Outlive by Peter Attia

Rating: 5/10

Aiming to provide a comprehensive guide to longevity and personalised preventative health care, Outlive covers topics such as exercise, nutrition, general medical information, and — to a much lesser degree — sleep and emotional health.

While Outlive is filled with gems of practical advice, it’s also consistently very technical and often repetitive. I also have some concerns regarding the applicability of the nutritional information to most readers (and recommend looking for collaboration).

Regarding sleep, I recommend reading Why We Sleep, and the chapter on mental/emotional health is significantly lacking. That said, I took a lot of useful notes on points that are worth remembering.

There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.

Bishop Desmond Tutu

[There are] five tactical domains that we can address in order to alter someone’s health:

  1. first is exercise, which I consider to be by far the most potent domain in terms of its impact on both lifespan and healthspan. Of course, exercise is not just one thing, so I break it down into its components of aerobic efficiency, maximum aerobic output (VO2 max), strength, and stability,
  2. Next is diet or nutrition—or as I prefer to call it, nutritional biochemistry.
  3. third domain is sleep,
  4. The fourth domain encompasses a set of tools and techniques to manage and improve emotional health.
  5. fifth and final domain consists of the various drugs, supplements, and hormones that doctors learn about in medical school and beyond. I lump these into one bucket called exogenous molecules, meaning molecules we ingest that come from outside the body.

General health thinking

  • The Four Horsemen [chronic diseases that account for >80% of deaths in those aged >50]: heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction.
  • Each one of the Horsemen is cumulative, the product of multiple risk factors adding up and compounding over time. Many of these same individual risk factors, it turns out, are relatively easy to reduce or even eliminate. Even better, they share certain features or drivers in common
  • the only way to create a better future for yourself—to set yourself on a better trajectory—is to start thinking about it and taking action now.

Philosophy of longevity

  • The time to repair the roof is when the sun is shining. — John F. Kennedy
  • To achieve longevity—to live longer and live better for longer—we must understand and confront these causes of slow death.
  • Longevity has two components. The first is how long you live, your chronological lifespan, but the second and equally important part is how well you live—the quality of your years. This is called healthspan, and it is what Tithonus forgot to ask for.

Medical advances

  • lifespans have nearly doubled since the late 1800s, the lion’s share of that progress may have resulted entirely from antibiotics and improved sanitation, as Steven Johnson points out in his book Extra Life.
  • if you subtract out deaths from the eight top infectious diseases, which were largely brought under control by the advent of antibiotics in the 1930s, overall mortality rates declined relatively little over the course of the twentieth century.

General (not solely medical)

  • objective → strategy → tactics
  • after the age of reproduction, natural selection loses much of its force. Genes that prove unfavorable or even harmful in midlife and beyond are not weeded out because they have already been passed on.
  • cancer, as well as heart disease, type 2 diabetes, and dementia (along with a few others), became collectively known as “diseases of civilization,” because they seemed to have spread in lockstep with the industrialization and urbanization of Europe and the United States.
  • “Résumé virtues,” meaning the accomplishments that we list on our CV, our degrees and fellowships and jobs
  • “Eulogy virtues,” the things that our friends and family will say about us when we are gone.

General (medical)

  • Medicine 2.0 treats everyone as basically the same, obeying the findings of the clinical trials that underlie evidence-based medicine. These trials take heterogeneous inputs (the people in the study or studies) and come up with homogeneous results (the average result across all those people). Evidence-based medicine then insists that we apply those average findings back to individuals. The problem is that no patient is strictly average.
  • In Medicine 2.0, you are a passenger on the ship, being carried along somewhat passively. Medicine 3.0 demands much more from you, the patient: You must be well informed, medically literate to a reasonable degree, clear-eyed about your goals, and cognizant of the true nature of risk. You must be willing to change ingrained habits, accept new challenges, and venture outside of your comfort zone if necessary. You are always participating, never passive. You confront problems, even uncomfortable or scary ones, rather than ignoring them until it’s too late. You have skin in the game, in a very literal sense. And you make important decisions.
  • [Sir Austin Bradford] Hill had helped sleuth out the link between smoking and lung cancer in the early 1950s, and he came up with nine criteria for evaluating the strength of epidemiological findings and determining the likely direction of causality, which we also referenced in regard to exercise.
  • The Bradford Hill criteria are (1) strength of the association (i.e., effect size), (2) consistency (i.e., reproducibility), (3) specificity (i.e., is it an observation of disease in a very specific population at a specific site, with no other likely explanation?), (4) temporality (i.e., does the cause precede the effect?), (5) dose response (i.e., does the effect get stronger with a higher dose?), (6) plausibility (i.e., does it make sense?), (7) coherence (i.e., does it agree with data from controlled experiments in animals?), (8) experiment (i.e. is there experimental evidence to back up the findings?), and (9) analogy (i.e., the effect of similar factors may be considered).
  • This experiment demonstrates how easy it is to be misled by epidemiology. One reason is because general health is a massive confounder in these kinds of studies. This is also known as healthy user bias, meaning that study results sometimes reflect the baseline health of the subjects more than the influence of whatever input is being studied—
  • it is so important to evaluate any intervention, nutritional or otherwise, through the lens of efficacy versus effectiveness . Efficacy tests how well the intervention works under perfect conditions and adherence (i.e., if one does everything exactly as prescribed). Effectiveness tests how well the intervention works under real-world conditions, in real people.

