ADHD, Chronic Illness & Hypermobility: The Hidden Link? | Dr Jess Eccles

0:00When we lay on top of the hypermobility, the inflammatory challenge, this fingerprint in the disease database looked like ADHD, looked like autism, looked like bipolar, it looked like substance misuse, and it looked like hip disease, and it looked like heart disease. And what does that tell you? What does that tell us? That this is... Welcome to The Hidden 20%, our neurodiversity charity on a mission to rewrite the future for people who think differently. Together with you and an eclectic range of brilliant guests, we can break the cycle of silence by smashing outdated stereotypes, exposing the myths and sharing the most up-to-date truths about what it really means to be just different, not deficient.

0:48The best way you can help is really simple. Subscribe so you never miss an episode and if you can donate to our charity through the link below. Enough preamble, I'm Ben, your host, let's get into today's episode.

1:11Dr Jess Eccles I am so glad that you're here and when we did our very formal briefing call firstly we couldn't shut up there weren't any awkward silences and yeah it kind of made me even more excited about meeting you in person and sitting down with you For the benefit of our listeners, I just want to read out this more formal bio or a bit about who you are so that you don't have to try and do it yourself and blush. So, yeah, we'll start here. Associate Professor in Brain Body Medicine at Brighton and Sussex Medical School and consultant psychiatrist with Sussex Partnership NHS Foundation Trust Neurodevelopmental Service.

1:59Yes. Co-leads the world's first neurodivergent brain body clinic and helped establish the Immunopsychiatry Research Clinic. Yes. Internationally recognized researcher exploring the links between neurodivergence, hypermobility, inflammation, autonomic dysfunction, chronic illness and mental health. Take a breath. awarded the 2024 Ehlers-Danlos Society Research Pioneer Award for groundbreaking work in hypermobility and neurodevelopmental conditions, has led pioneering studies into the overlap between ADHD, autism, Tourette's syndrome, pain, fatigue, emotion, regulation, and physical health, strong public communicator and advocate for challenging the false divide between mental and physical health.

2:45you've appeared across BBC, Channel 4, Channel 5 News, The Guardian, The New York Times including Channel 4's Sam Thompson, Is This ADHD documentary, you chair the Royal College of Psychiatrists, Neurodevelopmental Psychiatry Special Interest Group and sit on the Clinical Reference Group for the UK ADHD Task Force, nearly there and you are passionate about helping neurodivergent people feel, the big one, believed, understood and less medically fragmented. Yes, bendy brain. That's quite a resume. So let's start actually at the start with your work, which is why do we have this divide between the physical and the mental?

3:31So the divide between brain and body, I think we have to blame that man who told us, I think, therefore I am. He was called Descartes. And that set off a whole, what we call the Cartesian split between the brain and the body. And what has happened is that we have different hospitals for what we consider to be brain diseases or psychological diseases, because I talk about brain body, but a lot of people talk about mind body And some people talk about brain, mind, body. Gut. Let's throw gut in there. Yeah, yeah, yeah, yeah. Exactly. So the distinction has meant that our knowledge seeking, the way our hospitals are structured, the way our services are structured, are all predicated on the basis that there is a difference between the brain and the body.

4:22But of course, we all know that is not true, that the brain lives in the environment of the body and the body is connected to the brain. Though I did see on social media, there's this idea of the body keeps the score. Yes. And I think as a heuristic, it's actually quite good for neurodivergent people because they have often neurodivergent hypermobile people. they have these difficulties with alexithymia, so you know, difficulty describing and understanding emotions, and also difficulties with interception, the inner sense of what is happening in the body. And the problem is that for a lot of neurodivergent people, they only stop or allow themselves to stop when the body actually forces them to.

5:10So that idea of listen to your body when you can't actually interpret your emotions say like oh I'm really stressed and overwhelmed but you don't have the inner sense of feeling stressed and overwhelmed it's only when you physically can't carry on for a number of reasons that you actually might stop so I like that idea of the body keeps the score but there there's this big very famous neuroscientist called Carl Friston who published a paper recently that said the body doesn't keep the score everything is about the brain and to a degree when I first was involved in the world trying to explain about the relationship between having flexible joints and having anxiety, I was sort of prone to say, well, of course, everything's in your head, because that's where your brain is.

5:56So although I don't think that this is a necessarily a made up thing, everything, the brain is central, but I would take that back now. If I had to pedantically, literally, the brain is supposedly where consciousness happens, but that is influenced by the body and the body influences the brain and the brain influences the body. And we can't really separate the two. Yeah, but we have, like systemically. Oh, yes. And in fact, when I give a couple of talks, and you can see some of my talks on bendy brain link tree, I've stolen someone else's idea. It's called the big idea. And that is, should we ditch the distinction between physical and mental health?

6:39And this was from a big idea in The Guardian by Professor Edward Bullmore. And it says the false dichotomy, so the false distinction between body and brain, holds back research and it stigmatizes patients. And I would go further and say it doesn't just hold back research, it holds back clinical practice. It's massive. I think it's one of our biggest problems. And for people who are struggling physically, especially with these invisible illnesses that are poorly understood, they're quite worried, I think, about mentioning any mental health issues because they fear that they will overshadow another underlying problem.

7:19Yeah, if I can really generalize, I feel like maybe in the last 10 years, we've prioritized being fit from a physical perspective and then being happy from a mental perspective. Yes. And I don't think I'm lying when I say that neurodivergent people over-index on poor physical health outcomes. Oh, no, absolutely. We know that across the board. But what we also don't really understand is actually how difficult it is for neurodivergent people in some ways to be physically fit, to be healthy, that there are so many elements to being neurodivergent that actually make that quite difficult. And the same thing with being happy.

8:06And the other problem is that for neurodivergent people who may take things literally, there is this idea that you are somehow not living or not living correctly if you have not achieved those things. So on our YouTube channel, we interviewed this amazing woman called Jane Green, who has a charity called Zeds Collective. And I'm the patron of that charity. And her background is in education, trying to support neurodivergent pupils because of both their physical and their ND issues. Because there's this whole business of emotion-based school avoidance. So, you know, parents getting into terrible trouble for children not going to school and it all being put down to anxiety.

