Show Notes
A follow up Q&A to the PTSD deep dive earlier in the week with Dr. Trey Tippens. Dr. Ravi Kumar picks five of the most thoughtful listener questions and does a mini deep dive on each, tying together the key themes from the full episode and filling in a few of the practical and biological gaps.
If you listened to the Trauma, Memory, and the Mind episode earlier in the week and walked away with more questions, this is the follow up. Dr. Kumar walks through why telling someone with PTSD to “just calm down” is a biological non starter, why a nerve block in the neck has a real role in trauma treatment, what the actual Phase 3 data on MDMA assisted therapy shows and why the FDA still declined, how trauma is transmitted across generations both chemically and behaviorally, and whether post traumatic growth is a real, measurable phenomenon.
In this episode, you will discover:
- Why the rational mind cannot win the fear fight in PTSD: The amygdala fires before the prefrontal cortex even gets a chance to weigh in, so by the time logic could remind you that you are safe, the alarm is already ringing. In PTSD, neuroimaging shows the ventromedial prefrontal cortex, the region that normally puts the brakes on the amygdala, is structurally less active. The circuit that should let logic win has been compromised
- Why “just calm down” is a useless instruction: It is the neurological equivalent of telling someone with a broken leg to walk it off. The biology of the threat response system is dysregulated in a specific and well documented way
- What the stellate ganglion block actually does: A cluster of sympathetic nerves at the base of the neck is temporarily quieted, which dials down the fight or flight overdrive that makes traditional PTSD therapy unbearable for many patients
- The hard data on SGB for PTSD: A randomized sham controlled trial in JAMA Psychiatry in 2020 enrolled 113 active duty service members and showed two SGB injections two weeks apart produced significantly greater symptom reduction at eight weeks than sham. The block is most powerful as a springboard into therapy, not a standalone fix
- How MDMA actually works on trauma: It floods the brain with serotonin, oxytocin, and norepinephrine simultaneously, opening a therapeutic window where traumatic memories can be revisited from a less defended emotional state. The memories do not disappear, but they can finally be processed
- The Phase 3 results that changed the conversation: A 2021 Nature Medicine trial showed 67% of MDMA assisted therapy participants no longer met PTSD criteria after just three sessions versus 32% on placebo. A 2023 replication showed 71% versus 48%. Effect sizes that traditional therapy has not come close to matching
- Why the FDA still said no in August 2024: The rejection was not about efficacy. It was about the blinding problem. Participants know whether they got MDMA, which makes it nearly impossible to rule out expectancy effects. A legitimate scientific question, not a rejection of the underlying science
- The two pathways of generational trauma: Prenatal chemical exposure (a mother’s elevated cortisol and adrenaline alter gene expression in the developing fetus) and behavioral modeling (children calibrate their own threat detection to match a parent’s vigilance and avoidance)
- The Kosovo war study: Children of mothers who experienced sexual violence and torture showed higher cortisol levels and differential DNA methylation at glucocorticoid stress response genes, despite never experiencing trauma themselves
- Why early intervention matters so much: Children’s brains are dramatically more plastic than adult brains, so addressing trauma in a parent and a child together can interrupt the inherited patterns more completely than waiting
- Post traumatic growth is a real, measurable phenomenon: Tedeschi and Calhoun coined the term in the 1990s and built a validated scale. Studies in combat veterans, cancer survivors, and sexual assault survivors consistently show meaningful growth following trauma, with new perspectives, deeper relationships, and a changed sense of personal strength
- What growth actually means: Not getting back to who you were before the trauma. Becoming someone who has integrated the experience into a fuller, more honest understanding of life. As Dr. Tippens put it, “steel in their souls”
Key Takeaways
- PTSD is not a failure of willpower. It is a fear circuit that has been structurally and chemically dysregulated, and the brain region that should be talking it down is running with reduced activation
- The stellate ganglion block is a real, evidence backed tool, but its highest leverage use is as a runway into therapy, not a standalone treatment
- MDMA assisted therapy has the strongest effect sizes the PTSD field has ever seen. The FDA rejection is about trial methodology, not about whether the treatment works
- Trauma can be biologically transmitted from one generation to the next through prenatal stress hormone exposure and through learned behavioral patterns. Both pathways are documented
- Children’s neuroplasticity is a window of opportunity. The earlier trauma is addressed in the family system, the more completely the inherited patterns can be interrupted
- Post traumatic growth is real, validated, and measurable. PTSD is not a permanent destination, and recovery does not mean going back to who you were before. It means integrating what happened into a stronger, more resilient version of yourself
If you have not yet listened to this week’s main episode with Dr. Trey Tippens, Trauma, Memory, and the Mind: How PTSD Forms and How It Can Be Treated, start there. This Q&A builds directly on those concepts.