Ageing

  • “Aging is characterized by a progressive loss of physiological integrity, leading to impaired function and increased vulnerability to death,” wrote the authors of an influential 2013 paper describing what they termed the “ hallmarks of aging.” They continued: “This deterioration is the primary risk factor for major human pathologies, including cancer, diabetes, cardiovascular disorders, and neurodegenerative diseases.”
  • Not only do [centenarians] live longer, but these are people who have been healthier than their peers, and biologically younger than them, for virtually their entire lives.

Exercise

  • break down this thing called exercise into its most important components: strength, stability, aerobic efficiency, and peak aerobic capacity.
  • The three dimensions in which we want to optimize our fitness are aerobic endurance and efficiency (aka cardio), strength, and stability. All three of these are key to maintaining your health and strength as you age.
  • Increasing your limits in each of these areas is necessary if you are hoping to reach your limit of lifespan and healthspan.
  • We want to maintain physical strength, stamina, stability across a broad range of movements, while remaining free from pain and disability.
  • Yes, you should be doing more cardio. And yes, you should be lifting more weights.
  • Study after study has found that regular exercisers live as much as a decade longer than sedentary people.
  • peak aerobic cardiorespiratory fitness, measured in terms of VO2 max, is perhaps the single most powerful marker for longevity.
  • someone of below-average VO2 max for their age and sex (that is, between the 25th and 50th percentiles) is at double the risk of all-cause mortality compared to someone in the top quartile (75th to 97.6th percentiles). Thus, poor cardiorespiratory fitness carries a greater relative risk of death than smoking.
  • Someone in the bottom quartile of VO2 max for their age group (i.e., the least fit 25 percent) is nearly four times likelier to die than someone in the top quartile—and five times likelier to die than a person with elite-level (top 2.3 percent) VO2 max.
  • Cardiorespiratory fitness is inversely associated with long-term mortality with no observed upper limit of benefit
  • those with low muscle mass were at 40 to 50 percent greater risk of mortality than controls, over the study period. Further analysis revealed that it’s not the mere muscle mass that matters but the strength of those muscles, their ability to generate force.
  • movement and exercise, not merely aerobic exercise but also more complex activities like boxing workouts, are a primary treatment/prevention strategy for Parkinson’s. Exercise is the only intervention shown to delay the progression of Parkinson’s.
  • the epidemiology linking strength and cardiorespiratory fitness to lower risk for neurodegeneration is so uniform in its direction and magnitude that my own skepticism of the power of exercise, circa 2012, has slowly melted away. I now tell patients that exercise is, full stop and hands down, the best tool we have in the neurodegeneration prevention tool kit.
  • we are more interested in a finer distinction—not calories, but fuels . How we utilize different fuels, glucose and fatty acids, is critical not only to our fitness but also to our metabolic and overall health. Aerobic exercise, done in a very specific way, improves our ability to utilize glucose and especially fat as fuel.
  • training aerobic endurance and efficiency (i.e., zone 2 work) is the first element of my Centenarian Decathlon training program.
  • the zone 2 test: You’re able to talk in full sentences, but just barely.
  • a side benefit of zone 2 is that it also helps with cognition, by increasing cerebral blood flow and by stimulating the production of BDNF, brain-derived neurotrophic factor, which we touched on earlier. This is another reason why zone 2 is such an important part of our Alzheimer’s disease prevention program.
  • Where HIIT intervals are very short, typically measured in seconds, VO2 max intervals are a bit longer, ranging from three to eight minutes—and a notch less intense. I do these workouts on my road bike, mounted to a stationary trainer, or on a rowing machine, but running on a treadmill (or a track) could also work. The tried-and-true formula for these intervals is to go four minutes at the maximum pace you can sustain for this amount of time—not an all-out sprint, but still a very hard effort. Then ride or jog four minutes easy, which should be enough time for your heart rate to come back down to below about one hundred beats per minute. Repeat this four to six times and cool down.
