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Marco Pagani, MD - Guest
Marco Pagani, MD is a Senior Researcher at the Institute of Cognitive Sciences and Technologies of the Italian National Research Council (ISTC-CNR), and Associate Researcher at Karolinska University Hospital in Stockholm and at University Medical Centre in Groningen. His work focuses on the physiopathology of brain perfusion, metabolism, electrical activity and anatomy, applied to neurodegenerative, neurological and psychiatric disorders. He has published over 150 papers in peer reviewed journals, of which about 40 are related to PTSD and EMDR. Marco has presented more than 130 communications at international Conferences, has given more than 100 Keynotes, Plenary Lectures at International Conferences, CME, Workshops and Courses and has been awarded three International Prizes in the field of Neuroimaging. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (00:38):
Today, I'll be speaking with Marco Pagani, MD, Ph.D., who is a senior researcher at the Institute of cognitive sciences and technologies of the Italian national research council and associate researcher at Karolinska University hospital in Stockholm and at university medical center in Groningen. His work focuses on the physio, pathology of brain perfusion, metabolism, electrical activity, and anatomy applied to neurodegenerative neurological and psychiatric disorders. He has published over 150 papers in peer reviewed journals of which about 40 are related to PTSD. And EMDR. Marco has presented more than 130 communications at international conferences, has given more than a hundred keynotes plenary lectures at international conferences, CME workshops, and courses, and has been awarded three international prizes in the field of neuro imaging. Let's listen to the interview. Hi, Marco. Welcome. Thank you for joining us today.
Marco Pagani, MD, Ph.D. (01:38):
Hi Keith. My pleasure to be with you today.
Keith Sutton, Psy.D. (01:42):
Great. So, I learned about your work. I put together a workshop that I was doing on an introduction to EMDR for the Alameda county psych association here in the bay area. And I was looking for some recent research on EMDR and its mechanisms of action. And you are one of the co-authors of an article: How does eye movement to sensation reprocessing therapy work? A systematic review on suggested mechanisms of actions. And so, I was interested in talking and learning more, because I think this is one of the biggest controversial issues with EMDR about how does it work and there's different theories on this. And, oftentimes a lot of folks that are maybe skeptical of EMDR oftentimes say, oh, well, it's just exposure or so on. So I really love the article and would love to speak more with you about it, but would also love to hear kind of your work and how you got to doing what you're doing now and the thinking and the research and so on. So welcome, love to hear your story.
Marco Pagani, MD, Ph.D. (02:46):
Well, I had a lot of things altogether. I mean, it's not only one topic. I mean, there are several issues in this like introduction question, whatever. First of all, I introduce myself because otherwise people might not really understand what is my role in all this story. I am, let's say, what is called a neuroscientist. I've been working in neuroimaging with all kinds of neuroimaging since 1990 more or less. So now it is like 30 plus years of experience. And I am MD and I work for the Italian research council that is called the CNR.
Marco Pagani, MD, Ph.D. (03:34):
So my interest in the neurobiology of EMDR, because actually I'm not a therapist I'm never, I mean, CMDR, because I'm not a psychologist, I'm not a psychiatrist. As I told you, I deal with neurophysiology basically. And actually it is important to say that my main interest in science is in neurodegenerative disorders. So I started from trying to figure out how to predict not only the outcome, how to predict the evolution of neurodegenerative disorders like Parkinson's. Based on this background. I, well at the moment I live in Sweden, in this beautiful country where the summer is really amazing. I guess the same as in Washington state or Canada, when the summer is nice, it's the best that you can have in life. I was in Stockton because I completed my PhD in Stockton.
Marco Pagani, MD, Ph.D. (04:41):
And then professor of psychiatry asked me whether I wanted to supervise a student of him that actually was, was older than I was, because it was a supervisor in EMDR therapy and he wanted to run a study functional images about EMDR and that was the beginning of the story because in 2007, we published the first paper in which we compared the functional state before and after the EMDR in Metro and train drivers that killed suicidal people. So everything started from that moment. And then I started to continue this vein. Then I went back to Italy where Isabel Fernandez, who now is the president of EMDR Europe contacted me and offered some support to run a new imaging study about the neurobiology of EMDR in the way I was thinking was correct.
Marco Pagani, MD, Ph.D. (06:00):
So we discussed and we started to figure out how to do it in the most ecological way, in a way that will not hamper with more bias the data and the analysis and the, and the therapy itself. So we decided that the EEG electroencephalography would've been the best. So we run the first study, we publish in 2012, the first study ever in which a psychotherapy has been investigating during the occurrence of sector. But there is a realm in which you can see the images of the brain during the bilateral stimulation and in the moment in which the therapist asks to the client to concentrate on the worst image of the trauma. So we base it at the moment, we base not only understanding, but knowledge and, and our research on PTSD of course, on traumatization, because as you know very well now EMDR is used even for other, other pathologies.
Marco Pagani, MD, Ph.D. (07:18):
And actually from that point on, we went on trying to figure out not only on experimental base, but even on let's say on theoretical base. I mean, trying to figure out some hypothesis about the possible work mechanism of EMDR about this is very interesting because, again, I'm not in the field, I'm not, I don't have any conflict of interest. I don't care actually sure about no, no, but I mean, I have my, my source of interest as a scientist is just neurophysiology neuropathology, but it's very interesting because as soon as the EMDR, not some real weight and importance in the world of psychotherapies, I mean, people that were not using EMDR at that moment rose up and say, oh, but what is this EMDR? I mean, nobody knows how it works and nobody knows anything about that. Is it like which, just doing something? And actually at that moment, I was a bit I mean, like surprised because my first question was, okay, let's go. And I look how the other psychotherapy works. Sure. And then it checked, I checked and about the neuro biological mechanisms of CBT or psychodynamic psychotherapy or whatever, I found nothing.
Marco Pagani, MD, Ph.D. (08:56):
For example, the CBT world claims that the EMDR has no neuro biological explanation, but nobody knows at all zero, what is the neuro biological foundation of CBT? So I admit that actually there is an advantage in investigating EMDR because the advantage of investigating EMDR, I mean, almost everybody agrees that the real difference between different exposure therapies like brief exposure therapy or rather exposure therapy and EMDR is the bilateral stimulation combined with the imagination, with the image of the worst moment of the trauma. And that has allowed us to cut the EG during the 45, 50 minutes of therapy yeah. To extract, extract only those let's say slots in which bilateral simulation was performed. So actually we could really identify what was going on in the brain during that special part of the therapy, like during, when bilateral stimulation and focusing on the worst image of the trauma.
Marco Pagani, MD, Ph.D. (10:23):
And that actually is the big advantage on other psychotherapies, because for example, in CBT, what do you record your hour of therapy and then what, what would you extract for the hour of therapy words? Or I don't know what you can do. So that was the, the beginning of the story and the beginning of the story was that I started to to figure out, I mean, why not only the well known parts regions of the brain were activated and then were deactivated after psychotherapy because going I mean, just traveling the, the literature, you could see that even CBT, or other therapies, they made a lot of studies. What, what is going on before and after therapy. But my interest was, I mean, the first idea as a curious scientist was outcomes that on average EMDR therapy, I mean, to solve single traumas, six all sessions CBT takes some months and psychodynamic therapy takes a new, so there must be something that impacts on the time.
Marco Pagani, MD, Ph.D. (11:50):
Yeah. Why, why EMDR is faster than other therapies reaching in the end of the game the same result. So we went again through our files and we wanted to see what was going on in the brain in terms of waves that were recorded by, by the electroencephalography. And then I went to check the international literature about bilateral stimulation and cerebral waves. And then I found out what was for me, a very fundamental paper from nine, 2009 from the group of heart on Traumatology. And this paper describes very, very well how the brain waves, the Delta waves, actually the waves that are the low waves fear in the brain during Malo stimulation are very much alike. The waves that appear during the first phase of the sleep during the, this low wave sleep.
Marco Pagani, MD, Ph.D. (13:06):
Yeah. Then from that point on, we went backwards. And actually, we, we confirmed in our experiments that during the bilateral simulation, the old brain, all electrodes when the inter resonance and produced Delta waves, slow waves. And then from that point we, I mean, we generated the hypothesis is that the EMDR works because it replicates the Delta waves that appear during the sleep and the region, because it might, this is my hypothesis. I mean, you, you are mentioning a paper that I wrote with the, with the Spanish guy, with the Benedict in Aon , but previously, and, and in SAR, we, and BEIC as well, we produced another paper that was focused on our hypothesis about this low hypothesis. And in this paper, that is from 2017, we try to hypothesize how these waves that are produced in the brain during the be stimulation not only replicate, but they multiply by 30, 40, the number of Delta wave that you have during the sleep.