8:50When in fact, it could be put down to lots of physical things that we've been researching and others have too. So gut problems, dizziness when you stand up, asthma problems. There's lots of reasons. But Jane and I, we went to talk at a conference in the Netherlands and we were talking and Jane said that when her children were younger, she had taken the advice that you shouldn't put salt on food, literally, or that you should be sparing with your salt. And so she and her children didn't have any salt at all. And they felt quite ill. And it turned out that in neurodivergence, there is this big thing about this idea of postural tachycardia syndrome, which is where you get dizzy or lightheaded when you stand up.

9:36And it's partly to do with reduced blood volume. But it's also if you have hypermobility, if you have floppy connective tissue, your blood pools in your feet. Yes. and sometimes you can even see people's feet go a bit purple or red when they stand up you get these little white lumps that kind of pop out the back of the ankle and it can be brought on by having a large meal or by being in a hot environment which in the summer is a bit of a problem but actually for postural tachycardia syndrome for this difficulty when you are standing one of the recommendations is to eat more salt okay and so people take things very literally We've done this study that has been presented by one of my junior researchers, Israel Hussain, where we looked at all of the people born in Bristol and Avon in the early 1990s and saw if any of them, this was girls actually, whether they were diagnosed with an eating disorder.

10:28And we found that if you had autistic traits when you were very young, before 10, you were more likely to have an eating disorder at 18. But that relationship was actually explained by the presence of ADHD traits as well. So it's this sort of intercepting perfect storm of things. But this has given us real food for thought and actually writing a paper called Food for Thought at the moment. And you can see if you are neurodivergent, you might keep track of numbers, which is a big thing with the Internet, isn't it? Likes, what have you. But some of the numbers that you might keep track of are things like calories.

11:06All the health metrics, right? All the health metrics. How many fruits and veggies? All of the advice. You take that advice literally or the advice that you must walk 10 ,000 steps. Yep. And you can see. Which is absolute bollocks from the 70s Japanese Olympics. Anyone check it out? Okay. Well, that's a good fact checking. but you can see that if you take that advice literally even if your primary motivation is maybe not a fear of fatness which is what the diagnostic criteria typically describe in a anorexia nervosa eating disorder that all of these things you know you bring in the sensory sensitivities and you maybe have like a sudden massive change to your routine or there's a sense of unpredictability that you're you're thinking control and it all comes in and then suddenly these numbers are a way of kind of distilling that and it can really set you up.

12:05Do you think anorexia is a symptom of autism? I think there is a big overlap between any sort of what we might consider disordered eating and neurodivergence. What we have traditionally thought was that there was an overlap between anorexia nervosa and autism but what that study that i was just telling you about what that shows is it's not just autism is it it's adhd as well and it isn't just anorexia in nervosa it is also binge eating disorder it is also bulimia and they are all different bits of neurodivergence intersect to lead to problems with eating but the real issue and this is one of the things that i really hate is that although there is increased awareness of things like ARFID which I think has to be fantastic is that now a bit like having an autism diagnosis or an ADHD diagnosis can preclude you from services so yesterday I was talking with my registrar about a patient and we'd asked if they could have some form of non-drug therapy to a you know local service and they said no they're autistic is better explained by autism and of course there's no post-diagnostic autism support services and we have the same problem in that some people are referred for eating disorder and a very kindly minded and on the ball GP says oh I think there might be ARFID and then bang the shutters come down we're not commissioned to treat ARFID so you end up almost getting excluded because someone knew too much we can only be one thing yes we can only have one assessment one diagnosis yes but i think what's worrying is that that actually even is precluding people from having assessments so obviously ideally you'd want to have a thorough eating disorder assessment that covered all of the things but people potentially are being turned away because there is no pathway there is no service what do you see in your practice and research from a late diagnosis physical health perspective that's a big question well no it is but because we were noticing so many physical health issues in our neurodivergent patients and because myself and my colleague hugo critchley who also works in the same neurodevelopmental service as i and Rebecca Dew, nurse consultant, we set up the world's first neurodivergent brain body clinic.

14:42Thank you. We have rather a lot of data and patients that have come through this clinic, which is a research clinic. And so it's above and beyond the regular offer. And we find two things. One of the things that is so sad is we find patients who have a lot of physical health issues. They're really struggling with pain they're struggling with fatigue they're struggling with weird allergies possibly unusual autoimmune conditions and just lots of what seems quite random physical health things so gut problems bladder problems it's not fitting nicely into a single category and the thing that is really chilling is that they often say well I've given up going to talk to the doctor because I can't face not being listened to or not being believed and then not being anything that can be done.

15:43So this real sense of hopelessness and helplessness, which is obviously very worrying, but I have people who write to me about this all of the time, not just in this country, but throughout the world. And where is a worry? Is this actually stopping people seeking care? care, you know, life-saving care. Do you think a earlier understanding of someone's brain and body type from a neurodivergence perspective could make a difference to the potential outcomes physically and mentally for people? I think so. I also think it could make a big difference in terms of understanding, can make a big difference in terms of compassion.

16:34And I think it could make a big difference in terms of identifying people who are potentially at greater risk of medical and psychiatric problems. And what does the DSM say physical health wise? Oh, it doesn't. Sorry, the Diagnostic and Statistical Manual is only for mental health conditions. But it's a product of the need in America, I understand I could be wrong, to categorize every single little thing so that it can be appropriately itemized on an insurance bill. In the world, there are the ICD, which there's the mental and behavioral disorders ICD bit, and then there's the other categories.

17:15But yeah, the DSM is only for what they consider mental illness yeah so we've boxed boxed that into people's brains yes and therefore assessments yes aren't even taking in any physical history in that sense no exactly and as much as i value the sort of multidisciplinary nature of adhd and autism assessments there's a big market in terms of ones that are done privately for the nhs and there are a lot of people who potentially may kind of put themselves forward as having appropriate credentials to diagnose these conditions who may come from a variety of backgrounds. I work in a multidisciplinary team and my multidisciplinary colleagues, OTs, nurse specialists, midwives, they are phenomenal and fantastic, but they've got a big thing of support around them.

18:07And if you're getting a diagnosis, we need to include in sort of protocolizing how you do a good assessment that it must include consideration of physical health issues. Does psychiatry, though, even as an industry, does it allow for... Yes. It does. So this is a big thing is a lot of people are not quite sure what the difference is between a psychiatrist and a psychologist. It's a recurring theme. All psychiatrists are medical doctors. So they have all been to medical school. They will have all in this country certainly done two years of working as a doctor before they've entered into a psychiatric training program.

