Speaker 1: Today, for Mental Health Awareness Month, we're going to talk
Speaker 1: about anxiety. This is something close to everybody's experience, either
Speaker 1: because they've had it themselves or someone close to them
Speaker 1: has had it. So today we're going to ask several questions.
Speaker 1: Does your brain accidentally teach itself to stay anxious by
Speaker 1: looping on the same fears? Is anxiety helping you perform
Speaker 1: better or making everything harder? What happens when you stop
Speaker 1: running from anxiety and look straight at it. Is it
Speaker 1: possible to unlearn worry the same way that you learned it?
Speaker 1: What if curiosity is stronger than fear? Today we're going
Speaker 1: to talk with doctor Judd Brewer, who suffered with anxiety
Speaker 1: as a young man and then became a psychiatrist and
Speaker 1: a neuroscientist, and he's studied anxiety his whole career and
Speaker 1: he has a very different take on what can be
Speaker 1: done about it. Welcome to Inner Cosmos with me David Eagleman.
Speaker 1: I'm a neuroscientist and an author at Stanford and in
Speaker 1: these episodes, we sail deeply into our three pound universe
Speaker 1: to understand why and how our lives look the way
Speaker 1: they do. What does it mean to feel anxious. This
Speaker 1: is one of those experiences that most people know somehow,
Speaker 1: but if you're asked to define it, it kind of
Speaker 1: slips through your fingers. So most people will grab for
Speaker 1: words like fear and worry. But it actually has to
Speaker 1: do with something very fundamental in the brain, which is
Speaker 1: your brain's projections into the future. Your brain is fundamentally
Speaker 1: a simulation engine that's always running itself ahead of reality. Now,
Speaker 1: this is one of the brain's greatest powers. So although
Speaker 1: you might read a textbook on the brain and think, oh,
Speaker 1: it's just passively recording the present moment, that's not really
Speaker 1: what it's about at all. Instead, it's constantly constructing models
Speaker 1: of what might happen next. It's running simulations and imagining
Speaker 1: outcomes and hopefully preparing you. This capacity to unhook from
Speaker 1: the here and now, to imagine yourself in the there
Speaker 1: and then. This is what allows you to plan a
Speaker 1: trip to Hawaii, or to anticipate a tough conversation, or
Speaker 1: to avoid a situation that would otherwise be dangerous. But
Speaker 1: what happens when this system for simulating into the future
Speaker 1: runs unchecked. Instead of preparing you and guiding your actions,
Speaker 1: it starts to loop endlessly, and this looping, this repeated
Speaker 1: simulation of possible futures, often negative ones, This is what
Speaker 1: we call anxiety. Now. Anxiety shows up in a lot
Speaker 1: of different ways. Sometimes it's obvious, with a racing heart
Speaker 1: and a tight chest in a sense that something is wrong.
Speaker 1: Sometimes it's more of a background hum of worry. And
Speaker 1: sometimes it disguises itself totally. You might think you have
Speaker 1: a stomach problem or trouble sleeping or difficulty concentrating. But
Speaker 1: underneath it all, the brain is doing what it does best.
Speaker 1: It's generating possibilities. It's scanning for threats, trying to keep
Speaker 1: you safe. So the system designed to protect you can
Speaker 1: become self reinforcing. It begins to feed on itself. You worry,
Speaker 1: which makes you feel anxious, which makes you do something
Speaker 1: as a temporary relief. But that thing makes you worry more.
Speaker 1: And this is a loop, and once a loop for
Speaker 1: the brain. That's what we call a habit.
Speaker 2: Now.
Speaker 1: When we think about habits, we usually think about physical
Speaker 1: behaviors like smoking or eating or doom scrolling. These are
Speaker 1: habits that you can see and point to. But what
Speaker 1: if some of our most powerful habits are invisible? What
Speaker 1: if anxiety itself is a habit. What if it's something
Speaker 1: that your brain learns to do. That today's conversation, and
Speaker 1: it matters because instead of treating anxiety purely as a
Speaker 1: chemical imbalance or purely as a cognitive distortion, the question
Speaker 1: is whether there's another lens we can apply, in this case,
Speaker 1: a lens from neuroscience and behavioral science, a lens that
Speaker 1: raises the possibility that anxiety runs on the same machinery
Speaker 1: as every other habit that your brain learns. You have
Speaker 1: a trigger, you do a behavior, you get a result,
Speaker 1: and that lends adjusting that anxiety is at least in part,
Speaker 1: a learned loop that implies you might be able to
Speaker 1: unlearn that. The first step will be to ask, what
Speaker 1: is my brain getting out of this loop? Because, as
Speaker 1: we're going to see today, even the most frustrating patterns
Speaker 1: have some kind of payoff, and if we can understand
Speaker 1: that payoff, we can begin to loosen the loop. So
Speaker 1: today we're going to explore this idea with Judson Brewer,
Speaker 1: an MDPHD, known sometimes as doctor Judd. He grew up
Speaker 1: with anxiety and now he has a psychiatry practice where
Speaker 1: he deals with anxiety and he runs a neuroscience lab
Speaker 1: where he studies strategies in different approaches. He has spent
Speaker 1: decades studying the mechanisms of anxiety and habits formation. So
Speaker 1: we're going to talk about how anxiety can masquerade as
Speaker 1: a lot of different conditions, how it often operates below awareness,
Speaker 1: and how the act of worrying can create feeling of
Speaker 1: control even when it solves nothing. And we'll dig into
Speaker 1: something that can change things, curiosity. What happens when instead
Speaker 1: of running from anxiety, you examine it closely, the sensations
Speaker 1: and the patterns. So today we're going to explore a
Speaker 1: new way of understanding anxiety as something learned and possibly
Speaker 1: something that can be unwound. Here's my conversation with jud Brewer. Okay, Judge,
Speaker 1: So when somebody walks into your office and says I
Speaker 1: have anxiety, what does that mean?