Marco Pagani, MD, Ph.D. (14:33):
So this might be the reason because EMDR works so rapidly, but this implies another background. That the background is the physiology of memory. And not many people, because when I give courses, when I give lessons -- university, or, these conferences -- a lot of people do not have any idea how our memory works, how we store information. And actually, if you go into a physiology book, or if you read paper focused on that, you understand that the memory that we retain during our whole life has been built up during the sleep
Marco Pagani, MD, Ph.D. (15:26):
And the origin of this memory process are these slow Delta waves that originate from the same point in our cortex, from, from which the original information originated, then they move. I mean, the information move to the hippocampus that everybody knows that is there is the region in which the working memory is positioned. And then during the night, during this low wave sleep phase of the sleep, the information travels, moves from theca to the cortex.
Marco Pagani, MD, Ph.D. (16:14):
The problem with PTSD posttraumatic stress disorder is that the PTSD is a disturbance of memory. You have the memory of the event, but you cannot process. You cannot contextualize the memory of the event. So all that means that the memory pathologically sits in the hippo and in the amygdala, and does not move to the cortex in which, I mean, can be cognitive eyes or whatever you want to see. I mean, in which you, you put this bad memory in your books, she, and then you have, so with the help in this, during the night with the help of this slow sleep, the memory travels to the cortex and this movement, I mean, this travel is prevented by a short circuit that happens in the middle depo. That is the core of PTSD. Mm. So by stimulating slow waves to originate during bilateral stimulation. Yeah. What you do is just replicate what happens during the sleep, and to accelerate the possibility that the slow waves that appear three, four times during the night move your bad memory to the cortex. And this is from the experience of therapists, that state that sometimes during therapy, I mean, immediately the client gets rid of the bad memory. Yeah. And finally, it's free of trauma traumatization.
Keith Sutton, Psy.D. (18:12):
Let me see if I'm getting this right. So it's actually interesting. I was just watching a Netflix show. It's like an entertainment show on a hundred humans where they kind of do very MIS experiments and kind of reality show, but it's, but they talked about this in the memory about how important sleep is to memory and consolidation of memory. And yeah. That fits exactly what my con conceptualization of trauma that it's like puzzle pieces that haven't been put together and filed away. It's stuck like a log jam in the river or so on. So that's why the trauma kind of never gets processed. Is that right? That it's kind of that,
Marco Pagani, MD, Ph.D. (18:48):
Yeah, actually actually, something very physiologically, something that really comes from the basic neurophysiology memory. ,the basic neurophysiology of memory states that when in any event, in this case, a traumatic event travels from the, I mean, neuro region in the cortex, from where it originates, let's say we have image from the visual cortex or something from the associative cortex, for example, somato motor area gets into the middle. If, if this event is overwhelming, I mean, it's too much for, for what you can bear. The number of neurotransmitters that reach the amygdala are in excess. And then the amygdala is a hyper deed is an electric event.
Marco Pagani, MD, Ph.D. (19:51):
Like in, in your home, if you now switch on washing machine, dishwasher, air conditioning and the, and whatever you have electrical together, what's going on. Yeah, exactly. The fuses go go. And then you have this short circuit that impedes, I mean, prevents any light to be switched on. This is exactly what is going on in the amygdala when an excessive neurotransmitters coming from a very bad trauma gets into the amygdala then the Agram. That is a number of connection between neurons that represents the event.just sits there without any possibility to be, so then you need somebody that goes into diffuse changes, diffuse. Or, just lowers the lever and then you have light again. And this could be one of the mechanisms that this could happen is that, of course is a slow wave sleep. Yeah. All these low waves in general.
Keith Sutton, Psy.D. (21:01):
Now I'm wondering with the slow wave of sleep, cuz I, I know that one of the explanations of EMDR is that it's tapping into the processes of REM sleep, rapid eye movement and is slow wave sleep part of that REM wait, or, or is that part of–
Marco Pagani, MD, Ph.D. (21:17):
Sleep? No, no, that is a, that is a whole, this is an ancient story. Ah, it works like this. If you have a memory, the memory moves to the let's assume irrespectively whether the memory is stuck into the, or will move backwards after Zoe lived to the cortex. The moment in which the memory will retained in long term memory is during REM so slow wave. I mean, the event moves the memory into the amygdala during the night, the slow wave moves the memory back to the cortex.
Marco Pagani, MD, Ph.D. (22:05):
And during the phase of sleep, the REM sleep rip Thai movement. That is the phase in which the memory that has moved back will be retained because in that moment will happen that okay. Together with other waves coming from the autonomous.
Keith Sutton, Psy.D. (22:23):
Yeah.
Marco Pagani, MD, Ph.D. (22:24):
There is an epigenetic mechanism, epigenetic mechanism in which the neurons produce new connections between the then rights, modern neurons and these new connections during the re sleep, they will represent the memory forever.
Keith Sutton, Psy.D. (22:42):
Okay. That's what your–
Marco Pagani, MD, Ph.D. (22:44):
Exactly. The first phase, the first phase is the wave, move the memory from the hippocampus, go back to the cortex REM sleep and then fixation of the memory. Interesting. This is how it works. So this is why it was a thought that it, that actually the main actor was the REM sleep, but actually the, the initial actor of this play is the there always,
Keith Sutton, Psy.D. (23:11):
No, do you-- I know there's another theory too, around kind of working memory and almost like, like the, the being like a whiteboard and kind of holding this in mind while the bilateral stimulation.
Marco Pagani, MD, Ph.D. (23:23):
Exactly. I mean, this is another theory that actually has been by now in terms of neurobiology, neurophysiology proven only on healthy controls. I mean, I think just one study came out in which they use patients, but this principle is not very much different because what they state is that the bad memory is stuck into the omega or into the, let's say the complex hippocampus is sub-cortical in order to make this memory diluted in a way,
Marco Pagani, MD, Ph.D. (24:08):
Let's make a kind of a metaphor. You have a glass of very, very strong whiskey. Sure. And you're not able to swallow it because it's too much for your throat. I mean, you cannot stand the strong taste of the whiskey. What you do is you just headwater. And when the adding water, this whiskey is diluted, it's the same, the memory will be diluted if during the moment in which you concentrate, or you photos, yourself on the memory, you are distracted by something else. So if your working memory, in a sense, goes into two different directions is distracted.
Keith Sutton, Psy.D. (24:53):
Yeah.
Marco Pagani, MD, Ph.D. (24:54):
By some other event, since the working memory, the assumption of the touch that have like they support is working memory working memory theory. the working memory has a limited space
Marco Pagani, MD, Ph.D. (25:08):
So if you occupy completely this space with the trauma image or whiskey, very strong whiskey, you want to move the memory, but if you occupy this working memory space they have the visual sketchpad, the auditory sketch pad and things like this well, this increases the likelihood for the memory to move. And so it's, it is another theory. There is another theory that I appreciate very much is the theory about orienting, orienting response, that in a way something similar, because the high movements orient your, your attention to something that distracts you from the trauma. But about, I dunno if you have any question, because then I want to mention another fantastic study that was published on nature. Sure. Last year.
Keith Sutton, Psy.D. (26:04):
Well, so if a couple things one I don't know if you've heard of the flash technique at all. I also, for my podcast interviewed Bill Mansfield and was really interested too. And because I, I learned of his flash technique kind of in the beginning. And it's evolved since then. And it was kind of interesting you saying that really they're not even going into the memory very much, even at all. So I thought that was one thing I was wondering about another thing too. I mean, I don't know much at this, again, this is another thing I've heard of, but not gone into as much, but I know that I think Bessel van der Kolk is doing some neurofeedback work with trauma. And I was wondering if that also kind of affects the waves that you were mentioning about those slow waves, if that's a similar mechanism or if you even know about that Delta stimulation piece, if that plays in there.
Keith Sutton, Psy.D. (26:52):
And I guess just to put all my things out there, I think the other thing is just, I know for my experience with doing EMDR versus I've, I've only done prolonged exposure with one client, I'm not steeped in that, but what I always found with EMDR is that I oftentimes, I think about it as a puzzle piece, the verbal, the non-verbal, or like one client I was working with, I stopped the bilateral stimulation. I said, what's going on for you now? I said, I'm feeling really cold. And I said, okay, go with that. I had no idea what that had to do with anything. I thought maybe it's cold in here or something. And then I did another set of bilateral stimulation, and then I stopped and I said, what's going on for you now? And he goes, oh, I'm remembering after my uncle had abused me, he dropped me on the floor in the bathroom and the tile was cold.
