Ease Anxiety: Your Path To Calm

Introduction to Mindfulness and Dr. Brewer 0:00

This is Doctor Talks, real talk from real doctors on the issues that matter to you most. Welcome. And today I'm really excited to welcome Dr. Judd Brewer, who is a psychiatrist who practices at Brown University, who's a wonderful expert on anxiety and mindfulness and a host of things. And I have learned so much with Judd through the years. And so welcome to the summit. Thanks for having me. Yes, I'm really excited to just kind of dive into your expertise regarding mindfulness and maybe the effects of mindfulness practice on our physical wellbeing.

For example, if it affects our physiology, 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 wellbeing? Yes. So there are a lot of different definitions around mindfulness. I like to keep it very pragmatic. So 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 really curious and bringing that open-mindedness to what's happening.

And what that can help with, there are a lot of, mindfulness has been studied for the last 30 or 40 years now. So still relatively young in the grand scheme of things, but certainly developing an evidence base. And when it comes to physiology, you know, it's been shown when people are provoked with stress tests, for example, there's this Trier social stress test. When people get mindfulness training, it's been shown to help reduce, you know, where they have less of a kind of a physiologic response to stress.

So for example, their blood pressure doesn't go up as much. Some of these stress hormones and some of even some of the inflammatory markers are more regulated when somebody has gotten mindfulness training versus

How Mindfulness Affects Stress and Blood Pressure 1:57

when they haven't. Some of this great work has been done by Liz Hoege and others. And there's even work by Eric Lauks at Brown University where he's designed a program specifically for mindfulness training for blood pressure reduction. And he's found that it can really help people lower their blood pressure. If people have high blood pressure or borderline hypertensive, And also keep it down. One of his studies that he recently published was shown to keep blood pressure reduction gains for two years after this eight week training.

From a neurobiologic standpoint, we're learning more about how that works. So for example, there are things like anxiety that affect blood pressure for anybody that has white coat hypertension, where 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 and you're generally not going because of, it's like, hey, let's just hang out. It's often because there's something wrong or you're getting a checkup or you're not sure how your health is.

Hopefully all is well, but it's often not the case. So there was somebody actually in our unwinding anxiety program that specifically, he told me how he went to the doctor sat down got his blood pressure taken. And I think it was something in the like 170, 180 range over around 100 diastolic. And the office started to, you kind of mobilize like, Oh no, Oh no, Oh no. And he said, Hey guys, give me a second. and just sat down, did some, I think it was some breath awareness meditation or some curiosity meditation.

And they could just, you know, the next reading was almost normal and that, you know, they're all running around going, what, what did you just do? You know, because they wanted to give him some medications and do this and that. And really he was, he was just demonstrating in real time. how much our mind can both increase our blood pressure, but also how it can help regulate our blood pressure. And 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 really quiet when somebody's meditating.

So at a high level, I think of mindfulness as helping us be with our experience without reacting to it. And that reaction can often kind of make that blood pressure go up. 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 in a really quick manner on their own? One of my favorite practices, and this is, you know, people can find it. I have a YouTube channel where I walk people through it is, is called the five finger breathing practice.

So it's very simple where somebody is paying attention to the physical sensations of their breath. And they're also tracing their fingers as they're breathing. So as they breathe in. They're tracing up their pinky as they breathe out, they're tracing down and you get the idea. So over the course of five breaths or 10 breaths, they're just tracing their fingers. And that's a really helpful practice in helping somebody ground in the present moment. Our dorsal lateral prefrontal cortex, this working memory part of our brain only has the capacity to hold about four or a few more pieces of information at one time.

So that's, that's that working memory piece. And so for focusing on physical sensations on two hands, that's two things, the physical sensations of breathing, that's three things. And then looking at our hands, that's four things that can really kind of clear out that cache. So that our, or that cash or however you say that word, it's so that our brain kind of reboots. And for anybody that's taken five mindful or 10 mindful breaths. they might already notice there's a calming down of the physiology.

