Dr Danny: A lot of the patients I see, they've been told it's quote unquote all in their head, just go see a therapist. A lot of my fibromyalgia patients have been told at some point by a doctor, they don't really believe in fibromyalgia, it's not a real illness. These are really, they're quite traumatising things that people say to someone who's ill, and then when you take those things in, it certainly doesn't help your mental resilience.
Dr Rupy: Burnout, it is a massive topic, not fully understood and the mechanisms that drive stress, fatigue, brain fog and all the symptoms suggestive of poor resilience are multifactorial and complex, which is why it's so lovely to speak with a double board certified medical and integrative medicine doctor who's treated thousands of patients about this subject. Dr Danny Gordon is back on the podcast today. It can often be frustrating as well for people, particularly when you feel like you're doing all the right things. You eat the right foods, you exercise, you take all the supplements, you meditate, you do yoga, you do all the quote unquote correct things, yet you still have symptoms that make you feel that you're constantly treading water without any resolve. Dr Danny Gordon, if you haven't heard her before on the podcast, is an integrative medicine physician, leading expert in integrative and cannabinoid medicine and resilience. She's treated thousands of patients like I said with medical cannabis and is vice chair of the UK Medical Cannabis Clinician Society and author of the CBD Bible, one of my favourite books, and the new book, The Resilience Blueprint. Today, we are going to be talking about what we mean by burnout, what symptoms are suggestive of burnout, how resilience starts in the brain, the HPA axis, psychoneuroimmunology, the endocannabinoid system and the gut. And we also talk about supplements for sleep, general supplements for health, mind-body interventions, as well as the concepts that I'm leaning into, including compassion, optimism, gratitude, self-awareness and judgment. Remember, Dr Danny's medical practice is the Resilience Medicine Clinic, so you can find the link to that in the show notes, and she treats patients with a focus on mental health, chronic fatigue and complex chronic disease.
Dr Danny, if there's someone listening to this and they have features of what they identify as burnout or poor resilience or stress, fatigue, I wonder if you can give us the macro picture of just how widespread this issue is and how these people who are listening or watching on YouTube are not alone.
Dr Danny: Yeah, it's a great question, Rupy. So I think especially after COVID, more and more people are experiencing some degree of what they would call burnout. That might be feeling fatigued, chronically fatigued, where you have eight hours of bed and you still feel awful in the morning, mental health symptoms, like feeling low, feeling anxious more than usual, problems sleeping or getting a restful sleep, pain, chronic pain. So I think if you're at home listening to this and you're experiencing any of those things, just know that these are things that can get better. Even if you have an underlying condition that contributes to these symptoms that doesn't have a quick fix or a permanent cure, it doesn't mean you can't increase your resilience and lessen your symptoms, improve your quality of life and live a completely full life again. And I think that's always my main message to my patients. Some of the most resilient people I know actually suffer with chronic health conditions. So it's not, it doesn't mean you can't get better.
Dr Rupy: And how big of an issue is this? Do we have some statistics on the size of the problem, either here in the UK or the US or even globally?
Dr Danny: Well, certainly, I would say a lot of conditions that I see in clinic that affect resilience, like anxiety disorders, depression, chronic fatigue spectrum illness, including long COVID, but not confined to that, we're talking tens of millions, potentially hundreds of millions of people when you combine these things together. So I would say a large percentage of the UK population is suffering from one of these resilience-affecting conditions, whether it's chronic pain, whether it's fatigue, or whether it's mental health conditions. And all of these clusters overlap. For example, if you have chronic pain, then you're more likely to experience these mental health symptoms because of the brain networking issues, they're all involved in the same brain networking. Conversely, if you get long COVID, if we get COVID and you unfortunately, you're one of the people who develop long COVID, then you can get additional problems with pain that can come on or more fatigue. So it all kind of jumbles together to create an epidemic really, I would say, in people. Most people I speak to, even among my friend group, who are considered quote unquote healthy, have one of these problems to some degree, even if they're not seeing a doctor for them.
Dr Rupy: Yeah, and actually that brings me on to one of the stories in your book about Meg at the start of the book. And I think I can certainly relate with patients that I see, friends that I have, people who feel that they're quote unquote healthy and they do all the right things, and they eat well and they exercise, but they still have these lingering symptoms and they feel that it's something that they're not doing right, something that they're not optimising. And so they do one of those features or one of those pillars of lifestyle even harder. I wonder if you can talk us through that kind of patient that you see in clinic and how you approach that.
Dr Danny: Yeah, so this is the patient who frustratingly is doing so much for their wellbeing already, and they still feel kind of awful. And it's really frustrating because they're probably going to lots of yoga classes or they're eating really clean or they're taking a mountain of supplements, and they've maybe even made some positive lifestyle changes like quitting drinking for a month or cutting down on caffeine and they still feel awful. So a lot of times it's because they're doing the wrong thing at the wrong time for their particular body and their particular brain. Sometimes it's because they have genetic predispositions. When we do something like functional medicine panels, we look at their detoxification pathways and some of the genetic predispositions, they might just be have some low resilience in those areas genetically that just predispose them to having these problems. So sometimes it's that they're actually doing the right thing, but they need more help. So sometimes we use something like medicinal cannabis to help them or some more kind of prescribed nutraceuticals or sometimes it's a mind-body practice because they're doing so well in their diet, but they're so stressed and it's looking at that actually mind-body medicine component, finding them a meditation or a relaxation practice that works for their brain and their body that they can actually do every day and they can stick to. And that's the part that's missing for them. So it's finding the missing piece for that person who says I'm already doing everything, why do I feel so awful? Because there's always an answer, but it's also really hard to coach yourself. So when you're in it and you're trying to coach yourself, you're trying to doctor yourself, it's really, really difficult to do that well. I mean, I don't doctor my own self. It would be a recipe for disaster. That's why you don't doctor your family members for the same reason.
