being a human being.
- [43:17]
A
Yeah. And I think, like to be honest with yourself about the way you're living your life. You need to understand your power to get in and get out of that. It breaks my heart when a woman's like, she's on call, she's got kids, she's doing the arm share of the household labor. And then the man propositions her for sex and she turns him down. Then he gets pissy and she feels broken because she's got the low desire. And it's like, listen, I'm not telling you to quit your job. I'm not telling you to get rid of your kid. But I am saying you've got to carve out some space because it's unsustainable.
- [43:53]
B
It is. It's absolutely unsustainable and it's unfair to you. Why is it that you're bending over backwards? Why is it that you're overextended? Is it related to you feeling not enough? Is it because you're with a partner who is actually projecting that onto you? Is the partner not supportive? Is the work not supportive? Something's gotta give and I don't want
- [44:16]
A
it to be your health. Like, that's the thing is like, get out before you break. Get out before you get sick. Get out before really bad things happen again. Understanding actually our role in our day to day of like, you do have the power, but you can't do it all. You can't do 36 hours of things in 24 hours and still get sleep.
- [44:36]
B
No, you always have a choice. And the choice could be either you're going to make it to your kid's recital or you're going to have sex. It's going to be one or the other. You cannot make everyone happy. You just cannot. And you may have to let your partner down to be there for your kid. You know, you may have to let your boss down to be there for your partner. You cannot do it all. No one can.
- [44:57]
A
Well, being comfortable with letting people down might mean you addressing some trauma history that is right.
- [45:03]
B
You may have to take a careful look at your role and like, are you someone who ties your self worth to how much you can do for others? Are you someone who depends on that role as the people pleaser to be loved? Some of my patients is. Let's test that hypothesis. Let's say no and let's imagine the worst thing that can happen if you say no and let's write it down and then let's say no and let's see what happens. They're always shocked that the worst thing didn't happen. And these are intelligent people. But that's just the way the brain tries to control a situation. It tries to be risk averse and say don't do this, prevent the worst thing from happening. But the chances are that the worst thing from happening doesn't happen. It really doesn't happen. But the only way we know is to do it.
- [45:51]
A
I think it was Mark Twain who said the worst things. Maybe it wasn't him, but somebody, a famous writer was like, the worst things in my life are things that never happened.
- [45:59]
B
Mm, I like that.
- [46:03]
A
Like the worst things I've experienced are the things that I didn't actually experience because they were just in my brain.
- [46:08]
B
I'm guilty of that. I'm always on the plane like trying to control the pilot so he lands
- [46:12]
A
and it's like an out of control situation, that's for sure. All right. High functioning depression. All residency programs should buy this for their residents and give them time to read it so they don't do it on top of everything else. But just the more we can understand about ourselves and how our bodies work and the role of trauma in our current day to day is incredibly important and I think we're just getting started. And thank you for being an expert in the field.
- [46:39]
B
Thank you for having me. I really hope people benefit from this. You could buy my book everywhere that books are sold and follow me on my website and socials. Dr. Judith Joseph and take my quizzes. They'll really help you to see yourself and hopefully uncover your past trauma.
- [46:54]
A
I love it. Thanks for spending time with us.
- [46:56]
B
Thank you for having me.
- [46:58]
A
Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free. Join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and Adult Sex Ed Masterclass members. Get the masterclass for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor but not your doctor in this format and all of my platforms and guests including on this podcast are not giving individual medical advice or practicing medicine. See and consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time. Remember you are not broken.