Ease Anxiety: Your Path To Calm

Judson Brewer, MD, PhD

Thanks for having me.

Laurie Marbas, MD, MBA

I’m excited to just dive into your expertise regarding mindfulness and maybe the effects of mindfulness practice on our physical well-being. for example, that it affects our physiology by lowering blood pressure and such. Could you give us a little understanding of what mindfulness is and maybe how we’ve seen some more recent data on how it can affect our well-being?

Judson Brewer, MD, PhD

There are a lot of different definitions of mindfulness. I like to keep it very pragmatic. I think of two components. One is awareness, where we’re aware of what’s happening right now, and then also bringing this curious attitude in, where we’re not judging what’s happening. We’re just curious and bringing that open-mindedness to what’s happening. What that has can help with. There is a lot of mindfulness that has been studied for the last 30 or 40 years. still relatively young in the grand scheme of things. But we are certainly developing an evidence base. When it comes to physiology, it’s been shown that people are provoked by stress tests; for example, there’s this trigger social stress test. When people get mindfulness training, it’s been shown to help reduce their physiologic responses to stress. For example, their blood pressure doesn’t go up as much. Some of these stress hormones and even some of the inflammatory markers are more regulated.

When somebody has gotten mindfulness training versus when they haven’t. Some of this great work has been done by Liz Hughey and others, and there’s even work by Eric Loucks at Brown University, where he’s designed a program specifically for mindfulness training and blood pressure reduction. He’s found that it can help people lower their blood pressure if they have high blood pressure or borderline hypertension and also keep it down. One of his studies that he recently published was shown to maintain blood pressure reduction gains for two years after a week of training. From a neurobiological standpoint, we’re learning more about how that works. For example, there are things like anxiety that affect blood pressure for anybody who has white or white coat hypertension. They go to see their doctor, and suddenly they have high blood pressure. It’s not exactly the most pleasant thing to go to the doctor. You’re generally not going because it’s like, “Hey, let’s just hang out.” It’s often because there’s something wrong, you’re getting a checkup, or you’re not sure how your health is. Hopefully all as well, but it’s often not the case.

There was somebody in our unwinding anxiety program who specifically told me how he went to the doctor, sat down, and got his blood pressure taken. It was something in the 171–80 range of around 100 diastolic, and the office started to vocalize like, “Oh no.” And he said, “Hey, guys, give me a second.” He just sat down. He did some breathing awareness meditation or some curiosity meditation. The next reading was almost normal. They’re all running around, going, what did you just do? because they wanted to give him some medications and do this and that. He was just demonstrating in real-time how much our minds can both increase and help regulate our blood pressure. We’ve even done studies. Neuroimaging studies, where we look at people’s brains when they’re meditating, and we can see there’s this default mode network, this network that gets activated when we’re anxious, for example, when we worry, that gets quiet when somebody is meditating. I have a high level of mindfulness, which helps us be with our experience without reacting to it. That reaction can often make the blood pressure go up.

Laurie Marbas, MD, MBA

Could you give an example of maybe one practice that your patients or the person in your group might have been using in the doctor’s office that someone could utilize quickly on their own?

Judson Brewer, MD, PhD

One of my favorite practices, and I have a YouTube channel where I walk people through it, is called the five-finger breathing practice. It’s very simple: somebody is paying attention to the physical sensations of their breath, and they’re also tracing their fingers as their breathing says breathe in, then they’re tracing up their pinky as they breathe out, and they’re tracing them down. You get the idea. Throughout five or ten breaths, they’re just tracing their fingers. That’s a helpful practice for helping somebody in the present moment. Our dorsolateral prefrontal cortex, this working memory part of our brain, only can hold about four or a few more pieces of information at one time. That working memory piece. For focusing on physical sensations with two hands, that’s two things. The physical sensations of breathing—those are three things. then looking at our hands as four things that can clear out that cache so that our brain reboots. For anybody who’s taken five or ten mindful breaths, they might already notice that there’s a calming effect on the physiology. That’s helpful because then when they stop it, these worried thoughts come back in. They might not have the same emotional intensity or level as the physiology, and the two needed to be about the same. Think of it on the same wavelength for them to feed off of each other. If we’re thinking, we’re worried, and we’re feeling worried, those two are going to say, I’m worried now. I’m feeling worried now. Whereas if we’re feeling calm and a worry comes in, this is where mindfulness can come in. We can notice; that’s a thought; that’s a worry. Thoughts—I’m not feeling them. So we can notice those thoughts as thoughts and let them come and go, which is one of the mindfulness practices, which is to just note thoughts as thoughts, and that can help us not get caught up in the drama of our thinking mind.