Keith Sutton, Psy.D. (27:37):
And just that aspect of kind of the somatic, the verbal, the non-verbal, the putting all those pieces. Or I just felt like, I, I don't know if I would've gotten that from just telling the story over and over again and kind of exposure or so on, or even just that same client, actually later when we went back to the target at the end, I said zero to 10, where it's at at. And he said, it's at, it's at a zero now, but that image now, and he was an artist, he said that image I see is actually just one image in a million images that make up a mosaic self-portrait of myself. And I realize that moment is just a small part of who I am and there's millions of different moments that make up who I am. And it was just such an incredible visual image. And, of course we went and processed that. But yeah, just these things that I kind of have experienced with clients with EMDR in this kind of visual, or sometimes when they're connecting that kind of adult knowledge with that child knowledge, it's just yeah, it's incredible. It's just interested in any thoughts on that from a neuro biological perspective of like how, how all those kind of different and pieces, and I'm sure you've seen this in the research when you're doing the research on the subjects of kind of–
Marco Pagani, MD, Ph.D. (28:51):
I'd say it's very, it's very interesting what you say, because, we published four or five different studies with the EEG in populations that are completely different from each other population, with people that have been abused, traffic accidents people that witnessed the suicide of the partners or people that were suffering , the lost grief of losing people in earthquakes or people with breast cancer. I mean, if you, if you go through my publications, you can find everything. And what is really incredible was that at the end of the game, when the therapy was successful, coming back to what you say, the region of the brain that activated once the client was relieving the experience in the, exactly the same way in which was relieving before therapy, this activates region in the left cortex, that among neuroscientists is well known to be the multimedia association cortex. It's an association cortex to which, as a final, you say final, in English.
Keith Sutton, Psy.D. (30:11):
Yeah. The final
Marco Pagani, MD, Ph.D. (30:14):
Funnel, funnel, like, the one that you use with the bottles.
Keith Sutton, Psy.D. (30:16):
Oh, like a funnel. Yes. Uhhuh
Marco Pagani, MD, Ph.D. (30:18):
Funnel. Okay. Okay. Well funnel, yeah. It depends on the pronation in which, as a funnel. I mean, as you say, the sensations come from visual cortex, auditory cortex, some of the sensory cortex association cortex, and they join altogether in this image that is like one of your books behind the, in the bookshelves behind you. Yeah. And then he's just contextualize in the memory of the individual. So this is what's going on in my opinion, because otherwise would be absolutely impossible that in hundreds of different people with different traumas, the end of the therapy activates always exactly the same region.
Marco Pagani, MD, Ph.D. (31:05):
So it's something that is reinforces the reliability of the studies. Right.
Keith Sutton, Psy.D. (31:10):
So like putting all those puzzle pieces together, the verbal
Marco Pagani, MD, Ph.D. (31:13):
Yeah. But about yes, exactly. Exactly. Yes. Yes. And about what you were mentioning before, that is what actually most is of most, the major interest of psychotherapists when I give you courses or whatever his whether other types of stimulation would work or not
Marco Pagani, MD, Ph.D. (31:38):
Fixation point or flash or no movements only, the, the eight steps without, bilateral stimulation–
Keith Sutton, Psy.D. (31:47):
Yeah. That's what I've wondered.
Marco Pagani, MD, Ph.D. (31:49):
Well, in this respect, I mean, there is this very interesting paper that has been written by a group of Koreans by these shim. I don't never know whether they put first the surname or the Christian name. I mean, it's Jean, she, I don't know. And they, they replicate, it's very difficult to be read because you have to be in the business.
Marco Pagani, MD, Ph.D. (32:17):
But the replicated is replicated in mice. Exactly. The same conditions that you have in a therapy room when you deal with the IP person that you and traumatized.
Keith Sutton, Psy.D. (32:30):
Yeah.
Marco Pagani, MD, Ph.D. (32:31):
So, well, the reason because they use mice is because believe it or not, we have more than 90% of our genes are common with mice and in some particular let's say part not only of the brain, but even in terms of behavior, we have 99% of genes are common with mice, For example, hormonal, the, the General speaking. I mean, no, I don't want to overload people with protecting, but we have a very much common genetic.
Keith Sutton, Psy.D. (33:15):
Yeah.
Marco Pagani, MD, Ph.D. (33:16):
Genes in common with mice. So they use Marist, they traumatized the mice and then they put mice in another environment. And then they tried to detox in a way, I mean, to reduce the traumat traumatization of mice with the different methods.
Marco Pagani, MD, Ph.D. (33:44):
And to extinguish what is called the extinction of the bad memory.
Keith Sutton, Psy.D. (33:48):
Yeah.
Marco Pagani, MD, Ph.D. (33:49):
And they used, they put the mice in this cage in which they were showing along with the extinction condition in which the mice did not feel anymore. The electric shock, they showed fixed lights, flashing lights, no light or a lead going from left to right height, 180 degrees. And the only condition, the only one that distinguished completely the traumatization in the mic was the bilateral stimulation.
Keith Sutton, Psy.D. (34:27):
Interesting.
Marco Pagani, MD, Ph.D. (34:27):
So this experiment shows definitely that the best method to extinguish the trauma during an exposure therapy is bilateral stimulation.
Keith Sutton, Psy.D. (34:39):
Interesting.
Marco Pagani, MD, Ph.D. (34:40):
So this should, I mean, should make, as we say in Italian, I dunno whether it use the same expression should make justice to alter stimulation. Yeah. Because a lot of other people now they think they have found, for example, the fixation of things like it, but actually this experiment is very clear, is very, very, clear.
Keith Sutton, Psy.D. (35:07):
Yeah. Well, so you were also mentioning that there was some other work that you published in the journal nature. Was that it, or what were you–
Marco Pagani, MD, Ph.D. (35:15):
This work has been published on Nature in 2019, I think 2020, no, 2019. And if you just–
Keith Sutton, Psy.D. (35:25):
Was that the one you were wanting to bring earlier, this study?
Marco Pagani, MD, Ph.D. (35:30):
No, no. This one is a study with mice that was done by the Koreans. And if you just log in EMDR mice nature, it comes, pops up. No, actually I started with, I mean, my, the study that really made me interested in made the difference for myself in, in in the world of EMDR was this article that was published in 2012 on plus one about the neurobiology EMDR, but then another article that, I mean, in which I hypothesize them, the work mechanism is slow. Sleep has been published in the 2017 frontier in psychology, just a few months before the work with the Spanish boys and girls. about the systematic review of the mechanisms of work. I mean, function, function of EMDR.
Keith Sutton, Psy.D. (36:34):
Great. Well, it's wonderful. And how about the any, any knowledge about the neurofeedback and how this might play into the, the Delta way of–
Marco Pagani, MD, Ph.D. (36:45):
Well, Neurofeedback, apparently, I don't know which I mean, I was approached by people that used neurofeedback.
Marco Pagani, MD, Ph.D. (36:54):
And they wanted me to run some experiment, I don't know about the United States.
Keith Sutton, Psy.D. (37:03):
Yeah.
Marco Pagani, MD, Ph.D. (37:04):
But I guess the guy that I was told was the main guy in neurofeedback. He's a Canadian.
Marco Pagani, MD, Ph.D. (37:14):
As far as I understand he's a kind of guru and that the neurofeedback that he delivers and sales for neurofeedback, they are a kind of secret weapon. I mean, nobody knows what is inside and nobody tells so, so this is the main problem for me as a, as a neuroscientist and a neurophysiologist plus it would be very difficult for example, to position some electrodes on the, on the surface of the, of the scalp when some other stimuli electric stimuli is delivered.
Keith Sutton, Psy.D. (37:55):
I see.
Marco Pagani, MD, Ph.D. (37:57):
Anyway, if you have to be honest with everybody that is listening to this podcast would be very simple to write an experiment. I mean, my experiment experiment zero on neuro feedback.
Marco Pagani, MD, Ph.D. (38:14):
For two groups of people, one with neuro feedback and the other group of people laying on a back listening music without any neuro feedback for one hour or, or 30 minutes, and to see which is the real difference between neuro feedback and just listening pleasant music or whatever, and be completely relaxed in a, so that would be an experiment zero, because then you understand whether the neurofeedback adds anything or not. Yeah. Then you can explore what is going on.
Keith Sutton, Psy.D. (38:49):
Yeah. I was wondering, I had one more question about the Amy amygdala and some of the brain science around that. But, and I know we're ending the time. Was there any other pieces that you wanted to add in? Because I want to make sure we get into to all your, before I ask another question.