A Quick Breathing Practice for Calming Anxiety 5:50

And that's really helpful because then when they stop, if these worry thoughts come back in, they might not be at the same emotional intensity or same level as the physiology. And the two need to be about the same, think of it on the same wavelength for them to feed off of each other. So if we're thinking we're worried and we're feeling worried, those two are gonna feed, say, oh yeah, I'm worried. No, I'm feeling worried. Now I'm really worried. Whereas if we're feeling calm, and a worry thought comes in, this is where mindfulness can come in.

We can notice, oh, that's a thought. That's a worry thought. I'm not really feeling it. And so we can notice those thoughts as thoughts and let them come and go, which is really, that's one of the mindfulness practices is to just kind of note thoughts as thoughts. And that can help us not get caught up in the drama of our thinking mind. That's fantastic. And I love also how you kind of build or explain anxiety as a habit loop. Could you just kind of walk us through what that means or what a habit loop is and how anxiety is actually a habit?

Because I think that might help people as well. I'd be happy to. So this was something that I never learned in medical school or residency. I'm guessing you never learned it in medical school or residency either. So when I discovered this, and it wasn't that I came up with the concept, but I was struggling to help my own patients with anxiety and went back and looked at the literature and it turns out that back in the 1980s, a researcher named Thomas Borkiewicz suggested that anxiety could be driven like a habit.

So any habit needs three key elements, a trigger, a behavior, and a result. So the feeling of anxiety can trigger the mental behavior of worrying. I generally think of worrying or behaviors as, you know, like eating or scrolling on social media or something that we can see somebody do. But it turns out the mental behaviors count a whole lot when it comes to driving, you know, driving habits. So worrying is a bona fide mental behavior. You know, we worry about things and that at times or at least when this habit gets set up 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. And so that worrying gets reinforced where it says, oh, when you feel anxious, there's the trigger. You should worry there's the behavior because the result is, you know, you've got this feeling of control, this false sense of control really. But that feeds back so that we learn, oh, next time I feel anxious, I should worry some more. And we get stuck in these worry anxiety habit loops that ironically just drive us to be more anxious.

It doesn't actually help. Yeah, and then you kind of get... Well, I think you get the chest pressures and tightness and you call it constriction and the palpitations, which obviously we definitely could see higher blood pressure and things like that. So 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,

Anxiety as a Habit Loop 8:49

but can you just speak to the anxiety loop book and all that? Cause I think that's really important. Yeah, this turned out to be such a big deal because so we had, I found out about this hypothesis, my lab at Brown and before that at Yale had been doing habit change research for years. And so we had done some really good work with finding ways to help people break bad habits. Like we had a study where we had helped people quit smoking at five times the rates of gold standard treatment. And then we had started doing work with eating, helping people with habitual eating, which then led to somebody asking, hey, my eating is triggering me to stress eat.

I'm sorry, my anxiety is leading me to stress eat. Can you create a program for anxiety? So we had actually developed this app called Unwinding Anxiety and started testing it, did randomized controlled trials, did a bunch of research to figure out what was going on. We're getting these huge results, like 67% reduction in clinically-validated anxiety scores in people with generalized anxiety disorder. And so there was enough there and enough where people really haven't thought of anxiety as a habit that I wrote the Unwinding Anxiety book and ended up doing all right.

From there, I went back to this eating work and my publisher was very happy with the Unwinding Anxiety book and said, hey, can you write a book about eating? Because this is something that we really need. And I was thinking, wow, lots of books. written about eating, but she's like, well, nobody's really written it from the neurobiologic side. So really focused that it's called the hunger habit. And the hunger habits really about helping people identify these habit loops around eating, whether it's overeating, stress eating, eating out of boredom, eating out of comfort, all of these things.

So where that comes from, from a neurobiologic and a physiologic standpoint, there are a lot of things where hunger is kind of 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's big risk for increased risk for hypertension. Right. Well, I think many of the things that you've related to or done research on is smoking. That's definitely will increase your blood pressure, the mental health side, the anxiety, the stress, the worry.

