How Early Attachment Shapes Dysautonomia And Stress Responses with Dr. Matthew Tolstoy (Part 1) | E69

Can early childhood experiences influence concussion recovery, dysautonomia, anxiety, and the autonomic nervous system? 

In this episode of Life After Impact, Dr. Ayla Wolf sits down with integrative therapist Dr. Matthew Tolstoy to explore the fascinating connection between attachment theory, autonomic regulation, post-concussion syndrome, and brain injury recovery.

They examine how our earliest relationships help shape the brain's unconscious "survival programs"—patterns that influence how we respond to stress, danger, connection, and safety throughout our lives. While these attachment patterns often operate quietly in the background, a concussion can disrupt the brain networks that normally help regulate emotional and autonomic responses, making these deeply ingrained patterns much more apparent.

Dr. Tolstoy explains why attachment theory is about far more than romantic relationships. At its core, it is a neurobiological model of survival. From infancy, our nervous system is constantly learning whether the world feels safe, whether other people can be trusted, and how to respond when we experience threat. Those early experiences become deeply embedded within the autonomic nervous system and continue influencing physiology long into adulthood.

Together, we explore the four major attachment styles—secure, anxious, avoidant, and disorganized—and discuss how each one may shape autonomic regulation, stress responses, emotional resilience, and even the way patients experience dysautonomia after concussion.

In this episode, you'll learn:

•  What attachment theory really is—and why it extends far beyond relationships 
•  How early childhood experiences shape the autonomic nervous system 
•  The neurobiology connecting attachment, stress, and survival 
•  The four attachment styles and their characteristic physiological patterns 
•  Why two people with similar concussions can have very different autonomic responses 
•  The connection between attachment patterns and dysautonomia 
•  How concussion can uncover subconscious nervous system patterns that previously went unnoticed 
•  Why psychology and physiology cannot be separated when treating persistent concussion symptoms 
•  The importance of interdisciplinary care between rehabilitation specialists and mental health professionals 
•  How awareness creates an opportunity to reshape long-standing autonomic patterns through neuroplasticity 

Perhaps the most empowering message from this conversation is that attachment styles are not life sentences. They are learned patterns of nervous system regulation that developed to help us survive. As Dr. Tolstoy explains, awareness becomes the bridge between unconscious autonomic responses and intentional healing. When we begin to understand why our nervous system reacts the way it does, we also begin creating the possibility for change.

Whether you're recovering from a concussion, living with dysautonomia, working with patients who have persistent post-concussion symptoms, or simply fascinated by the intersection of neuroscience, psychology, and autonomic regulation, this episode offers a powerful new perspective on what it truly means to heal.

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Medical disclaimer: this video or podcast is for general informational purposes only, and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice diagnosis or treatment. Consumers of this information should seek the advice of a medical professional for any and all health related issues. 

Transcript

Threat, Distance, And Nervous System Defense

Dr. Matthew Tolstoy 0:00

You now see the presence of threat is at this level. You feel this dysregulated, and this person is this close right now. You know that that's not going to work. I don't have a lot of reps inside of my nervous system and memory encoding that says this is going to go well. What do I need to do? I probably need to step back. I probably need to distance. I probably need more space. Ah, yes, that feels more comfortable. Here I go. And then their physiology and psychology knows what to do in that organization of stressor, self, and other.

Dr. Ayla Wolf 0:30

Welcome to Life After Impact, the Concussion Recovery Podcast. I'm Dr. Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating, and overwhelming journey of concussion and brain injury recovery. This podcast is your go-to resource for actionable information. Whether you're dealing with a recent concussion, struggling with post-concussion syndrome, or just feeling stuck in your healing process, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. Dr. Matthew Tolstoy, welcome to the show.

Dr. Matthew Tolstoy 1:09

It's great to see you.