Dr Rupy: Yeah, even though my family members do try and get me to doctor them as much as possible. And you know, from my own experience, actually working in A&E and I do sort of well-being talks for my colleagues and stuff, and I have a lot of these instances where people are, look, I cook your recipes, I exercise really well, I try and go to sleep on time when I'm not doing night shifts and stuff. I still have these lingering symptoms, fatigue, IBS, bloating after meals. I've tried these elimination diets, all these different things. They're trying all these different sorts of strategies and they still don't feel well in themselves. And I feel it's because we over-index on certain elements of lifestyle. And so this is a real sort of problem for people who are quite educated around these different areas. So before we dive into where things might be going wrong, let's take a step back and define exactly what we mean by these terms that I've been bounding around and I tend to bound around a lot, like burnout and resilience. What do we actually mean by these sort of terms and what kind of things do they cater for with this umbrella?
Dr Danny: So resilience has so many definitions. Of course, I'm a medical doctor, I'm an integrated medicine specialist and a cannabinoid medicine specialist. So for me, when I talk about resilience, I'm thinking about holistic health resilience. So for me, that means the ability to bounce back better from setbacks, whether that's an emotional setback, a physical health setback, or just a general life setback. And the ability to basically use stresses as, which we all experience, we can't get rid of stress in our life, as a growth experience for the brain and the body. So instead of pushing the stress beyond the breaking point, which lowers our resilience, we find a way to handle more stress on a brain level in a positive way, so it actually builds our resilience over time, meaning our ability to bounce back. So basically, it's the ability to bounce back and the ability to balance all of the systems that need to work in the brain and the body. So the ability to balance hormones and neurotransmitters and just the ability of the body to self-regulate, essentially.
Dr Rupy: So I like this concept of bouncing back and resilience not being sort of the absence of stress or the removal of triggers for stress. It's the, it's the sort of the flow, the ability to absorb the normal ups and downs of your day and still carry on moving forward. Is that, is that sort of how you would describe it to patients?
Dr Danny: Yeah, exactly. And it's about quality of life too. So for example, if you are dealing with cancer, you know, it doesn't, you know, a lot of my patients say, oh, well, I have cancer, I obviously I haven't done a very good job for my resilience. But that's not the case. We all get sick, we all have genetic and environmental influences that impact our health. But if you are going through even something as challenging as a cancer diagnosis, you can still feel more resilient and improve your quality of life each day. And that's always my message to people. So it's not, you're not stuck with the resilience level that you're born with, you're not stuck with the resilience level that you have right now. If you're in a really low place right now, it's okay. It doesn't mean you're going to stay there forever. You can actually change. The brain and the body can always change.
Dr Rupy: Yeah. Let's talk about some of the key symptoms that you're listening out for when you're taking a history and how do you monitor those and what are you excluding from sort of your mental differential diagnosis?
Dr Danny: So a lot of my patients have what they would describe themselves as a shopping list of diagnoses when they come to see me. They have usually seen a lot of other doctors first. They usually have a variety of symptoms that overlap and can get very confusing to tease apart for them. Those include things like fatigue, not just normal, oh, I feel a bit tired, but fatigue that is affecting their ability to function despite being in bed for those eight hours. They often feel tired but wired. So it's so frustrating. They feel like they're exhausted, but when they go to rest and to sleep, they don't get that deep restorative rest. So the tired but wired, the fatigue, the brain fog, so cognitive dysfunction, and mood ups and downs. That's really, really common. And then added on to this kind of core constellation of symptoms, some people have also pain as well. So when we, when I look at a patient who has a lot of these things going on, I always think, okay, where do we start first? Because you can't do everything at once and you have to do the right thing at the right time for each person. So a lot of times it's focusing on the basics first. It's getting sleep back on track. We know that if people get better restorative sleep, they their pain networks are less lit up, they are able to regulate mood better, and they feel less anxious. And this often requires more than just CBT for sleep, which a lot of people have tried. It's great, but the kind of patients I see, they are past that. They need more, they need more support in sleep. So sleep is often where I start with people, not always, but often.
Dr Rupy: And with regards to a differential diagnosis, what are the things that you're trying to exclude from somebody who is presenting with tired but wired, fatigue, pain, brain fog, all those sort of things that we would be listening out for with someone who's describing burnout?
Dr Danny: Yeah, so, you know, obviously there's a lot of times they have more than one diagnosis because these symptoms are overlapping clusters. But those things that we look for include things like depression, sometimes bipolar disorder that's been undiagnosed for a long time, not as commonly, but it does happen. Anxiety disorders, trauma, PTSD and complex PTSD. Trauma can drive a lot of these symptoms or be a trigger for a lot of these symptoms and often times no one's even asked them. You have to be careful how you ask about trauma because you don't want to go too deep into it to trigger the trauma, but if you ask in a way that at least lets you know if it's there, it's really, really helpful. Then we are ruling out in the fatigue and pain areas, ruling out or sometimes ruling in, I often diagnose a lot of missed autoimmune disorders. So things like rheumatoid arthritis, ankylosing spondylitis, but without the fusion in the spine, things that can get missed sometimes. Some people have part of these diagnostic labels, but not all, they don't meet the full criteria for them, but they still have an autoimmune component to their illness. Then we look at the thyroid axis, the thyroid function, we look at nutrient imbalances, like low iron, even if someone's ferritin is okay, if their saturation of the iron is low, we want to look at that if they're really tired. And then their adrenal function. So we want to look at all of the different ways the brain communicates with the body about energy, essentially, for the energy component of symptoms.
