The Melanie Avalon Biohacking Podcast Episode #268 - Dr. Sara (Gottfried) Szal

TRANSCRIPT

(Note: This is generated by AI with 98% accuracy. However, any errors may cause unintended changes in meaning.)

Melanie Avalon:
Welcome back to the show. I am so incredibly excited and honored about the conversation I'm about to have. So the backstory on today's conversation, I first read Dr. Sarah's work probably a decade ago when her one of her books came out. So the first one, The Hormone Cure. Was that your first book? That was number one. Yes. I literally remember listening to it on Audible. I think it was probably when I was first getting into listening to audiobooks as well. So I have like memories of listening to it. And I was just so in awe of all of the science and all of the work that you were doing. And it was so incredible. And so it was a dream. I mean, it's a dream now to be talking to you. Since then, we first had you not on this show, but on the intermittent fasting podcast for the brain body diet. And that was around 2019 when I was with Jim Stevens. And that as well was an incredible interview. And then since then as well, we were going to have you on the show for your prior book, Women, Food and Hormones. Scheduling was crazy, but it's all good because we are here now with Dr. Sarah's newest book, which is The Autoimmune Cure. So the subtitle is Healing the Trauma and Other Triggers That Have Turned Your Body Against You. And also one other side note, I did get to meet Dr. Sarah in person sort of recently at Dave Asprey's biohacking conference, which was so fun. Are you going to go next year, by the way, to Austin?

Dr. Sara (Gottfried) Szal:
Probably. I mean, let's see if Dave invites me back, but it was fun to be in Dallas and it was so great to meet you, Melanie.

Melanie Avalon:
me too. I saw you and I was like, Oh my goodness, they could get to meet you in person. So yeah, that was absolutely, absolutely amazing. So back to your newest book, The Autoimmune Cure. Well, first of all, I was so excited to, when I saw the title, I was excited because this is an issue that affects so many people, I think so much more than people realize, especially with things like diagnosing them. And there's a lot of uncertainty and lack of clarity. So the work you're doing is amazing. And I was curious the angle that was going to be in this book. And it ends up going into an angle that I really haven't read the depth and the science on to any extent, which is the role of trauma, and particularly something called the PI network in autoimmune conditions. And it's beyond fascinating. There are so many tidbits in this book, so many things we can talk about, like the night before is like a last minute prep. When I'm interviewing my guests, I go read all the Amazon reviews, you actually don't have any negative reviews on this book. Usually I have some. Well, I feel like I know like literally all books, like all books normally have something every single was positive. I was like, this is amazing. Yeah, people are really, really appreciating what you're doing so much. I have so many questions as well. So thank you so much for taking the time and for being here. My pleasure. What a delight to be with you to start things off. I'm pretty sure the majority of the audience is very familiar with you, but for those who are not, could you tell them briefly a little bit about your backstory, you know, in conventional medicine and making the turn to where you are today? And then in particular, what epiphany or what life change or mindset shift happened that made you want to go in this direction with this approach to autoimmune conditions?

Dr. Sara (Gottfried) Szal:
Yeah. So the backstory is that I was in my thirties. I was married. I had one kid already and I was postpartum. I was having a lot of trouble losing weight. I was working in what I call McMedicine. I was seeing a lot of patients, about 40 patients a day. And I just felt in my thirties, like I was pushing a rock up the hill. You know, there was a way that I felt like I was aging faster than I should have been. And it was interesting. This is right around the time that Elizabeth Blackburn, Elizabeth Blackburn at UCSF, got the Nobel Prize for her work on telomeres, telomeres as a marker of how faster aging. And so she published this landmark study. She's a woman, so she studied women. Very important. We don't get that enough. She studied women. And she found in this research that when you look at women who have kids and you have, she hypothesized that women who had a sick kid, like a kid who was in the intensive care unit, that they would age faster than women who had a healthy kid. So she looked at these two populations in San Francisco, where I live, and she found that that was not the case. What happens, actually, is that if you have high perceived stress, whether your kid is sick or not, that's what accelerates aging. So I heard that, and that just stopped me in my tracks. And I thought, oh, my gosh, I'm so screwed. So that got me on this path of trying to look at, OK, what's going on? Why am I feeling so stressed? Why does it feel like my hormones are totally out of whack? And I did what a lot of women do. I went to my primary care doctor, and I had my list of issues to talk about with him, and what he said just floored me. He said, number one, sounds like a hormone issue. Let's start you on a birth control pill. Number two, it's simple math, Sarah. If you want to lose weight, exercise more and eat less. You know, he said that in kind of a condescending way. And then third, if you're so stressed, why don't we start you on a selective serotonin reuptake inhibitor, Prozac. And so that was my epiphany, Melanie. I heard this and something in my system just said, no, this is not right. And if I'm a doctor and I'm hearing this from a primary care doctor, that means there's millions of women who are being told this very same thing and it's not right. So that's what got me to say, okay, there's got to be another way. I left his office. I went to the lab. I silenced myself because I can order my own labs. At least I could at that point. And I found through some really basic lab testing that's available through most insurance that my cortisol was three times, which should be my stress hormone. I had insulin resistance. My fasting insulin was in the twenties. I had really low progesterone levels. I had high estrogen levels. My thyroid was sluggish. And so this kind of opened up this whole world for me. I was already a gynecologist. So I knew a lot about hormones, but this made it personal. And that's what kicked off my first book, The Hormone Cure. And then I loved writing so much that I, you know, with each book, I basically just listened really deeply to my clients and my patients and what I found pre-pandemic and also during the pandemic is that I had so many people coming to me, men and women with audit meat disease. And one of the common threads that I found was the history of trauma. Because I ask everyone that I see about their adverse childhood experiences or ACEs, I also ask them about lifetime stress and trauma that they've experienced as an adult, and I found that the majority of these folks had a history of trauma and then superimposed on that. I did my own functional medicine testing. I order an autoimmune panel on everyone that I see. And I was testing positive for anti-nuclear antibodies, which is one of the most basic autoimmune tests that you can do to see if you've got, you know, kind of pre-autoimmunity. So I had positive anti-nuclear antibodies. I've got an elevated score of adverse childhood experiences. And so I realized, okay, I've got to help myself. And always the way that I help myself is to help others. And that's what got me here to write this book, to look at the role of trauma as a trigger for autoimmune conditions. And as someone who practices functional medicine, now I'm not just looking at autoimmune disease, the hundred known autoimmune diseases like Hashimoto's thyroiditis, type 1 diabetes, multiple sclerosis, psoriasis. I'm looking at what leads up to that diagnosis. And it typically is about five to 14 years before you receive a diagnosis where you can actually intervene. So that's what led to me writing this book. And then I'll just share one other statistic, Melanie, because I think it's relevant, especially if there are people who are listening or seeing, okay, sounds bad, but doesn't apply to me. My friend Mark Hyman has this test called ”Function” and as part of it, there's an auto immune panel. It's kind of a basic blood panel that we do as functional medicine doctors. Have you had function done?