  • VO2 max can always be improved by training, no matter how old you are.
  • you don’t need to spend very much time in the pain cave. Unless you are training to be competitive in elite endurance sports like cycling, swimming, running, triathlon, or cross-country skiing, a single workout per week in this zone will generally suffice. You’ll pretty quickly find that it boosts your performance across the rest of your exercise program
  • after just ten days of bed rest, which is about what a person would experience from a major illness or orthopedic injury, study participants lost an average of 3.3 pounds of lean mass (muscle).
  • It takes much less time to lose muscle mass and strength than to gain it, particularly if we are sedentary. Even if someone has been training diligently, a short period of inactivity can erase many of those gains. If that inactivity stems from a fall or a broken bone, and lasts longer than a few days, it can often kick off a steep decline from which we may never fully recover,
  • One study looked at sixty-two frail seniors (average age seventy-eight) who engaged in a program of strength training and found that even after six months of pure strength training, half of the subjects did not gain any muscle mass. They also didn’t lose any muscle mass, likely thanks to the weight training, but the upshot is, it is very difficult to put on muscle mass later in life.
  • BMD is important, demanding at least as much attention as muscle mass, so you should at least check your BMD every few years. (Particularly if your primary sports are nonweight-bearing, like cycling or swimming.)
  • think of strength training as a form of retirement saving. Just as we want to retire with enough money saved up to sustain us for the rest of our lives, we want to reach older age with enough of a “reserve” of muscle (and bone density) to protect us from injury and allow us to continue to pursue the activities that we enjoy.
  • (A good goal is to be able to carry one-quarter to one-third of your body weight once you develop enough strength and stamina.
  • Fundamentally I structure my training around exercises that improve the following: Grip strength, how hard you can grip with your hands, which involves everything from your hands to your lats (the large muscles on your back). Almost all actions begin with the grip. Attention to both concentric and eccentric loading for all movements, meaning when our muscles are shortening (concentric) and when they are lengthening (eccentric). In other words, we need to be able to lift the weight up and put it back down, slowly and with control. Rucking down hills is a great way to work on eccentric strength, because it forces you to put on the “brakes.” Pulling motions, at all angles from overhead to in front of you, which also requires grip strength (e.g., pull-ups and rows). Hip-hinging movements, such as the deadlift and squat, but also step-ups, hip-thrusters, and countless single-leg variants of exercises that strengthen the legs, glutes, and lower back.
  • there is an enormous body of literature linking better grip strength in midlife and beyond to decreased risk of overall mortality. The data are as robust as for VO2 max and muscle mass,
  • One of the standards we ask of our male patients is that they can carry half their body weight in each hand (so full body weight in total) for at least one minute, and for our female patients we push for 75 percent of that weight.
  • it is far more important to learn and practice ideal movement patterns than to be pounding heavy weights all the time.
  • we like to see men hang for at least two minutes and women for at least ninety seconds at the age of forty.
  • The final foundational element of strength is hip-hinging, which is what it sounds like: You bend at the hips—not the spine—to harness your body’s largest muscles, the gluteus maximus and the hamstrings.
  • first commandment of fitness: First, do thyself no harm. How do we do this? I think stability is the key ingredient.
  • stand with one foot in front of the other and try to balance. Now close your eyes and see how long you can hold the position. Ten seconds is a respectable time; in fact, the ability to balance on one leg at ages fifty and older has been correlated with future longevity, just like grip strength. (Pro tip: balancing becomes a lot easier if you first focus on grounding your feet, as described above.)