Dr. Ayla Wolf 1:11

Yeah, so you and I had a very long conversation the last time that I was in New York, and you started talking about attachment theory and its relevance to dysautonomia. And at one point, I'm gonna totally out you as a nerd by saying this, but you pulled up a quote that was saved on your phone by Eric Kandell, the guy who wrote the book, The Principles

Why Attachment Touches Autonomics

Dr. Ayla Wolf 1:35

of Neural Science, And essentially that quote was saying, you know, we've got it all wrong when we think about psychology and physiology as being two totally different things. And so we this was like such a great conversation. I wish we had recorded the whole thing. So I was going to try to see how well can we recreate this today. Let's just have you maybe start by explaining what attachment theory is and then how you've been looking at it from the perspective of how does this affect the autonomic nervous system with your background in both a somatic body worker and in psychology and as a Chinese medicine practitioner. You've started to recognize that the way that we have our attachments in the world affects our autonomic nervous system and that we can't just approach autonomic dysregulation purely from a physical standpoint of let's just pharmaceutically control this or let's come in and just try to, you know, stimulate the vagus nerve. Like there's just so much more to it. So I'm gonna let you talk and maybe start there.

Dr. Matthew Tolstoy 2:45

Yeah, of course. Um, and I mean first and foremost, I wish that we had recorded that conversation too, because it was such a great time and it was so great to sit down and chat with you in detail about this because it is something that is so, well, interesting and compelling to me just because of what I've seen clinically over time, and that's how I've sort of ended up in this space. And so when we talk about the overlap between autonomic regulation and attachment, I think we have to just appreciate how much autonomic regulation is wired into multiple systems of feedback inside the brain. So if we think about it, autonomic regulation is such a central experience in our physiology. You know, we can think about the ways we behaviorally respond to relational stress or physical stress, or when we're moving and working out in the gym and all of these ways that we act in the world. But what has to happen first in order to do that is our heart rate has to speed up or slow down. Our blood pressure has to change, sweating has to change, all of these, all of these autonomic regulatory functions have to fire off quickly, as it's in the name, automatically. They have to adjust themselves in real time. And so this the idea that this system has so many other systems feeding back into it to tell it what it needs to do actually makes a lot of sense when you think about the way that the gears in the brain sort of intersect with each other, that that that feedback loop needs to be there. So on the surface, it looks like my relationship to people who I really care about somehow changes the way that my heart pumps blood. Seems a little bit far-fetched from the beginning. But when we begin to appreciate just like what the human system needs to do in order to respond to its environment, both internal and external. And of course, that includes other people, that these systems actually have a lot of overlap. And as we found out over time, that they actually share a lot of circuitry in the brain. This is not just like an abstract, theoretical, like symbolic overlap, that there's actually neuroanatomical overlap between these systems that then influence each other that way.

Dr. Ayla Wolf 4:51

Right. And I think that with my surface level uh introduction to attachment theory being a book that was called Attached, that was really kind of like the mass media version of attachment theory for people trying to find love, right? Like trying to have relationships. But what you're saying is attachment theory like goes all the way back to, you know, the moment you were born and really is um something that's developing through your entire life and has a huge input or influence on how our autonomic nervous system is functioning. And so that's I think where I had that aha moment of, oh, this isn't just about finding the right partner. This is about like your entire physiology and how it responds. And so often when I have patients that come in with autonomic dysregulation, I'm not a counselor, I'm not a psychotherapist. I can see trauma, I can see that people are struggling. But I think that this is where I'm so fascinated. And how can I help these people better by even just guiding them towards here are some things to look at. So that's why, you know, your blend of all of this is just so brilliant.

Dr. Matthew Tolstoy 6:05

Well, yeah. And I I think your entry into attachment theory is pretty much the main way that people get exposed to attachment theory if they're exposed to uh attachment theory. You know, you read stuff online, you read articles that are mostly geared towards romantic relationships because that is the clearest way we see in adulthood our attachment styles show up. However, like we're saying, we're pointing to it's a much more interconnected and vastly influential system on all of these different aspects of being human. But yes, romantic relationships are the way that we hear about and can put a lens on understanding how this functions for us.