18:53When we admit people into the hospital or when you take a history in clinic, part of it would include a physical health history or a systems review. that is in our training but obviously you know there is a degree to which you might focus less on it but it's really important to focus on because there are lots of physical health issues so you could have a high thyroid hormone level and that could make you look as though you were manic for example or you could have a tick bite or you could have a rheumatological condition like lupus and this could cause brain effects and there's increasing research showing that about the relationship between the immune system and mood we did a study this was with my colleague Lisa Kwok we showed that neurodivergent characteristics predicted the presence of chronic pain and fatigue and that that was because of joint hypermobility that was just published a couple of months ago it's in my link tree but we also did a study where we looked at people with chronic pain and fatigue and we looked to see if an inflammatory challenge made their symptoms worse and we showed that their immune responsivity was one of the factors that seemed to determine if an inflammatory challenge made their symptoms worse, which is a bit like long COVID, which, you know, something comes along and kind of tips people over the edge.

20:30Yeah. Where's the thinking, or based on your work, Jess, as neurodivergent people, are we physically predisposed? Or is it because, you know, let's take myself, Because I wasn't assessed until I was 39, not understanding my brain and the environments I needed to be in or the support I need, etc. has then led to autoimmune problems, physical health challenges. Which way round is this? Is it the chicken or the egg? Yeah. It's both. I'm sure it's both. So this is a real problem I have thinking about the difference between the medical model and the social model. I do think the social model is very important, but the work that we have been doing essentially suggests that, I mean, obviously neurodivergence is a very broad church.

21:27You can't possibly say every single person is the same, but that there seems to be this particular brain body type. So this body type associated with difference in connective tissue that seems to be associated with being more likely to be neurodivergent and more likely to have a number of mental health and physical health consequences. So maybe more likely to have gut problems, maybe more likely to have inflammatory bowel disease, more likely to have asthma, more likely to have anxiety, depression, bipolar disorder. And although clearly society plays a huge role in how we support and shape people, I think that we need to also acknowledge that neurodivergent people may not only think differently, but they may be built differently.

22:17And that that predisposes potentially to issues that many people think are unrelated, but are actually probably true. And absolutely, we need to support people and we need to get in there and diagnose early so we can give people what they need to thrive. So we need to recognize all of this, recognize it early. But I do not think that it is just about society. It's a medical thing too. And being built differently has strengths and challenges too. So the thing I'm interested in, the flexible joints, hypermobility. There are certain piano pieces that can only be played by people with hypermobile fingers.

23:00Most musicians, gymnasts, ballet dancers, they're all hypermobile. Well, not all of them, but... I thought I was hypermobile in this room. Oh, brilliant. Oh, fantastic. Yeah. Yeah, well, exactly. Which I had no idea. So we did a study inspired by a collaboration with the film director Nigel Colt, looking at whether hypermobility was associated with being more likely to be creative. He had observed that in the sort of film industry, television industry, there seemed to be a lot of people who looked like they were struggling with hypermobile related problems. And so we looked and we found that being hypermobile predicted creativity because of neurodivergent traits.

23:40It can, in certain circumstances, with the right support, be advantageous. And people like Simone Biles and Michael Phelps are neurodivergent and hypermobile. Yes. And they are literally like in a class of their own. I think Simone Biles only really competes with herself. Yes. But we also know that she struggles in competing with herself, those twisties and things. Yes. Just to pick up on that, because we've had a wonderful lady, a professional cyclist, sat in your seat, Connie, and she basically said, and I'm paraphrasing, there's loads of neurodivergence within sport. Yes. But because it's seen as a weakness, no one talks about it.

24:19And someone like Simone Biles is like the perfect articulation of what you're talking about in terms of like brain body. Yes. Right. Where she's ADHD and being ADHD is part of also hypermobility and her amazing talent yes but also her brain and the challenge there is a struggle there too and it isn't i and i've talked before about really wanting to resist this sort of superpower tragedy narrative it shows much more nuance but it also may be that you know going into gymnastics or exercise much as i loathe the idea of exercise actually can be for some people really helpful with adhd symptoms it's a way of sort of burning off that mental energy and that if you can't exercise it's really hard to regulate and it is the whole brain body thing but where does trauma fit in this oh this is a fascinating stuff really so i have these wonderful colleagues in glasgow helen minnis and rutica gajwani who wrote an editorial a couple of years ago now called double jeopardy and helen has given talks you know is it the chicken or is it the egg and for a long time in psychiatric and pediatric practice, because you have to remember that actually quite a lot of autism diagnosis is going on in pediatrics, particularly before a certain age.

25:39People seem to think that you couldn't easily diagnose autism or ADHD if someone was also traumatised. Sorry, and how recent is that thinking? That thinking is pervasive still to this day. We're not pervasive, yes. So it's like if you're autistic, you can't actually get access to other services physically to help. And if you are not autistic, the trauma piece. I think it is. It's really difficult. People don't seem to like giving labels to children. And so if someone has been traumatized, there's so much trauma here, we can't say whether it's autism or not. But what this work that they have been doing basically turned this whole thing on its head and said that people who have been traumatized, people who have had adverse childhood experiences, are actually more likely to be neurodivergent.

26:32And I think because of the work that we've been doing about hypermobility, this brain body type, that neurodivergent people, because of this brain body type, are more likely to experience trauma differently. So we're in the process, Helen and Ruchika and I and a woman called Claire Jameson, of rewriting that article. It's called The Vantage Point, basically saying that if you take into consideration these factors and the brain body type, we've got the opportunity for intervention. and that we can use some of these kind of brain-body regulatory strategies and also, you know, sort of attachment strategies to actually help young people before they run into problems because they also showed, I think, in a large Swedish cohort, so people you follow up, that the neurodivergent teenagers were more likely to experience mania or bipolar in later life.

27:40So where does trauma fit in? I really think that we mustn't think it's one thing or the other. So an output and an input? It's an output and input and that for some reason neurodivergent people seem to be more likely to be traumatised. And as I said, I think they actually process trauma differently because the work, if we think that quite a few of them I've got this variant connective tissue that that means that your involuntary nervous system, your flight or fright nervous system is kind of reacting more quickly, well, reacting more powerfully, is more variable, more uncertain, that that means you're more likely to possibly experience physical symptoms of hypervigilance.