Metabolism and cardiovascular disease

  • an average adult male will have about five grams of glucose circulating in his bloodstream at any given time, or about a teaspoon. That teaspoon won’t last more than a few minutes, as glucose is taken up by the muscles and especially the brain, so the liver has to continually feed in more, titrating it precisely to maintain a more or less constant level. Consider that five grams of glucose, spread out across one’s entire circulatory system, is normal, while seven grams—a teaspoon and a half—means you have diabetes. As I said, the liver is an amazing organ.
  • Stress, presumably, via cortisol and other stress hormones, has a surprising impact on blood glucose,
  • It doesn’t take much visceral fat to cause problems. Let’s say you are a forty-year-old man who weighs two hundred pounds. If you have 20 percent body fat, making you more or less average (50th percentile) for your age and sex, that means you are carrying 40 pounds of fat throughout your body. Even if just 4.5 pounds of that is visceral fat, you would be considered at exceptionally high risk for cardiovascular disease and type 2 diabetes, in the top 5 percent of risk for your age and sex.
  • why some people can be obese but metabolically healthy, while others can appear “skinny” while still walking around with three or more markers of metabolic syndrome. It’s these people who are most at risk,
  • insulin resistance itself is associated with huge increases in one’s risk of cancer (up to twelvefold), Alzheimer’s disease (fivefold), and death from cardiovascular disease (almost sixfold)—all of which underscores why addressing, and ideally preventing, metabolic dysfunction is a cornerstone [in longevity].
  • What is the most common “presentation” (or symptom) of heart disease? It wasn’t chest pain, left arm pain, or shortness of breath, the most common answers; it was sudden death. You know the patient has heart disease because he or she has just died from it. This is why, he claimed, the only doctors who truly understand cardiovascular disease are pathologists.

Nutrition

  • Four problems that have plagued humanity since the beginning: (1) how to produce enough food to feed almost everyone; (2) how to do so inexpensively; (3) how to preserve that food so it can be stored and transported safely; and (4) how to make it highly palatable . If you optimize for all four of these characteristics, you’re pretty much guaranteed to end up with the [standard American diet, SAD], which is not so much a diet as a business model for how to feed the world efficiently.
  • your “total cholesterol,” the first number that people offer up when we’re talking about heart disease, is only slightly more relevant to your cardiovascular risk than the color of your eyes.
  • the advisory committee responsible for the US government dietary guidelines finally conceded (in 2015) that “ cholesterol is not a nutrient of concern for overconsumption.”
  • Monounsaturated fats, found in high quantities in extra virgin olive oil, macadamia nuts, and avocados (among other foods), do not have this effect, so I tend to push my patients to consume more of these, up to about 60 percent of total fat intake. The point is not necessarily to limit fat overall but to shift to fats that promote a better lipid profile.
  • Instead of diet, we should be talking about nutritional biochemistry. That takes it out of the realm of ideology and religion—and above all, emotion—and places it firmly back into the realm of science.
  • any dietary intervention that compromises muscle, or lean body mass, is a nonstarter—
  • Nutrition is relatively simple, actually. It boils down to a few basic rules: don’t eat too many calories, or too few; consume sufficient protein and essential fats; obtain the vitamins and minerals you need; and avoid pathogens
  • If your great-grandmother would not recognize it, you’re probably better off not eating it.
  • If you bought it on the perimeter of the grocery store, it’s probably better than if you bought it in the middle of the store.
  • Plants are very good to eat. Animal protein is “safe” to eat
  • The more refined the carb (think dinner roll, potato chips), the faster and higher the glucose spike. Less processed carbohydrates and those with more fiber, on the other hand, blunt the glucose impact. I try to eat more than fifty grams of fiber per day.
  • brown rice is only slightly less glycemic than long-grain white rice.
  • Nonstarchy veggies such as spinach or broccoli have virtually no impact on blood sugar. Have at them.
  • Foods high in protein and fat (e.g., eggs, beef short ribs) have virtually no effect on blood sugar (assuming the short ribs are not coated in sweet sauce), but large amounts of lean protein (e.g., chicken breast) will elevate glucose slightly.
  • If you consume more protein than you can synthesize into lean mass, you will simply excrete the excess in your urine as urea.
  • How much protein do we actually need? It varies from person to person. In my patients I typically set 1.6 g/kg/day as the minimum, which is twice the RDA. The ideal amount can vary from person to person, but the data suggest that for active people with normal kidney function, one gram per pound of body weight per day (or 2.2 g/kg/day) is a good place to start—nearly triple the minimal recommendation.
  • It would require an overwhelming effort to eat more than 3.7 g/kg/day (or ~1.7 g/lb of body weight), defined as the safe upper limit of protein consumption
  • Putting all these changes into practice typically means eating more olive oil and avocados and nuts, cutting back on (but not necessarily eliminating) things like butter and lard, and reducing the omega-6-rich corn, soybean, and sunflower oils—while also looking for ways to increase high-omega-3 marine PUFAs from sources such as salmon and anchovies.
  • the most comprehensive review of this topic, Polyunsaturated Fatty Acids for the Primary and Secondary Prevention of Cardiovascular Disease, published by the Cochrane Collaboration in 2018—a 422-page summation of all relevant literature from forty-nine studies, randomizing over twenty-four thousand patients—drew the following conclusion: “Increasing PUFA probably makes little or no difference (neither benefit nor harm) to our risk of death, and may make little or no difference to our risk of dying from cardiovascular disease. However, increasing PUFA probably slightly reduces our risk of heart disease events and of combined heart and stroke events (moderate-quality evidence).”
  • “reducing dietary saturated fat reduced the risk of combined cardiovascular events by 17%” […] “little or no effect of reducing saturated fat on all-cause mortality or cardiovascular mortality.” Furthermore, “There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI.”
  • “mainly no association of total fat, monounsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA), and saturated fatty acid (SFA) with risk of chronic diseases.”
  • frequent longer-term fasting has enough negatives attached to it that I am reluctant to use it in all but the most metabolically sick patients.
  • the type of mindless eating-just-to-eat that the Japanese call kuchisabishii, for “lonely mouth.”
  • frequent, prolonged fasting may be neither necessary nor wise for most patients.
  • you must eat enough to maintain lean mass (muscle) and long-term activity patterns.
  • focus on eliminating those types of foods that raise blood glucose too much, but in a way that also does not compromise protein intake and lean body mass.
  • Protein is actually the most important macronutrient, the one macro that should not be compromised. Remember, most people will be overnourished.