Dr. Ayla Wolf 6:42

But I think sell the most books.

Dr. Matthew Tolstoy 6:45

And also sell the most books, get on social media. We can convince you why your ex was a narcissist, you know what I mean? All these things that are just very sticky. Well, but also other jokes aside, why is it so sticky? It's because attachment experiences, both positive and negative, signal very strongly to us about the nature of our survival. That sounds like a big jump right there, but I think that that gets to what we're talking about, about why attachment is so central to many experiences and uh why attachment is in our nervous system and brain to begin with, that it really speaks to what attachment is from a neurobiological and evolutionary biology standpoint, rather than just, let's say, like a dating trope. It shows up there, but it's its origin is much deeper. And when we say something like our attachment experiences, positive or negative, signal to us about our survival, that might sound like, well, that escalated quickly. But it really is the foundation of attachment theory. So it might be good to take a second to kind of

Survival Roots Of Attachment In Infancy

Dr. Matthew Tolstoy 7:50

go back to that level and talk about like, well, well, what is this, what is this function? And like, why is it here? And how does it show up inside of so many different experiences in our life? And sort of the answer to that is you have to think about think about how unique humans are in terms of our developmental arc. Think about how long it takes a human to become self-sufficient in the world.

Dr. Ayla Wolf 8:13

Right. We're completely useless for many, many years. Yes.

Dr. Matthew Tolstoy 8:17

Yeah. So this is a feature of evolutionary biology. You know, so nature, our big survival advantage is like, look, you got this big brain with a big cortex. And the thing is, that takes up a lot of space. Your head is really big, especially when you're a baby. And so the compromise that nature made was saying, like, look, okay, in order for you to be mechanically birthed through a human body, your brain's got to be smaller when you're born. And it's gonna have this long developmental arc where we grow our cortex, our cortex, this outer layer of the brain that can run our higher order functions. It grows over time through experience because it needed to be smaller and underdeveloped when we were born. However, this leads us to be incredibly dependent on our caregivers from the jump. You know, think about it again if we're talking uh, you know, hunter-gatherer times. How old does a human need to be before they can go find the berries? How old does a human need to be before they can catch a squirrel? Not be eaten by a predator. These are the things that that really have a long developmental arc in humans that compared to other mammals is incredibly long. You know, that deer pops out and is born and in a few minutes is walking, and then they spend about a year with mom, and that's it. That's it.

unknown 9:29

Right.

Dr. Ayla Wolf 9:30

And so that's that's what you mean when you say attachment's really about survival. Without the attachment piece, why would our mothers even bother to take care of us for five years before we're able to go find berries and be contributing members of society?

Dr. Matthew Tolstoy 9:46

Yes, exactly. And so that go that goes both directions in terms of the relational experience and how these attachment circuits get shaped over the course of experience, particularly in infancy, particularly in the first two years of life, because the the brain is going through a sensitive period of growth where many, many, many millions of neurons are being wired up between different regions of the brain. And a lot of those are being shaped by the experience you have with a caregiver. And so babies are incredibly sensitive to changes in vocal tone, to postural changes from caregivers. Does it seem the baby is always reading out? Does it seem like what just happened relationally is bringing me closer to this person and maintaining safety by being in their good graces? Or did what just happened, what did I just express, how did I just behave, did that lead to what felt like a subtle distancing or rejection from this person? And those, again, they have survival-based consequences that nature has kept inside of our nervous system. And so it might just seem like on the outside, like, oh, it's nice to be kind of cozy and comfortable with mom or dad or whoever your primary caregiver is. And it must be a little bit of a bummer when they're not as available as you like. And we we have this sort of, you know, projected adult experience, but we really have to understand that at that time, when those experiences are happening at that age, there's such a level of vulnerability and dependency that is hardwired into our nervous system that is shaping the encoding of these relational experiences, shaping our behavior, shaping our autonomic regulation. Meaning, when mom seems far away or dad seems far away, do I speed up? Do I cry louder? Do I get, do I, does that keep me connected to them? Or if I deactivate, do I, do I seem like I have it all together and I'm I'm I'm less forceful in my pleas for connection? Does that seem to get me more connected to them and more likely to be cared for? That these things shape so much of our experience of who we are and how we experience others. Again, because the system is designed around not dying. And I use that language very specifically because it does carry that life or death sense of stakes from the beginning.