Melanie Avalon:
That specific panel or functional medicine in general?

Dr. Sara (Gottfried) Szal:
The Function. It’s called function health.

Melanie Avalon:
I have not, no.

Dr. Sara (Gottfried) Szal:
We can talk more about it and I can put a link maybe in the show notes for people who want to check it out. So what I found talking to Mark is that he's had a total of 100,000 people get their blood drawn and get this autoimmune panel. With the 100,000 people, they're mostly healthy, you know, people like you and me. And he's found that 30% of the people who've had their blood drawn have positive anti-nuclear antibodies, 30%. So one out of three of us who are listening or viewing right now have positive anti-nuclear antibodies. About 13% have antibodies against their thyroid. So it's a very common problem that's flying below the radar right now.

Melanie Avalon:
Wow. Okay. So I think listeners can see now a reason that I just so adore the work that you're doing because it's personal and you have all of this data and science and experience and knowledge. You're talking about the, you know, the doctor-patient relationship. And I thought it was really refreshing because you literally have a sentence in the book where you talk about how you feel like a lot of patients are gaslit by their doctors. It was just validating to see that imprint from a doctor because I think it's such a common experience, like you had where, you know, you're experiencing these health issues and you go in and they just want to put you on prescriptions or, you know, tell you to eat, you know, eat less or exercise more. And it's really, really upsetting, honestly. I actually as well, I was put on birth control in 10th grade for acne, which was completely unnecessary. I was also prescribed an SSRI briefly. They told me it would help my IBS issues. Yeah. So a lot of overlap there. Okay. Question about so many different questions.

Dr. Sara (Gottfried) Szal:
Well, I want to say a quick thing about being gaslit, because, you know, what, what I see taking care of both men and women is that it's mostly women that are gaslit. And there's a lot of reasons for that. I mean, patriarchy is one of them. Another big part of it is that most of the research funding goes to men's health. And when we've got these important discoveries, often they're made in men and assumed to apply to women. And that's often not the case. And it leads to a pretty huge gender gap. And it's from that gender gap that things get worse when you go in and describe what you're experiencing and you're told, oh, you're just getting older. You're 40 now. Of course you feel that way. Yeah, you know, sleep too bad that it's so elusive. Do you want a sleeping pill? So that quick response, that knee-jerk response to prescribe a pharmaceutical, which, you know, let's be frank, it's disrupting a biochemical pathway in the body. That's what pharmaceuticals do. Vegetables don't do that. Diet doesn't do that when you're eating a healthy diet. But that issue of being gas-lit is so important. And I appreciate you calling it out because, you know, I share my own experience not because I think it's unique or I think I'm so great. It's because we need to shine a light on these experiences that women have, like being gas-lit. And we also need to stop tolerating that. Conventional medicine is not going to change in this way. They're not going to suddenly start listening to women. It's really on us as women to demand that they change. We need a cultural shift.

Melanie Avalon:
I could not agree more. I'm actually having flashbacks. I think the most eye-opening moment I had where I realized how much I wasn't being listened to was, and you'll appreciate this because it relates to autoimmune stuff, I had anemia and I was in the hospital for it actually. And I've been taking LDN, maybe we can talk about that later, but I've been taking LDN for about a long time, like a decade. So they had asked me about what drugs I was on. I said I was taking lotus naltrexone. Later, when I was discharged, I got the doctor's notes, and I was reading all of them. And they literally wrote in my notes, patient says she doesn't drink excessive alcohol, but she's on naltrexone. And so the explanation for listeners who are not familiar is lotus naltrexone. And actually, I would love your thoughts on lotus naltrexone, but people go on it for autoimmune conditions, for inflammation. I was first prescribed it for GI health. So I was, and it helps my sleep and my mood. I just actually really like it. I don't take it for alcohol. Naltrexone is prescribed for like in the full, in the higher dose is prescribed for getting off of opioids and alcohol and things like that. So it was literally an experience where I was telling them one thing. And then I got to read what they were saying about me behind my back. And they literally were not believing what I was saying. It was so frustrating. Yeah, I mean,

Dr. Sara (Gottfried) Szal:
And that's classic misattunement, where they are making assumptions about why you're taking it. They probably don't even understand what low-dose no-trucks anything is for, because it's something that we started using, as you said, you know, 10, 15 years ago. And here's the sad truth. When you finish medical school in residency and you go out in the world as a clinician, that's when you've got kind of the biggest knowledge base. And most clinicians do very little to keep that knowledge base up to date. They may know how to set a leg, you know, if you break your leg. They may know the latest antibiotic to take if you've got pneumonia. But are they going to keep up on concepts like low-dose no-trucks, which I prescribe all the time for people with autoimmune conditions? I think it's one of the most important immunomodulators. It helps to tonify your immune system. Vitamin D does that too, but there's a time and a place for low-dose no-trucks. I use it not just for the classic autoimmune diseases, but I also use it in pain syndromes and other conditions, especially that women face, where the body is attacking itself, such as endometriosis, adenomyosis, and even some cases of irritable bowel syndrome, because there are types of irritable bowel syndrome where you can demonstrate antibodies, basically your immune system is making weapons against your bowel. So I use low-dose no-trucks a lot, and I've taken it myself because I always, if I can, I usually try something myself before I prescribe it. I appreciate the story because it just shows, you know, how much conventional medicine misses the boat.