Dr Rupy: Yeah. Let's double down on that about how resilience starts in the brain. I think that's one of the chapters in your book, and I really like how you described the hypothalamic pituitary adrenal axis there. Why don't you talk us through the HPA and how that relates to resilience as we've defined it?
Dr Danny: So there's a thing called the HPA axis, and what that means is it's how the brain, a specific part of the brain in the hypothalamus, communicates with our adrenal glands in that little glands that sit on top of our kidneys that make our stress hormone. And when this axis is working well, your adrenal glands make enough stress hormone to keep you energised and to help you, you know, run a race and to do your daily life without feeling fatigued, but not so much that you feel chronically stressed and tired but wired. But when you have chronic stress that's not managed well on a brain level, this system can get basically flicked on all the time. So you start creating more and more and more cortisol and more stress hormone, and then it's a vicious cycle and you basically feel tired but wired all the time, and then your adrenal glands start to be able to not keep up. And then you start to have the low cortisol kind of dipping down, and then you kind of feel like you just, you just don't have energy in the tank, you're just running on empty. So at first it feels like kind of driving with the brakes on at the the first kind of aspect of getting fatigue, and then as as the fatigue progresses, it feels like you just have nothing in your tank. So we can actually influence this pathway from a brain perspective with mind-body medicine techniques. We can also influence it from a food perspective, from a supplement perspective, and using things like power plants and cannabinoids, cannabis medicines in some cases.
Dr Rupy: Why don't we, because we've mentioned a few things in passing here, genes, detox, deficiencies and certain nutrients. Let's imagine the listener themselves as a caricature in the middle of a diagram. And underneath the caricature of this listener who might describe or identify themselves as having burnout or fatigue, we have their list of symptoms. And we have these big arrows pointing at this caricature that are the drivers of said symptoms. Let's talk about those individual arrows in turn. So we've mentioned genes, we've mentioned nutrient deficiencies. What are the key ones that you're thinking of when you're coming across a patient who's coming in with all these different symptoms? What are those big arrows and what do they represent?
Dr Danny: Yeah, so this is something we do in our process is looking at a timeline of events and, you know, often times I'm asking patients about what happened to them when they were a child and the kind of health problems they suffered with and they're in their 50s, but this all is all related. So if you're in the centre, you can think of all these different influences that affect resilience, including things like the foods we have access to, the foods we eat, environmental influences like pollutants, pesticide exposure, other exposures. Then we have our mental health related factors, like do we have a history of trauma? Are we in a safe environment? Is there any family history of mental health conditions? Are you currently suffering from anxiety? So all the mental health factors, which are again influenced by the environment, so excess screen time, pressures at work and at home, being a parent with young children and not having the support that you might need. These are all things that influence the ability of the system to be resilient. Then you have things like, like you said, deficiencies in areas where you might want to bring in supplementation, nutrient deficiencies, insufficiencies. And then you also have lifestyle things. Like is this person at their ideal weight? What is their life like? You know, doctors don't really ask, I mean, you and I do, but a lot of doctors don't really ask, what is this person's life actually like? Like what is their daily reality? Because those habits and the challenges that they face on a daily basis impact all those other things. It impacts their stress level, it impacts what they eat, it impacts how they sleep. So it's, it's looking at this person as you say at the centre and saying, yeah, what are the specific drivers of resilience versus vulnerabilities in this person?
Dr Rupy: And how do you reframe resilience to people? Because I think universally, stress and all these factors that can impact one's ability to tolerate the stresses are generally thought of as a bad thing. But actually, there is evidence to suggest that stress can be good, right?
Dr Danny: Correct. Yeah, so there's something that we've known about for over 100 years called the Yerkes-Dodson law, and this is a fancy way of saying basically, we know that up to a certain point, when stress is at a handleable level, that stress improves performance. But that after you get to a certain point where the stress suddenly feels, and this is where it comes into interest, the stress suddenly feels unmanageable on a brain level, then stress levels actually decrease resilience. So what we can actually do is we can actually use things like mind-body techniques, power plants, medical cannabis is a tool I use all the time, diet, all the things that we do in integrated medicine to shift how much stress your brain can perceive as handleable. And then you're able to handle more stress without dipping down into burnout. So this is what we try to do with our patients. Even if you have a chronic illness, a lot of people with a chronic illness will say, yeah, I got in, we'll get them into remission, and then they have a huge life stress and then their illness can flare up again. So it's helping them manage the flares of stress in their life so that their baseline level of resilience is higher and higher and higher, slightly higher over time.
Dr Rupy: So how would you walk someone through improving their resilience response and literally rewiring their brain to tolerate those stresses better?
Dr Danny: Well, usually the first thing if you're listening to this is what I always starting with sleep. Sleep resilience is, it's, it's a huge, huge factor. And the reason why is again, because sleep controls so many biological processes in the brain and the body. It impacts our immune system, it impacts our ability to handle stress. So the first thing I do is do a total sleep reset with people. This includes the things you've already heard about probably, like getting off screens and not eating before you go to, you know, two hours, three hours before you go to bed and all those things, as well as specific supplements usually, sometimes cannabinoid medicines if people really need extra help with sleep, and doing a gentle mind-body practice, all the things to prepare the body for sleep, getting rid of blue light, wearing blue blocking glasses, basically a total overhaul of their sleep. After we do that, we usually get some shifts already. Then we look at the specific areas where they need the most help. So we usually do some functional medicine testing and saying, okay, how is the gut-brain axis functioning? Do we need help with a dysbiosis in the gut? Are you making enough short-chain fatty acids for your neurotransmitter balance? What's going on in the gut? So it's usually sleep, then gut, and then it's all the other stuff. So we look at their hormones, I look at their mitochondrial function, their diet, of course, their lifestyle, their exercise patterns, all these things, but it's usually one thing at a time because what I've found over the years doing this for about a decade and a half now, is that if you give everything to someone up front, even though they say that they want to do everything at the same time, it always fails. It's too overwhelming. People are already overwhelmed. A lot of our lives are already overwhelming. So it's, it's just taking one thing at a time, doing it really well, and then moving on to the next thing.