And then also, of course, like you said, obesity, which can drive heart disease and hypertension and lots of other things. So any of your books, any of your groups, your website is drjed.com, right? Yes, drjud.com. Yeah, perfect. So any information there, we'll put links here as well, but really amazing stuff. And I will utilize it a lot with my own patients and send them your way for sure. Obviously still to this day, but I do want to speak to maybe if we can talk a little bit also about the smoking piece of that, because I think someone who is smoking or maybe even the hunger cues if you want to go into that a little bit more, but just really speaking to how lifestyle and how you're utilizing these practices of mindfulness and habits, how people can literally change their lifestyle.

And of course, obviously that will help blood pressure. Can we speak to that a little bit? I'd be happy to. Yes. So there are a number of lifestyle factors that have direct impact on blood pressure.

The Unwinding Anxiety Book and Habit Change Research 12:18

For example, smoking, you know, big, big driver of hypertension. We've approached smoking in a slightly unorthodox way, which is now, hopefully we'll start to become more mainstream as people see that actually can work pretty well. And the unorthodox way is, you know, 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 say, well, you're probably going to smoke anyway, right?

That's why you're coming to me to try to quit smoking. So pay attention as you smoke. Pay careful attention. And what we've found, so not just in my clinic, but we've even done studies on this, is that really 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. And simply put, our brains are going to keep doing things that are rewarding, and they're going to stop doing things that aren't rewarding. And so typically, people start smoking in their teenage years where there was enough of a reward to fit in, to rebel, to whatever, that they actually overcame all of their body signals that said, hey, you're putting toxin in here, all the nausea, all that stuff.

And so now they smoke as they're not paying attention to the cigarettes as they smoke them. For example, I had somebody who came in who had been smoking 40 years, and we calculated the number of times he had reinforced this habit loop, it was roughly 300,000 times. Not exaggerating, it was roughly, it was like in the 290,000s. Because if you smoke 20 cigarettes a day for 40 years, that adds up pretty quickly. So I had him pay attention and I said, go home, pay attention as you smoke. And he comes back and he says, how did I not notice this?

You know, these things taste like crap. And what he was highlighting was that shift in how rewarding that behavior was in his brain. He hadn't noticed it. He was actually not paying attention. Most people when they smoke, they'll pay attention to something else because cigarettes don't taste very good. So we can actually leverage that really strong learning mechanism in our brain to help us change behavior without willpower. This isn't about, oh, I should stop smoking. Everybody already knows that.

It's really about what am I getting from this? So asking this simple question, what am I getting from this? So we even did a study with our Eat Right Now app to help people pay attention as they overeat. So we can see that this isn't just smoking, but this applies to any habitual behavior. So as somebody overeats, we have them pay attention as they overeat. It only takes 10 to 15 times of somebody paying attention as they overeat for that reward value to drop below zero. they start to shift that behavior.

So it's not a matter of how many times we've reinforced a behavior. It could be 300,000 times. It's really a matter of remembering, one, that our brain is really adaptable. It's going to adapt quickly to changing environments. And that awareness, that's number two, The awareness helps us really see, oh, there's 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? And 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.

Mindfulness, Smoking, and Reward-Based Behavior Change 15:48

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. You know, and this is something I think you've really helped people see very clearly, uh, with, you know, just the benefits of eating a healthy diet, you know, especially a big fan of the, you know, the whole food plant based diets, because people can see real changes in their lives that they never noticed because it was such a habit to eat crappy food their entire life.

And then they, they shift and they say, wow, how did I not notice this? Well, what do they need for that awareness? So that awareness is the key for all of these habits. I think it also goes back to curiosity, which you always said is your superpower, which I've stolen that phrase multiple times, but I just want to highlight a story in my own experience as a physician regarding the smoking because nicotine is a very difficult chemical to overcome by sheer willpower to quit, but I had a patient who had also smoked multiple panics a day for 40 plus 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. So he came back one day and he had said, Dr. Morris, I quit smoking. I was like, What did you do? Cause it was nothing I did. And he said, well, my granddaughter came up to me and said that she had learned in school that, well, basically this is a story. So he's sitting in his chair. I get a little more drama cause 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.