Dr. Ayla Wolf 12:02

Okay. So as you were talking, something just occurred to me, and I could be way off base because I've never heard anybody talking about this, but you're talking about survival, attachment, autonomic dysregulation. When people suffer from migraines, there is autonomic dysregulation as part of that picture. And I recently was just talking to this brilliant naturopath that's down the road from my practice, and he's having phenomenal success treating migraine with intranasal oxytocin. So obviously, oxytocin is the hormone of bonding, right? Is there potentially any kind of interface between giving an adult oxytocin and having some kind of effect on the autonomic nervous system going back to this like attachment theory?

Dr. Matthew Tolstoy 12:52

Sure. Oh man, that's such a that's such a great question. And I think it really highlights the sort of multimodal input into autonomic regulation. You give somebody exogenous oxygen, right? And that will change the way we experience relationships. That will uh change the way we experience ourselves and our sense of security in the world via that felt experience that comes from this exogenous substance, right? Right.

Dr. Ayla Wolf 13:21

Just like taking ecstasy, all of a sudden your relationship with everybody around you completely changes. Not that I would know about that.

Dr. Matthew Tolstoy 13:28

Exactly. Purely theoretical discussion.

Dr. Ayla Wolf 13:30

Purely theoretical, just anecdotal.

Dr. Matthew Tolstoy 13:32

Right. But exactly. It changes the way our models of self and other are representing themselves to us in the moment. Because that's what happens with attachment and relational experiences, is we have these models inside that get encoded via our experiences, and particularly encoded via these early experiences, because that's when the

How Caregiver Cues Wire Stress Responses

Dr. Matthew Tolstoy 13:55

brain is wiring itself up most sensitively. So those experiences weigh more than the ones that you have later in life. They remain open and plastic your whole lifetime. You can shift it whenever it's not a life sentence, but there's a leverage to when these experiences happen and they get stored a certain way. But then you have a substance that changes how they activate, and all of a sudden, me in relationship to the world feels very different. Suddenly, this feels a lot more secure in the case of what we were just talking about. And like, wow, my autonomics change like crazy. My body feels more relaxed. My heart rate maybe is going down. You know, maybe I think about that stressful experience where I got to pay that bill, but it doesn't resonate inside me as intensely. The way that I'm regulating my autonomics as it relates to stress is now resonating differently. The predictive models inside about how dangerous this thing is relative to my sense of connection and stability in the world. Those scales are now different when I have that exogenous substance in there that's communicating relational security. And now all of a sudden I have a different physiological and psychological response to the same stressful event.

Dr. Ayla Wolf 15:58

Yeah, that makes so much sense. And now I know you've also differentiated between bonding versus attachment. So let's talk about that. And then let's talk about the different attachment styles. Because I think you also go kind of one level deeper than what's out there in the mainstream when it comes to these attachment styles and what they actually mean and look like in real life.