Dr Rupy: Let's talk about sleep supplements because that's definitely something that I get asked about a lot. And, you know, which supplements should I be taking? I do all the right things. I eat early, I get off my screens, but I'm still freaking wired in the middle of the night. And honestly, this happens to me as well. I've started a meditation practice myself before bed. I've really limited my caffeine intake to the first part of my morning, and that's had a demonstrable effect, but I still suffer with this myself. And I'm sure there's a lot of other people as well. What have you found have been pretty good interventions from a supplement standpoint and perhaps some of those mind-body interventions as well?
Dr Danny: Yeah, well, I think the thing to remember, and I'm the same as you, I love coffee. Unfortunately, I can't tolerate much of it without disturbing my sleep. It's just I've just had to accept it over the years. What we want to remember is sleep dysfunction is a 24-hour problem. It is not a just at night problem. And when I convince patients of this, they start to understand why we have to change the whole 24-hour cycle of things that they're doing. So yes, the first thing is actually you got to get rid of all caffeine, not forever, but I wean people off of caffeine. I substitute it with an herbal adaptogen for the morning, usually cordyceps and reishi or something like that. But there's other ones depending on the person. Sometimes I use ginseng if they're really fatigued without coffee. And I wean them off all caffeine. And I do that for six weeks. That's a big one. Sometimes you have to take away things before you add things for sleep. Then throughout the day, I get them to do what I call resilience resets, which is a one-minute practice, a one-minute version of the relaxation or meditation practice that we've chosen together. So sometimes it's just a breathing practice, super, super simple. It might be a minute of mindfulness. Whatever we decide they're going to do, they do just a minute of that throughout the day, at least three times a day. I like to do them five times a day. It's only five minutes out of the day. But what it does is it interrupts those stress pathways because if we have stress building up over the day, then this impacts our circadian rhythm, our clock genes, our ability to actually get to sleep easily and stay in sleep. So that's the next thing we focus on is the resilience resets throughout the day. Then you get to the evening and yes, you do all the right things as you've already said. And then sometimes we add some things as well, like passion flower extract. Sometimes I add skullcap. Sometimes valerian, but I don't usually use valerian on its own.
Dr Rupy: Passion flower extract. What's passion flower extract? So I haven't come across that.
Dr Danny: So passion flower is a, it's, it's more of a relaxant herb versus a sedative hypnotic herb. There's sedative hypnotic herbs that are very strong, and then there's kind of more relaxant herbs. Passion flower is more on the relaxing category. Not too strong, but just helps kind of relax the nervous system. And then I usually combine it with some nutraceuticals. Sometimes I use something called lactium, which is basically a milk protein, milk protein hydrolysate. That's another really nice kind of calming ingredient that you could also use in the daytime for anxiety in some cases. So I combine those things together usually. And then sometimes other things as well. So if I do a functional medicine panel and someone has a glycine need for glycine, some people who have low glycine, if you give them glycine amino acid at night as part of their supplement stack, that helps with their sleep, but it doesn't help with everyone. So sometimes you have to either do functional medicine testing to get more specific or just try and see, just do trial and error yourself and experiment yourself. Then there's some people who still need more support for their sleep, and that's where I use medical cannabis and it can be extremely effective and even works when someone's tried sleeping pills and the sleeping pills haven't agreed with them. So I use a lot of low dose medical cannabis in an oil form to help with sleep as well when I need to.
Dr Rupy: What is skullcap and what kind of, how is that affecting sleep? What's the thinking behind it?
Dr Danny: So there's basically active plant compounds in all of these different herbals that we think work on the adrenal stress pathways and have some kind of calming effect on the nervous system through various pathways. We don't know it all yet. Skullcap is an herb that's been used for hundreds, probably thousands of years to help with relaxation. So it's another one I add. And what I find when I work with herbals is it's not just adding one thing. You want to stack the botanicals on top of each other because you get a more synergistic effect in that way. A lot of times people have tried something with valerian root and it hasn't worked for them or some of them you can use on their own too, but it works better when you when you stack them usually.
Dr Rupy: Yeah. And so and lactium, is that the soporific effect of lactium? Is that because of the particular milk protein that is isolated? Is that, is that the reason why it might have an impact on sleep?
Dr Danny: Yeah, so they they've had they have small studies on all of these botanicals for sleep. You know, they're not huge studies, but they're small. And they have shown that it has, you know, a slightly beneficial effect on sleep with that protein, that milk protein.
Dr Rupy: And when you introduce these sleep aids, like you alluded to there, I'm assuming it's sort of like in a stepwise fashion. So it's not like we're going to give you the everything like the kitchen sink. It's like, okay, we're going to try you on this. We're going to increase the dose slightly. And then, you know, if that doesn't work or that you need something else, then we would add something else. Is that the way you think about it and the way you explain it to patients?
Dr Danny: In some cases, yes. When I see more of kind of the people who, I do corporate wellness stuff as well. So people who are coming to me quite early on in the burnout phase, so they're not very sick and they just want to do a tune up. So for kind of peak performance end, yes, that's how I do it. But for the patients I see in the clinic who are already quite sick and they've tried everything, a lot of times we go straight to medical cannabis, add a customised stack of herbals for them, and we're doing a lot at the same time and all we focus on is sleep for that period of time. So, yeah, in reality, when you have people who are quite sick and have tried a lot of these things before, you have to be, you have to go all guns blazing. But if someone is is just starting their well-being journey and they're actually pretty good, but they just want a little bit of a tune up, then you can be more selective and go a bit slower.
