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This Is Going To Hurt is, read with a clinical eye, a textbook case study of moral injury and post-traumatic stress in a competent doctor, narrated by the patient himself, with the diagnosis hidden in plain sight.
I'm increasingly convinced gray hair is at least partly due to oxidative stress from the average diet now that's mostly processed food, as well as lack of heavy exercise and obesity
Honored to be speaking at the 2026 Innovations in Psychotherapy Conference (Nov 10–13 in Anaheim & Online)! Join us for evidence-based education & practical strategies to enhance your practice. Use code SPEAK26 to save $50:
That's why we're expanding Pharmacy First. The idea is simple: Qualified pharmacists can assess patients, dispense medicines and prescribe treatment for a range of common conditions, helping people get care quickly and close to home.
For postmenopausal women—and women with premature estrogen deprivation for other reasons—vaginal estrogen is a safe and highly effective therapy to alleviate the genitourinary syndrome of menopause, prevent recurrent UTIs, and likely to save lives.
If you suffer from amygdala hyperactivity that gives you one of the aforementioned psychiatric disorders, I think that not only should you be offered elective amygdalectomy, but your health insurance should be glad to pay for it (especially if done via ultramodern very safe radiosurgery) one time, rather than for a lifetime supply of more expensive, less effective talk therapies and medications.
It may not be stored there, but what you're tapping into, it's not a repository of the memory, but it's part of this mind-body feedback loop where there's a sensation that your brain has an association to that might have a familiarity to a time in which you felt sad or scared.
if you do for some reason generalize maladaptively to thinking this didn't work and I tried this, this didn't work, and I tried this and I'm really bad at this. That can lead not only to loss of motivation, but what we might call clinical depression.
there are some people who have pure apathy, no depression like David. And there are other people who can be depressed, they can be sad, they can be hopeless about the future, but they don't necessarily lose motivation. They can have pure depression.
But I also think that this is not mutually incompatible with the view that there's also overdiagnosis. And I think we need very careful ways of making diagnosis because the conventional way is you take a history from a person about what the problem is.
And the evidence suggests that wanting pursuit of a goal is mediated or modulated at least by dopamine whereas actually the liking the pleasure you might get from an outcome is not that seems to be related to uh opioid neurotransmitters in the brain.
Those include that having that sense of purpose, making sure that you have a network of people, that you're socially connected as your age, and also remaining curious, open to new ideas. Those factors turn out to be almost as important as some of the physical things we do.
So, I thought this was a really cool study because it showed very clearly that there is temporal persistence in emotions and sadness probably has one of the longest time constants as we know from personal experience. But it's separate from just declarative memory.
If I just take the general population on average it's the case that those people who would have a diagnosis of autism or who score higher on autistic traits even if they don't have a diagnosis look less at faces.
And so what you realize is not only is this very hard to keep burn under control, but also it's just this is the inappropriate place to exercise spending review. Spending review has to come earlier. You have to have some concept of budgeting.
I think one of the things that makes science the company very special is that it has both of those cultures and is able to integrate them and we're able to simultaneously do some really cool research that I think is really at the edge of the Overton window while simultaneously running clinical trials in six countries now with an approved medical device in Europe and clinical trial results in the New England Journal of Medicine.
I claim that if you sleep as much as you want, you’ll probably sleep too much and become more susceptible to depression.
Their words now
while I still believe that the quality of the existing sleep science is extremely low, I advise against trying to decrease the amount of sleep you’re getting based on this article
When patients don't get the help they need, they don't come away thinking, I didn't get good treatment. They come away thinking, I am too broken to be helped. They leave more hopeless and demoralized than when they came. That is harm.
The Rumpelstiltskin effect is not a claim that receiving a diagnosis is a net benefit or a net positive. It is a claim that the mere act of receiving a diagnosis can be beneficial.
So there have been lots of studies where they've done cooling hypothermia in people after traumatic brain injuries and concussions hasn't really shown much of an effect. What seems to be important is preventing hyperothermia.
However, there's an increasing body of literature that shows that by engaging older adults in novel cognitive activities, you see improvements in function. So that can be language learning. Uh that can be uh complex like coordinative movement or exercise. You see the same things with um like musical training like people learning a new musical instrument or learning um musical theory trying to identify different patterns in music. And you see in randomized control trials improvements particularly in executive function that seems to be most common across those different interventions.