Transcript
[00:00 –> 00:27] Dr. Ravi Kumar: Hey folks, Dr. Kumar here. Earlier this week, I interviewed Dr. Trey Tippens on PTSD and about many of the treatments that are genuinely changing this field. And I got a lot of really thoughtful questions from you guys. So I picked five of the best ones to do some mini deep dives on. I think this will tie together most of what we covered earlier in the week.
[00:27 –> 01:23] Dr. Ravi Kumar: Okay, so the first question is, why can’t people with PTSD just remind themselves they’re safe? If they know logically that they’re home, why doesn’t that help? Well, this one seems obvious from the outside, but it’s actually one of the most important things to understand about PTSD. And that is that the rational mind and the fear response don’t run on the same circuit in the brain. When a threat is detected, whether real or perceived, the amygdala fires first. It fires fast, and it fires before your thinking brain even has a chance to weigh in. So by the time your prefrontal cortex starts firing, and this is the part of the brain that could tell you, hey look, you’re fine, you’re at home, everything’s good, the alarm bell that was sounded by the amygdala has already been sounded, and you’re in fight or flight.
[01:23 –> 02:17] Dr. Ravi Kumar: In people with PTSD, the literature suggests this problem is compounded neuroanatomically. What I mean by that is that neuroimaging research has consistently found that the ventromedial prefrontal cortex, the region that’s responsible for regulating the amygdala and putting the brakes on the fear response, shows reduced activation in PTSD patients compared to control patients. So it’s not that the person is being irrational. It’s that the biology of their threat response system has become dysregulated in a very specific and well documented way. The rational mind isn’t losing because the person’s weak, it’s losing because the circuit that’s supposed to let it win, like it does in most normal people, has been structurally compromised. That’s why saying just calm down to someone with PTSD is about as useful as telling someone with a broken leg to just walk it off.
[02:17 –> 03:06] Dr. Ravi Kumar: Okay, so the next question. You mentioned the stellate ganglion block. Isn’t that a pain procedure? Why would a nerve block in the neck help with PTSD? This is a great question, and this one caught me a little off guard the first time I really dug into it too, because you’re right, the stellate ganglion block has been used in anesthesia and pain management for decades. But the application to PTSD is based on a pretty elegant piece of logic. The stellate ganglion is a cluster of sympathetic nerves sitting at the base of the neck, right around the first thoracic and lower cervical vertebrae. The sympathetic nervous system is your fight or flight system, and in people with PTSD, that system is running on overdrive.
[03:06 –> 04:02] Dr. Ravi Kumar: Blocking that stellate ganglion temporarily quiets the sympathetic chain, which interrupts the hyperarousal that makes traditional PTSD therapy so hard to tolerate. The evidence is actually solid on this point. A randomized sham controlled clinical trial in JAMA Psychiatry in 2020 enrolled 113 active duty service members and found that two stellate ganglion block injections, given two weeks apart, produced significantly greater reduction in PTSD symptoms at eight weeks compared to a sham procedure. Where this gets really interesting, as Dr. Tippens described, is when the block is used as a springboard into therapy rather than a standalone treatment. Lowering someone’s baseline hyperarousal enough that they can actually sit through prolonged exposure without shutting down is a fundamentally different use case than just getting a periodic shot to manage symptoms. That combination approach may turn out to be where the real long term benefit lies.
[04:02 –> 05:01] Dr. Ravi Kumar: Okay, next question. What is the actual science behind MDMA helping PTSD? And wasn’t the FDA approval rejected? Another good question. And to answer the FDA question first, yes, it was rejected. But that doesn’t mean it doesn’t work. Okay, so let me explain this to you. MDMA works partly by flooding the brain with serotonin, oxytocin, and norepinephrine all at once. The result of having this chemical change in your brain happen when you’re in a therapeutic setting with trained guides is that you have a state of heightened emotional openness and reduced fear that allows you to revisit traumatic memories without the usual overwhelming emotional response. It’s not that the memories go away. It’s that the brain can process it from a less defended place, which is exactly what the exposure based therapies that we talked about in the main episode are trying to do, but in a much more arduous mental environment.
[05:01 –> 05:37] Dr. Ravi Kumar: The clinical results have been striking. The first Phase 3 trial published in Nature Medicine in 2021 found that 67% of participants receiving MDMA assisted therapy no longer met diagnostic criteria for PTSD after just three sessions. Compare that to the 32% in the placebo group. A second Phase 3 trial published in Nature Medicine in 2023 replicated these findings, with 71% losing the PTSD diagnosis in the treatment group versus 48% in the placebo group. These are large effect sizes, especially when compared to what we typically see in psychiatric treatment trials.