Dr Rupy: Gotcha. And you've mentioned medical cannabis there and that sort of brings me on to your sort of specialist subject, endocannabinoid receptors and the endocannabinoid system. Why might certain people be more prone to stress? Is it something to do with how their ECB system isn't, ECS system isn't working? Is that, is there some evidence around that?
Dr Danny: Well, I mean, the endocannabinoid system, we're still learning a lot about it, certainly. And we know that it is the major overarching balancing system in the brain and the body. So because of that, it's involved with the immune system, the energy system, mood, sleep. So because of its very nature, if there is a dysregulated endocannabinoid system, you can get issues that are more likely to pop up ranging from depression and anxiety to autoimmune diseases, to chronic fatigue syndrome, long COVID, gut problems, irritable bowel syndrome, which I'm going to say in quotation marks because it's usually a bucket diagnosis. You have to really dig and see what's actually going on. But yeah, the endocannabinoid system dysfunction, dysregulation is thought to play a role in many of these chronic illness conditions. So it's sometimes it's working from that perspective as well. We don't just work with the endocannabinoid system, but it's one system we do consider. For example, there is a working theory that chronic fatigue and fibromyalgia syndromes and some other clusters that are hard to treat with conventional drugs like IBS, chronic migraines have a endocannabinoid deficiency syndrome is playing a role in these conditions. There's some preliminary evidence for that, but it's probably not the case for everyone. Some people might have a different type of dysregulation in their endocannabinoid system. And we can't directly measure that right now. So what we have to do instead is say, okay, this is what we know about the mechanisms, this is what the patient cluster of symptoms is, and then what medications are going to be best to help rebalance this person. And that can include medical cannabis because the medical cannabis plant compounds work on our own endocannabinoid system.
Dr Rupy: Gotcha. And are there particular genes that we can look at? So single nucleotide polymorphisms that affect certain receptors that could, not they're not deterministic, they're not suggestive of, okay, you're definitely going to have a diagnosis of stress or depression at some point in your life, but they're certainly risk-related. Are there certain things that you would look at to determine whether you're going to try someone on medical cannabis?
Dr Danny: Not for medical cannabis. Medical cannabis can be used in most patients actually quite safely. And also, you know, functional medicine testing is great. I do use a lot of functional medicine testing, but a lot of patients, you know, they're on a budget. So by the time you do, you have to pick and choose your functional medicine panels pretty carefully because it can add up to a few thousand pounds otherwise. And then you haven't even given them the medication yet. And none of this stuff is covered in the NHS. This is the problem. So a lot of times I'm, I don't start out with a lot of functional testing. I'm actually pretty good at targeting based on my experience and symptom clusters. And then we use them where we need to. But to your point, yes, there's, there are genetic predispositions or genetic versions of genes that are correlated, that are associated with people having more of these problems. So in something called methylation pathways, acetylation pathways, the breakdown of certain substances, detoxification pathways, and also genetic variants of genes that, yes, predispose someone to having what's called a low stress tolerance genetically. So I do some of these functional medicine tests for patients who, you know, have the finances to support them, but also patients who, they just want to know that it's not their fault. And it is really helpful when you see it on paper, okay, I'm trying so hard to do all the, to do everything right and I'm still feeling depressed. Okay, well, there might be a genetic predisposition. So I'm actually doing a good job. And obviously, my job is to make them feel better than, you know, get traction from what they're doing presently. But it's, it's sometimes it's comforting to people to know that there's a physiological reason why they're experiencing what they're experiencing because a lot of the patients I see, they've been told it's quote unquote all in their head, just go see a therapist. A lot of my fibromyalgia patients have been told at some point by a doctor, they don't really believe in fibromyalgia, it's not a real illness. These are really, they're quite traumatising things that people say to someone who's ill. And then when you take those things in, it certainly doesn't help your mental resilience. So sometimes when you look at these pathways and you find something, it's like a big relief for someone and it's like an aha moment. Okay, there are reasons why I might have, I might be struggling more.
Dr Rupy: Yeah. I want to talk a bit about psychoneuroimmunology. So this term I've heard in the last few years, I never really understood what it was about. Can you give us a primer as to the science of psychoneuroimmunology and and how that relates to resilience?
Dr Danny: Yeah, so this is a kind of a new field of medicine that realises and recognises that there's actually a physiological, meaning chemical and biological link, direct link between our immune system, our brains and basically our mental health. And it encompasses a lot of disorders that I treat in the clinic. So anything from long COVID and chronic fatigue spectrum illnesses to even depression, anxiety, autoimmune conditions, they all involve the immune system as well as the brain and the software, the mental health software that we have in our brain and the brain hardware. So for example, we now know that there's certain types of depression that don't respond to SSRIs, to conventional medications, and that a proportion of these at least respond to anti-inflammatory protocols because there's an inflammatory part driving the depression. It's not everyone with depression, but there is a subsection of treatment-resistant depression where this is the case. And now we're looking at inflammatory markers in a lot of the research studies, especially looking at picking out these people so we can treat them differently. We also know that patients who have chronic fatigue spectrum illness, fibromyalgia, they might have what's called activated microglia in their brain. This is the brain's immune cells that can become hyperactive, basically. And create some of, kind of like you have a leaky gut, you can have a bit of a leaky brain as well. So sometimes we use medications to kind of calm down those microglia in really sensitive patients, some patients with fatigue, widespread pain conditions, MCAS, so mast cell dysfunction. And these are immune mechanisms. So one of the tools I sometimes use is low-dose naltrexone, and that's, we think it works in the brain's immune system. And it doesn't work for everyone, but for some people it makes a difference. And then you can also tackle the immune system part of a disorder from an anti-inflammatory diet perspective, from a supplement perspective, and interestingly, from a brain software, mental software perspective, and that's about meditation. So we can actually calm down some of these pathways and affect the immune system by using a mind-body intervention like meditation. There's been some interesting work done in the past with cancer patients and doing a visualisation of the, of, you know, a dolphin or kind of something coming in and gobbling up all the bad cells. And when you, when you draw their blood after, they have increased amounts of certain immune factors that were going to gobble up the bad cells. So we know that, you know, even in a serious condition, obviously this is not a primary treatment for cancer, but we know that as an add-on to therapy, if you get patients to do some of these things, it can have a beneficial effect on the brain psycho-immune axis, shall we say.