I think she's about eight and she was really crying. She's like, pop up. you're going to die." And he's like, sweetie, I'm not going to die. And she's like, yes, you are, because I learned in school, people who smoke are going to die. And you smoke, that means you're going to die. And he literally said that had such an impact on her, on him, having seen her cry, that he literally stopped that day and had no desire. Simply in one fell swoop, remove the rewards. I thought that was such a wonderful example of what you're describing.

Can we just go back to the eating piece of that? Because when you say when people are overeating and becoming aware, where are they aware? What does that look like? Can you make that a little bit more practical so people can understand how maybe they can even just start using that today? It's a really good question. So this is an important shift for a lot of people. So a lot of people are stuck in their heads. They're not really paying attention to their body sensations. And so they'll say, oh, I shouldn't overeat or they'll go on some calorie restriction diet.

It worked for a little while and then they regained the weight, you know, that whole yo-yo dieting thing. So the key here is really bringing that awareness into our body, our stomach, our body, It's very wise. It knows when we've eaten too much. So really bringing that into our body and keeping in mind things like, it takes about 15 minutes for our body to register satiety. So if we can not just shove a bunch of food down quickly, but we don't have to eat extremely slowly, but just remember it may 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 body's already sending us signals saying, hey, you're starting to fill up. I think of this as hitting the pleasure plateau. And so that can help us bring curiosity to each bite and really see, oh, am I starting to hit the top here before we go over that cliff of overindulgence? So just really paying attention Oh, am I full or am I close to full?

And 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. So it's really about just being curious, like, oh, How much does my body need right now? Listening 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 really where behavior change comes from.

And it'll also tell us if we've had enough. So I'm assuming slowing down, eating, setting down your utensil, not being distracted by screens or the phone or something. Is there a eating hygiene protocol that you might suggest for someone kind of like a sleeping protocol or sleeping hygiene that might be helpful to help people engage in that mindfulness awareness practice? Here I would say keep it simple. So removing distractors. And I will say, many of us, most or all of us eat a lot of meals in some type of a social setting.

So just keep in mind that this can be more challenging if we're at the dinner with friends or even at the dinner table with our family.

Eating Awareness and the Hunger Habit 21:00

we can start practicing by, you know, when we have an opportunity to email by ourselves. And so here, instead, you know, putting away the book, the television, the phone, the tablets, you know, all the things that we tend to do, you know, to distract ourselves from life, putting those away, and then Bringing curiosity to the dinner table with us, right? And just getting really curious. So simple thing, putting down our fork between each bite and really paying attention as we chew until we swallow that next bite.

We can even notice, is there an urge to get another bite before we finish chewing? and we're not even actually paying attention or enjoying the food that's in our mouth right now. So simple things, put away the distractors and put down the fork or the spoon between each bite and just pay attention. What's this taste like? What's this feel like in my mouth? Really, if we're gonna eat, we might as well pay attention to what we're eating. And ideally it might be something that's pleasant, so we'll enjoy it even more when we do pay attention.

So keeping it simple like that. I love keeping it simple. Absolutely. So I do want to thank you so much for joining us everyone today, but I hope you found this conversation insightful and engaging. And if you're a summer purchaser, stay right here because we're about to dive even deeper into this conversation. And if you're not click on the button below or to the side and get access to the rest of the conversation. And if you're watching this, thank you for being a valuable member of our community.

And I just want to ask a few more questions of Dr. Brewer and really regarding the eating component of that. Could you talk to us a little bit about what the raisin experiment is? Cause I think that is really cool because it really becomes highlights different parts of the body and how to kind of connect back the mind body connection. Could you speak to that and where it came from and how is it helpful or maybe some other exercises that you find is helpful? Sure. So the raisin exercise is this now famous or infamous practice that is typically offered on the first day of a mindfulness-based stress reduction program.