Melanie Avalon:
It also made me realize, made me rethink all of these studies I read about trials and patient studies and I realize I've been doing those as just numbers and words on paper and I'm like these were all real people, you know, and it's just hard to really grasp that in our minds. It's true. It's a really good question.

Dr. Sara (Gottfried) Szal:
good point, Melanie, because most of conventional medicine is based on population studies. So, for instance, prescribing a statin for high low-density lipoprotein LDL, that's based on mostly studies in men, and you have a group of the population, half the population that gets randomized to get a statin, and then the other half of the population that gets randomized to receive a placebo, and then you determine if the treatment works, if the pharmaceutical works. But the problem there is that you end up getting medicine for the average. You are looking at, you know, kind of a bell-shaped curve. You're not doing personalized medicine for the individual, and that leads to a lot of problems. So, I was taught at Harvard Medical School that a randomized trial is really important, especially for pharmaceuticals, but the better quality of evidence, which speaks to the point you're making of these individuals and their experience with some of these treatments that we're talking about, and how when you do end-of-one experiments and each person serves as their own control, that's how you can make it really precise. That's not medicine for the average. That's a way to really personalize the right treatment for an individual.

Melanie Avalon:
You were talking about how issues can start, you know, years before a condition actually manifests. I'm curious with the individuality interpreting lab work. So if people get tests for antibodies, for example, the breakdown isn't zero, right? Like, isn't it like less for the different ones? Isn't like less than a certain number and then you're considered negative versus positive? That's correct. So my question is that cutoff determination for less than a certain percent equals a negative result. How is that determined? And if you have any amount, would that indicate that you're headed in a certain direction? Or is it true that it's safe if you're below a certain amount?

Dr. Sara (Gottfried) Szal:
It's a good question. I don't have the answer. I can say as a as a scientist thinking about this, generally your immune system has some background noise and so and there's also some cross-reactivity between different proteins in the body of which antibodies that B cells make in your immune system there can be some cross-reactivity and so what we know is that I'm not sure how the cutoffs were determined. I imagine it probably was in men. You know another question another way to ask this is for a given laboratory so let's say function health for a given laboratory they usually will have a cutoff that's determined based on you know what's what's the sensitivity of that particular test? What's the sensitivity and the specificity? So there's a few different ways you can define what the cutoffs are. You can look at you know a population if we take Ashimoto's thyroiditis as an example you can take a group of ideally women because it's seven to ten times more common in women than men. You can take a group of women who've got totally normal thyroid function and you can measure thyroid proxies and thyroglobulin antibodies in that population and then you can take a group of women who have Hashimoto's thyroiditis and measure the same antibodies in that population and then you can look and see okay how high do the antibodies get and the people who are totally normal they've got an ultrasound showing that their thyroid is normal there's no destruction versus the women who've got Hashimoto's. So if you follow that it's a way of determining what the cutoff is is that the way it was actually done in the study.

Melanie Avalon:
use? I don't know. You mentioned earlier, you know, these different triggers that can lead to autoimmune conditions and you know, the role of trauma. Determining where an autoimmune condition manifests in the body, does the immune system have some sort of central decision maker that decides to have an autoimmune response and infested condition or is it on a, like a location by location basis, so like a person who has a thyroid issue versus arthritis, like why do people, why do we, I'm assuming we all have these triggers and these exposures, so why do different people get different autoimmune conditions in different places?

Dr. Sara (Gottfried) Szal:
It's a great question. So the way I would answer that is to talk about what we think of as the three-legged stool. So when someone develops an autoimmune disease, there's three requirements. The first is a genetic predisposition. The second is leaky gut, which in medicine we call increased intestinal permeability. And then the third is a trigger. And you're right, triggers are everywhere. Triggers can be things like getting COVID or trauma, as we talked about. What I see a lot of in my practice, because I take care of so many perimenopausal and menopausal women, is that big hormonal changes like pregnancy, postpartum, perimenopause, menopause, those are really common triggers. So all of those service triggers and this question about the immune system, it's good because the immune system is pretty decentralized. And it might be helpful just to talk about the immune system for a moment. It's pretty complex, but let me try to simplify it as much as I can without oversimplifying it. I think of the immune system as this distributed military of the body. And the job of the military is to defend you against invaders, like viruses, like bacteria, and also to protect your body's cells. And so it's a group of different organs and cells and what are known as signaling molecules, like the antibodies that B cells make. And I wish there was a central area where you could kind of point to, okay, there's this organ and that is not working right. So we need to change the decision making in that organ, but it's not quite that simple. So if you look at the main cells of the immune system, those are B cells and T cells. Those are made by stem cells. They're made from stem cells in your bone marrow. And then, for instance, T cells go from your bone marrow, such as in your thigh bone, your femur, to your thymus, which is in your upper mid chest. And the problem here is that these cells can get confused in their role as your military, and they can start attacking your own healthy tissue. So that's called a loss of tolerance. And that includes, for instance, something I had where you can start to make antibodies, B cells can start making antibodies against the nucleus of your cells. That's known as anti-nuclear antibodies. Or another sign of confusion is that your B cells start to make antibodies against your thyroid, such as in Hashimoto's Thyroiditis or Graves. As I mentioned, that could be thyroid proxies antibodies. It could be anti-thyroglobulin antibodies. So I wish there was one place that kind of is making a decision about your vulnerability to autoimmune disease. It seems to be a little bit more complex than that I see is that some people have a vulnerability in one direction or another. Like I've got a patient, for instance, who's got celiac. She was diagnosed with celiac. And then when she was postpartum, she was diagnosed with Hashimoto's Thyroiditis. And then when she was going through perimenopause, she was diagnosed with multiple sclerosis. So that's an example of someone who's got a genetic predisposition. She definitely had leaky gut. And then she had triggers, including a lot of adverse childhood experiences. So the point here is that it's hard to know exactly what one's vulnerability is and whether you've got a tendency toward rheumatoid arthritis or Hashimoto's Thyroiditis. Although checking your genetics, especially the MHC genes, the major histocompatibility complex genes, that's a good place to start.