Dr. Matthew Tolstoy 16:19

Yeah, sure. Sure. Many people have heard about the different attachment styles, and and there's there's a lot of, you know, you go, you spend five minutes on social media and you'll be flooded with all different types of information about this. But we're talking about attachment styles, if we're if we're speaking most most broadly, we're talking about patterns of behavioral responses as well as internal autonomic regulation that we experience when we are stressed. That's basically it. At the broadest level, when we feel sufficiently threatened and stressed and vulnerable, it activates inside of us the way that we navigate relationships with other people. So these fall into these broad categories of attachment. Well, first and foremost, there is such a thing as securely attached, which means that you have a healthy relationship with others, you can call on them for help, you can express your needs, you have expectations that people will be able to reasonably meet you where you're at and understand you. If they don't, that's a bummer, but you can kind of handle that. That's okay. You can deal with the distress of that, but it's not totally sinking your ship. And that you can kind of go with the flow where you have a good sense of you can rely on yourself, and you have a good sense of you can rely rely on others when it's available and deal with the inevitable ups and downs that come along with that, because life is complicated. Okay. So that's securely attached. Then we have avoidant attached, which is typically what people experience when there is unavailability of a caregiver when you're young, or you experience a little bit of some distancing from a caregiver when you express your needs a little too loudly. And what this ultimately is, it's a behavioral and internal physiological relationship to deactivation. This baby and then this adult has learned, hey, look, if I can kind of deactivate the outward displays of my stress response and distance myself from my distress, the likelihood that I maintain a what I what feels to me like a safe level of connection with people is higher. And so these people oftentimes they do distance themselves from each other, but they also distance themselves from their own experience a little bit. The really interesting research on the physiological component of avoidantly attached people is that we see that there is a big disconnect between their subjective experience of their stress and their physiological markers of stress.

Dr. Ayla Wolf 18:57

Oh, interesting.

Dr. Matthew Tolstoy 18:59

So we'll ask them, you know, to recall a really difficult event, a painful separation. They'll describe it, they'll connect with it, and we'll have them on heart rate, we'll have them on HRV, we'll have them on uh skin conductance, which is a measure of autonomic stress. And the person will tell the story and we'll ask them, like, hey, cool, on a scale of whatever to whatever, how stressed do you feel? And they will dramatically underrate it and be like, ah, you know, it's whatever they rate it as very low. But when we measure their physiology, their physiology actually has stronger stress responses than the other attachment styles. And so we can see this as an internal organization for this person where they say, hey, look, look, look, my best bet for navigating these stressful events is to kind of keep these things on separate channels. My physiology is going to do what it's going to do. I don't even have the internal experience of doing that. And when I don't let it into my awareness, I don't communicate it to other people because other people don't want to hear that. That's what they have internalized. And so, therefore, that leads to a sense of stability around deactivation. I don't express, I feel like it's a good idea to not only hide that information from the other person, but also from myself. Um, vulnerability is a real spicy thing for me. I don't like to even consider what it would be like to let others help me. I'm overly self-reliant, and I'm not going to let other people super close to me, particularly when I feel stressed and threatened, because that threatens my sense of self-reliance. And I've learned that when my self-reliance is lower, I'm more at risk. I'm less likely to be able to handle the stressor. And so that's how that person gets organized around that as a behavioral as well as internal autonomic strategy of responding

Oxytocin, Felt Safety, And Regulation

Dr. Matthew Tolstoy 20:44

to stress, stressors, and threats.

Dr. Ayla Wolf 20:47

And so this is why, like in the, again, kind of mainstream attachment theory, you you just often these people are described as being like hot and cold, where in some moments they seem super available, and then in other mo moments, absolutely not at all. They just are like gone. And is that because when they are stressed out, like that's their response is to then just, like you said, deactivate.

Dr. Matthew Tolstoy 21:09

Right. Right. Yeah. And I th I think this brings up a good point about, well, the difference between, like we like you had asked a few minutes ago about the difference between bonding and attachment, right? Bonding is simply when we feel close to people and it's nice and, you know, just kind of hanging out and feel comfortable, but there isn't the presence of vulnerability and threat yet. And avoidance feels great with bonding, because it's a certain amount of closeness minus the vulnerability. And again, not because necessarily they're all narcissists and whatever in that, you know, they're all just uh pathologically organized. It's no that they've learned that that level of vulnerability, the other person's not going to meet me where I need to be met, and it's gonna be very painful. So self-reliance is more safe in those moments. So bonding is great because every, you know, I love, I love being there and being comfortable and it feels like a good time. But then when something happens and the avoidant person feels sufficiently vulnerable, all of a sudden closeness means something very different. Now, when that's activated and the system goes, whoa, whoa, whoa, hey, look, you now see the presence of threat is at this level, you feel this dysregulated, and this person is this close right now, you know that that's not gonna work. I don't have a lot of reps inside of my nervous system and memory and code encoding that says this is gonna go well. What do I need to do? I probably need to step back, I probably need to distance, I probably need more space. Ah, yes, that feels more comfortable. Here I go. And then their physiology and psychology knows what to do in that organization of stressor, self, and other.