Marco Pagani, MD, Ph.D. (39:03):
Oh, I have, I have just, whatever we are telling now would be material for one morning course. So it's, it's too many information given in a few minutes, but assume that we know now let's say let's simplify everything. The am is like your home in which when you overload with electricity, just something, some fuse pops up and then the information gets stuck into the, but, but you have three possible chances to free the AMD from the, the first, please–
Keith Sutton, Psy.D. (39:40):
Part, part what I was just wondering too, and this may be some old knowledge or so on. This is something I remember hearing an undergrad and I had asked my neuroscience teacher years later about it too that she had said that the neurons in the amygdala were the only ones that once they made a connection, the connection didn't go away. And I've heard that you, when you are overcoming a phobia or a fear or so on, that you're making new connections to kind of overriding that. But she was saying that, if you had a fear of the dark as a child, you still have a fear of the dark as an adult. That doesn't necessarily, those are the only ones that don't-- not go away, but disconnect or whatever. But I don't know if that's correct. And that's just my 20 year old brain remembering a, a mis–
Marco Pagani, MD, Ph.D. (40:25):
No, no, but you, you have to consider, you have to consider that what is called the Agram. The Agram is the group, is created by a group of neurons that have created connections between each other and they represent neurophysiologically event. So the Ingram, the pathological traumatic Ingram neighbor disappears, it is just over imposed by the new Ingram that you create with your cortex. And that I mean, during this epigenetic mechanism, Uhhuh, and that represents the good vision of the event, let's say the, the process, the, whatever you want to call it, contextualize the cognitive wise vision of the event.
Keith Sutton, Psy.D. (41:23):
Yeah. The new narrative or the new–
Marco Pagani, MD, Ph.D. (41:24):
The new years. I mean, the new Agram superimposes to the old one.
Marco Pagani, MD, Ph.D. (41:32):
And then the memory of the event is not traumatic anymore. But going back to the middle in which you have this short circuit, in which you have your memory confined into the middle, then you have three possibilities.
Marco Pagani, MD, Ph.D. (41:47):
The 97.4 of people is resilient
Marco Pagani, MD, Ph.D. (41:55):
So that implies that some very important signal signals come from the frontal prefrontal cortex. And in the, in the minutes immediately after the event has happened immediately after the traumatized has created this trauma traumatic Agram in the, into the Ming, this connection with the prefrontal cortex helps immediately the, I mean, plugs in again, the Amala to, to the rest of the, okay, so this is the first possibility. The second possibility occurs during the nights after the event, slow wave sleep. 1, 2, 3, 4 nights, and then you are free from the trauma. But then if the PTSD becomes chronic, so if it lasts more than three months, then the third possibility to it, you have to freedom evenly psychotherapy. So you have the very first moment prefrontal cortex during the next days or weeks, slow sleep from the brain, from the cortex. Then when you get a chronic PTSD is psychotherapy, possibly reproducing this low sleep, but is something that has to be.
Keith Sutton, Psy.D. (43:20):
Yeah. Do you, do you have any thoughts on, I know that attachment relationships oftentimes can be a preventative against trauma. I know some of the research around nine 11 and the people that were in secure, close, connected relationships, either with family or with a partner were less like to experience PTSD than those maybe who were disconnected socially or, or support wise. I think–
Marco Pagani, MD, Ph.D. (43:44):
This is a general, this is a general thought about resilience. I mean, the most resilient people are people with good family and social connections, people they have a high level of education. Yeah. People that have for example they take care of themselves in a way, not only mentally, but physically. So the healthier you are physically and socially.
Marco Pagani, MD, Ph.D. (44:14):
Then the more likelihood you have to be resilient to, but this is why, for example, the kids, they have very little resilience because they've not built up yet. ,kind of, social connections. Of course they have the family, but they don't have the level of education that would help them in this, but they cannot cope properly.
Keith Sutton, Psy.D. (44:38):
Yeah. So I think for the last piece, I think before we wrap up here, I think what you were saying about the Amy amygdala and that kind of grouping of neurons and kind of then connecting the new narrative or so on to it. I, I don't know if this made me think about oftentimes what ends up happening in the EMDR that I'm doing. Like oftentimes the person as the adult knows, maybe I've worked with a lot of people they've been into a lot of therapy, different therapists before, and they know cognitively that, they're kind of resolved it or so on. Although emotionally they still get triggered in the present and are reacting dis before to the current situation. because it's triggering that trauma, but it's almost like they're, they're kind of connecting that adult mind with that child mind and kind of once they almost like connect those, then it's like the trauma ends up kind of actually really shifting. And, and I'm wondering if neuro biologically, it's almost like if, if fits kind of that, that grouping in the Amy amygdala is almost separate from that kind of more higher cortical area–
Marco Pagani, MD, Ph.D. (45:37):
The area, the group, the group in the, the amygdala processes, the emotional memories, the hippocampus, that, to which the, anyway, the information of the event gets contemporary to the amygdala processes, the autobiographic value or the episodic value of the event. So it's likely in these people that they have a precise idea in terms of episodic memory or, cognitive memory of, because from the hippocampus, the memory is already freed, but they still have the emotional part in the middle. So it's very clear that these two subcortical structures, they play different roles in memory, in building up the memory. So it could be that in this case of these clients that, I mean, they have a clear vision of the episode, but still they cannot get rid of the emotional part.
Keith Sutton, Psy.D. (46:46):
And so is there a connection that's made between those two in the EMDR and a different way?
Marco Pagani, MD, Ph.D. (46:51):
There is a, well, my, my hypothesis is that once you, you perform the bilateral stimulation, I mean, this is low wave that comes to a brain like a tsunami. They reactivate all connections. Yeah. They like, they free, they free the road from an accident in principle. Yeah. And then they, the memory can go. Yeah. But about the last thing about what we were telling you about the social connections, we run an experiment in a place in which a school collapsed killing 27 kids.
Keith Sutton, Psy.D. (47:29):
Right.
Marco Pagani, MD, Ph.D. (47:29):
And our population on the study were kids that survived or parents that lost kids, but the MD EMDR intervention was made 10 years after the collapse.
Keith Sutton, Psy.D. (47:46):
Wow.
Marco Pagani, MD, Ph.D. (47:47):
And the level of trauma of these people, even they, if they had lost kids or they were, trapped for hours below the, the school, it was much more how you say diluted than for example, people that have been abused because our hypothesis is that during this tenure, like a common trauma and people have been talking so much about that. Yeah. Speak out about experiences, whatever, whereas somebody that is abused usually does not talk to everybody about is abuse or her abuse. Yeah. So even this is social intermingling with other people, especially if other people had the same trauma.
Marco Pagani, MD, Ph.D. (48:34):
Anyway, as you say, possibly,
Marco Pagani, MD, Ph.D. (48:38):
Is therapeutical.
Keith Sutton, Psy.D. (48:40):
Well, yeah. And the way I think about it too, is that like , oftentimes I'm assessing for the level of how much the person's worked on it or what, what extent there's dissociation, cuz somebody that's done a lot out of therapy, talked about this, a lot, talked about it with their current partner husband or wife or whatever it might be oftentimes because they've worked on it so much. The EMDR goes much quicker versus somebody like one of my plans who had been in therapy for 10 years and never talked about the abuse, even with this other person had just buried it so much. And so when she was finally coming up in, in our situation, working on it, there was a lot of work to do because it was a complex trauma and, and dissociation had just kind of buried it away. So yeah, I think that's definitely a piece. And like you're saying with a trauma that affected so many people like the school or like nine 11, there's a lot of room to talk about it. Versus as somebody talking about the abuse they had as a child, which oftentimes they don't, feel comfortable or they don't feel other people can handle or people get uncomfortable if they're talking about or so on. So they stay alone with that until maybe they go to therapy or, or a group therapy or so on.
Keith Sutton, Psy.D. (49:49):
So I really appreciate this. I love of the aspects and really understanding the depths of it. And, and , I really liked in that article too, they talked also about some of the specific differences between C B T and exposure and EMDR and some of the mechanisms, which I thought and goes very much into the neurobio biology. And I really appreciate you simplifying and using the metaphors that was really helpful. I was honking my head somewhat through the article trying to figure out I was like where. And so this is a really illuminating and definitely I recommend to my readers to read this article and, and your other work. Cuz yeah, I think it's , again, for whatever reason in the beginning that people decided EMDR, I, I kind of, came into it in 2007. So I think a bit of the controversy, whenever that came around, when it started kind of, I think left a bad taste in some folks' mouth, but it's really extremely effective and, and just kind of impressive that, that I found. So yeah, really appreciate you taking the time and, and doing this podcast from halfway across the world from here.
Marco Pagani, MD, Ph.D. (50:52):
Okay, it's been very nice talking to you and I hope that I was not too complicated in my, explanation and expression because I, again, I mean all this artwork could have been expanded in a one day course. I mean, to really understand what is behind all this.
Keith Sutton, Psy.D. (51:13):
Yeah.