Melanie Avalon:
That stool, the genetics, the leaky gut, the triggers, all three of those are required to manifest an autoimmune condition or one is required.

Dr. Sara (Gottfried) Szal:
So all three are required. This is really important.

Melanie Avalon:
So if you didn't have leaky guy.

Dr. Sara (Gottfried) Szal:
Yeah, so leaky gut is so common, I don't even test for it anymore because pretty much everyone I test is positive for leaky gut. This work, I should give credit where credit is due. So the guy who developed this three-legged stool hypothesis, which has been pretty well proven is a guy named Alessio Fasano, and he's a gastroenterologist who works at Massachusetts General Hospital in Boston. He initially did a lot of work with Celiac as a pediatric gastroenterologist, and he found this three-legged stool was true in all of his patients with Celiac. And then he got curious about other autoimmune diseases and started to look, is this three-legged stool true in other autoimmune diseases as it is? So he's published widely about this. It's that you need to have all three to develop an autoimmune disease. Wow, okay. Here's the good news. Two of those are under your control, right? So can't do much to change your genes. You know, you can make epigenetic changes, you can change the way that your DNA is expressed, but you can certainly address leaky gut, and you can certainly address your triggers.

Melanie Avalon:
I was really curious about our level of control in all of these. It seems like with triggers, I mean, can a person actually eradicate all triggers? Is that just life?

Dr. Sara (Gottfried) Szal:
Well, I would say you can't eradicate them. I mean, when you look at, for instance, according to the research on adverse childhood experiences, one of my aces was that my parents got divorced. So I'm not going to eradicate that. You know, my parents made that decision when I was about a year old. So what you can do is you can turn down the volume on it. You can work to resolve the way that the trauma lives in your system. So I have certain behaviors that may have been related to my parents divorce, you know, fear of abandonment and, you know, being extremely self-reliant and being an overachiever and, you know, kind of a goody, goody straight A student, all of those things are things that I can modify. And, you know, one of the reasons why I wrote the autoimmune cure is because I felt like the latest ways of approaching trauma with trauma informed treatments, EMDR, somatic experiencing, psychedelic assisted therapy, which I hope we'll get to eventually. What I found is that those things turned down the volume on my own trauma more than anything I've ever experienced. So that was really another major reason why I wrote this book.

Melanie Avalon:
I'm really fascinated by that aspect of addressing the triggers with these different therapies and modalities and, I guess, mindset-related things. Going back to the stool and the mindset, would it be possible then for people to have a radical change in mindset and have a spontaneous remission of an autoimmune condition? If that were to happen, would we assume that they don't have leaky gut and that epigenetics got addressed? I guess I'm still going back to this question of this central potential in the body to reverse a condition. Can we do that through mindset change?

Dr. Sara (Gottfried) Szal:
It's a good question. I don't know that we have the answer to it. I mean, I, I mean, the other thing I think of as you ask this question again, with a little bit different nuance is that spirits involved. You know, this question of spontaneous remission, I've seen a lot of people who have gotten into remission with their autoimmune disease. I've seen it with Hashimoto's thyroiditis. I've seen it with one patient who's in the book who's got type 1 diabetes. And she was, she still had some function of her pancreas or eyelid cells. She still had some that were working. And she's been able to extend her honeymoon using the concepts that are in the book, the treatments, elimination diet, and addressing trauma, and some of these somatic therapies. So there, there are definitely cases of remission. I've got another client who has gotten multiple clients who've gotten into remission with Crohn's disease, a type of inflammatory bowel disease. So yes, remission is definitely possible. I would say it's more than just mindset though. So maybe, maybe you could think your way into a different physiological state because so much for a reaction, maybe to something like, you know, in my case, my parents divorce, the way that that altered my physiology and put me at greater risk of metabolic dysfunction and led to me having prediabetes when I was in my thirties. You know, that's something I've been able to put into remission. And I would say it's more than a mindset shift. It's, it's really resolving trauma, getting to the point where I look at the facts of how I was born and my childhood without getting triggered by them and without being, you know, kind of led around by the nose by them. So mindset, I think you're using maybe as a placeholder for a bigger concept of, you know, could we change our state? Could we change our physiology? And could we do that with resolving trauma and with shifting, you know, sort of the way that our mind works so that we're able to witness it more and we're not enslaved by it.

Melanie Avalon:
approaching these different modalities. Something fascinating you talked about in the book is you look at the difference between the effects and roles of something like talk therapy versus these other modalities to address trauma. And you mentioned some of them already, like EMDR and even psychedelic-assisted therapy and things like that. And you talk about, no pun intended, how talk therapy may be more appropriate for things like anxiety and depression. But when it comes to trauma, that these other different modalities might be more effective. And you said that people who have higher inflammation don't respond as, well, wait, I wanna get it the right way. I think people who have higher inflammation are less likely to respond to talk therapy. I wasn't sure if that was because they're less likely to go or they just don't respond as well.

Dr. Sara (Gottfried) Szal:
Yeah, that's a good question. I learned about this from my friend and colleague, Will van de Veer, who's a psychiatrist. He's a co-founder of the Integrative Psychiatry Institute in Colorado. When I first, yeah, the point is that there's kind of different subtypes of people with mental health challenges. And if you look at the group of people with depression, as an example, there's a large portion of them who have increased inflammation. So their immune system is activated. And when you've got increased inflammation, some of these treatments that are standard of care, like talk therapy, are less likely to be effective. You have to have a more holistic approach where you're addressing inflammation. And then if we shift to what you were starting with, which is for people with trauma, when I was researching this book, I looked, okay, what's the gold standard? You got someone who walks in the door and they've got symptoms of post-traumatic stress disorder. What's the latest thinking in conventional medicine for how to treat it? And the latest thinking is still talk therapy, sometimes trauma informed, but not always. And then there are three drugs, selective serotonin rhabtic inhibitors that are used and FDA approved for the treatment of PTSD. So talk therapy with or without an SSRI has an efficacy of about 30%. So if you have 100 people with PTSD and you treat them with talk therapy and one of these SSRIs that are FDA approved, about 30% of them will get better and no longer meet criteria for PTSD. I think that's abysmal. So 30%, if when I started talk therapy in my twenties with my first bout of depression, if someone said to me, Hey Sarah, your partial PTSD has an efficacy of 30% response to this weekly psychotherapy that you're starting. I don't think I would have done it. So if we then shift and look at MDMA assisted therapy for post-traumatic stress disorder, it has an efficacy of 67 to 71%. So it's more than double as effective as the standard of care, which is part of what makes the FDA's rejection of the use of MDMA for PTSD so inferior.