Cancer

  • A randomized trial in 131 cancer patients undergoing chemotherapy found that those who were placed on a “fasting-mimicking diet” (basically, a very low-calorie diet designed to provide essential nutrients while reducing feelings of hunger) were more likely to respond to chemotherapy and to feel better physically and emotionally.
  • the working hypothesis is that because cancer cells are so metabolically greedy, they are therefore more vulnerable than normal cells to a reduction in nutrients—or more likely, a reduction in insulin, which activates the PI3K pathway essential to the Warburg effect.
  • stacking different therapies, such as combining a PI3K inhibitor with a ketogenic diet, we can attack cancer on multiple fronts, while also minimizing the likelihood of the cancer developing resistance

Neurodegeneration

  • One reason why Alzheimer’s and related dementias can be so tricky to diagnose is that our highly complex brains are adept at compensating for damage, in a way that conceals these early stages of neurodegeneration.
  • When we have a thought or a perception, it’s not just one neural network that is responsible for that insight, or that decision, but many individual networks working simultaneously on the same problem,
  • There is redundancy built into the system. The more of these networks and subnetworks that we have built up over our lifetime, via education or experience, or by developing complex skills such as speaking a foreign language or playing a musical instrument, the more resistant to cognitive decline we will tend to be. The brain can continue functioning more or less normally, even as some of these networks begin to fail. This is called “cognitive reserve,” and it has been shown to help some patients to resist the symptoms of Alzheimer’s disease.
  • There is a parallel concept known as “movement reserve” that becomes relevant with Parkinson’s disease. People with better movement patterns, and a longer history of moving their bodies, such as trained or frequent athletes, tend to resist or slow the progression of the disease as compared to sedentary people.
  • it’s difficult to disentangle cognitive reserve from other factors, such as socioeconomic status and education, which are in turn linked to better metabolic health and other factors ( also known as “healthy user bias”).
  • movement and exercise, not merely aerobic exercise but also more complex activities like boxing workouts, are a primary treatment/prevention strategy for Parkinson’s. Exercise is the only intervention shown to delay the progression of Parkinson’s.
  • the evidence on whether cognitive reserve can be “trained” or used as a preventive strategy, such as by learning to play a musical instrument or other forms of “brain training,” is highly conflicted and not conclusive—although neither of these can hurt,
  • tasks or activities that present more varied challenges, requiring more nimble thinking and processing, are more productive at building and maintaining cognitive reserve. Simply doing a crossword puzzle every day, on the other hand, seems only to make people better at doing crossword puzzles.
  • The same goes for movement reserve: dancing appears to be more effective than walking at delaying symptoms of Parkinson’s disease, possibly because it involves more complex movement.
  • Several studies have found that spraying insulin right into subjects’ noses—administering it as directly as possible into their brains—quickly improves cognitive performance and memory, even in people who have already been diagnosed with Alzheimer’s disease.
  • the epidemiology linking strength and cardiorespiratory fitness to lower risk for neurodegeneration is so uniform in its direction and magnitude that my own skepticism of the power of exercise, circa 2012, has slowly melted away. I now tell patients that exercise is, full stop and hands down, the best tool we have in the neurodegeneration prevention tool kit.
  • Sleep disruptions and poor sleep are potential drivers of increased risk of dementia. If poor sleep is accompanied by high stress and elevated cortisol levels, as in Stephanie’s case, that acts almost as a multiplier of risk, as it contributes to insulin resistance and damaging the hippocampus at the same time.
  • Another surprising intervention that may help reduce systemic inflammation, and possibly Alzheimer’s disease risk, is brushing and flossing one’s teeth.
  • WHAT’S GOOD FOR THE HEART IS GOOD FOR THE BRAIN. That is, vascular health (meaning low apoB, low inflammation, and low oxidative stress) is crucial to brain health.
  • WHAT’S GOOD FOR THE LIVER (AND PANCREAS) IS GOOD FOR THE BRAIN. Metabolic health is crucial to brain health.
  • OUR MOST POWERFUL TOOL FOR PREVENTING COGNITIVE DECLINE IS EXERCISE.