Whereas aerobic exercise on that kind of intensity spectrum we just talked about seems to particularly benefit the gray matter which includes the hippocampus. Resistance training seems to particularly benefit the white matter.
This study directly shows that working really hard, releasing a lot of cortisol in high-intensity interval training actually improves hippocample structure and function um over over time.
but I mean in reality when you look at the data on sleep loss and dementia risk The cut off is really around 6 hours. So if you're consistently sleeping fewer than 6 hours, that's where risk starts to increase.
Join my on-demand course with @YogaUOnline—Unlocking the Past: A Yogic Perspective on Healing Intergenerational Trauma, exploring how yogic approaches can resolve inherited trauma.
Ahamed, the banker and investment manager whose previous book Lords of Finance: The Bankers Who Broke the World covered the crash of 1929, writes well.
They get women to sleep with them, but they attract both men and women and cause them to surrender their better judgment and make bad choices in a variety of contexts, including the voting booth.
But in the walking group the group that was randomly assigned to walk three four times a week for 40 minutes compared to a stretching group who's still engaging in exercise but not cardiovascular exercise. The walking group their you know hippocamp is actually increased in volume by 1%. So you're changing the the brain, but you're also changing the behavior. Their memory was much better a year later.
Population-level studies will keep struggling to prove that short sleep shortens life, because they are structurally unable to separate cause from symptom—and the genetic tools meant to overcome this limitation inherit a different fatal flaw.
At this point, I had pretty much given up and filed Thunderbolt's "wake from sleep" promise in the "unreliable" folder, right next to Bluetooth Pairing.
Research shows that children are far better able to sit still, focus, and learn when they've had the exercise, sunlight, freedom, and fun of recess. The same is true for adults.
Really the only tip I could ever give someone at this point is to pull away, reflect, do something you like, and talk to a human who cares about your current spiraling.
When a parent is stressed, low on sleep, or otherwise depleted, they may be even more prone to reacting harshly to normal kid behavior and boundary-pushing.
The phrase "your feelings are valid" does not invite curiosity or deeper self-understanding, which is the point of psychotherapy. It is the mirror image of "stop whining and get a grip." One sounds warm and one sounds harsh, but neither deepens self-awareness.
There are many practices that promise to transform and improve us-therapy, meditation, psychedelics-, but that branding doesn't mean that they actually do much for us: it is common to see people use these techniques for years without any obvious progress on their problems.
Excessive manufacturing requirements are a pervasive problem, especially in the field of cell and gene therapy and they are killing countless of promising medicines before they ever reach patients.
Until manufacturing and regulatory risks become easier to underwrite, capital will keep drifting away from one of the most promising technologies of the last century.
Make sure you're not trying to addict your users. And if anybody is, there's always other jobs, and there's always other better companies. And don't chase the money for tearing apart what it is, the fabric of the society that we built.
the ballerina and the kind of performer, that's the wrong reference class. Right now we have a lot of jobs where you have different tasks. So this is the task-based model jobs where you have like a lot of different tasks. So like a doctor, what is their job? They're filling out insurance documents. They're you know, going and like calling different pharmaceutical companies. And one of their tasks is to actually see the patient and talk to them, but that's like actually not the main part part of the job.
The work that I've been involved in is consistently shown that I was wrong in my biases coming into the work and I've really been almost traumatized by this. Like again and again I've come into a project with some kind of guess about what the data was showing and then the data doesn't show that.
Underneath anger is sadness over all your cumulative experiences in life of not being responded to, past and present. The sadness around powerlessness. Unresolved grief.
Another conclusion might be that the online ecosystem has become so polluted-so fragmented, deceptive, overstimulating, ersatz-that it has warped our ability to exercise taste at all.
It's working too hard, right? But that actually isn't burnout. That's just like getting tired. Another piece that's super critical to burnout is not having your values aligned.
just cuz the test suite passes doesn't mean that the web server will boot. You know, there's there's always a chance that when you actually try in the real world, something's not going to work.
Polyvagal theory provided me with a coherent framework for understanding why cognitive insight alone often fails when a nervous system is in defensive dominance. In such states, higher-order cortical processes are functionally constrained.
The central clinical proposition of polyvagal theory-that autonomic state functions as an organizing platform shaping perception, emotion, and relational behavior-was not empirically disproven in the critique.
Lastly, the duration of a clinical trial does not merely determine how fast an individual therapy reaches patients. It also shapes which diseases attract serious investment and which do not.