Melanie Avalon:
And that rejection, what's the latest on that? Because I know when I was reading the book, it was talking about like March 2024, which is now, I'm not sure if that was for MDMA. I'm curious, what is the current like right now? How are things going with different psychedelics?

Dr. Sara (Gottfried) Szal:
Yeah, so the advisory board voted on it this summer, and they voted against it. And then we wouldn't say decision just two weeks ago in August of 2024 against approval for MDMA. So it's really unfortunate. We think that there's pharmaceutical influence because you can imagine being treated two to three times with MDMA, assisted therapy, and having all of these people, you know, veterans, other people with the experience of trauma, having them come off of their long-term antidepressants and SSRIs, that's a big hit to pharmaceutical companies. So it's a messy situation and we've got to keep fighting, especially for people who are traumatized, who deserve access to this treatment. Do they give a reason for the rejection? They have a lot of reasons. They say that there's concerns about safety. There was one episode of sexual impropriety in one of the randomized trials. And so are there concerns sufficient to not FDA approve it? I don't think so. But, you know, I think the, I'm not an expert, there are particular reasons. And what I would do is I would point people to maps and Rick Doplin to learn more about what you can do and how we can redouble our efforts to make this available more widely and FDA approved.

Melanie Avalon:
I mean, I just know personally, I mean, I've had massive, massive paradigm shifts surrounding this because I was raised, well, I don't know, I was, I guess I was raised with a general messaging being don't do drugs, like this blanket statement and psychedelic type things were all lumped into this, you know, very bad camp of don't do any of that. And I wasn't until I really started podcasting and I feel like despite this setback, there has been a lot of rapid evolution in the past few years, just seeing how in the past few years, even how I felt about all of this and started learning more and people talking about it on podcasts. And I was really blown away. The more I learned about just how, how the narrative is so, so different from what is actually happening here. Like, and yeah, I was, I would love to hear more about your thoughts on the different psychedelic potential here and your experience, you know, MDMA, ketamine, psilocybin, what actually is found and when they do the studies for these.

Dr. Sara (Gottfried) Szal:
I really appreciate your point because I was raised the same way, Melanie. You know, I was basically taught just say no to drugs. And when I said that I was a goody two shoes growing up, like I never tried pot. I never taught acid. Like mushrooms were not on the menu in college. I was in the library or at a football game. So I never used any drugs of any sort. Until I started to see the data coming out on MDMA. And this began, you know, I started to look at the data maybe five years ago. There's a couple of nature publications on the randomized trials looking at MDMA for PTSD. And they report what I described earlier. So in the initial trial that was done in people with severe PTSD. And then in the second phase three trial, because the FDA wanted more diversity in the study population, that first study was mostly white folks. They then did a more diverse patient population with moderate to severe PTSD. And in those people, they found that there was a 71% efficacy where people no longer met criteria for PTSD. So those studies were published in arguably one of the best journals that we have in the world, Nature Medicine. And that kind of efficacy is really, you know, it's head and shoulders above the gold standard. And the FDA is supposed to protect us. It's also supposed to look at the data and make decisions about whether the benefits outweigh the risks. And when you look at some of these medicines that we're talking about, like MDMA or ketamine or psilocybin, they are so much more effective than what's currently on the market. And they're safer than alcohol. It's these medicines are safer than riding a horse. David Nut is sort of famous for saying that he's a British guy. So I talked quite a bit about the different psychedelics in the book. There's I'm certified in MDMA, ketamine and psilocybin. Ketamine is the only one that is FDA approved, although we use it off label. It's FDA approved as ketamine for people with treatment resistant depression. But we're finding that it's really helpful for trauma. It's helpful for eating disorders. It's helpful for anxiety, as well as depression and psilocybin. Similarly, we've got multiple randomized trials showing that a single dose of psilocybin is effective for treating major depression, major depressive disorder. We really need access to these medicines. And Rick Doblin is kind of let the charge to get the FDA to approve MDMA for trauma. He chose trauma because he felt like there are so many people affected by trauma right now. There's so many people with post-traumatic stress disorder. And the gold standard is so poor that he thought it was the best population in whom to prove that MDMA was worth a small amount of risk. And I firmly believe it is. We also, you know, his thought was that people with trauma are the most sympathetic audience, most sympathetic subjects that we could get FDA approval for. But MDMA works for other things as well. So those are some of the indications for these different treatments. Psilocybin has been also very helpful with substance use disorder, with end of life care, or with, you know, kind of preparing for death. There's a lot of really interesting work coming out of NYU in that regard. And we've seen all of these psychedelic centers pop up around the country. You know, initially we just had a place at Johns Hopkins, the Center for Psychedelic Studies, and now we've got, you know, at UCSF, University of California, San Francisco, we've got a really great group of psychedelic investigators. And we're on the verge of a revolution. It's just the FDA is slowing the revolution down a bit.

Melanie Avalon:
Are these studies primarily macro dosing or is it micro dosing as well?

Dr. Sara (Gottfried) Szal:
So these studies I just spoke about are macrodosing. Microdosing is when you take a sub perceptual level of some of these medications and you can microdose on pretty much anything. A lot of people think that you can't microdose on MDMA but I can tell you you can. Probably what's been most studied is psilocybin and microdosing. Most of the protocols have you take it every three days somewhere around 75 to 150 milligrams and I've experimented with that. I use it a lot of my clients and you know to kind of connect it back to the book and to autoimmunity I find that psilocybin in particular is a really effective immunomodulator. So we've talked about vitamin D as an immunomodulator a way of tonifying the immune system so that it's back into balance. I would say that lotus naltrexone also well demonstrated although not big randomized trials and same thing with microdosing mushrooms or psilocybin.