Dr Rupy: Yeah. And inflammasomes and stress, is this sort of related to the same topic around psychoneuroimmunology?
Dr Danny: Yeah, so inflammasomes are kind of complexes of proteins that basically drive inflammation. And exactly, they're turned on by stress. It could be environmental stress, it could be exposures to toxins, it could be mental stress. And this impacts the immune system again. And the immune system is just so tightly linked with mental health and with gut health. The gut health connection is because a lot of our, you know, we can't measure the neurotransmitter level in the brain from looking at the gut, but we know that most, the percentage, the large percentage of neurotransmitters are actually made in our gut, the total volume of neurotransmitters. And the brain in the gut, there's actually a little brain in your gut that communicates with your big brain. And this also communicates with your immune system. So for example, if you have non-gluten, non-celiac gluten intolerance and you're eating a ton of gluten and you're really stressed, your gut junctions can open up and you your gut can start being become more permeable or leaky. And food proteins can go into the bloodstream where they shouldn't be, causing an immune reaction. Sometimes these immune reactions can impact mental health. So sometimes they can cause brain fog and low mood. So it's all really connected.
Dr Rupy: Yeah. And in terms of the gut, I think this is a really important topic because I get asked a lot about probiotics. And I describe probiotics as very important, but I think there's a few big wins that you can do prior to having to fork out for probiotic supplements. You can certainly get probiotics in your food through different ferments, etc. But I think providing variety, diversity, a polyphenol-rich diet, an anti-inflammatory diet, removing the crap basically and putting in the good stuff, that's sort of the mainstay of what we should be thinking about. But you've also mentioned in your book sort of the gut and these endocannabinoid receptors as well. I wonder if you could talk a little bit about how those interact with different microbes and and perhaps the role of probiotics in that respect.
Dr Danny: Yeah, so we're still learning a lot about what the endocannabinoid system does in the gut, but we know that it is active there. And from a clinical perspective, I use medical cannabis in patients who suffer from really difficult to treat gut-related conditions. That includes the IBS umbrella, which is a, you know, obviously, you know, we we dig down and find out what's actually going on there, but also even inflammatory bowel disease. Sometimes we use medical cannabis because it does seem to impact the inflammation levels in the gut. So that's kind of the endocannabinoid point. Now, how the endocannabinoid system, how that relates to the micro, the micro population, how it shifts the micro population, we don't have really big studies for that yet. But certainly I am with you in that a polyphenol-rich diet, dietary change, providing prebiotic and probiotic, and you can, as you know, different prebiotics seem to influence the gut microbiome in slightly different ways in some people. So partially hydrolysed guar gum might be different than psyllium fibre in the types of species of bacteria that are promotes. And that's really the first step is the diet because we know for sure from solid, solid research that you can change the microbiome with diet. There's some types of imbalances like small bowel bacterial overgrowth and intestinal methanogen overgrowth, which are two really big words, but basically called SIBO and methanogen overgrowth, where a really healthy polyphenol-rich diet is just not cutting it. And that's when we have to be more prescriptive. So I do a lot of therapeutic diets with people, therapeutic diets combined sometimes with medications. Sometimes to get rid of that SIBO, you have to use pharmaceuticals and botanicals in this big protocol to really eradicate it, combined with a diet as well.
Dr Rupy: Yeah, yeah. And this is where I always say to people, like, you know, you really need to do this in conjunction with a therapist, a nutritionist, a doctor, because it's very easy to hear something that is antimicrobial or good for SIBO, and then buy said supplement or whatever intervention it is, take it, you know, in conjunction with a whole bunch of other things, and you really have no sort of idea of exactly how this is going to impact you or what your individual variation to that product is. So you have to do things in a stepwise fashion. So yeah, I think that's really important. As a general rule of thumb, sort of looking at the supplement stack that you feel most people would benefit from, do you have some go-to supplements that you tend to talk about with people?
Dr Danny: Definitely, just for general wellbeing, obviously I start with things like vitamin D in an oil format because it's better absorbed with vitamin K2 because we know that these nutrients should be taken together because excessive vitamin D consumption without taking K2 can lower K2 levels and K2 is a really important cofactor in a lot of reactions in the body. So vitamin D with K2, magnesium glycinate is one that I use all the time with patients because it just supports so many cellular reactions and most people are not magnesium deficient, but they're magnesium insufficient. And the only way you know is to do a fancy functional medicine test that looks at the red blood cell magnesium. I don't do this in most people because it's expensive. I just treat them and it, you know, you get a benefit.
Dr Rupy: Just to double click on magnesium there for a second. Is there a particular reason why you use magnesium glycinate versus all the other sort of cheaper forms of magnesium that you tend to find in average supplements like magnesium citrate or etc, etc?