Trials serve two distinct functions: validation — confirming whether a drug works and is safe — and learning, or generating biological data to refine our understanding of a disease, a compound, and the relationship between the two.
Like any addictive consumer product that routinely exposes users to graphic sex, extreme violence, and anonymous sexual predators, social media in its current form causes a variety of harms to people of all ages. But we allow adults (often defined as age 18) to make decisions that are bad for them.
basically transplant patients today surprisingly frequently miss organs that are on route to them because there's a timing problem. Um, so like you know, organs expire um very quickly after they become available from a donor.
The ORS is a brief, 4-item measure designed to assess areas of life functioning known to change as a result of therapeutic intervention. It takes less than one minute to complete and score.
The SRS is a brief, 4-item measure designed to assess the therapeutic alliance. It provides immediate feedback on the quality of the relationship and allows for course correction in real time.
Consider using a noise machine to offset environmental sounds or earplugs if necessary. Temperature controlled mattresses such as Eight Sleep are great.
Use red and amber lights in the evening . Bluelight is bad for sleep. You can get blue light blocking apps (f.lux), glasses and also turn red mode on your phone.
can lead to imposter phenomenon. In this book, a leading psychologist looks at the science behind our inner voice and new research into how to harness it and improve your physical and mental health.
Best books I read in 2025: Just a note that these books weren’t all necessarily published this year (though some were). A Story is a Deal: How to use the science of story to motivate and persuade by Will Storr Bringing Up Baby: An Evolutionary View of Pediatrics by Paul Turke Bad Therapy: Why the Kids Aren’t Growing Up by Abigail Shrier
1929 by Andrew Ross Sorkin The reverberations from the Great Depression are still being felt 100 years later so I loved learning more about the characters involved in that fateful time.
the dorman was doing multiple things, many of which were human and kind of tacit. Security would be one. You know, there are no vagrants to sleep in the doorway, hailing taxis, dealing with luggage, recognizing regular guests, providing status to the hotel. There are loads and loads of value creation components to that dorman which aren't captured in the open the door definition.
For language acquisition, Pimsleur is by far my favorite online/app program. (Even Mr. Mari, who gathers no joy from learning languages, was addicted to it for a while!)
They have a general sense which is also by the way extremely robust in people like whatever it is the human value function whatever the human value function is with a few exceptions around addiction it's actually very very robust
There's even a case to be made that those policies actually depressed the manufacturing share of GDP: by boosting output and capacity above where they would have been otherwise, subsidies probably contributed to the sustained decline in prices for China's manufactured goods over the past few years, weighing on their share of nominal output.
These models don't really have this distillation phase um of taking what happened, analyzing it, obsessively thinking through it, um basically doing some kind of a synthetic data generation process and distilling it back back into the weights
you can either see AI as an opportunity for your company to grow and do more or you can look at it as like cost cutting efficiency but I think the growth part is way more exciting.
I think the main muscle you can exercise is this muscle, the muscle of self-discipline. Not your biceps or your pecs or anything else. Because if you get to train that one, everything else just comes by itself.
One thing that changed was that Eukodal was not available anymore, so the drug that Hitler actually had become physically addicted to was suddenly not available anymore. This had to do with the bombardment of the Merck company, the factory in December 1944. British bombers destroyed the production facilities.
Likewise, self-diagnosis should be understood as an attempt to secure the therapeutic effect of a medical intervention to which patients do not have official access.
If a clinical diagnosis can have a therapeutic effect, then, at least in some instances, diagnoses are medical interventions in themselves and ought to be treated and researched as such, with an eye to both positive effects and potential iatrogenic harms.
Their experiences highlight a striking, neglected and unchristened medical phenomenon: The therapeutic effect of a clinical diagnosis, independent of any other intervention, where clinical diagnosis refers to situating the person's experiences into a clinical category by a clinician or the patient.
I just think about like really simple things like access to mental health care, access to education, access to medical advice, access to legal advice. We're essentially taking expertise and making it a commodity. And I think that will is generally democratizing.
Poverty reduction is never a purely technocratic exercise, and questions about industrial policy can never be entirely divorced from those of political economy—including those of global geopolitics.
But by the available evidence, the War on Drugs was far less successful at reducing use among the “hard core” of users, mostly meaning people addicted to their drug of choice.
Recently I reviewed Adrian Kind’s 2025 book, “How Does the Psychiatrist Know?: On the Epistemology of Psychiatric Diagnostic Reasoning,” on this substack. I had mentioned that Kind’s book is the first systematic, in-depth, book-length philosophical investigation into how psychiatrists arrive at their diagnostic conclusions.