Dr. Ayla Wolf 22:41

Okay, that makes perfect sense. So we've talked about the secure attachment. We've talked about the avoidant, and then we have what the stage five clinger next.

Dr. Matthew Tolstoy 22:51

We have anxious attachment, yes. And and again, yeah, classically, you know, if we think in social media. Terms, we, you know, what gets what gets mistermed on the avoidance side is, you know, these people don't care about closeness. And then on the anxiously attached side, these people care too much about closeness, which is so not a helpful way of thinking about it, though I can understand how it gets to be that way. But when we think about the organization psychologically and physiologically for anxiously attached people, is that these are people for whom, likely when they were younger and then has been repeated throughout the rest of their life, that when stressed, more closeness with other people is what the answer is going to be. And likely what happens, the hallmark of the caregiver experience that a lot of these people have early in life is intermittently available closeness with the caregiver. Whereas the avoidant person likely experiences the caregiver as like distant and unavailable and slightly dismissing and rejecting. The anxiously attached person has a caregiver that's sometimes really attuned, sometimes really available, sometimes really engaged, maybe sometimes even too much so, like it can feel intrusive and like just a lot of energy that is difficult for the baby to regulate. And then that's punctuated by times when the caregiver is unbelievably absent and they've lost that intense closeness. And then what that baby learns to do is if I amplify my distress, again, if I cry louder, if I protest more, if I make myself appear and seem more helpless, that breaks through the distance. And then more often than not, the caregiver comes back and I get the care, closeness, and attention that I need. And so as this gets repeated over time and encoded inside of this person, the physiological ramifications are when stressed, amplify, speed up. It's a more sympathetically dominated strategy so that that

Bonding Versus Attachment Under Threat

Dr. Matthew Tolstoy 24:58

sympathetic energy fuels my reaching out, fuels my protest, fuels my desire and expression for closeness. And so then I'm attempting to stay close to that person. I'm really sensitive and scared of rejection. And then what's also kind of a tragic about this type of insecure attachment is that then when the caregiver or the or the loved one returns, they oftentimes have trouble receiving that soothing. Because the amplification is the strategy, it's sometimes scary on an unconscious level to deactivate that because that person's system has procedurally unconsciously encoded that distress equals care. So if the person comes back and then suddenly I'm not distressed anymore, they might leave again. So what we often see, especially with the infants, when we do these studies where they reunite with a distant caregiver who had left the room for a little bit, there's there's oftentimes still a lot of anger and protest where they're still really upset and they're not soothed very easily. Their physiology takes a long time to come back down if we have them on heart rate and things like that. Because again, we see how the physiological patterning has become encoded with the predictions of safety. And so this is what anxiously attached is organized around. Amplification equals closeness, which equals safety. And so they will behaviorally and physiologically upregulate as a way of securing themselves in relationship to stress. So it's again, other or sorry, stress, myself, and other, how does that all hang together when the stress gets high enough? Amplification and then closeness. And then that's how I survive the stressor.

Dr. Ayla Wolf 26:44

Wow. And so to kind of land this plane in the world of concussion recovery, um, you know, we have this idea that we have a brain injury, and then all of a sudden a lot of the autonomic or kind of like

Secure And Avoidant Patterns In The Body

Dr. Ayla Wolf 26:58

coping mechanisms that were in place maybe got knocked offline. And our prefrontal cortex, which plays such a huge role in modulating all of our emotional responses, often is affected. And so this is where it seems like people that have autonomic dysregulation, based on whether they have an avoid an attachment kind of program running in their subconscious or an anxious attachment, those two physiological responses to stress are completely different. And so this is where you can't just have like one protocol for let's improve autonomic regulation that we just, you know, give to everybody because these physiological responses are completely different.