Dr Danny: Yeah, it's a good question. So if someone's really, really constipated, then sometimes I do use citrate or citrate as a magnesium form and I use higher amounts of it because it doesn't tend to be as absorbed as well as the glycinate form. The magnesium oxide and some of those ones, it doesn't tend to be absorbed as well. So it's cheaper, but you would have to take so much more of it that it's actually cheaper to just get the glycinate in the end. There's also another form called magnesium threonate, which is actually quite hard to find and actually a lot more expensive than the glycinate. And some people think that that's actually more absorbed as far as like the brain cells and that sort of thing. But I find magnesium glycinate is a nice middle road for everyone. I don't know that there's enough evidence to support needing the threonate. So I use glycinate for most of my patients. The next one is omega-3s because, you know, we can get omega-3s from the diet. If I can convince my my my patients to eat small fish, like, you know, when I cook, I try to put little anchovies sometimes on baked vegetables or on salmon to just get some more omega-3s. But unless you're eating a ton of that and you have a medical condition like depression, for example, or anxiety or, you know, attentional problems, I think it's probably good to have more. So not everyone, but a lot of people could be benefiting, I think, from an omega-3 supplement. And then the other thing is just a really good quality multivitamin because there's so many trace minerals that because of the soil depletion that we unfortunately are dealing with in the foods and from the time that the food goes from being picked to you eating it, there are some depletions that happen. I think it's good to have a general multivitamin with those good trace mineral support. So that's kind of my my base.
Dr Rupy: Gotcha. Yeah. Is with omega-3 supplementation, I think a lot of people have become fearful, particularly of the variation in quality. There was a Guardian article that came out, I think it was a year or two ago about how a lot of the oils are rancid because of storage. You know, people question whether it should be refrigerated or not. Do you have any particular opinions on that?
Dr Danny: Yeah, I do. I think it has to be fine filtered, especially for toxins. Unfortunately, a lot of our fish populations, even the wild fish populations are adulterated because of the environments they live in. So I only use brands that are very high quality. They are more expensive because of that. I also like the liquid form because you can smell if it's gone off. You have to use that more quickly and it needs to be kept in the fridge. Especially with pediatric patients, obviously liquid is the way to go, but even for even for adults, I often use the liquid. But then I also just use some capsules as well that's from a very good company. I have a few companies that I don't know if you want me to say, I'm not associated with any of these brands or anything, but I can I can say which ones if if it's helpful.
Dr Rupy: Oh, go ahead. Yeah, yeah, yeah.
Dr Danny: Yeah, so so Eskimo oil or Nordic Naturals, there's two reputable brands. There's many others, but those are some ones to to to trust.
Dr Rupy: Gotcha. Do you ever use algae-based oils? Do you have any opinions on those? Because I understand that because they're created in very clean conditions, you can get like a purified oil, so you have less concerns, not completely eradicated, but less concerns about pollutants. Do you have any opinions on those?
Dr Danny: Definitely. Yeah, I do use algae-based ones as well, depending on availability. Sometimes it's just more expensive than the other ones, but yeah, I think algae is great. So, you know, like 1,000 milligrams of an algae-based EPA, high omega-3 supplement versus two and a half grams of one from small fatty fish, you need less of it potentially as well because it's so concentrated.
Dr Rupy: Let's go back to Meg. So, you know, she's this kind of person that I certainly know many people would identify with that, like very alpha, you know, clean diet, exercise well, does all the right things, you know, changes up her complete kitchen utensils and pans so there's no toxins or pollutants, takes walks in the park, all that kind of stuff. And I think there's a section in your book that really resonated with me because you're talking about resilience traits and how to be more resilient, you need to utilise factors like optimism, or you need to practice compassion and tolerance and flexibility. This whole idea of being self-aware, but also readily ready to absorb whatever life hits at you. And I think this is key when it comes to resilience and burnout because it's not like we can magically away the stresses of daily life. So I wonder if we can dive into these kind of factors around how you teach people to practice optimism and to practice compassion because I think they're generally thought of as sort of softer subjects, but they obviously have a huge impact, as we've talked about the HPA axis, the psychoneuroimmunology, like these are these are actually real powerful tools, right?
Dr Danny: Yeah, they are. They absolutely are. And, you know, it depends, I teach these things to my patients and I it's not just teaching them, it's it's just going through the journey with them because they've heard all these things before, but it's actually just giving them practical bite-sized things to do. So for learned optimism, a really good practice from CBT is just reframing. So every time you have kind of a self-defeating thought or a negative thought, you just, you write it out and then in the next column, you basically just make a little sheet of paper with two columns, the thought I have now and how I can reframe it. And so, oh, you know, it's raining again today, it's going to be an awful day. Then you could say, it's it's raining today. So, um, I don't know, I'm just thinking of something off the head. It's raining today, so the flowers are going to get lots of water and I can still have a fantastic day and I can go out in the rain because I'm not going to wilt. Um, and I can just wear a rain coat. Like something like this. Like it's just, we have so many thoughts that come into our head all the time.
Dr Rupy: It's so funny you say that. That's literally what I say to my wife every time because she, she's from Sydney, right? So she's Australian, she's used to sunny weather and she's lived in the UK now for like 10 plus years and she's always complaining about the weather and her her sort of mood in the morning is conditional on what the weather app shows her and what the weather outside is looking like in that moment of time. And she's complaining about it. I'm like, and I literally say this to her and she finds it so frustrating to no end. I'm this eternal optimist. I'm like, the flowers are going to get watered. We live in a climate where we're not going to get flooding. It's not like we live in Bangladesh where this is actually a risk to our livelihoods. You know, this is amazing. I'm so grateful it's raining today. I'm so grateful it's grey. But I know for that works for me, but I got to I got to be careful about how often I express that sort of like, um, you know, irritating optimism as she refers to it.