Laurie Marbas, MD, MBA

That’s fantastic. I also love how you build or explain anxiety as a habit loop. Could you just walk us through what that means, what a habit loop is, and how anxiety is a habit? That might help people as well.

Judson Brewer, MD, PhD

I’d be happy to. This is something that I never learned in medical school or during my residency. I’m guessing you never learned it in medical school or residency either.

Laurie Marbas, MD, MBA

I learned it from you.

Judson Brewer, MD, PhD

When I discovered this, it wasn’t that I came up with the concept, but I was struggling to help my patients with anxiety and went back and looked at the literature. It turns out that back in the 1980s, a researcher named Thomas Berkovitz suggested that it could be driven like a habit. Any habit needs three key elements that trigger a behavior and a result. The feeling of anxiety can trigger the mental behavior of worrying. I generally think of worrying or behaviors as, like eating or scrolling on social media, something that we can see somebody do. But it turns out that mental behaviors aren’t a whole lot when it comes to driving habits. Worrying is a bona fide mental behavior. We worry about things, and at times, or at least when this habit gets set up, it can feel like it’s rewarding enough because it feels like we’re in control when we’re worrying. Or, truthfully, it probably feels better to do something than not do anything when we’re feeling anxious. so that worrying gets reinforced when it says, when you feel anxious, there’s the trigger. You should not worry; there’s behavior. Because the result is that you’ve got this feeling of control, this false sense of control, but that feeds back so that we learn that next time I feel anxious, I should worry some more when we get stuck in these worry anxiety habit loops that ironically just drive us to be more anxious. They don’t. It doesn’t help.

Laurie Marbas, MD, MBA

Then you get well, you get the trust pressures and tightness in, you call it constriction, and the palpitations, in which we could see higher blood pressure and things like that. You have an excellent book all about this. You want to share a little bit about your book, and then you have an upcoming book as well. But I want to have another question, but can you just speak to the anxiety loop book and all that? 

Judson Brewer, MD, PhD

This turned out to be such a big deal because, as we had discussed, I found out about this hypothesis. My lab at Brown and before that at Yale had been doing habit-change research for years. So we had done some good work finding ways to help people break bad habits. We had a study where we helped people quit smoking at five times the rates of gold standard treatment. Then we started doing work with eating, helping people with habitual eating, which then led to somebody asking, “My anxiety is leading me to stress eat. Can you create a program for anxiety?” We developed an app called Unwinding Anxiety and started testing it in randomized controlled trials. I did a bunch of research to figure out what was going on. We’re getting these huge results, like a 67% reduction in clinically validated anxiety scores in people with generalized anxiety disorder.  There was enough there and enough where people haven’t thought of anxiety as a habit. I wrote the Unwinding Anxiety book and ended up doing all of it.

From there, I went back to this eating work, and my publisher was very happy with the Unwinding Anxiety book and said, “Can you put a book about eating? Because this is something that we need?” I was thinking, Well, there are lots of books written about eating, but she’s like, Well, nobody’s written it from the neurobiological side. So focused that it’s called The Hunger Habit. The Hunger Habit is about helping people identify these habits around eating, whether it’s overeating, stress eating, eating out of boredom, eating out of comfort, or all of these things. Where that comes from, from a neurobiological and physiologic standpoint, there are a lot of things where hunger is important to help us survive. Yet somehow wires got crossed in our brains, and we’ve learned, ironically, to eat when we’re not hungry, which is an anti-survival mechanism not so helpful, including obesity, which is a big risk for increased risk for hypertension.

Laurie Marbas, MD, MBA

Many of the topics you’ve discussed or researched involve smoking. That’s going to increase your blood pressure, your mental health, your anxiety, your stress, and your worry. then also, of course, like you said, obesity, which can drive heart disease, hypertension, and lots of other things. any of your books, any of your groups, your websites, or drjud.com.

Judson Brewer, MD, PhD

Yes. drjud.com.