28:19And we were talking just before we came on about this business about aphantasia and hyperphantasia, this very vivid mental imagery. It seems that neurodivergent people are sort of more on the extremes of that, So they're more likely to have less visual mental imagery, but they're also more likely to have heightened visual mental imagery. So you can see if you put that all together, another way of being an elephant is remembering everything. And I have a number of patients who really do remember everything. And then you have this sort of associative ADHD type brain that means that every date is then resonant, something, you know, echo of something else.

28:51So you put that in and then you put in the sort of propensity to flight and flight and this, you know, vivid, vivid imagination. And you basically do have a recipe for having a really difficult time with being traumatised. How do you sleep at night, Jess? What, they're thinking of all of this? Yeah, I'm four years into this space and I can drive myself sort of around in circles and in knots, being kind of overwhelmed, excited, scared, curious, the whole gamut around trying to understand this space. And it's so complex and it's complex enough. It's not complicated, but it is complex and it's nuanced and it's individual and it's layered and we don't know everything.

29:35And we're trying to catch up on dispelling myths that we very much believe to be true. Oh, yeah, yeah, yeah. No, no, no. Whilst also learning what now is the truth, whilst also understanding that there is a huge section of society that have lived for decades. Oh, yes. Not knowing any of this. I know. And so I'm like, I'm sitting here thinking, well, shit, I'm just trying to understand my brain. And now I need to understand my body. Yes. Through a neurodivergent lens. Yes. And I know, sat here right now, I know I'm not alone in terms of the people listening and watching. Yes. Also going, da-da-da-da-da-da-da-da.

30:19Like, what about my body? Yes. What advice would you give for neurodivergent people listening in terms of their understanding of their bodies? Ah, well, that you are not alone. And if you have a body that seems to let you down or is confusing, consider whether you might have hypermobility, which we have shown is highly associated with neurodivergence. So in 20 or 22, 2021, we published a paper, neurodivergent is linked to dysautonomia, which is this weird feeling you get when you stand up. It's an abnormality of the fight or fright, nervous system, fight or flight. I always say that wrong. And also to pain.

31:01So we showed that neurodivergent people are more likely to experience physical health problems because of hypermobility. So I would really start looking into some hypermobility resources. and my link tree we've got lots of papers and i list some key resources on the link tree so link tree bendy brain and then bendy is like a misnomer for hypermobility it's actually more about being stretchy like having a stretchy gut or stretchy bladder or stretchy skin stretchy ligaments but you know so bendy brain is my moniker um youtube channel is bendy brain as well so to have a look into those things there is this charity of which i'm a patron i mentioned about jane green it says connective that is a good resource we're also in bendy brain episode five i interviewed my mother who got diagnosed at 72 with adhd and i think we talked earlier didn't we about what if you know if we could know earlier what is it about the late diagnosis stuff and i've been working on but i've got a number of papers that we're working on and I struggle sometimes to prioritize appropriately one of the papers I was working on is a opinion piece for the BMJ in which you know you said the British Medical Journal yeah the British Medical Journal in which if we knew then what we know now yeah a huge part of my physical and mental health trajectory could have been predicted within the first year of my life, which sounds a little bit bizarre.

32:36When I was at medical school, we were taught, you know, obviously that neurodivergence, well, I was taught that autism and ADHD probably affected nine times as many boys as girls. Oh, it's been a 20 though, wasn't it? Autistic people, no theory of mind, that type of thing. And although in that lecture that I had about autism, I did think, well, maybe this could be me because they mentioned something about Thomas the Tank Engine and my mother always said I could have taken a GCSE in Thomas the Tank Engine. Really? Yes. I was also a fan of Thomas the Tank Engine. Were you a fan? Yeah. Not real trains.

33:11No. But Thomas the Tank Engine. Thomas the Tank Engine, particularly the television show. Yep. That was a trope. That was a thing. Back in 2002 when I was learning about autism at medical school, that was the thing that it's like autistic boys like Thomas the Tank Engine. But one of the things that we think is associated with autism and ADHD is being born early. So I was born early. But what we now know is that hypermobile women are more likely to have pregnancy problems, meaning that they have children who are born early. And as I mentioned, my mother, who not only hypermobile, diagnosed ADHD 72.

33:47So maybe that would have helped recognize that she was hypermobile. Sure. And also that she was neurodivergent. Yes. And that I might end up being both hypermobile and neurodivergent. And also I think, and I hope she doesn't mind me saying this, that she will have kind of internalized some sense that it was her fault. Of course. And also had other problems to do with not having a proper hip socket, which turns out was one of the very first things that's described in joint hypermobility literature. So, you know, they have these tests on newborn babies to see if they have clicky hips. Yes, yes. So clicky hips are associated with hypermobility.

34:23and I had quite severe case of that and ended up having a hip replacement when I was 36. So you go the through line from clicky hips, hypermobility, ADHD. Yeah, yeah, yeah, you could. It would be very simplistic there. Absolutely, you could. And I'm not saying that all children... But precursors too, right? Yes, exactly. That's a biomarker, isn't it? Exactly. And that's what people say about ADHD. I'm like, biomarker could be hypermobility. If you're interested in a biomarker, but I have a role at the university where I am responsible for junior doctors, well, they're called resident doctors now, who are getting involved in research as part of their training.

34:58So I have several academic clinical fellows. I have one in psychiatry, Stephen Norse, and one in paediatrics, Isra Hussain. They're both wonderful. Isra is looking at, she's just literally, she texted me at the weekend to say she's looked through the records in the last three months of all of the children who attended a particular children's hospital emergency department. And she specifically looked at the patients, the children and young people. So this is people under 17 attending the mental health. They came to A &E for a mental health related reason. And so she looked through to see if anywhere in the notes did it say whether they had an ADHD or an autism diagnosis, whether that was being queried.

35:43and she found that of those 133 children, some of whom had multiple attendances, 77 % of them were either confirmed or suspected as neurodivergent. So four-fifths. I mean, that's... But we did something similar in the adult A &E department and found that, and this is under review at the moment with the British Journal of Psychiatry open, We found four-fifths of adults using mental health crisis services in A &E were likely autistic. And if you use a really conservative measure, that was using a screening tool. Isra was only looking at the notes in terms of whether it was written in there. That was at least half of the people attending A &E were likely autistic.

36:27We didn't even look at ADHD. So these are wild. But then what Israel was saying was that she was going through and she was working out how many hospital appointments the people who were attending hospital because of a mental health problem, how many physical health appointments they were having in the children's hospital. And what she said is as she was doing this, she realized that there was lots and lots of queries about asthma and allergies. And there were also queries about clicky hips and DDH. And so I hope that her next DDH, developmental dysplasia of the hip being the clicky hip issue. And that is wild.