Dr. Matthew Tolstoy 27:45

Yes. Yes, exactly. And just pre- and briefly to swing back, there actually is one more attachment style that has a physiological signature, but relates deeply to what you just said, and we can kind of then swing back into it. The last attachment style that uh that also fits the insecure attached category is disorganized attachment. And what disorganized attachment is, is when the if we talk speak physiologically first, that's when we run sympathetic and parasympathetic strategies simultaneously. And this is why it's called disorganized, is that in these last two examples, we've talked about a fairly consistent organization. I distance, I self-rely, I deactivate. It all kind of like makes a certain internal logic, or I speed up and I amplify and I reach out. And then there's an organization to that. Disorganized does not have that same organization inside, hence the name, where we'll see people who simultaneously will distance, but then don't feel the satisfaction of the self-reliance. It actually triggers their sense of abandonment and they become highly aware of the aloneness and it goes, oh, that doesn't feel good. And then they'll take steps to get closer, but then they'll feel fear the closeness, fear then the risk of abandonment because now I'm too close. And there's this tragic thing that happens inside of these people where neither territory begins to feel safe and oftentimes will oscillate between them. And at a physiological level, we see again parasympathetic and sympathetic responses running at the same time, which is why that's so difficult to manage, and relationships are often most challenging for these people over time, because it's very hard to find somewhere that feels secure, very hard to find somewhere that even feels like a compromise. That's okay. And so when we go back to now your question about this person gets a head injury, or any of these people get a head injury, and that bumps and maybe damages some functional connectivity between certain parts of the prefrontal cortex, the limbic system and the brainstem, and all of these circuits that run and influence autonomics. Well, where this person was starting from in terms of patterning could be very, very, very different. How much do they speed up in response to stress to begin with? Are they a deactivator? Are they an avoidantly attached person? Are they secure and somewhere in the middle? Are they disorganized? And you'll do the tilt table a bunch of times and maybe not always see the same response physiologically. And then behaviorally, we don't see the thing. So you can see how this makes then physiological treatment of dysautonomia uh much more complicated than simply, okay, X should be Y, it should be Z, and we take you through the protocol, and here we go. It's different. And then also, I think what we've spoken about over time that doesn't get a lot of airtime, is that then these people's relationship with you as the provider will potentially activate relationship archetypes inside of this circuit that change their autonomic regulation in the moment with you as you're attempting to give them care.

Dr. Ayla Wolf 30:49

Okay. That's a big one.

Dr. Matthew Tolstoy 30:51

That's a big one.

Dr. Ayla Wolf 30:52

That's a huge one yes.

Dr. Matthew Tolstoy 30:55

Yeah, that's a big one.

Dr. Ayla Wolf 30:56

Yeah. Yeah. And I think sometimes as the provider, you probably have no concept that that is going on unless you have a degree in psychotherapy, like you.

Dr. Matthew Tolstoy 31:07

Exactly. And I think, you know, speaking to my experience as starting out on the physical rehabilitation side for so many years before getting involved in psychotherapy, I can now reel the tape back in my mind and go, oh, that's what happened with that person. That's why I felt so blindsided by how they responded to my seemingly well-intended extensions of personal and professional care. Things that were baffling to me that just didn't make any sense because this person had an attachment style that I just was not aware of and was very different from mine. Things relationally meant very different things to me than they did to them. And then therefore they had a very different response. And admittedly, it was very disorienting and painful and felt like I made a lot of these mistakes that I, you know, like the trapdoor opened from underneath me. And um, those can be very for the for the physical medicine practitioners listening, um, those can be very, very, very difficult moments to wrap your head around when you when you don't have a concept of what these relationships can sometimes mean and activate inside of people historically.

Dr. Ayla Wolf 32:17

Absolutely.