Laurie Marbas, MD, MBA

Any information there, we’ll put links here as well, but amazing stuff. I want you to utilize it a lot with my patients and send them your way for sure, still to this day. But I do want to speak to someone who is smoking, or maybe even the hunger cues, if you want to go into that a little bit more. But just speaking to how lifestyle changes when you’re utilizing these practices, mindfulness, and habits, people can change their lifestyle. Of course, that will help blood pressure. Can we speak to that at least a little bit?

Judson Brewer, MD, PhD

I’d be happy to. Several lifestyle factors have a direct impact on blood pressure. For example, smoking is a big driver of hypertension. We’ve approached smoking in a slightly unorthodox way, which is now, hopefully, starting to become more mainstream as people see that it can work pretty well. The unorthodox way is that when I have a patient come into my office, they want to quit smoking. I tell them to smoke; typically, somebody’s doctor doesn’t tell them to smoke. But I add something to that. I said, You’re going to, probably go smoke anyway. That’s why you’re coming to me to try to quit smoking. Pay attention as you smoke. Pay careful attention. What we’ve found, not just in my clinic, but we’ve even done studies on this, is that the best way and some would argue, the only way to break a bad habit is to change the reward value of that behavior in our brain.

Simply put, our brains are going to keep doing rewarding things, and they’re going to stop doing things that aren’t rewarding. So typically, people start smoking in their teenage years when there’s been enough of a reward to fit in, to rebel, to whatever, that they overcame all of their body signals that said you’re putting toxin in here, all the nausea and all that stuff. So now they smoke because they’re not paying attention to the cigarettes as they smoke them. For example, I had somebody who came in and had been smoking for 40 years, and we calculated the number of times he had reinforced this habit loop. It was roughly 300,000 times. While not exaggerating, it was roughly what it was like in the 290,000 because if you smoke 20 new cigars a day for 40 years, that adds up pretty quickly. I had him pay attention. I said, Go home; pay attention. As you smoke, he comes back, and he says, How did I not notice this? These things taste like crap. What he was highlighting was the shift in how rewarding that behavior was in his brain. He hadn’t noticed it. He was not paying attention.

Most people, when they smoke, pay attention to something else because cigarettes don’t taste very good. We can leverage that strong learning mechanism in our brain to help us change behavior without willpower. This isn’t about me; I should stop smoking. Everyone already knows that. It’s about what I’m getting from this. asking this simple question: What am I getting from this? We even did a study with our Eat Right Now app to help people pay attention as they overeat. We can see that this isn’t just smoking; this applies to any habitual behavior. As somebody overeats, we have them pay attention as they overeat. It only takes 10 to 15 times for somebody to pay attention as they overeat for that reward value to drop below zero, and they start to shift that behavior. It’s not a matter of how many times we’ve reinforced a behavior. It could be 300,000 times. 

It’s a matter of remembering, one, that our brain is adaptable. It’s going to adapt quickly to changing environments, and that awareness. That’s number two. That awareness helps us see that this is a change here. If we’re not paying attention, we’re just going to keep doing the old behavior habitually. But if we pay attention, we’ll see. Is it rewarding? Is it not rewarding? We describe this as becoming disenchanted with the behavior. If we’re overeating, it doesn’t take very long to see that. It just doesn’t feel very good to overeat if we’re eating crappy food. This also directly applies to hypertension, when somebody is eating food that’s just not good for them. It feels very different. The results feel very different than when they’re eating healthy food. And this is something you’ve helped people see very clearly—the benefits of eating a healthy diet. I’m an especially big fan of the whole plant-based diet because people can see real changes in their lives that they never noticed. After all, it was such a habit to eat crap food their entire life. then they shift, and they say, How did I not notice this? Well, what do they need for that awareness? That awareness is the key to all of these habits.

Laurie Marbas, MD, MBA

Anything else, it is about curiosity. What you said is your superpower, and I’ve stolen that phrase multiple times, but I just want to highlight a story from my experience as a physician regarding smoking because nicotine is a very difficult chemical to overcome by sheer willpower to quit. But for a patient who had also smoked multiple packs a day for 40+ years and did not change his habits, regardless of what I told him, there was no fear of anything. It didn’t matter. The cost, the fear of lung cancer—nothing. He’s like, “I enjoy it.” I’m like, “Okay.” He came back one day, and he said, Dr. Marbas, I quit smoking. It’s like, What did you do? Because it was nothing I did. He said, Well, my granddaughter came up to me and said that she had learned in school that this is a story. He’s sitting in his chair. I get a little more drama because I’ll pretend like I’m the little girl, but she came up to him, and he’s smoking a cigarette, and she came up to him. She was about eight, and she was crying. She’s like, “Papa, you’re going to die.” He’s like, “Sweetie, I’m not going to die.” She’s like, “Yes, you are. Because I learned in school that people who smoke are going to die, and if you smoke, that means you’re going to die.” He said that had such an impact on him having seen her cry—that he stopped that day and had no desire, simply in one fell swoop. For me, the rewards were such a wonderful example of what you’re describing. Can we just go back to the eating piece of that? Because when you say that people are overeating and becoming aware, where are they aware? Like, what does that look like? Just can you make that a little bit more practical so people can understand how maybe they can even just start using that today?