37:08And hopefully, well, Israel will be writing this up. And the adult ANU stuff, that's already on its way to hopefully being published. We hope that Israel will be able to do some more work. She's a paediatric trainee, so she's studying to be a children's doctor. But about this intersection between mental, physical health and complexity. And I think these over-diagnosis debates aside, and there is no magic money tree. If we have to work out how to support people, why not think about this congregation of where mental and physical health complexity seems to converge in neurodivergence in places like in hospitals, in schools, children who are maybe not able to attend or who get excluded from schools.

37:55These are all the places where it's almost, it's not quite too late already, but this is where so much work is needed to be done. But what I hear you talking about is a, like a dot to dot that hasn't been done. No, no, no. And we tried a couple of years ago. We wrote a proposal for a prestigious research council exactly outlining that and saying, you know, where this complexity is, this is this thing. Didn't even get past the first stage. And it goes right back to what you were saying at the beginning, these silos. So because people are just thinking about mental health problems, they're not thinking about physical health problems.

38:36And when people are thinking about physical health problems, they are not thinking about mental health problems. The danger, I guess, and this is a double-edged sword, isn't it? There's a lot that's been beneficial about the quote-unquote banner of mental health. Yes. And it not being siloed just into depression, anxiety, mood disorders, etc. There's a lot, yeah, there's a lot of good that has come from that. And it's given us a kind of a term to talk about and socialize and all the rest of it. And I know there's a lot of good that can come from neurodiversity being a quote unquote banner and a term and a collective.

39:17But then I guess there's also danger in us having the three legged stool of like mental health, physical health, neurodiversity and us not looking at the whole person. No, I think that is a real risk and it does risk sort of perpetuating silos yet again. And that is an issue within the sort of neurodiversity space of the idea of it neurotribes. The nerves aren't just in the brain, they're in the body and it's a whole brain body type, not just a neurotype. I know, you know, ADHD is not an official diagnosis, but we cannot surely end up with the alphabet after our name. No. With dis-ODHD, you know, HM for hypermobility.

40:10Like we can't. No, we can't. I think we could rationalise it. Like it's all actually, maybe for some people it's just one thing. But I do think it's great that there is more awareness. and I don't know what year you were at school, but I was in primary school in the 80s and second school in the 90s. I left in 2001. So I left in 2000. So yeah, there really wasn't much conversation in schools about a mental health tool. And there were some children who seemed to have a dyslexia diagnosis and they were sort of scurried off and had extra reading outside of the classroom. And that was about the only thing that was going on.

40:45And I do think it's great that the conversation has moved on and that young people are able to talk about these things. But I do think that they are under a huge amount more pressure and scrutiny in terms of the whole, we grew up being able to take photographs and stuff and listen to music without everything being recorded of every moment on the internet forever. But we still learnt how to use the internet. So, yeah, I do think that what you say about the three-legged stool is really important. I mean, it's fine if there's one stool. But it's when there's three stools. Yeah, we need a one-stop shop.

41:20We need a one-stop shop. And we need, as difficult as it is to say, that there are genuine medical issues that are disordering and disabling associated with neurodivergence. And I think that's the qualifier of, yes, our brains are different. We think differently and we respond to things differently and we see things differently, but there's a physical aspect as well that we hear from so many people who've spent so long hiding and masking. Yes. And I think, and myself included, so much of that has been focused on the mental side and maybe the emotional side and not enough maybe attention given to the physical side.

42:11Absolutely. And also how they are almost certainly set fire to each other. And if you have an autoimmune condition, well, we know that if you have asthma or a skin condition, it's worse if you're stressed. And if your skin condition or asthma condition is worse, your mental health may be worse, they just feed into each other. And you need to think about them both together. It's the perfect storm, isn't it? It is the perfect storm. And this is interesting because we've just been, myself and some collaborators working on a hypothesis paper called The Perfect Storm. Okay. So... How many papers have you got going on?

42:48How many projects have you got going on, Jess? I talk about it vaguely in Bendy Brain episode five when we interview my mother who has like 60 or 80 tomato plants. I'm not interested in gardening, but I am in research ideas. I am, and I'm interested in tomatoes. I'd like to talk to your mother. And so the problem is I've got too many research projects. Yeah, it sounds like I'm feeling that. Yeah, this idea of everything intersecting, that it isn't one thing or another, it's a combination of factors and that occasionally, just as we were saying, something comes along and that person might have been able to withstand or tolerate a particular stressor in the past or even in the future.

43:28But because of that dynamic intersection of everything, bang, there is the thing that tips you over the edge. Is hypermobility heritable? Well, this is the interesting thing. Just like autism and ADHD, there are some rare cases. So some people with hypermobility have something called Ehlers-Danlos syndrome. The most common one is hypermobile Ehlers-Danlos syndrome, in which they have not identified a clear genetic cause. The other Danlos syndromes, which are very rare, there are single genetic causes. Just as in ADHD and autism, there are some syndromes in which autism or ADHD feature. So something like Fragile X, people with Fragile X, autistic, hypermobile.

44:11What is Fragile X? Fragile X is the genetic syndrome that predominantly affects boys because it is to do with the way it's carried on the X chromosome. So because boys only have one, typically gender is very complicated as is sex. Because typically males only have one X chromosome. That means if they inherit a fragile X gene on their X chromosome, they don't have another one to even it out. So there are a lot of women who are fragile X carriers, often autistic, hypermobile people with fragile X, autistic or hypermobile. So there is a genetic test for that. You could run a fragile X panel. But there isn't for autism or ADHD and there isn't for most forms of hypermobility.

44:57But they do seem to be as heritable as height. They do seem to run in families. And we have a paper, which was a study, part of my MQ versus arthritis fellowship, where we have shown in hypermobile people, there are a number of connective tissue features. So hypermobility, joint hypermobility is a bit of a red herring. It really isn't just about having flexible joints. It's about having, you know, skin that is stretchy or soft, that bruises easily, that scars in a particular way. It is about having long thin fingers and narrow wrists. It's about having propensity to stretch marks and to this organ prolapse and all of these things.

45:38So in the diagnostic criteria for the connective tissue features, if we add them up, so your number of features, that correlates with your sensory sensitivities. So the degree of connective tissue involvement seems to correlate with your sensory sensitivities. It also seems to correlate with your propensity for brain fog. But that's another paper, different paper. Can you become hypermobile? That is, that was what I was coming around to. I'm getting there. You know, that's all right. So what would I really like to know is, is this a genetic thing, which comes first? To what degree is our connective tissue influenced by other factors?