Marco Pagani, MD, Ph.D. (51:13):
Anyway, thank you very much for inviting me, has been very, very nice.
Keith Sutton, Psy.D. (51:18):
I really appreciate it. Thank you so much for your time. Take care.
Marco Pagani, MD, Ph.D. (51:23):
Okay. Thank you.
Keith Sutton, Psy.D. (51:25):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c)(3) nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (00:38):
Today, I'll be speaking with Marco Pagani, MD, Ph.D., who is a senior researcher at the Institute of cognitive sciences and technologies of the Italian national research council and associate researcher at Karolinska University hospital in Stockholm and at university medical center in Groningen. His work focuses on the physio, pathology of brain perfusion, metabolism, electrical activity, and anatomy applied to neurodegenerative neurological and psychiatric disorders. He has published over 150 papers in peer reviewed journals of which about 40 are related to PTSD. And EMDR. Marco has presented more than 130 communications at international conferences, has given more than a hundred keynotes plenary lectures at international conferences, CME workshops, and courses, and has been awarded three international prizes in the field of neuro imaging. Let's listen to the interview. Hi, Marco. Welcome. Thank you for joining us today.
Marco Pagani, MD, Ph.D. (01:38):
Hi Keith. My pleasure to be with you today.
Keith Sutton, Psy.D. (01:42):
Great. So, I learned about your work. I put together a workshop that I was doing on an introduction to EMDR for the Alameda county psych association here in the bay area. And I was looking for some recent research on EMDR and its mechanisms of action. And you are one of the co-authors of an article: How does eye movement to sensation reprocessing therapy work? A systematic review on suggested mechanisms of actions. And so, I was interested in talking and learning more, because I think this is one of the biggest controversial issues with EMDR about how does it work and there's different theories on this. And, oftentimes a lot of folks that are maybe skeptical of EMDR oftentimes say, oh, well, it's just exposure or so on. So I really love the article and would love to speak more with you about it, but would also love to hear kind of your work and how you got to doing what you're doing now and the thinking and the research and so on. So welcome, love to hear your story.
Marco Pagani, MD, Ph.D. (02:46):
Well, I had a lot of things altogether. I mean, it's not only one topic. I mean, there are several issues in this like introduction question, whatever. First of all, I introduce myself because otherwise people might not really understand what is my role in all this story. I am, let's say, what is called a neuroscientist. I've been working in neuroimaging with all kinds of neuroimaging since 1990 more or less. So now it is like 30 plus years of experience. And I am MD and I work for the Italian research council that is called the CNR.
Marco Pagani, MD, Ph.D. (03:34):
So my interest in the neurobiology of EMDR, because actually I'm not a therapist I'm never, I mean, CMDR, because I'm not a psychologist, I'm not a psychiatrist. As I told you, I deal with neurophysiology basically. And actually it is important to say that my main interest in science is in neurodegenerative disorders. So I started from trying to figure out how to predict not only the outcome, how to predict the evolution of neurodegenerative disorders like Parkinson's. Based on this background. I, well at the moment I live in Sweden, in this beautiful country where the summer is really amazing. I guess the same as in Washington state or Canada, when the summer is nice, it's the best that you can have in life. I was in Stockton because I completed my PhD in Stockton.
Marco Pagani, MD, Ph.D. (04:41):
And then professor of psychiatry asked me whether I wanted to supervise a student of him that actually was, was older than I was, because it was a supervisor in EMDR therapy and he wanted to run a study functional images about EMDR and that was the beginning of the story because in 2007, we published the first paper in which we compared the functional state before and after the EMDR in Metro and train drivers that killed suicidal people. So everything started from that moment. And then I started to continue this vein. Then I went back to Italy where Isabel Fernandez, who now is the president of EMDR Europe contacted me and offered some support to run a new imaging study about the neurobiology of EMDR in the way I was thinking was correct.
Marco Pagani, MD, Ph.D. (06:00):
So we discussed and we started to figure out how to do it in the most ecological way, in a way that will not hamper with more bias the data and the analysis and the, and the therapy itself. So we decided that the EEG electroencephalography would've been the best. So we run the first study, we publish in 2012, the first study ever in which a psychotherapy has been investigating during the occurrence of sector. But there is a realm in which you can see the images of the brain during the bilateral stimulation and in the moment in which the therapist asks to the client to concentrate on the worst image of the trauma. So we base it at the moment, we base not only understanding, but knowledge and, and our research on PTSD of course, on traumatization, because as you know very well now EMDR is used even for other, other pathologies.
Marco Pagani, MD, Ph.D. (07:18):
And actually from that point on, we went on trying to figure out not only on experimental base, but even on let's say on theoretical base. I mean, trying to figure out some hypothesis about the possible work mechanism of EMDR about this is very interesting because, again, I'm not in the field, I'm not, I don't have any conflict of interest. I don't care actually sure about no, no, but I mean, I have my, my source of interest as a scientist is just neurophysiology neuropathology, but it's very interesting because as soon as the EMDR, not some real weight and importance in the world of psychotherapies, I mean, people that were not using EMDR at that moment rose up and say, oh, but what is this EMDR? I mean, nobody knows how it works and nobody knows anything about that. Is it like which, just doing something? And actually at that moment, I was a bit I mean, like surprised because my first question was, okay, let's go. And I look how the other psychotherapy works. Sure. And then it checked, I checked and about the neuro biological mechanisms of CBT or psychodynamic psychotherapy or whatever, I found nothing.
Marco Pagani, MD, Ph.D. (08:56):
For example, the CBT world claims that the EMDR has no neuro biological explanation, but nobody knows at all zero, what is the neuro biological foundation of CBT? So I admit that actually there is an advantage in investigating EMDR because the advantage of investigating EMDR, I mean, almost everybody agrees that the real difference between different exposure therapies like brief exposure therapy or rather exposure therapy and EMDR is the bilateral stimulation combined with the imagination, with the image of the worst moment of the trauma. And that has allowed us to cut the EG during the 45, 50 minutes of therapy yeah. To extract, extract only those let's say slots in which bilateral simulation was performed. So actually we could really identify what was going on in the brain during that special part of the therapy, like during, when bilateral stimulation and focusing on the worst image of the trauma.
Marco Pagani, MD, Ph.D. (10:23):
And that actually is the big advantage on other psychotherapies, because for example, in CBT, what do you record your hour of therapy and then what, what would you extract for the hour of therapy words? Or I don't know what you can do. So that was the, the beginning of the story and the beginning of the story was that I started to to figure out, I mean, why not only the well known parts regions of the brain were activated and then were deactivated after psychotherapy because going I mean, just traveling the, the literature, you could see that even CBT, or other therapies, they made a lot of studies. What, what is going on before and after therapy. But my interest was, I mean, the first idea as a curious scientist was outcomes that on average EMDR therapy, I mean, to solve single traumas, six all sessions CBT takes some months and psychodynamic therapy takes a new, so there must be something that impacts on the time.
Marco Pagani, MD, Ph.D. (11:50):
Yeah. Why, why EMDR is faster than other therapies reaching in the end of the game the same result. So we went again through our files and we wanted to see what was going on in the brain in terms of waves that were recorded by, by the electroencephalography. And then I went to check the international literature about bilateral stimulation and cerebral waves. And then I found out what was for me, a very fundamental paper from nine, 2009 from the group of heart on Traumatology. And this paper describes very, very well how the brain waves, the Delta waves, actually the waves that are the low waves fear in the brain during Malo stimulation are very much alike. The waves that appear during the first phase of the sleep during the, this low wave sleep.
Marco Pagani, MD, Ph.D. (13:06):
Yeah. Then from that point on, we went backwards. And actually, we, we confirmed in our experiments that during the bilateral simulation, the old brain, all electrodes when the inter resonance and produced Delta waves, slow waves. And then from that point we, I mean, we generated the hypothesis is that the EMDR works because it replicates the Delta waves that appear during the sleep and the region, because it might, this is my hypothesis. I mean, you, you are mentioning a paper that I wrote with the, with the Spanish guy, with the Benedict in Aon , but previously, and, and in SAR, we, and BEIC as well, we produced another paper that was focused on our hypothesis about this low hypothesis. And in this paper, that is from 2017, we try to hypothesize how these waves that are produced in the brain during the be stimulation not only replicate, but they multiply by 30, 40, the number of Delta wave that you have during the sleep.