Judson Brewer, MD, PhD

It’s a good question. This is an important shift for a lot of people. A lot of people are stuck in their heads. They’re not paying attention to their body sensations. So they’ll say that they shouldn’t overeat, or they’ll go on some calorie restriction diet at work for a little while, and then they’ll regain the weight—that whole yo-yo dieting thing. The key here is bringing that awareness into our body, our stomach, and our body. It’s very wise. It knows when we’ve eaten too much. Bringing that into our body and keeping in mind things like, It takes about 15 minutes for our body to register satiety. If we can’t just shove a bunch of food down quickly but also take our time, we don’t have to eat extremely slowly. But just remember, it’s going to take a few minutes to register satiety, but at the same time, we can also start paying attention.

As we’ve eaten a little bit with each bite, we can ask ourselves, Is this more or less pleasurable than the last one? Because our bodies were already sending our signals, saying, You’re starting to fill up. of this as hitting the pleasure plateau. That can help us bring curiosity to each bite and see. Am I starting to hit the top here before we go over that cliff of overindulgence? Just paying attention if I am full or close to being full. Then, of course, if we overeat, we can pay attention to what that feels like because that can also feed us feedback so that the next time we’re eating a meal, we can remember what that was like so that we’re less likely to do that in the future. It’s about just being curious, like, how much does my body need right now to listen to our body as compared to trying to think our way through something? My mantra is that our feeling body is much stronger than our thinking brain because that’s where behavior change comes from. It also tells us if we’ve had enough.

Laurie Marbas, MD, MBA

I’m assuming slowing down eating, setting down your utensil, not being distracted by screens, the phone, or something. Is there an eating hygiene protocol that you might suggest for someone, like a sleeping protocol or sleeping hiding, that might be helpful to help people engage in that mindfulness awareness practice?

Judson Brewer, MD, PhD

I would say to keep it simple. Removing distractions, and I will say many of us feel most or all of us eat a lot of meals in some type of social setting. Just keep in mind that this can be more challenging if we’re out to dinner with friends or even at the dinner table with our family. So we can start practicing when we have an opportunity to eat by ourselves. So here instead, of putting away the books, the television, the phone, the tablets, and all the things that we tend to do to distract ourselves from life, putting those away, and then bringing curiosity to the dinner table with us. Just getting curious. It is a simple thing, putting down our fork between each bite and paying attention as we chew until we swallow that next bite, we can even notice whether is there an urge to get in that bite before we finish chewing, and we’re not even paying attention to or enjoying the food that’s in our mouth right now? Simple things: put away that distractor and put it down; put down the fork or spoon between each bite; and just pay attention. What does this taste like? What’s this feeling like in my mouth? If we’re going to eat, we might as well pay attention to what we’re eating. Ideally, it might be pleasant, so we will enjoy it even more when we do pay attention. Keep it simple like that.

Laurie Marbas, MD, MBA

I love keeping it simple. I do want to thank you so much for joining us, everyone, today, but I hope you found this conversation insightful and engaging. If you’re a summit purchaser, stay right here, because we’re about to dive even deeper into this conversation. If you’re not, click on the button below or go to the site and get access to the rest of the conversation. If you’re watching this, thank you for being a valuable member of our community. I just want to ask a few more questions of Dr. Brewer, and regarding the eating component of that, could you talk to us a little bit about what the raisin experiment is? Because that is cool because it highlights different parts of the body and how to reconnect the mind-body connection. Can you speak to that, where it came from, and how it is helpful, or maybe some other exercises that you find helpful?