Summarizing all of that into my advice right now: Get Whoop for 9.5/10, reliable, convenient sleep tracking with an excellent app (once you get to know it a bit). Get Oura for 10/10 tracking, if you're ok with the ring form factor.
Summarizing all of that into my advice right now: Get Whoop for 9.5/10, reliable, convenient sleep tracking with an excellent app (once you get to know it a bit). Get Oura for 10/10 tracking, if you're ok with the ring form factor.
I didn't find 8Sleep to be very reliable in its sleep tracking. The scores don't make as much sense to me when I wake up, and as we saw above they don't correlate very strongly with Whoop or Oura.
You don't stop a problem by replacing it. And so I didn't have a girlfriend, I didn't have all that. I just realized that I was truly taking away from something from my future wife.
Friedman and Schwartz becomes the playbook for the Federal Reserve. We have lived through this, the financial crisis. The Federal Reserve is ready to loan. Covid, the Federal Reserve does all kinds of new things, because no Federal Reserve chair wants to be in Friedman-Schwartz 2.0 that somebody writes, where they're the bad guy who let the economy meltdown.
What is important to note though is that they thought of all of those as emergency measures to get through the emergency not as permanent alterations in the state of what had to be and not permanent alterations between state and market
If one really wanted to know whether a treatment (e.g., CBT, IPT, ACT, EMDR) was more effective, it had to be directly compared to an approach intended to help - what Wampold and colleagues termed, a "bona fide" treatment. Doing otherwise, they argued, conflated artifacts of research design with actual research results.
Since 2012 when the first study appeared in the literature, others have been published documenting the tendency of practitioners to overestimate their effectiveness - on average, by 65% (1, 2).
It turns out that therapists who perform well on the FIS establish stronger relationships and are more effective (2). More to the point, the evidence shows FIS-related skills are trainable and that such training leads to better results (3, 4, 5).
Over the last 50 years, treatment methods have proliferated despite a lack of evidence of differential effectiveness between approaches. And even when a randomized controlled trial indicates a particular approach works, none show practitioners become more effective when they are trained in that modality.
I think for me, the frontier in modern physics, where the new physics lies is not in high energy particle physics, it’s not in quantum gravity, it’s not in any of these sort of traditionally sold, “This is going to be the newest deepest insight we have into the nature of reality.” It is going to be in studying the problems of life and intelligence and the things that are sort of also our current existential crises as a civilization or a culture that’s going through an existential trauma of inventing technologies that we don’t understand right now.
Indeed, as I've reported in previous posts, research not only shows therapists do not improve with time and experience in the field, but on average become less effective (1, 2, 3, 4).
But unfortunately, today, we know conclusively that it is simply not true. A great amount of people's personalities, dispositions, beliefs, and dysfunctions are genetically-driven.
People tend to get excited about investments when stocks are going up and they get depressed when they're going down. And I think that's just inherently human. You have to reverse that. You have to get excited when things get cheaper and you got to get concerned when things get more expensive.
The more addicts rely on these stimuli, the less pleasure they receive. At a certain point, this cycle creates anhedonia—the complete absence of enjoyment in an experience supposedly pursued for pleasure.
Burnout is the ultimate agency-killer. This is so true that I’ve learned to identify a reduction in agency as one of the first signs of burnout, one that shows up even before I consciously realize what’s happening.
Take the free Attachment Style Quiz and get personalised insight into how you connect, where your patterns come from, and your next step toward secure love.
In my practice, I have seen that opening neural pathways can lead to profound change, to brand-new traits and behavior, sometimes in a matter of minutes.
Most of our fears begin to subside when we just allow ourselves to be in this moment, as anxiety and worry stem from a preoccupation with an anticipated or envisioned future.
I spoke with @mariamenounos about the link between emotions and illness, and the importance of focusing on mental health, on her Heal Squad podcast. To listen to the full episode, please follow: https://t.co/XPIKAvi8tH
Experiencing sleepiness is normal and does not necessarily imply that you are undersleeping.
Their words now
Therefore, I realized that it’s very important to be as awake as possible and that my model of sleepiness where you can be “awake”, “sleepy” and “asleep” is dumb.
Our Tendency shapes every aspect of our behavior, so understanding this framework lets us make better decisions, meet deadlines, suffer less stress and burnout, and engage more effectively.