Marco Pagani, MD, Ph.D. (14:33):
So this might be the reason because EMDR works so rapidly, but this implies another background. That the background is the physiology of memory. And not many people, because when I give courses, when I give lessons -- university, or, these conferences -- a lot of people do not have any idea how our memory works, how we store information. And actually, if you go into a physiology book, or if you read paper focused on that, you understand that the memory that we retain during our whole life has been built up during the sleep
Marco Pagani, MD, Ph.D. (15:26):
And the origin of this memory process are these slow Delta waves that originate from the same point in our cortex, from, from which the original information originated, then they move. I mean, the information move to the hippocampus that everybody knows that is there is the region in which the working memory is positioned. And then during the night, during this low wave sleep phase of the sleep, the information travels, moves from theca to the cortex.
Marco Pagani, MD, Ph.D. (16:14):
The problem with PTSD posttraumatic stress disorder is that the PTSD is a disturbance of memory. You have the memory of the event, but you cannot process. You cannot contextualize the memory of the event. So all that means that the memory pathologically sits in the hippo and in the amygdala, and does not move to the cortex in which, I mean, can be cognitive eyes or whatever you want to see. I mean, in which you, you put this bad memory in your books, she, and then you have, so with the help in this, during the night with the help of this slow sleep, the memory travels to the cortex and this movement, I mean, this travel is prevented by a short circuit that happens in the middle depo. That is the core of PTSD. Mm. So by stimulating slow waves to originate during bilateral stimulation. Yeah. What you do is just replicate what happens during the sleep, and to accelerate the possibility that the slow waves that appear three, four times during the night move your bad memory to the cortex. And this is from the experience of therapists, that state that sometimes during therapy, I mean, immediately the client gets rid of the bad memory. Yeah. And finally, it's free of trauma traumatization.
Keith Sutton, Psy.D. (18:12):
Let me see if I'm getting this right. So it's actually interesting. I was just watching a Netflix show. It's like an entertainment show on a hundred humans where they kind of do very MIS experiments and kind of reality show, but it's, but they talked about this in the memory about how important sleep is to memory and consolidation of memory. And yeah. That fits exactly what my con conceptualization of trauma that it's like puzzle pieces that haven't been put together and filed away. It's stuck like a log jam in the river or so on. So that's why the trauma kind of never gets processed. Is that right? That it's kind of that,
Marco Pagani, MD, Ph.D. (18:48):
Yeah, actually actually, something very physiologically, something that really comes from the basic neurophysiology memory. ,the basic neurophysiology of memory states that when in any event, in this case, a traumatic event travels from the, I mean, neuro region in the cortex, from where it originates, let's say we have image from the visual cortex or something from the associative cortex, for example, somato motor area gets into the middle. If, if this event is overwhelming, I mean, it's too much for, for what you can bear. The number of neurotransmitters that reach the amygdala are in excess. And then the amygdala is a hyper deed is an electric event.
Marco Pagani, MD, Ph.D. (19:51):
Like in, in your home, if you now switch on washing machine, dishwasher, air conditioning and the, and whatever you have electrical together, what's going on. Yeah, exactly. The fuses go go. And then you have this short circuit that impedes, I mean, prevents any light to be switched on. This is exactly what is going on in the amygdala when an excessive neurotransmitters coming from a very bad trauma gets into the amygdala then the Agram. That is a number of connection between neurons that represents the event.just sits there without any possibility to be, so then you need somebody that goes into diffuse changes, diffuse. Or, just lowers the lever and then you have light again. And this could be one of the mechanisms that this could happen is that, of course is a slow wave sleep. Yeah. All these low waves in general.
Keith Sutton, Psy.D. (21:01):
Now I'm wondering with the slow wave of sleep, cuz I, I know that one of the explanations of EMDR is that it's tapping into the processes of REM sleep, rapid eye movement and is slow wave sleep part of that REM wait, or, or is that part of–
Marco Pagani, MD, Ph.D. (21:17):
Sleep? No, no, that is a, that is a whole, this is an ancient story. Ah, it works like this. If you have a memory, the memory moves to the let's assume irrespectively whether the memory is stuck into the, or will move backwards after Zoe lived to the cortex. The moment in which the memory will retained in long term memory is during REM so slow wave. I mean, the event moves the memory into the amygdala during the night, the slow wave moves the memory back to the cortex.
Marco Pagani, MD, Ph.D. (22:05):
And during the phase of sleep, the REM sleep rip Thai movement. That is the phase in which the memory that has moved back will be retained because in that moment will happen that okay. Together with other waves coming from the autonomous.
Keith Sutton, Psy.D. (22:23):
Yeah.
Marco Pagani, MD, Ph.D. (22:24):
There is an epigenetic mechanism, epigenetic mechanism in which the neurons produce new connections between the then rights, modern neurons and these new connections during the re sleep, they will represent the memory forever.
Keith Sutton, Psy.D. (22:42):
Okay. That's what your–
Marco Pagani, MD, Ph.D. (22:44):
Exactly. The first phase, the first phase is the wave, move the memory from the hippocampus, go back to the cortex REM sleep and then fixation of the memory. Interesting. This is how it works. So this is why it was a thought that it, that actually the main actor was the REM sleep, but actually the, the initial actor of this play is the there always,
Keith Sutton, Psy.D. (23:11):
No, do you-- I know there's another theory too, around kind of working memory and almost like, like the, the being like a whiteboard and kind of holding this in mind while the bilateral stimulation.
Marco Pagani, MD, Ph.D. (23:23):
Exactly. I mean, this is another theory that actually has been by now in terms of neurobiology, neurophysiology proven only on healthy controls. I mean, I think just one study came out in which they use patients, but this principle is not very much different because what they state is that the bad memory is stuck into the omega or into the, let's say the complex hippocampus is sub-cortical in order to make this memory diluted in a way,
Marco Pagani, MD, Ph.D. (24:08):
Let's make a kind of a metaphor. You have a glass of very, very strong whiskey. Sure. And you're not able to swallow it because it's too much for your throat. I mean, you cannot stand the strong taste of the whiskey. What you do is you just headwater. And when the adding water, this whiskey is diluted, it's the same, the memory will be diluted if during the moment in which you concentrate, or you photos, yourself on the memory, you are distracted by something else. So if your working memory, in a sense, goes into two different directions is distracted.
Keith Sutton, Psy.D. (24:53):
Yeah.
Marco Pagani, MD, Ph.D. (24:54):
By some other event, since the working memory, the assumption of the touch that have like they support is working memory working memory theory. the working memory has a limited space
Marco Pagani, MD, Ph.D. (25:08):
So if you occupy completely this space with the trauma image or whiskey, very strong whiskey, you want to move the memory, but if you occupy this working memory space they have the visual sketchpad, the auditory sketch pad and things like this well, this increases the likelihood for the memory to move. And so it's, it is another theory. There is another theory that I appreciate very much is the theory about orienting, orienting response, that in a way something similar, because the high movements orient your, your attention to something that distracts you from the trauma. But about, I dunno if you have any question, because then I want to mention another fantastic study that was published on nature. Sure. Last year.
Keith Sutton, Psy.D. (26:04):
Well, so if a couple things one I don't know if you've heard of the flash technique at all. I also, for my podcast interviewed Bill Mansfield and was really interested too. And because I, I learned of his flash technique kind of in the beginning. And it's evolved since then. And it was kind of interesting you saying that really they're not even going into the memory very much, even at all. So I thought that was one thing I was wondering about another thing too. I mean, I don't know much at this, again, this is another thing I've heard of, but not gone into as much, but I know that I think Bessel van der Kolk is doing some neurofeedback work with trauma. And I was wondering if that also kind of affects the waves that you were mentioning about those slow waves, if that's a similar mechanism or if you even know about that Delta stimulation piece, if that plays in there.
Keith Sutton, Psy.D. (26:52):
And I guess just to put all my things out there, I think the other thing is just, I know for my experience with doing EMDR versus I've, I've only done prolonged exposure with one client, I'm not steeped in that, but what I always found with EMDR is that I oftentimes, I think about it as a puzzle piece, the verbal, the non-verbal, or like one client I was working with, I stopped the bilateral stimulation. I said, what's going on for you now? I said, I'm feeling really cold. And I said, okay, go with that. I had no idea what that had to do with anything. I thought maybe it's cold in here or something. And then I did another set of bilateral stimulation, and then I stopped and I said, what's going on for you now? And he goes, oh, I'm remembering after my uncle had abused me, he dropped me on the floor in the bathroom and the tile was cold.