Anxious And Disorganized Stress Strategies

Dr. Ayla Wolf 32:18

And most people that practice different forms of physical medicine don't necessarily have degrees in psychology or psychotherapy or these kinds of in-depth trainings to be able to even have that kind of peripheral awareness of how these factors are interwoven. And at the same time, I often feel like patients are finding themselves in a place where a lot of doctors are saying, Well, I, you know, I don't know what's wrong with you physiologically, so it must all be psychological. And we also, I feel like patients get railroaded into trying to be in either one place or the other. And I'm like, there is no one box or the other. This is all the same brain, the same nervous system. And so I just think even to how our entire medical system is organized, it just misses approaching people in their totality with what they're walking in with on uh with any on any given day with any person.

Dr. Matthew Tolstoy 33:17

Yes.

Dr. Ayla Wolf 33:18

I don't know how you fix that.

Dr. Matthew Tolstoy 33:19

Yeah, it's really tough. Where the and I and look, I'm really I'm really sympathetic to both sides of this conundrum. And what I mean by that is I really I really have seen the negative impact of the sequestering and siloing of medical specialty. How the blank doctor doesn't speak to the blank doctor, but yet you have a problem that spans both of their specialty, and there we don't have a system that really encourages, incentivizes, or really looks much at interdisciplinary integration. And that has caused a lot of people to fall through the cracks in healthcare, and a lot of them end up in my office, and like I'm very sensitive to that. And I understand how, well, how do we go about doing that in a complete way? That is not just like excitedly confounding everything together, where it feels good sometimes to just like feel all these connections between these disparate areas, and it feels like we're becoming the masters of the universe and like seeing how everything is everything and it's all so connected. And there can be something intoxicating about that on the integrative medicine side of things that causes us to see connections where they aren't, and that sometimes leads us to, you know, make our own mistakes in healthcare and to also not appreciate how it takes so many factor analysis to understand why something either works or doesn't work. And so I do my best to hold both sides of this and to understand that a lot of people are just trying to do the best they can, try to learn what they can learn. The integrative piece is needed, but like how do we do this in like a sincere and sober way without collapsing to one side or the other of this polarized spectrum is just very hard. So, anyway, that's my spiel about the state of public health and the state of healthcare is that it's very hard to hold these things about the unity inside of a system and how do we get people the care that they need. But you know, bringing this back to maybe a little bit more specifics of what we're talking about, you know, rehab practitioners, people who practice psychotherapy. I think having at least an understanding where we can reach across the aisle and not the presumption here is not to say that you need to take on people's psychological treatment, and then that's how you become a better functional neurologist or a better rehab pro or a better medical provider. It's not a it's not really about that. I think it's about being able to recognize and understand when somebody's potentially displaying patterns that would be well suited to another type of care in junction with yours. I have really trusted physical therapy colleagues who now know, over the course of our friendship and our shared treatment with people, now know when they have little relational interactional moments with somebody that begin to feel a certain way to them, they'll say, Hey, I think you should talk to Matt. And here's why. And then we begin to co-treat at these levels. Oftentimes these people have a trauma history or they have something that their physical rehabilitation is activating inside of them, whether they know it or not. And then that really helps us get the care that they need. So when we're talking about all of this, you know, incredible integration of these systems and the different ways that people's attachment can influence their autonomic regulation. It can sometimes feel overwhelming to people on either side of the spectrum, treatment-wise, to be like, oh my God, I now have to learn X, Y, Z. And it's like, no, no, no. It's in the same way that we learn red flags for referral to other medical providers. There are ways that we can learn to kind of understand what might be at play

Concussion, Dysautonomia, And One Size Fails

Dr. Matthew Tolstoy 37:14

here.

Dr. Ayla Wolf 37:15

This was part one of my conversation with Dr. Matthew Tolstoy. Tune in next time for the second half. Medical disclaimer. This video or podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice, diagnosis, or treatment, and consumers of this information should seek the advice of a medical professional for any and all health related issues. A link to our full medical disclaimer is available in the notes.