Dr Danny: Yeah, I think, I think it has to, it has to come from, you know, it has to come internally from the person because it has to feel aligned with them, right? As a person because, yeah, I am also an irritatingly optimistic person. Um, but even I get stuck sometimes too. Like even I go through tough, you know, even I've gone through tough times and I really have to get back to this learned optimism because I notice myself and, you know, my partner will say, ooh, like that doesn't sound very optimistic. And even I get in ruts too because, you know, you go through tough times sometimes and you your brain can get really stuck because our brains are programmed to see threats. So if you have a series of threats that happen to you and your brain is just seeing those all the time, it's really easy for even for an optimistic person to get caught up here. So it's going back to that practice, just writing it down, like something more optimistic. Um, you can also work with a therapist, like CBT therapists are really good at working with people one-on-one with this as well. Um, but you know, another one is compassion. There's there's a really simple loving kindness meditation that I share with patients and it's just really simple. It's just, you know, may I be safe, may I be happy, may I live with ease. And you just repeat this and you think of yourself first, and then you think of people who you like and are easy to love and send that love to. And then eventually you get to the point where you can even send those feelings of compassion to someone you don't like very much. Um, but you don't have to do that all at once. That can be over like a year's long process. You can just do it five minutes a day. Um, the most important is self-compassion actually for for that because what I find with my patients is, especially my sickest patients, they have the least compassion for themselves. They're just, they're so hard on themselves. And um, it's, it's shifting that is really healing for people. For me, it's been, it's like a constant process, but it's, it's really helpful. Um, and I think also the other thing is I see in in clinic with a lot of really high performers is they're often over scheduled, over exercised, over everything. And just letting it go for even like a weekend and just letting themselves rest and not have a schedule is also really healing.
Dr Rupy: Yeah, yeah. It's so funny you mentioned the over scheduling because if you looked at my Google calendar, everything is scheduled down to the sort of 15 minute meetings I have to the sort of, yeah, everything, holidays, even dinners with my wife, like everything is in the diary. So everything sort of looks, you know, very, yeah, it looks very hierarchical and very organised, which it is. But I've I've sort of introduced a bit of flexibility to that. I think it comes down to this sort of concept that you talk about in the book as well around self-awareness and and um, and generating self-esteem and allowing and ensuring that your self-esteem isn't conditional on certain um, certain parts of your life or um, I wonder how you introduce this concept of self-awareness into your patients um, uh, stack of of of well-being interventions. How do you, how do we become a lot more self-aware? What are the practices that you've come across that are impactful in that?
Dr Danny: Um, it depends on the patient. Sometimes I start with a body-focused awareness practice, like a body scan. But some of my patients already are really good at that. They're actually over-aware of their body. So in those patients, we start with a mental practice. Um, like naming thoughts and emotions. It's a mindfulness-based skill practice. It's super simple. You just basically start in a really relaxed position, take a few deep breaths, prepare your mind for a minute. And you just watch your thoughts as they go by. I always think of myself sitting on a cliff meditating and I'm watching my thoughts go by with like clouds. And every time there's a thought, you can just name it. It might be an emotion. You might, you might have a pain. So you just naming is actually really helpful for awareness.
Dr Rupy: Yeah, yeah. And I I definitely do body scans. I think that's part of my meditation practice in the mornings, just to sort of be self-aware of how I'm feeling. And it's not just a physical feeling, it's a mental feeling. And I I wanted to talk a bit about compassion and tolerance. I think these are things that are being eroded in our with within our sort of mental capabilities, um, as a result of technology, as a result of anxiety-provoking um, platforms that we tend to to use. Um, it's definitely something that I've I've noticed. I mean, as soon as you go on Twitter, you can see like, uh, everyone has become less tolerant and I think it's almost rewarding to be less tolerant and more flamboyant and more flagrant in one's opinions. Um, and I think this comes down to this sort of concept of uh, judge being judgmental. And I have become a lot more aware of the judgments I make. I mean, living and working in London, going on the tube, going to the supermarket, and in my head, I'm I'm constantly judging, not not things that I would like love to, you know, share in the spirit of vulnerability. I think in, um, I think it's really important to just be aware of the judgments that you have inside yourself. Um, is this something you talk about with patients in terms of like how to reframe that?
Dr Danny: Yeah, it depends on the patient, but you know, a lot of my patients are, I need to get them to the point where they can even think about these next level skills because when you're so fatigued and in pain, um, you can't really, a lot of times they are potentially not compassionate for themselves and for others and they're having a lot of conflict in their life because they can't actually devote mental resources to those things because their pain and fatigue is so bad. So we have to get them better first. But then after we get them better, usually it's at that three to six month mark, sometimes people who are really sick like a year mark, and then we're talking about these things because they have capacity and they're really motivated. Um, so yeah, I mean, I think self-compassion and tolerance, it's, it's there's all kinds of informal practices you can do. Um, I think having, being around, even if you don't have your own children, being around children is a great one. Um, having having animals, um, doing the self-compassion like mindfulness meditation, um, I think, you know, going to therapy, I think in North America, um, going to therapy doesn't mean you're messed up. It means that you're working on your personal development. In the UK, I think a lot of people are pretty resistant to therapy. Um, so I think, I think, hey, if I could, you know, do more therapy, I would be so, I'd be more excited to do to do more therapy for personal development. So I think, um, sometimes, you know, it's just taking one of those tools that resonates with someone and then just applying it to their life. And sometimes seeing someone professionally too.
Dr Rupy: Yeah, yeah. Well, this has been really enlightening for me, I think, in terms of like how you approach patients in clinic, what I can learn from that. And the book is awesome as well. And I just, I love your approach to these things and the fact that you come from a traditional medical background and you're integrating all these different practices, a bit of functional medicine, a bit of natural medicine, a bit of natural medicine. Um, I think it's it's fab. So, um, yeah, keep on doing what you're doing, Danny. It's epic.
Dr Danny: Thanks, Rupy. It's nice to be here. Thanks for having me.