46:21and this could be like infections, micronutrients, you know, the soup. Yeah. What things in the soup actually affect the connective tissue and does that affect neurodivertics? So that would be my question because we make assumptions and I've often assumed, you know, that you're sort of born hypermobile and I told you about my mother and hip stuff. But to what degree are there other factors at play? because we aren't, I'm sure, going to find a single gene. I think that we have to consider that there are so many processes going on. But there is this really exciting piece of work that we did with PhD students.

47:00Well, our Action for ME, so ME is ME-CFS, is people with chronic fatigue. So this was funded by Action for ME and also versus arthritis. we did this study where we didn't look at people's genetics we looked at something called transcriptomics and you'd be like what is transcriptomics you've got the genetic code your c's and a's and t's and g's and that that genetic code which is supposedly stable you know we we inherit it it can mutate but we have this code not all of that code is expressed all of the time in all people absolutely not but what we wanted to do was see how that is translated those the bits that are translated which would then go on to make proteins and things that are in the cell that changes that's dynamic all the time so moment to moment you can see that the building blocks that come from the genes are actually different and we we looked at a group of people and we classified them into whether they were hypermobile or not they had an inflammatory challenge which is this typhoid vaccination okay and so we look to see the at this sort of fingerprint of the things being produced by the genes whether that was different in the hypermobile people compared to the not hypermobile people and crucially that fingerprint a bit like they used to well they do you know in crime we we put it into a database and said what other diseases does this look like that popped out and we've published this in abstract form but we need to publish it in actual proper form shortly that popped out as saying that hypermobility without the inflammatory challenge looked like lupus looked like eczema looked like dermatitis looked like actually looked like aids which is an old term before people knew what hiv was well i mean people could still then develop aids but it's basically an immune problem so it's looking like hypermobility somehow looks like an immune problem and then we look to see when we gave the inflammatory challenge how did the hypermobile people respond differently to the non-hypermobile people in response to the inflammatory challenge so mathematically this is quite cool it's like you know two by two design but we find that now this absolutely we didn't blow my mind it was beautiful and i hope it will blow people's minds and break the internet um is that when we lay on top of the hypermobility the inflammatory challenge, this fingerprint in the disease database looked like ADHD.

49:42It looked like autism. It looked like bipolar. It looked like substance misuse. And it looked like hip disease. And it looked like heart disease. And what does that tell you? What does that tell us? That this is a gene environment dynamic interplay of factors in a constitutionally vulnerable person that leads to both physical and neuropsychiatric phenomena and that maybe at its root is a connective tissue difference that's maybe being influenced by all of this gene environment stuff but that's an immune process and that that immune process is then furthermore altered by the environment and also by trauma we know that trauma changes the brain it changes biology we did this amazing study with lisa quatt where we showed again in all of the children born in bristol and avon in the 1990s they're a very useful resource it's called the alsback birth cohort we published this last year i think so we there were six no maybe more 10 11 000 seven nine-year-olds we showed that there were ones that had autistic or adhd features before 10 so they were they were sampled i think their parents reported at seven on what they were like at three in terms of autism and at nine they reported on their hyperactivity and that was ADHD feature so one scoring higher there were twice as likely to have chronic disabling fatigue at 18 even if we adjusted for depression but that relationship was because the children with the neurodivergent characteristics they had higher levels of inflammation aged nine okay So we don't know, again, chicken and egg, but there is something going on about the immune inflammatory processes in these children, in neurodivergent people that is contributing to this perfect storm.

51:44Does that take you anywhere near toxins, vaccines, the water, UPF? Ultra processed foods. I think it could take us to poor nutrients. Microplastics, the list goes on. I mean, I was talking to a friend this morning about vaccines don't cause autism. Autism causes vaccines. But we are realising and COVID showed us that people respond differently to vaccines. Yes. Yes, I think that the picture is far more complicated than we previously understood. and in sort of the history of scientific thinking in medicine, there has been this idea of a single pathological thing. So, you know, like a virus, this particular spike protein, this one virus, it comes along, it causes an illness.

52:38And then there is a specific single magic bullet that is then deployed, particularly in this sort of war-laden metaphor of medicine to eradicate the single thing that is causing the problem. And I suppose what's interesting about the things that we're talking about is it's actually multiple, multiple things. And you might have a little bit of this or a little bit of that and at different times you might have less or more, but it's how they all interact. Yeah, and we don't really know. No, and we really don't know. But it is not as simple as one single thing leads to that. Yes. Of course, that may be the case.

53:17But that's a lot easier for journalists, you see, if it's just one thing. It was all that screen time that caused that. And it's like, yes, of course, there was ADHD and autism long before there were screens. And vaccines. Vaccines, yeah, yeah, yeah. My brother was a big fan of Dennis the Menace and the Beano. I'm sure Dennis. Dennis. Yeah. And when I was a young... Postcard potential for ADHD. Postcard potential, yeah, yeah, yeah. And Tigger. And Tigger. And I loved this book that was turned into a TV show, Anna Green Gables. Okay. And classic, or the HD. And also, what about Dennis' dog? Did you know, what is he called?

53:59Basher? No, I've forgotten what Dennis. Nasher. Nasher, Dennis the Menace's dog. So imagine this. So obviously I'm interested in hypermobility. Are you? Oh, yeah. Oh, no, no, no, no. I barely ever mention it at all. So there are two wonderful animal models of hypermobility. One that's been published and one that hasn't. So the first one that I heard about is that hypermobile dogs, and you can tell whether a dog is hypermobile by about the dysplastic hips. So you can get out some measuring, you know, take some x-rays, you get out your protractor, you can work out how hypermobile a dog is. The hypermobile dogs more likely to experience thunderclap phobia.

54:42So we have an animal model for panic disorder. 70 % of people with panic disorder are hypermobile compared to 20 % in the general population. Okay. So that's cool. And then we have... Do you think dogs can be ADHD? This is the next bit. I've got you out of your seat. I've got you out of your seat. Yeah, yeah, yeah. So the next bit is they took a load of dogs. These were incredibly well-trained dogs. They were service dogs. Okay. So they are like... Well-behaved. Super well-behaved. And they worked out whether they were hypermobile or not. And they found that the hypermobile ones were more excitable, which is a lovely animal model of ADHD.