Melanie Avalon:
If listeners would like to learn more about microdosing, I did an interview with Paul Austin. He has a book called Microdosing Psychedelics, so I'll put a link to that in the show notes. When you say you're certified, what does that mean? Where does a person get certification?

Dr. Sara (Gottfried) Szal:
Yeah, I'm certified through the Integrative Psychiatry Institute. So I mentioned one of the co-founders, Will Van De Veer. The other co-founder is Keith Kerlunder. I got certified in the three medicines that I mentioned, MDMA, Ketamine, and Psilocybin. I've done some of the MAPS training, kind of the level one training. And then I've done two additional certifications in Ketamine. So what does certification mean? It, you know, right now with psychedelics, it's kind of the Wild West. There's some states that allow you to use some of these medicines. So for example, in Oregon, they've gone through this process over the last couple of years to train psilocybin guides and providers. Colorado is close behind them. In Oakland, California, where I used to live, psilocybin has been decriminalized. So you have to kind of check what's going on with your local state. But I have a certification, a year training that I've done to learn about these medicines and how to safely provide them. And then, you know, what we're waiting for, at least above, above ground is for MDMA and psilocybin to be FDA approved.

Melanie Avalon:
a two-part question about using these for potentially different autoimmune conditions. It's a two-part because I'm starting to ask it and I'm realizing we need to clarify something. Is there a gender-sex difference in how people respond to these potentially four autoimmune conditions? And then that led to the clarifying question, which you have a section in the book about the difference between gender and sex, and I'm curious in general in autoimmune conditions, is there a difference in gender and sex in response to autoimmune conditions, just like stats and all of that? It's such a good question.

Dr. Sara (Gottfried) Szal:
So yeah, in the book I talk about how the difference between sex and gender is that sex is biologically constructed. So you're born typically with either XY or XX in your chromosomes, your sex chromosomes. There's some variations in intersex, but most of us are one or the other. And so you're assigned particular sex at birth and then gender is socially constructed. I would say both sex and gender affect your risk of autoimmunity. So sex difference first, we know that four out of five people with autoimmune disease are women. So definitely having an XY increase your risk fourfold. And then there's gender differences too. And I would say this, if we look at those triggers, the three-legged stool as an example, women experience more trauma than men. So that's not a sex difference. That's a gender difference. Women experience a lot more sexual trauma. In the original studies, looking at childhood adverse experiences that were done in the 1990s with the Centers for Disease Control and Kaiser Permanente, they found that women overall had about 10% more adverse childhood experiences compared to men. And the study was designed to look at middle-aged people who were mostly middle-class and had insurance through Kaiser Permanente. And they were asking them in midlife about their childhood experiences, so different experiences of trauma, neglect, abuse before age 18. And then they mapped it to chronic health conditions in middle age. And they found overall that having one or more adverse childhood experiences increase your risk of chronic disease quite significantly, like more than we ever anticipated. There's more than 45 different chronic diseases that are increased as a result of adverse childhood experiences. And some of those make sense, increased risk of depression, suicide, cardiovascular disease, but also chief among those chronic conditions is autoimmune disease. So there's both a sex and gender difference when it comes to autoimmunity. And then I think you may have also been asking, and correct me if I'm wrong, maybe we should clarify this, are you asking also if psychedelic medicine has a sex or gender difference? Yes. Well, that's the subject of my next book because

Melanie Avalon:
Oh my goodness, teaser!

Dr. Sara (Gottfried) Szal:
Yeah, total teaser. So I think there is, I think there's a different, there's a way that these medicines kind of open up women differently than they open up men. That's my experience with sitting with a lot of people over the past three years. And we are at the very beginning stages of understanding this. But when you look at, for instance, this experience of trauma and how women have more trauma than men, then it would make sense to me that women potentially have more to gain, more to, you know, more of a benefit, especially when it comes to trauma. So that's a hypothesis that we have to test.

Melanie Avalon:
Oh, I love this and now I'm very excited about your next book. That's awesome. Yay. Question about what you just said about women having more trauma than men. There was a part in your book where you're talking about men may have more, I don't want to get the quote wrong, but basically trauma that they're not aware of, like suppressed trauma. Is it possible that women are more in tune with their trauma than men are aware of?

Dr. Sara (Gottfried) Szal:
of it. It's a little tricky to answer because men tend to have more physical violence as their form of trauma. You know, they also, of course, have sexual trauma, sexual abuse, but the rates in women are so much higher of sexual trauma. The part that gets a little bit tricky is that when you look at a stress response, you know, it was defined in the 1930s of fight or flight. So your sympathetic nervous system responds to a threat by going into fight or flight. That was defined in men, and it was assumed that women do the same thing.

Melanie Avalon:
Oh, interesting.

Dr. Sara (Gottfried) Szal:
But we don't always. So you can imagine, Melanie, if you're a woman on the Savannah at the time that our stress response was developing, if you've got an infant in one arm and you've got a toddler in the other arm and you're faced with a threat, fighting a tiger or some other predator, it's not going to work so well for you. Running is also not going to work so well for you. So women don't usually fight or flee. They tend to do some other things. They tend to be more immobilized. And that's an important point because women under stress are more likely to fawn or people please freeze or faint. So the stress response is much broader than just the sympathetic fight or flight. It's fight, flight, freeze, fawn, faint. And the opposite of that kind of the counterbalance is your parasympathetic nervous system, which we think of as rest and digest or feed and breed or stay in play. It's really important to have a good dynamic balance between your synthetic nervous system and your parasympathetic nervous system. And women who go into this fawn response, which frankly I used to do when I was a kid, like the way I dealt with the volatility and the stress in my household was to people please. I got really good at it. And so a big part of this experience with psychedelic assisted therapy in my later years has been to undo that fawn response and to have a more mobilized response. So the idea with a stress response is that you don't become frozen in time. You don't let that stress become embedded in your nervous system and you find ways to discharge it. So I think that's a really critical piece. So your question about, you know, men have more suppressed trauma. I don't know the answer. Hard to say.