Keith Sutton, Psy.D. (27:37):
And just that aspect of kind of the somatic, the verbal, the non-verbal, the putting all those pieces. Or I just felt like, I, I don't know if I would've gotten that from just telling the story over and over again and kind of exposure or so on, or even just that same client, actually later when we went back to the target at the end, I said zero to 10, where it's at at. And he said, it's at, it's at a zero now, but that image now, and he was an artist, he said that image I see is actually just one image in a million images that make up a mosaic self-portrait of myself. And I realize that moment is just a small part of who I am and there's millions of different moments that make up who I am. And it was just such an incredible visual image. And, of course we went and processed that. But yeah, just these things that I kind of have experienced with clients with EMDR in this kind of visual, or sometimes when they're connecting that kind of adult knowledge with that child knowledge, it's just yeah, it's incredible. It's just interested in any thoughts on that from a neuro biological perspective of like how, how all those kind of different and pieces, and I'm sure you've seen this in the research when you're doing the research on the subjects of kind of–
Marco Pagani, MD, Ph.D. (28:51):
I'd say it's very, it's very interesting what you say, because, we published four or five different studies with the EEG in populations that are completely different from each other population, with people that have been abused, traffic accidents people that witnessed the suicide of the partners or people that were suffering , the lost grief of losing people in earthquakes or people with breast cancer. I mean, if you, if you go through my publications, you can find everything. And what is really incredible was that at the end of the game, when the therapy was successful, coming back to what you say, the region of the brain that activated once the client was relieving the experience in the, exactly the same way in which was relieving before therapy, this activates region in the left cortex, that among neuroscientists is well known to be the multimedia association cortex. It's an association cortex to which, as a final, you say final, in English.
Keith Sutton, Psy.D. (30:11):
Yeah. The final
Marco Pagani, MD, Ph.D. (30:14):
Funnel, funnel, like, the one that you use with the bottles.
Keith Sutton, Psy.D. (30:16):
Oh, like a funnel. Yes. Uhhuh
Marco Pagani, MD, Ph.D. (30:18):
Funnel. Okay. Okay. Well funnel, yeah. It depends on the pronation in which, as a funnel. I mean, as you say, the sensations come from visual cortex, auditory cortex, some of the sensory cortex association cortex, and they join altogether in this image that is like one of your books behind the, in the bookshelves behind you. Yeah. And then he's just contextualize in the memory of the individual. So this is what's going on in my opinion, because otherwise would be absolutely impossible that in hundreds of different people with different traumas, the end of the therapy activates always exactly the same region.
Marco Pagani, MD, Ph.D. (31:05):
So it's something that is reinforces the reliability of the studies. Right.
Keith Sutton, Psy.D. (31:10):
So like putting all those puzzle pieces together, the verbal
Marco Pagani, MD, Ph.D. (31:13):
Yeah. But about yes, exactly. Exactly. Yes. Yes. And about what you were mentioning before, that is what actually most is of most, the major interest of psychotherapists when I give you courses or whatever his whether other types of stimulation would work or not
Marco Pagani, MD, Ph.D. (31:38):
Fixation point or flash or no movements only, the, the eight steps without, bilateral stimulation–
Keith Sutton, Psy.D. (31:47):
Yeah. That's what I've wondered.
Marco Pagani, MD, Ph.D. (31:49):
Well, in this respect, I mean, there is this very interesting paper that has been written by a group of Koreans by these shim. I don't never know whether they put first the surname or the Christian name. I mean, it's Jean, she, I don't know. And they, they replicate, it's very difficult to be read because you have to be in the business.
Marco Pagani, MD, Ph.D. (32:17):
But the replicated is replicated in mice. Exactly. The same conditions that you have in a therapy room when you deal with the IP person that you and traumatized.
Keith Sutton, Psy.D. (32:30):
Yeah.
Marco Pagani, MD, Ph.D. (32:31):
So, well, the reason because they use mice is because believe it or not, we have more than 90% of our genes are common with mice and in some particular let's say part not only of the brain, but even in terms of behavior, we have 99% of genes are common with mice, For example, hormonal, the, the General speaking. I mean, no, I don't want to overload people with protecting, but we have a very much common genetic.
Keith Sutton, Psy.D. (33:15):
Yeah.
Marco Pagani, MD, Ph.D. (33:16):
Genes in common with mice. So they use Marist, they traumatized the mice and then they put mice in another environment. And then they tried to detox in a way, I mean, to reduce the traumat traumatization of mice with the different methods.
Marco Pagani, MD, Ph.D. (33:44):
And to extinguish what is called the extinction of the bad memory.
Keith Sutton, Psy.D. (33:48):
Yeah.
Marco Pagani, MD, Ph.D. (33:49):
And they used, they put the mice in this cage in which they were showing along with the extinction condition in which the mice did not feel anymore. The electric shock, they showed fixed lights, flashing lights, no light or a lead going from left to right height, 180 degrees. And the only condition, the only one that distinguished completely the traumatization in the mic was the bilateral stimulation.
Keith Sutton, Psy.D. (34:27):
Interesting.
Marco Pagani, MD, Ph.D. (34:27):
So this experiment shows definitely that the best method to extinguish the trauma during an exposure therapy is bilateral stimulation.
Keith Sutton, Psy.D. (34:39):
Interesting.
Marco Pagani, MD, Ph.D. (34:40):
So this should, I mean, should make, as we say in Italian, I dunno whether it use the same expression should make justice to alter stimulation. Yeah. Because a lot of other people now they think they have found, for example, the fixation of things like it, but actually this experiment is very clear, is very, very, clear.
Keith Sutton, Psy.D. (35:07):
Yeah. Well, so you were also mentioning that there was some other work that you published in the journal nature. Was that it, or what were you–
Marco Pagani, MD, Ph.D. (35:15):
This work has been published on Nature in 2019, I think 2020, no, 2019. And if you just–
Keith Sutton, Psy.D. (35:25):
Was that the one you were wanting to bring earlier, this study?
Marco Pagani, MD, Ph.D. (35:30):
No, no. This one is a study with mice that was done by the Koreans. And if you just log in EMDR mice nature, it comes, pops up. No, actually I started with, I mean, my, the study that really made me interested in made the difference for myself in, in in the world of EMDR was this article that was published in 2012 on plus one about the neurobiology EMDR, but then another article that, I mean, in which I hypothesize them, the work mechanism is slow. Sleep has been published in the 2017 frontier in psychology, just a few months before the work with the Spanish boys and girls. about the systematic review of the mechanisms of work. I mean, function, function of EMDR.
Keith Sutton, Psy.D. (36:34):
Great. Well, it's wonderful. And how about the any, any knowledge about the neurofeedback and how this might play into the, the Delta way of–
Marco Pagani, MD, Ph.D. (36:45):
Well, Neurofeedback, apparently, I don't know which I mean, I was approached by people that used neurofeedback.
Marco Pagani, MD, Ph.D. (36:54):
And they wanted me to run some experiment, I don't know about the United States.
Keith Sutton, Psy.D. (37:03):
Yeah.
Marco Pagani, MD, Ph.D. (37:04):
But I guess the guy that I was told was the main guy in neurofeedback. He's a Canadian.
Marco Pagani, MD, Ph.D. (37:14):
As far as I understand he's a kind of guru and that the neurofeedback that he delivers and sales for neurofeedback, they are a kind of secret weapon. I mean, nobody knows what is inside and nobody tells so, so this is the main problem for me as a, as a neuroscientist and a neurophysiologist plus it would be very difficult for example, to position some electrodes on the, on the surface of the, of the scalp when some other stimuli electric stimuli is delivered.
Keith Sutton, Psy.D. (37:55):
I see.
Marco Pagani, MD, Ph.D. (37:57):
Anyway, if you have to be honest with everybody that is listening to this podcast would be very simple to write an experiment. I mean, my experiment experiment zero on neuro feedback.
Marco Pagani, MD, Ph.D. (38:14):
For two groups of people, one with neuro feedback and the other group of people laying on a back listening music without any neuro feedback for one hour or, or 30 minutes, and to see which is the real difference between neuro feedback and just listening pleasant music or whatever, and be completely relaxed in a, so that would be an experiment zero, because then you understand whether the neurofeedback adds anything or not. Yeah. Then you can explore what is going on.
Keith Sutton, Psy.D. (38:49):
Yeah. I was wondering, I had one more question about the Amy amygdala and some of the brain science around that. But, and I know we're ending the time. Was there any other pieces that you wanted to add in? Because I want to make sure we get into to all your, before I ask another question.