And I wrote almost an entire chapter, I think, in The Hunger Habit about this because it's so iconic. so helpful and also has so many misconceptions around it. And the idea is, and it doesn't have to be a raisin, but raisins tend not to, you can keep them in a box for a while, you can hand out a bunch of them to a bunch of people. And raisins are something that almost all of us have had experience with to one degree or another. So, 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 really start to bring what's described in mindfulness practices as this beginner's mind to the raisin. So instead of, you know, the way that we typically eat raisins, which is like by the mouthful and absent-mindedly, you know, we just take one of those little boxes and just pour it into our mouth and it's like, you know, gone. You know, 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 really look at them carefully. We can even notice what they sound like. If we kind of roll them between our fingers and listen to that little crinkly sound, we can bring them up to our nose and really notice what does a raisin smell like? I'm remembering last time I did this, there's like an earthy tone that I hadn't really noticed. And then we can we can deposit them in our mouth and really pay attention to what it feels like before we even bite into it.

And then as we bite into it and remember, it's like it releases all this explosion of flavor. But after we bite into the raisin, it tends not to be, you know, until we've broken through the skin of it. And what the raisin exercise highlights is a couple of things. One is that we tend to eat mindlessly.

The Raisin Exercise and Mindful Eating 24:58

We don't pay attention to our food. And two, that when we, and it's not like we have to do this slowly. That's one of the misconceptions is like, oh, this means I have to eat slowly all the time. No, no, no. This is an example of when we slow down for a moment, we can start to notice all of our conceptions around eating. So for some people, they're like, I hate raisins, you know, and we can notice others a thought. Or for some people, it's like, I love raisins. For some people, they're like, whatever raisins, you know, I don't really care that much one way or the other.

So we can notice all of our conceptions around these things as well. And we can also notice that if we pay attention, you know, life is much richer. Even, you know, no matter what's happening, it's not like life is always going to be wonderful. But when we really pay attention, we start to see all the things that we are missing. And the raisin exercise is a great example that highlights all of the parts of life every day that we're just going through habitually on kind of zombie mode. No, I think that's a great thing.

It can translate not only from food, but to other parts of your life and things that you just ignore, right? I agree. That's part of living this life is paying attention. No, that's fantastic. So just one more question. As far as when you're saying being curious and being mindful while we'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, you know, one engage maybe in healthier lifestyle practices or becoming aware of their mental challenges, like any good resources or anything else you would suggest?

It's a really good question. So most people are social creatures. And one thing that I think research is starting to highlight more and more is that loneliness is really not good for our health. So finding a community that's supportive for us, you know, for some people this is church or a religious group, for other people it's volunteering, for other people it's finding individuals that like to be out, you know, go hiking, like a hiking group or a exercise group, 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, oh, I could go check 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. So as an example, in our digital therapeutics, we have an online community for each of these, whether it's the smoking community,

Community Support and Recovery Resources 27:48

eating, anxiety, and we actually have a depression program that's now launched. So people can come together and support each other in that way. And so online communities can be really helpful. And those are examples where folks can find online communities where there might be a pain point that they rally around, whether it's anxiety or overeating or whatever, where they can come together and really support each other. And I really think that that's a wonderful thing. I'll mention one other example.

We just started this nonprofit for addiction treatment called MindShift Recovery. And one of the core components of that is really training peer specialists to be, you know, help each other, you know, where somebody that has struggled with addiction, whatever their addiction is, can be trained to actually support somebody else with another addiction. I've seen this in my clinic work way too much where, you know, somebody in AA or another support group, there's like, They're like, oh, get a sponsor.

And unfortunately, there's not a lot of training in a lot of these grassroots movements. And so sometimes sponsors are wonderful and sometimes sponsors aren't so wonderful. And sometimes they cause more harm than help. So another example of providing community and support where there are people that are really drawn to give back where they've been helped. I think that's a beautiful way to end our discussion. But again, I wanted to say thank you so much for joining us on the summit and I'm certain people are going to truly appreciate and benefit from your resources.

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