I would recommend that anyone who thinks they're suffering from trauma (eg PTSD) try a trauma-focused therapy like EMDR before trying to address nightmares directly, unless the nightmares are overwhelmingly worse than all their other trauma symptoms.
This online community is a powerful way to stay in touch with other schema therapists around the globe, on a regular basis; to be part of the ever-growing ST community.
Now a self-help classic, Disarming the Narcissist is a practical, step-by-step communication guide to help you cope with and confront the narcissist in your life.
This video series is grounded in an understanding, both conceptually and practically, of the essential value of the therapy relationship in schema therapy
In the end, the only point of any personal productivity system, goal-setting technique or "life planning" exercise is to help you make a slightly better decision about what to do, right now
First, it justifies various psychotherapies - EMDR and coherence therapy seem to come out especially well here - that focus on trying to get the brain to pay unusually precise attention, under unusually safe conditions, to something it usually represses.
The Splendid and the Vile is a brilliant account of another era of widespread anxiety: the years 1940 and 1941, when English citizens spent almost every night in makeshift shelters as massive bombs rained down on them.
Is there a financially justifiable reason to send a customer an exorbitant gift like a football jersey? Gary makes a very compelling case for such a move and others like it. It's a great exercise in thinking about unconventional marketing opportunities.
For your health and sanity, do not force yourself to learn a language using a method you hate, no matter how good other people say it is. Trying to do so will only lead to disappointment, and ultimately burnout.
the approach that I use is called Schema Therapy, and Schema Therapy is designed to work with very complex personality types, personality disorders, and even those that are happening along a spectrum
In 30+ years of working with narcissistic men mostly - yes, it is possible for people to change. And even narcissists can change. Now, I don't really believe anyone changes completely, but it is possible to get meaningful change.
And no one should feel burdened to become the therapist of the narcissist in their life. It's not your responsibility as a partner, as a child of a narcissist, or even a friend.
undergoing some of these experiments was incredibly fun and a great excuse to study a number of textbooks on biochemistry (I liked "Molecular Biology of the Cell"), biology (I liked Campbell's Biology), human nutrition (I liked "Advanced Nutrition and Human Metabolism"), etc.
Everyone needs to read this book. The observations were made in a pre-internet era, and they’re 10x as relevant today. Nothing will do more to help cure your information addiction that the healthy dose of reality provided in these pages.
I found that the book consistently overstates the problem of lack of sleep, sometimes egregiously so. It misrepresents basic sleep research and contradicts its own sources.
Eye movement directed reprocessing (alternative when the book was written, now basically establishment) where you move your eyes back and forth while talking about your trauma, and this seems to somehow help you process it better.
I suggested that psychedelics might work by strengthening the brain's top-down priors.
Their words now
A more recent paper by Carhart-Harris and Friston provides compelling evidence that psychedelics probably work by _weakening_ the brain's top-down priors, meaning I got this one maximally wrong.
Compassionate Inquiry is an in depth teaching and distillation of the approach I have developed to working with human beings beset by personal issues, health problems that need gently guided exploration, mental health challenges, addictions, relationship difficulties and, above all, an unhealthy relationship to their own selves.
I love anything that doesn't come with battery anxiety, like, well, my Masahiro Maruyama eyeglasses, or my original Withings Activité watch, which is waterproof, so I almost never take it off.
The likelihood that someone is providing high-quality information in these domains is lower than in less controversial areas like physics or neuroscience.
One thing that I think hasn’t gotten enough attention is the fact that NuSI staff, particularly Attia, paid themselves enormous salaries while they were at NuSI
Their words now
NuSI executives didn’t set their own compensation, as I and others have implied.
There's another ancient text I could have mentioned: Galen's That the Best Physician is Also a Philosopher. It's essentially a call to arms for doctors to concentrate on the perfection of their clinical skills and to give up on ideas of attempts to get rich through their art. It shows all the ways in which he doesn't trust those doctors who use their talents for a gain other than the benefit of their patients. It is short and elegant.
So it's a book which is utterly original and gets at something very real and valuable about convalescence. Sometimes I find myself recommending it to patients.
I use a Chili Pad to be cold while I sleep if I can't get the room cold enough, which is great but loud (I set it up to have the cooler unit outside my room).
It takes more than 20 sessions, or about six months of weekly therapy, before 50 percent of patients show meaningful improvement. It takes more than 40 sessions for 75 percent of patients to show meaningful improvement.
A korrent is a belief a person has stated in their own words: one
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