Sleep

  • A good versus bad night of sleep makes a world of difference in terms of glucose control. All things equal, it appears that sleeping just five to six hours (versus eight hours) accounts for about a 10 to 20 mg/dL (that’s a lot!)
  • Athletes who sleep poorly the night before a race or a match perform markedly worse than when they are well rested. Endurance drops, VO2 max drops, and one-rep-max strength drops. Even our ability to perspire is impaired.
  • One large-scale survey found that the more interactive devices subjects used during the hour before bedtime, the more difficulties they had falling asleep and staying asleep—whereas passive devices such as TV, electronic music players, and, best of all, books were less likely to be associated with poor sleep.

Mental health

  • addiction can take many forms, not merely to drugs or alcohol. Often, he continued, it is an outgrowth of some trauma that has happened in a person’s past. Paul is an expert in trauma, and he saw that I displayed all the behavioral signs: anger, detachment, obsessiveness, a need to achieve that was fueled by insecurity.
  • Trauma generally falls into five categories: (1) abuse (physical or sexual, but also emotional or spiritual); (2) neglect; (3) abandonment; (4) enmeshment (the blurring of boundaries between adults and children); and (5) witnessing tragic events.
  • Trauma is a pretty loaded word, and the therapists at the Bridge were careful to explain that there can be “big-T” trauma or “little-t” traumas. Being a victim of rape would qualify as a big-T trauma, while having an alcoholic parent might subject a child to a host of little-t traumas. But in large enough doses over a long enough time, little-t traumas can shape a person’s life just as much as one major terrible event.
  • the Trauma Tree. The idea behind it is that certain undesirable behaviors that we manifest as adults, such as addiction and uncontrolled anger, are actually adaptations to the various types of trauma we suffered in childhood. So while we only see the manifestation of the tree above the ground, the trunk and branches, we need to look underground, at the roots, to understand the tree completely. But the roots are often very well hidden,
  • situations in question may or may not have been life-or-death, he explained, “but to a child with an undeveloped brain, it may have seemed that way.”
  • researchers looked at junior scientists who had applied for NIH grants and separated them into two groups: One group had scored just above the threshold for funding, while the other had scored just below the funding line, meaning their grants were not funded. While the near-miss group were more likely to drop out of science in the immediate aftermath, those who stuck with it eventually outperformed their peers who had received funding on their first try. The early setback had not impaired their careers but may have had an opposite effect.
  • The most important thing about childhood trauma is not the event itself but the way the child adapts to it. Children are remarkably resilient, and wounded children become adaptive children.
  • dysfunction is represented by the four branches of the trauma tree: (1) addiction, not only to vices such as drugs, alcohol, and gambling, but also to socially acceptable things such as work, exercise, and perfectionism (check); (2) codependency, or excessive psychological reliance on another person; (3) habituated survival strategies, such as a propensity to anger and rage (check); (4) attachment disorders, difficulty forming and maintaining connections or meaningful relationships with others (check).
  • read Terrence Real’s book I Don’t Want to Talk About It,
  • “90% of male rage is helplessness masquerading as frustration.”
  • “Family pathology rolls from generation to generation like a fire in the woods taking down everything in its path until one person, in one generation, has the courage to turn and face the flames. That person brings peace to his ancestors and spares the children that follow.”
  • children don’t respond to a parent’s anger in a logical way. If they see me screaming at a driver who just cut me off, they internalize that rage as though it were directed to them.
  • trauma is generational, although not necessarily linear. Children of alcoholics are not inevitably destined to become alcoholics themselves, but one way or another, trauma finds its way down the line.