Melanie Avalon:
I love this picture concept of the stress response and, you know, you were talking in the book, I think you said that, like, in theory, when we have a stressor, it should take about 90 seconds that we get rid of it, which is, like, mind-blowing to think about, wouldn't that be nice? 90 seconds, done. And then you were talking about, you know, this observation that animals, when they have a stressful encounter, they shake, and they shake off the stress, which is also really, really interesting to think about. Is there also another F in the stress response? Somebody, I'm trying to remember who it was, might have been Dave Asprey. I interviewed somebody, and they were talking about the stress response, and they said, also, there's another F, which the polite word for it would be fornicate as a stress response. It sounds like Dave might have said that, yeah. I mean, it does sound like a Dave thing. The sixth F.

Dr. Sara (Gottfried) Szal:
Like, did they ask me? I mean, that is a good stress response. Yes. I mean, one another thing that women do that is more effective, and with SoulKeeper, your episode clean, is that women, you know, when you go back to visualizing that woman on the Savannah, who's got young kids, if she's surrounded by a group of women, and there's strength in that community, and they look out for each other, and they protect each other. That's called tend and befriend. And that's another strategy for stress that's incredibly effective. So I sort of agree with, with Dave, but I would also say, let's call it tend and befriend.

Melanie Avalon:
I love it. I love it. That's so interesting. Something you talk about also in the tendon befriend world and in the hormone world, the work of oxytocin and how it's a double-edged sword with women because it's also highly involved, I believe, in the stress response. So it can be a good thing, but also it can make us more vulnerable. I guess what is the role of oxytocin in women and stress?

Dr. Sara (Gottfried) Szal:
Yeah, oxytocin is super interesting. It's a hormone and a brain chemical or neurotransmitter. And most people think of it as released when you have an orgasm, or you're breastfeeding, or you're delivering a baby. It's the hormone of love and bonding. So it's a really important counter hormone when it comes to the stress response. So if you think about just the hormonal part of the stress response, there's the increase in adrenaline, epinephrine, followed by an increase in cortisol, which is the main stress hormone. And oxytocin, like if you're feeling stressed, you just got an email that upsets you and you reach out to someone you love, ideally in that, you know, maybe within 90 seconds. And you say, hey, this is going on. And they listen to you and attune to you and reassure you. Then you feel that rise of oxytocin. You feel that connection, that love and bonding. And it's a way of just resetting your cortisol and resetting the stress response. So it's a really important countermeasure that some of us are really good at. And some of us could maybe use a little help to produce more oxytocin and to feel the benefits of oxytocin.

Melanie Avalon:
Is there supplemental oxytocin?

Dr. Sara (Gottfried) Szal:
Yeah, you know, there was, I remember when I first started working with combating firmacies maybe 25, 20 years ago, we used to use oxytocin trochees, these little lozenges with oxytocin. I never found that they were that helpful. There's occasionally a clinical situation where it might be worthwhile, but for the most part supplemental oxytocin doesn't seem to have the promise that we hoped it did. And there's very little data showing that it has any benefit. Most of the studies are either no improvement, no change in outcomes, or, you know, sort of a minimal effect that hasn't been replicated.

Melanie Avalon:
Okay, that's not surprising to me. I feel like that is a case often with some hormones It's kind of like when they would do all the studies on leptin and that they don't work

Dr. Sara (Gottfried) Szal:
It's true, it's better for you to make it on your own and modulate it on your own. Yeah, okay. There's no shortcuts, unfortunately.

Melanie Avalon:
Would you argue psychedelics are a little bit like a shortcut though?

Dr. Sara (Gottfried) Szal:
in a way. I wouldn't call them a shortcut. I think they're an amplifier. But, you know, for those of us who are listening, who've done true psychedelic assisted therapy, which is very different than going to a rave and taking Molly, if you've done true psychedelic assisted therapy, it is big work, like capital B, capital W. And if you really are in the business of transformation and you want to change the way that your psyche interprets the world and you want to resolve the signature of trauma in your body, it's a fair amount of work. So I wouldn't call it a shortcut. I would call it, you know, sort of an accelerator.

Melanie Avalon:
Okay. Yeah. Yeah. I'm really glad we're talking about this because I definitely, I mean, so I actually, I have not done any psychedelics. I would like to, I really would. Come to Northern California. I know. I need to move back. I lived there for 10 years. So I think there's definitely a perception out there, which I clearly partly harbor or I'm curious about where it seems like, okay, it's, it seems like a shortcut because, you know, instead of doing these other therapy modalities for years and years and years, it's like I, you know, you do this, you know, a few, a few times of this thing and have this massive transformation. But I'm so I'm really glad to hear what you just said about the, is a lot of work. Sounds like it's not shortcut. It's just a new door you didn't know existed.

Dr. Sara (Gottfried) Szal:
That's right. It's no door. I would say it's more efficient so that you're not churning and spinning your wheels and, you know, 10 years of psychotherapy. And I think I calculated once that I've spent maybe $250,000 on talk therapy. And I, you know, mostly what it did was reinforce my thought patterns around it rather than resolving them because the part of your brain that understands what happens to you, what happened to you, is different than the part that heals. So yeah, I would say psychedelic assisted therapy is more efficient and it's a way of when it's done correctly with the right set mindset, the right setting, the right environment, and the right intention, then I think it can be very effective. But you also have to be careful, you know, like with, we talked about how psychedelic medicine right now is the Wild West and you want to be cautious. Like I, as a licensed physician, I can't recommend any treatment below ground, even though there's a long tradition of indigenous healers in the space and, you know, pretty much every, almost every culture on the planet has an experience with psychedelic medicine as part of spiritual inquiry and work. I also have these limitations and regulations that I have to live within as a licensed physician. They can be an accelerator and they may sound like it would help you leapfrog, but I would say that's with the right set and setting.

Melanie Avalon:
How are you navigating that- writing this book that we're talking about and writing your next book.

Dr. Sara (Gottfried) Szal:
Well, it was so funny because my publisher did the most intensive legal review.

Melanie Avalon:
I bet, I was gonna say, I bet that those calls were.