55:21Okay. One of the things that concerns me about this space is there are so many amazing people like you. Oh, thank you. doing so much amazing work and learning such important things. And then, and this is a criticism of research and academia, actually. It's not a criticism of you, but it is a criticism of research and academia. That my concern is all this great work doesn't go anywhere because the outcome of this work ends up on BMJ. and the Lancet. And that's where, and a big generalisation here, I see it just, it stops. Yes, and that is an issue. And people say to me all the time or write comments on videos and things, how does my daughter not know this?

56:20But was told, and I'm pretty sure this is probably right, that it takes, I don't know, 12, 15 years for research to translate to textbooks or even to regular thinking. So that is a real problem. I think with regards to the BMJ and the Lancet and stuff Yes, there is this real idea in some ways of scientists in their ivory tower Producing papers that people then have to pay for But I would say that we are trying to do that slightly differently In that wherever possible we scrape together Or you sing for our suffer to have papers published open access Yes So the paper that I told you about that I was really proud of well one of the ones about joint hypermobility links neurodivergence to dysautonomia and pain that has been viewed on the internet now something like 230 ,000 times I'm pretty sure not by many scientists and doctors I think a lot of that is um is members of the public who are absorbing that information yeah we I put a lot of talks and things on my link tree and obviously the bendy brain YouTube channel, but that is sort of considered in some ways slightly unusual for scientists, doctors to go out and talk about their research.

57:33Obviously, you can tell I can't stop talking about it. Yeah. It's slightly compelled, but that is unusual. But we need the research. Yeah, we do. Because otherwise it's guesswork. Yeah, and I can see how things like the BMJ and like publishing papers and stuff, when you have an opportunity, platforms like this and opportunities to have conversations like this and share directly with the public what's going on, in some ways we're bypassing the historical way that it was done, which was I go and see my doctor and what they tell me is how it is. Oh, yeah, no, no, no, I think it is. And that's amazing.

58:18And it is more power to the people because these things are not well taught at medical school because we're only really just finding out about them. And it's not just medical school. We need this better education across the health sector. Yes. But education, politics everywhere. Yeah, everywhere. There isn't a single realm in which it is not important. And I think people do write to me and they say, you've explained various bits of what's been happening in my life, or I've known this for a very long time, but now waiting for science to catch up with what the community has known all along. And there is that idea of a lot of patients have been joining the dots for a very long time.

59:00But we do also need the research because we need the research to make that pattern spotting credible. Yeah. And one of the funders who funded one of my things, MQ, they had a campaign. Without research, it's just guesswork. Yeah. And that is true, but we need that credibility. And I feel very privileged to have a job where I spend two days a week in the NHS seeing, you know, adults, ADHD, autism, Tourette's assessments, and also have a neurodivergent brain body clinic. And then three days a week at the university, mainly doing research, but also doing some teaching. And they all feed into each other.

59:44So my clinical practice really helps inform my research. So I get ideas about what we should research next from my patients, from talking to them. And then also we are able to feed in our research findings directly into our clinic. And for me, that's a beautiful thing to be able to do all of that. And then it's just sort of, well, not bizarre, but along the way, started out before I did any of this research, knowing I was hypermobile. That wasn't why I got into hypermobility. You know, you said, how do I sleep at night? Because there's so much stuff. But partly that is actually because everything has been, to me, quite gradual.

1:00:19It started in 2009 when I met Professor Hugo Critchley and he got me to look at these brain scans of people, see whether they were hypermobile and whether they weren't. And we found that hypermobile people had a different size part of the brain responsible for fear and emotion processing, the amygdala. So anyway, that's started off all of it. And then along the way, gathered all of this other stuff. but that's been quite I mean at times it's been quite intense but it's been going on for nearly 20 years yeah whereas sometimes if a talk or someone might watch a podcast and be like this is loads of stuff this is too much stuff you just slow down yeah and I can see that it can be a bit overwhelming I think it is I think it's overwhelming for just it's overwhelming for people it seems and we hear from you know our community of just like what do i do well and i think that is the thing i gave a talk recently which is sort of subtitled when when the pattern is both the solution and the problem yep and that is kind of true and one of the things is it's all very well for me to be curious about all of these connections which i really do like and i do like the maths of it but it is practically what can be done yes and what can be done is advocating we wish you don't have to advocate for yourself but you know the they're the eds uk so that's the ellis danlos society uk gp toolkit so if you think that you might be hypermobile to present that to your gp or to other doctors so you've got that solid stuff and some of the articles in the link tree the resources pots uk feeling faint dot com seds connective the hypermobility syndrome association in Ella Stanloss UK.

1:02:03There are lots of support organisations. Seds Connective, particularly, obviously patron of, and I'm also patron of ADHD Aware, particularly they look at the whole neurodivergence picture and the whole body picture, which is unusual. But I think it's about just starting conversations. The sort of third audience of this, of like, we can do all this, you know, loads of great research, There's lots going on in academia. We've got society who are going to figure it out themselves. Yes, but it's getting it into the right places. Yeah, and then you've got the GP, the NHS. Wow, yeah. And that's what we're thinking with the Neurodivergent Brain Body Clinic is it's all very well, like one or two people coming to see us a couple of times a month.

1:02:51But actually what we should really be doing is educating recruiting other medical practitioners so that they can deal with the majority of these problems without having to make specialist referrals. Exactly. Because actually GPs are our friends. They are really well suited because they are brain, body, the whole lifespan. First line. First line. They are generalists and they're well equipped to help support. So we really need to get them on side and also to educate. I feel like since my diagnosis, in some areas I have regressed. Yeah, yeah, yeah. Or maybe loosened. Maybe. Or I just find some things harder.

1:03:32Well, you realise you find them harder. Is there any sort of physical regression that you've seen from them? Oh, yeah, I see this. I don't have research to back it up, but we do see this a lot, the sort of the process of unmasking potentially and also realising how much you might have been bracing or masking yourself previously. and it looks like possibly regression in that you are maybe a bit firmer about, actually, I'm not going to sit here in this hot jacket. You know, you're going to be more assertive about your sensory needs or about directions from your employer or something. Yes. You might be more liable to stand up for your employment rights.