  • reframing entails taking a step back from a situation and then asking yourself, What does this situation look like through the other person’s eyes? How do they see it? And why is your time, your convenience, or your agenda any more important than theirs?
  • My deep self-hatred and loathing still contaminated most of my thoughts and emotions, and I didn’t even realize it—nor did I understand why it was happening.
  • “I need to be great,” he said, “in order to feel like I’m not worthless.”
  • had built a structure of perfectionism and workaholism on the pillars of performance-based esteem. This structure rested on a foundation of my shame, some of which was brought on by trauma and some of which was inherited, as children take on the shame of those around them.
  • had stopped wanting to celebrate my birthdays when I was about seven; in fact, I revealed, I would keep my birthday a “secret” until well into my twenties. His questions made it clear that this was not something a healthy child would do, and it likely masked something more deeply wrong.
  • more little-t traumas, hidden in the cracks, that had affected me even more profoundly. I hadn’t been protected. I hadn’t felt safe. My trust had been broken by people who were close to me. I felt abandoned. All of that had manifested itself as my own self-loathing as an adult; I had become my own worst enemy.
  • break the chain reaction of negative stimulus → negative emotion → negative thought → negative action.
  • overarching theme is mindfulness, which gives you the ability to work through the other four: emotional regulation (getting control over our emotions), distress tolerance (our ability to handle emotional stressors), interpersonal effectiveness (how well we make our needs and feelings known to others), and self-management (taking care of ourselves, beginning with basic tasks like getting up in time to go to work or school).
  • Buddha, who said that “your worst enemy cannot harm you as much as your own unguarded thoughts.”
  • Seneca improved on that in the first century AD, observing that “we suffer more often in imagination than in reality.” And later, in the sixteenth century, Shakespeare’s Hamlet noted, “There is nothing either good or bad, but thinking makes it so.”
  • My therapist at PCS told me to imagine instead that my best friend had performed exactly as I had done. How would I speak to him? Would I berate him the way I often berated myself? Of course not.
  • slightly different take on reframing, forcing me to step outside myself and really see the disconnect between my “mistakes” (minor) and the way I talked to myself about those mistakes (brutal).
  • anger was rooted in shame, but very often my anger would also create more shame. If I yell at my kids, for example, especially when I do it because I’m upset about something else, I feel shame. That shame then becomes an obstacle to my ability to reconcile with them, so I feel more shame. It’s like I’m digging myself into a hole,
  • something very important: changing the behavior can change the mood. You do not need to wait for your mood to improve to make a behavior change.
  • simply thinking about problems might not help if our thinking itself is disordered.
  • it’s important to seek pleasurable activities “consistent with your own values.”
  • “Maybe the journey isn’t so much about becoming anything,” he writes. “Maybe it’s about unbecoming everything that isn’t really you, so you can be who you were meant to be in the first place.”
  • I wanted to live longer, I think, only because deep down I knew I needed more runway to try to make things right. But I was only looking backward, not forward.
  • longevity is meaningless if your life sucks. Or if your relationships suck. None of it matters if your wife hates you. None of it matters if you are a shitty father, or if you are consumed by anger or addiction. Your résumé doesn’t really matter, either, when it comes time for your eulogy.
  • My obsession with longevity was really about my fear of dying. And something about having children was making my obsession with longevity ever more frenetic. My obsession with longevity was really about my fear of dying. And something about having children was making my obsession with longevity ever more frenetic. I was running away from dying as fast as I could. Yet at the same time, ironically, I was also avoiding actually living.
  • “If you want to find someone’s true age, listen to them. If they talk about the past and they talk about all the things that happened that they did, they’ve gotten old. If they think about their dreams, their aspirations, what they’re still looking forward to—they’re young.”