Marco Pagani, MD, Ph.D. (39:03):
Oh, I have, I have just, whatever we are telling now would be material for one morning course. So it's, it's too many information given in a few minutes, but assume that we know now let's say let's simplify everything. The am is like your home in which when you overload with electricity, just something, some fuse pops up and then the information gets stuck into the, but, but you have three possible chances to free the AMD from the, the first, please–
Keith Sutton, Psy.D. (39:40):
Part, part what I was just wondering too, and this may be some old knowledge or so on. This is something I remember hearing an undergrad and I had asked my neuroscience teacher years later about it too that she had said that the neurons in the amygdala were the only ones that once they made a connection, the connection didn't go away. And I've heard that you, when you are overcoming a phobia or a fear or so on, that you're making new connections to kind of overriding that. But she was saying that, if you had a fear of the dark as a child, you still have a fear of the dark as an adult. That doesn't necessarily, those are the only ones that don't-- not go away, but disconnect or whatever. But I don't know if that's correct. And that's just my 20 year old brain remembering a, a mis–
Marco Pagani, MD, Ph.D. (40:25):
No, no, but you, you have to consider, you have to consider that what is called the Agram. The Agram is the group, is created by a group of neurons that have created connections between each other and they represent neurophysiologically event. So the Ingram, the pathological traumatic Ingram neighbor disappears, it is just over imposed by the new Ingram that you create with your cortex. And that I mean, during this epigenetic mechanism, Uhhuh, and that represents the good vision of the event, let's say the, the process, the, whatever you want to call it, contextualize the cognitive wise vision of the event.
Keith Sutton, Psy.D. (41:23):
Yeah. The new narrative or the new–
Marco Pagani, MD, Ph.D. (41:24):
The new years. I mean, the new Agram superimposes to the old one.
Marco Pagani, MD, Ph.D. (41:32):
And then the memory of the event is not traumatic anymore. But going back to the middle in which you have this short circuit, in which you have your memory confined into the middle, then you have three possibilities.
Marco Pagani, MD, Ph.D. (41:47):
The 97.4 of people is resilient
Marco Pagani, MD, Ph.D. (41:55):
So that implies that some very important signal signals come from the frontal prefrontal cortex. And in the, in the minutes immediately after the event has happened immediately after the traumatized has created this trauma traumatic Agram in the, into the Ming, this connection with the prefrontal cortex helps immediately the, I mean, plugs in again, the Amala to, to the rest of the, okay, so this is the first possibility. The second possibility occurs during the nights after the event, slow wave sleep. 1, 2, 3, 4 nights, and then you are free from the trauma. But then if the PTSD becomes chronic, so if it lasts more than three months, then the third possibility to it, you have to freedom evenly psychotherapy. So you have the very first moment prefrontal cortex during the next days or weeks, slow sleep from the brain, from the cortex. Then when you get a chronic PTSD is psychotherapy, possibly reproducing this low sleep, but is something that has to be.
Keith Sutton, Psy.D. (43:20):
Yeah. Do you, do you have any thoughts on, I know that attachment relationships oftentimes can be a preventative against trauma. I know some of the research around nine 11 and the people that were in secure, close, connected relationships, either with family or with a partner were less like to experience PTSD than those maybe who were disconnected socially or, or support wise. I think–
Marco Pagani, MD, Ph.D. (43:44):
This is a general, this is a general thought about resilience. I mean, the most resilient people are people with good family and social connections, people they have a high level of education. Yeah. People that have for example they take care of themselves in a way, not only mentally, but physically. So the healthier you are physically and socially.
Marco Pagani, MD, Ph.D. (44:14):
Then the more likelihood you have to be resilient to, but this is why, for example, the kids, they have very little resilience because they've not built up yet. ,kind of, social connections. Of course they have the family, but they don't have the level of education that would help them in this, but they cannot cope properly.
Keith Sutton, Psy.D. (44:38):
Yeah. So I think for the last piece, I think before we wrap up here, I think what you were saying about the Amy amygdala and that kind of grouping of neurons and kind of then connecting the new narrative or so on to it. I, I don't know if this made me think about oftentimes what ends up happening in the EMDR that I'm doing. Like oftentimes the person as the adult knows, maybe I've worked with a lot of people they've been into a lot of therapy, different therapists before, and they know cognitively that, they're kind of resolved it or so on. Although emotionally they still get triggered in the present and are reacting dis before to the current situation. because it's triggering that trauma, but it's almost like they're, they're kind of connecting that adult mind with that child mind and kind of once they almost like connect those, then it's like the trauma ends up kind of actually really shifting. And, and I'm wondering if neuro biologically, it's almost like if, if fits kind of that, that grouping in the Amy amygdala is almost separate from that kind of more higher cortical area–
Marco Pagani, MD, Ph.D. (45:37):
The area, the group, the group in the, the amygdala processes, the emotional memories, the hippocampus, that, to which the, anyway, the information of the event gets contemporary to the amygdala processes, the autobiographic value or the episodic value of the event. So it's likely in these people that they have a precise idea in terms of episodic memory or, cognitive memory of, because from the hippocampus, the memory is already freed, but they still have the emotional part in the middle. So it's very clear that these two subcortical structures, they play different roles in memory, in building up the memory. So it could be that in this case of these clients that, I mean, they have a clear vision of the episode, but still they cannot get rid of the emotional part.
Keith Sutton, Psy.D. (46:46):
And so is there a connection that's made between those two in the EMDR and a different way?
Marco Pagani, MD, Ph.D. (46:51):
There is a, well, my, my hypothesis is that once you, you perform the bilateral stimulation, I mean, this is low wave that comes to a brain like a tsunami. They reactivate all connections. Yeah. They like, they free, they free the road from an accident in principle. Yeah. And then they, the memory can go. Yeah. But about the last thing about what we were telling you about the social connections, we run an experiment in a place in which a school collapsed killing 27 kids.
Keith Sutton, Psy.D. (47:29):
Right.
Marco Pagani, MD, Ph.D. (47:29):
And our population on the study were kids that survived or parents that lost kids, but the MD EMDR intervention was made 10 years after the collapse.
Keith Sutton, Psy.D. (47:46):
Wow.
Marco Pagani, MD, Ph.D. (47:47):
And the level of trauma of these people, even they, if they had lost kids or they were, trapped for hours below the, the school, it was much more how you say diluted than for example, people that have been abused because our hypothesis is that during this tenure, like a common trauma and people have been talking so much about that. Yeah. Speak out about experiences, whatever, whereas somebody that is abused usually does not talk to everybody about is abuse or her abuse. Yeah. So even this is social intermingling with other people, especially if other people had the same trauma.
Marco Pagani, MD, Ph.D. (48:34):
Anyway, as you say, possibly,
Marco Pagani, MD, Ph.D. (48:38):
Is therapeutical.
Keith Sutton, Psy.D. (48:40):
Well, yeah. And the way I think about it too, is that like , oftentimes I'm assessing for the level of how much the person's worked on it or what, what extent there's dissociation, cuz somebody that's done a lot out of therapy, talked about this, a lot, talked about it with their current partner husband or wife or whatever it might be oftentimes because they've worked on it so much. The EMDR goes much quicker versus somebody like one of my plans who had been in therapy for 10 years and never talked about the abuse, even with this other person had just buried it so much. And so when she was finally coming up in, in our situation, working on it, there was a lot of work to do because it was a complex trauma and, and dissociation had just kind of buried it away. So yeah, I think that's definitely a piece. And like you're saying with a trauma that affected so many people like the school or like nine 11, there's a lot of room to talk about it. Versus as somebody talking about the abuse they had as a child, which oftentimes they don't, feel comfortable or they don't feel other people can handle or people get uncomfortable if they're talking about or so on. So they stay alone with that until maybe they go to therapy or, or a group therapy or so on.
Keith Sutton, Psy.D. (49:49):
So I really appreciate this. I love of the aspects and really understanding the depths of it. And, and , I really liked in that article too, they talked also about some of the specific differences between C B T and exposure and EMDR and some of the mechanisms, which I thought and goes very much into the neurobio biology. And I really appreciate you simplifying and using the metaphors that was really helpful. I was honking my head somewhat through the article trying to figure out I was like where. And so this is a really illuminating and definitely I recommend to my readers to read this article and, and your other work. Cuz yeah, I think it's , again, for whatever reason in the beginning that people decided EMDR, I, I kind of, came into it in 2007. So I think a bit of the controversy, whenever that came around, when it started kind of, I think left a bad taste in some folks' mouth, but it's really extremely effective and, and just kind of impressive that, that I found. So yeah, really appreciate you taking the time and, and doing this podcast from halfway across the world from here.
Marco Pagani, MD, Ph.D. (50:52):
Okay, it's been very nice talking to you and I hope that I was not too complicated in my, explanation and expression because I, again, I mean all this artwork could have been expanded in a one day course. I mean, to really understand what is behind all this.
Keith Sutton, Psy.D. (51:13):
Yeah.
Marco Pagani, MD, Ph.D. (51:13):
Anyway, thank you very much for inviting me, has been very, very nice.
Keith Sutton, Psy.D. (51:18):
I really appreciate it. Thank you so much for your time. Take care.
Marco Pagani, MD, Ph.D. (51:23):
Okay. Thank you.
Keith Sutton, Psy.D. (51:25):
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