1:04:15Sure. But anything physically, yeah, I don't know. So I'm not sort of suggesting that people are like coming out in hives after they've been diagnosed. Well, they might do or they might realise that they are. They might have just forgotten, not forgotten, or they just might not have paid attention because I think people are so often used to not being believed or constantly being dismissed that they're just like, oh, I wouldn't even notice it. When I'm talking to people in clinic, I often ask them about physical health symptoms and they say, oh, not really. I'm like what does not really mean does that mean and then and you'll be like do you feel dizzy when you stand up oh not really and then be like what does not really mean and then it'd be like is this you know once a week every day it's like most days and you just get this picture of people completely minimizing the difficulties they are going through dismissing it ignoring it minimizing it which is actually I'm not saying it's their fault but it is perpetuating the structural damage that is being done to them they are doing to themselves yes if i give you a magic wand what do you do with it i would like to convince government that this needs to be taken seriously at all levels and that this particular intersection in health care basically by investing or joining the dots together you are going to save money you are going to save lives and you are going to improve people's well-being.

1:05:49But it sounds awful because this time last year, it was estimated there were 750 ,000 people waiting for autism or ADHD assessment, which is obviously outrageous. Based on our recent UK study, we're a million. Yeah, I wouldn't be at all surprised. And although it is terrible, the state of affairs in autism and ADHD and Tourette's at the moment, absolutely awful. there are at least services there is nice guidance so there is policies and there are services hypermobility and these perplexing i put that in in inverted for those listening for those listening perplexing physical health symptoms there are no pathways there is no guidance so people who go to their gp and say i wonder if i'm hypermobile and they may be sent to msk or they're maybe sent to rheumatology they say oh no we don't deal with hypermobile eds or there is no nice guidance you know it is the wild west because a lot of people are driven to see people privately because there's very few things in the nhs yeah and so as look although it is awful that there are the problems that the demand that we have for adhd and autism exceeds our capacity though i think there are ways that we could improve that but that's a different conversation we need to make everyone aware of the physical health issues associated with this.

1:07:13With neurodivergence. Yes, because if you're not looking at that, you've missed half the picture. Yeah, so magic wand, everybody's now aware. Not necessarily that they're aware, but there are pathways, there are services. So there's a system. There's a system for it because awareness is important. Sure. But that needs to actually translate into action, investment and services, which we don't currently have. And what gives you hope that that's going to happen? It gives me hope that there are a lot of very motivated neurodivergent people out there, many of whom will be affected by these issues. So I hope that we can work together to shout this from the rooftops.

1:08:05Is there anything else that I haven't asked you or that you haven't said that you think is important that people know? Yes. One thing I think that people should know that I haven't really touched on is this idea about emotion regulation. And emotion regulation is a really important overlooked part of difficulties in neurodivergence. Not in the diagnostic criteria, but big autism, ADHD, all of it. Emotion regulation problems, the bugbear of a lot of people's life. And one of my favorite pieces of work that we have done is to show that neurodivergent characteristics are associated with emotion regulation difficulties.

1:08:52and those difficulties are about sense of your sensory uncertainty and so this sensory uncertainty about where you are in space seems to be affecting the relationship between neurodivergence and emotion regulation which seems pretty wild and then that effect is double in people who are hypermobile so it's a weird thing but it nicely links brain and body and i think it also nicely gives us hope for the future because you know a lot of neurodivergent people hypermobile people they struggle with side effects from medicines you know and psychiatric medicines can have some really awful side effects and also you know not every neurodivergent person gets on with therapy though you know if they're adapted they're promising and could be helpful but sometimes you're so dysregulated that talking about something isn't going to help so this idea that potentially improving our sense of where we are in space could actually help with regulating our emotions or improving our sensory certainty full stop could help regulate our emotions.

1:09:58I find that really promising. Where does neurodivergent people's inability to recognise their emotions Yes, alexithymia. Alexithymia play into that. I think it's huge. I think they amplify each other Because actually when I say emotion regulation in this paper, what we were specifically looking at is dissociation, tendencies towards dissociation, which are very important in trauma. And I have a wonderful medical student, Lisa Quatt and I have been working with, Rebecca Gazet, who she's basically looking at how dissociation is related to alexithymia and inner differences in interoception, this inner sense of what's happening in your body.

1:10:37And shutdowns. Yes, so it's all that, how this all converges, this sort of trigger happy body and you're not really sure what's going on. Emotionally, you haven't really necessarily, not really understanding. And then that sort of leads to dissociation. Situational mutism, I would put in that. Exactly. And that this is this brain body trauma intersect. Yeah, yeah. Oh, that's another thing. I'm going to ask you one last question. Okay, of course. And I'm not going to give this to you physically right now. I'll give it to you afterwards. Yes. Green dots. Yes, green dots. Yes. Yeah, symbol of support for neurodiversity.

1:11:14That simple. I've got a second badge for you, Jess. Who would you like to give it to? I would like to give it to Rebecca Dew. Rebecca Dew is our nurse consultant. I call her matron. She was matron in our amazing, I think amazing, neurodevelopmental service. So she is neurodivergent herself. She has modelled within our team, which includes a lot of neurodivergent staff members, a way of being and working that I think is genuinely inclusive in a way that most people couldn't imagine. So she chairs our team meetings, sometimes in sunglasses, sometimes from her exercise bike. And she once, I remember, chewed on a chewable necklace whilst chairing a meeting.

1:12:01And in order to promote a genuinely inclusive environment and set up neurodivergent staff clinic within our trust is you have to have that modelling from the top. You do. It's so important. and it sets such brilliant precedents. Exactly. So, yes, so Bex, I will. What do you think she'll say when you give her this? I'm not sure exactly. She's quite understated in some ways, but she has been spotting these patterns for longer than I've had hot dinners, I'm sure. Thanks, Jess. Thank you, Ben. I sort of feel like we've been a bit like rabbits, kind of going deep and then coming out and going into another rabbit hole and coming out.

1:12:47It could be called ADHD. Yeah, you could call it that. And I hope people have followed along. I'm sure they have. But I'm conscious that obviously we've thrown lots of information out there, which is amazing because this is complex and we shouldn't shy away from that complexity and be okay with holding misdiagnosis, underdiagnosis, all this stuff. Exactly. It's about embracing complexity. Yeah. It really is. And it is really grey and that that is okay. I often say, and Bette and I say, sometimes the more complicated things seem. So you read something on paper, you're like, you're patient for this long history.

1:13:29The simpler it is, that actually the complexity, and this is why I like the work, is it kind of reduces once you've got this handle on it. Yeah. Thank you. Thank you.

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