Dr. Sara (Gottfried) Szal:
Yeah, it was super interesting because, you know, I've, I've published books on hormones and I talk a lot about perimenopause and hormone therapy and I've got a book about resetting your hormones with your food, no legal issues at all. And on this book had like months and months of legal debate. And when it published in the UK, the United Kingdom, it was even more aggressive. Yeah, I mean, the way I deal with it is to be, you know, which you'll notice in Chapter 12 is that I say over and over again, this, these things are not FDA approved. Ketamine is the only thing that's FDA approved. There's lots of extra cautions that the legal team added. So, you know, it's sort of a necessary part of this process and I can live with that in order to try to get the message out to as many people as possible, especially those who are going to benefit from this type of work.

Melanie Avalon:
One thing I've been grateful for, this is a weird twisty gratefulness, but the fact that I'm not a doctor so I don't have to worry quite as much, knock on wood, about the you know the legal ramifications and such attached to you know being a doctor and every you know what you're saying is medical advice and

Dr. Sara (Gottfried) Szal:
That's right. You're more f-

Melanie Avalon:
free. Yeah. So I really applaud you because you're doing everything that is so incredible and spreading all this awareness and you're doing it with all these credentials, which are amazing. And you're taking on that challenge and that risk. And so I'm just really, really grateful.

Dr. Sara (Gottfried) Szal:
Thank you for doing it. Thank you, Melanie. It's, you know, service is really the bottom line here. And to reach out to people who are suffering, that's really the reason for writing these books.

Melanie Avalon:
Well, it touches so many people. Was there any other topics or anything you want to draw attention to in this whole sphere?

Dr. Sara (Gottfried) Szal:
I think the main thing for people who are listening to this is to know what's going on inside your body. Start with a really basic test and look at what's going on with your immune system. You can do a complete blood count. You can do high sensitivity C-reactive protein as a way of measuring these things. Those are basic tests that almost any primary care clinician is going to order. Then if you want to go deeper, if you want to look at anti-nuclear antibodies or antibodies against your thyroid, then consider doing something like the functionhealth.com test. As we mentioned earlier, maybe we can add that to your show notes for people who want to bypass the wait list and check that out.

Melanie Avalon:
We'll definitely add that. And actually, can I selfishly ask you a personal question that relates to that? And it actually brings everything full circle. So like I said, I've been on LDN, I was first put on it about a decade ago. I'm laughing in my head because I know you mentioned Mark Pimentel in your book. And, um, when I first started getting IBS issues, like a decade ago, I was in LA. And I, I was like, I'm going to see Dr. Pimentel, like I made it my, my goal, my mission. And I like kept emailing like them trying to get in and I couldn't get in. And so then I got in, so then I like looked up all the papers he was on and I was like, well, what other, what other doctors does he work with? So I, so I like found a doctor that was like, did a study with him. And then I remember I went to the actual appointment and it was literally next door. Like Dr. Pimentel's office was next door and I was like, I'm so close, but it didn't manifest. Point being, that's when I first got prescribed LDN for IBS related things. I've been on it since then because I liked the effects of the mood. And sleep and everything. I'm just wondering what your thoughts, and I've had this question actually from a lot of listeners as well. So I'm wondering what your thoughts are on just being on it long-term. And then you mentioned the CRP. My CRP is always a complete flat line and it has been for years. And I saw a new functional practitioner recently and she was saying maybe, maybe the LDN and everything was too much inflammation suppression and that it, maybe that wasn't a good thing, which that had never occurred to me. What are your thoughts on long-term low dose naltrexone and also long-term just flat line CRP?

Dr. Sara (Gottfried) Szal:
with lotus naltrexone is that we don't have long-term data. What I tend to do with something like lotus naltrexone is I give it as pulses. So I don't like to just give it chronically for years on end, five or ten years. What I typically do is give it for six months or a year and see through an end of one experiment, does it help? So I'll do that with patients with psoriasis or multiple sclerosis or Hashimoto's thyroiditis. I especially use it in people who've got positive antibodies, but their thyroid function is normal. And then we'll do a little drug holiday where they come off for six to 12 weeks and see if they notice any difference in how they feel or if their labs change. So I'm not sure about the whether it chronically suppresses high sensitivity C-reactive protein. I'm someone who always had a really low HSCRP like down around 0.1 until my last function test, it was elevated at 1.1. So I'm looking into why that might be. So generally what I would say is it might be worthwhile to do a little drug holiday, a little experiment and just freshen up those receptors and see if you feel any different. After six to 12 weeks, that's what I would say.

Melanie Avalon:
patients okay that's what she suggested so that sounds pretty in line well oh my goodness okay how can people best follow your work do you have any timeline for for the new book well it's not due

Dr. Sara (Gottfried) Szal:
until March of next year. So the best way is to go to Sarahgottfriedmd.com. And I, I was telling you at the beginning, before we started recording, I went through a divorce last year. So I'm changing back to my maiden name, which is Szal, S-Z-A-L. And so eventually that website's going to be Sarah, S-A-R-A-Szal, S-Z-A-L-M-D.com. So that's the best place to find me.

Melanie Avalon:
Well, thank you so much, Sarah. I really cannot express enough how grateful I am for your work. You've been personally affecting me and impacting me for years and years. And I see it in so many other people as well. And I'm just so honored that you're at the forefront of the changes that we need in the medical system when it comes to health and wellness of our world. The last question that I ask every single guest on this show, and it is because I just realize more and more each day how important mindset is. And by mindset, I mean, I guess just the typical definition. What is something that you're grateful for?

Dr. Sara (Gottfried) Szal:
My daughters are what come to mind immediately. They're just the most important teachers in my life. I love them so much. I've got one who's 19 and she goes to college in Texas. And then I've got another one who's 24. And she works in San Francisco and wants to become a therapist. So incredibly grateful for these amazing young women that I have in my life. Awesome.

Melanie Avalon:
Well, I love it so much. Thank you so, so much. I will continue to follow all of your work and hopefully we can have you back on the show for that new book in the future. It'll be so exciting. And it sounds great, Melanie. Thank you so much. Thanks, Sarah. Bye.