Judson Brewer, MD, PhD

The raisin exercise is a now-famous or infamous practice that is typically offered on the first day of a mindfulness-based stress reduction program. I wrote almost an entire chapter about the hunger habit because it’s so iconic, so helpful, and also has so many misconceptions around it. The idea is that it doesn’t have to be a raisin, but raisins, you can keep them in a box for a while, and you can hand out a bunch of them to a bunch of people. It’s in raisins or something that almost all of us have had experience with to some degree or another. Some of us love raisins, some of us hate raisins, some of us are indifferent to raisins, and most of us aren’t allergic to raisins.

But we can take something like a raisin, and we can start to bring what’s described in mindfulness practices as this beginner’s mind to the raisin. Instead of the way that we typically eat raisins, which is by mouthful and absentmindedly, we just take one of those little boxes and pour it into our mouth. It’s like, gone; we don’t even notice what they tasted like. We can take a single raisin, and again, we can do this with anything. But raisins are nice because they’re small. We can start paying attention to what they look like and looking at them carefully. We can even notice what they sound like if we roll them between our fingers and listen to that little crinkly sound. We can bring them out of our noses and notice what does a raisin smells like. I’m remembering the last time I did this; there’s like an earthy tone that I hadn’t noticed. then we can. We can deposit them in our mouths and pay attention to what they feel like before we even bite into them. then as we bite into it and remember, it’s like it releases all this, this, explosion of flavor. But after we bite into the raisin, it tends not to be until we’ve broken through the skin of it. The what’s our raising exercise highlights are a couple of things. One is that we tend to eat mindlessly. We don’t pay attention to our food until that time, and it’s not like we have to do this slowly. That’s one of the misconceptions: This means I have to eat slowly all the time, and this is an example of how when we slow down for a moment, we can start to notice all of our conceptions around eating. For some people, I hate raisins, and we can notice other thoughts, or for some people, it’s like, I love raisins. For some people, they’re like, whatever, raisins; I don’t care that much. One way or another. We can notice all of our conceptions around these things as well. We can also notice that if we pay attention, life is much richer, even if, no matter what’s happening, it’s not like life is going to be wonderful. But when we pay attention, we start to see all the things that we are missing. The raisin exercise is a great example that highlights all of it—all of the parts of life every day that we’re just going through habitually in zombie mode.

Laurie Marbas, MD, MBA

That’s a great thing because it can translate not only to food but also to other parts of your life and things that you just ignore. I agree. That’s part of living this life: paying attention now. That’s fantastic. I just have one more question. As far as being curious and mindful while you’re eating, are there any other things that they can do as well? Are there support groups or other therapeutic interventions that might help people that you might suggest besides just the mindfulness piece to help, one, engage maybe in healthier lifestyle practices or become aware of their mental challenges, like any good resources or anything else you would suggest?

Judson Brewer, MD, PhD

It’s a good question. Most people are social creatures. One thing that research is starting to highlight more and more is that loneliness is not good for our health. finding a community that is supportive of us; for some people, this is a church or a religious group. For other people, it’s volunteering; it’s finding individuals that like to be out and go hiking, like a hiking group or an exercise group; or there are all sorts of community activities that are out there that are available because that’s what we tend to do as humans, and often we’re not aware of these because we just haven’t thought about them. I could go check it out to see what’s available in my community. On top of that, there are now online communities where people can get together and support each other. As an example, in our digital therapeutics, we have an online community for each of these, whether it’s a smoking community eating them or a depression program that’s now launched, so people can come together and support each other in that way.

Online communities can be helpful. Those are examples where folks can find online communities where there might be a pain point that they rally around, whether it’s anxiety, overeating, or whatever, where they can come together and support each other. I  think that that’s a wonderful thing. I’ll mention one other example. We just started this nonprofit for addiction treatment called Mind Shift Recovery. One of the core components of that is training peer specialists to help each other where somebody who has struggled with addiction, whatever their addiction is, can be trained to support somebody else with another addiction. I’ve seen this in my clinic way too much where, somebody in AA or the support group, there’s like they’re like, oh, got to get a sponsor, and fortunately there’s not a lot of training in a lot of these grassroots movements. Sometimes sponsors are wonderful, and sometimes sponsors aren’t so wonderful, and sometimes they cause more harm than help. Another example of providing community and support is when there are people who are drawn to give back where they’ve been helped. 

Laurie Marbas, MD, MBA

That’s a beautiful way to end our discussion. But again, I wanted to say thank you so much for joining us at the summit. I’m certain people are going to truly appreciate and benefit from your resources.