[05:37 –> 06:36] Dr. Ravi Kumar: Now, the FDA did decline to approve MDMA assisted therapy in August of 2024. The rejection was not primarily about efficacy. It was about the blinding problem, which we touched on in the episode. Because MDMA produces an obvious subjective experience, participants know whether they’ve received the drug or the placebo, which makes it nearly impossible to run a truly blinded trial. The concern is that expectancy, that’s what you expect and believe, could be creating some therapeutic effect rather than the drug doing that itself. That’s a legitimate scientific question, and it’s one the field is working to answer. But I’ll say this, even if part of the benefit is expectation driven, 67 to 71% no longer meeting PTSD criteria after just three sessions is a benchmark that traditional therapy has not come close to matching after years of treatment. The story on MDMA is just getting started, and it’s super exciting.
[06:36 –> 07:23] Dr. Ravi Kumar: Okay, next question. Can trauma actually be passed down from parents to children through biology, or is it just a psychological idea? This one surprised me when I went back and looked at the literature, because it sounds like something that’s wild and theoretical, right? But the data is real. There are two distinct transmission pathways here, and they’re both documented. The first is prenatal chemical exposure. So when a pregnant woman has PTSD or is experiencing active trauma during pregnancy, her body is producing elevated levels of cortisol, adrenaline, and other stress hormones. The developing fetus is bathed in those chemicals, and there’s now good evidence that this alters the expression of genes involved in stress regulation in a child’s brain.
[07:23 –> 07:53] Dr. Ravi Kumar: A study published in 2021 examined children of women who had experienced sexual violence and torture during the Kosovo war. 72% of those women had PTSD symptoms during pregnancy, and their children showed higher cortisol levels and differential DNA methylation at genes involved in glucocorticoid stress responses. These are the same genes that regulate how sensitively the body reacts to stress. The children hadn’t experienced any trauma themselves, but the changes were transmitted through the in utero environment.
[07:53 –> 08:41] Dr. Ravi Kumar: The second pathway is behavioral modeling, and it’s just as powerful. Parents who have unresolved trauma develop behaviors that communicate to a child that the world is unsafe. Vigilance, avoidance, emotional reactivity, those patterns get internalized by a child as normal and adaptive. They grow up calibrated to a threat level that doesn’t match their actual environment, just like their parents. So the takeaway is important. If you’re a parent and you’re carrying unresolved trauma, getting help is not just for you. The earlier trauma is addressed in the parent and in the child, the more completely those patterns can be interrupted. Children’s brains especially are neurologically plastic in a way that adults are not, and that’s an opportunity that offers hope with early intervention.
[08:41 –> 09:19] Dr. Ravi Kumar: Okay, so last question. Dr. Tippens mentioned post traumatic growth. Is there real evidence that people come out of PTSD stronger, or is that just something we say to make people feel better? Well, maybe it’s a little bit of that, but I hear you on this one. We often hear the phrase, what doesn’t kill you makes you stronger, and maybe that is to make you feel better about some pain that you experienced in the past. But in terms of PTSD, it turns out to be real, based on the literature and based on the research.
[09:19 –> 09:50] Dr. Ravi Kumar: So post traumatic growth, which is a really cool name for the recovery from PTSD, refers to the positive psychological change that emerges as a result of the struggle with highly challenging life circumstances, like trauma. It’s not the same as resilience, which is about bouncing back when you get knocked down. Growth, or post traumatic growth, is about coming out differently with new perspectives, deeper relationships, a revised sense of what’s possible, and often a changed sense of personal strength.
[09:50 –> 10:35] Dr. Ravi Kumar: A couple of researchers named Tedeschi and Calhoun, who coined this term in the 1990s, developed a validated scale to measure it. And studies across populations including combat veterans, cancer survivors, and sexual assault survivors have consistently found that many people report meaningful growth following trauma. The basic concept is that a person’s prior worldview was actually challenged hard enough with the trauma that it had to be rebuilt in a more resilient model. And as Dr. Tippens put it, some people describe it as putting steel in their souls. That was very poetic, but it actually maps out to what the literature describes as a fundamental reorganization of identity and meaning making in the aftermath of trauma.
[10:35 –> 11:09] Dr. Ravi Kumar: None of this means trauma is something we need to seek out, or that people who don’t experience growth after trauma are failing somehow. People heal at their own pace and in their own way. But the data does say clearly that PTSD is not a permanent destination. Recovery is possible, growth is possible, and the goal isn’t to get you back to who you were before the trauma. It’s to become someone who has integrated the experience into a fuller, more honest understanding of what life is.
[11:09 –> 11:25] Dr. Ravi Kumar: Okay, so that’s it folks. I hope this helps you or someone you love understand trauma better and have hope for a happier tomorrow, because it’s definitely possible and it’s definitely out there for you. Cheers, and I’ll see you next week.