Speaker 3: That could mean a lot of things to a lot
Speaker 3: of different people. You know, a lot of people don't
Speaker 3: even know what anxiety is. So let's start with a
Speaker 3: standard like dictionary definition, which is, you know, feeling of
Speaker 3: nervousness or unease about something with an uncertain future. Basically,
Speaker 3: I think of it as fear of the future. That's
Speaker 3: probably the simplest way that I explain it to my patients.
Speaker 3: And what are the symptoms of that, for example, worry.
Speaker 3: So there can be a physical symptoms and that's typically
Speaker 3: how people experience anxiety, and then there, as you're highlighting,
Speaker 3: there can be some mental elements that come along with that.
Speaker 2: The biggest mental one is worrying, for sure.
Speaker 3: The feeling tends to be a feeling of restlessness, of nervousness,
Speaker 3: and people describe it as like a tightness or contraction.
Speaker 3: They often feel it and their their stomach, their chest,
Speaker 3: their throat, even their head. And for some people they
Speaker 3: don't even know that they have anxiety. I know a guy,
Speaker 3: this guy who had irritable ball syndrome at the end
Speaker 3: of college, and I didn't know what it was. I
Speaker 3: did a lot of backpacking in college, so I chalked
Speaker 3: it up to getting Jardia for not filtering my water properly.
Speaker 3: Was not jardia. I went to student health. The doc
Speaker 3: was like, could you be anxious? I was like, no,
Speaker 3: I run I played the violin.
Speaker 2: I'm a vegetarian. He's like, okay, you know.
Speaker 3: So he gives me the Zipro, the antibiotic of course
Speaker 3: doesn't work. And then I realized that summer before I
Speaker 3: started medical school that this was actually a manifestation of anxiety.
Speaker 3: My body was trying to tell me, Hey, you know
Speaker 3: this is anxious. Wake up to this, so you know,
Speaker 3: it really can be a shape shifter for a lot
Speaker 3: of people.
Speaker 1: What were you anxious about?
Speaker 2: I don't know.
Speaker 3: Well, I was going to medical school and life, I'd
Speaker 3: just broken up with my girlfriend.
Speaker 2: You know, a lot of things to be anxious about.
Speaker 1: Got it? So are there different flavors of anxiety? Does
Speaker 1: everyone have the same thing?
Speaker 2: There are a lot of different flavors.
Speaker 3: So people can have panic disorder where it's related to
Speaker 3: panic attacks. They can have social anxiety where they have
Speaker 3: they're afraid of going out in public. They you know,
Speaker 3: far into the spectrum like obsessive compulsive disorder, where people
Speaker 3: have these obsessive thoughts and these compulsive behaviors. And then
Speaker 3: the most common category, if you think of this diagnostically,
Speaker 3: is the generalized anxiety disorder category where people basically wake up,
Speaker 3: they feel anxious all day, they worry all day, they
Speaker 3: go to speed, go to sleep at night, and they
Speaker 3: repeat the process.
Speaker 1: And is that just a big bucket that we throw
Speaker 1: the rest in, or what is generalized mean in this case.
Speaker 2: I think that's a good way of putting it.
Speaker 3: It's a big bucket that we throw a lot in
Speaker 3: to the Diagnostic and Statistics Manual, the DSM, this kind
Speaker 3: of the psychiatric bible for a long time has had
Speaker 3: these categories, but I'm not sure that it has caught
Speaker 3: up to where the science is showing us that there's
Speaker 3: probably a lot of more individualization and it's hard to
Speaker 3: categories people into you know, like here you all have
Speaker 3: generalized anxiety disorder, for example, although I will say, you know,
Speaker 3: one of the very common things is the behavior of worrying,
Speaker 3: this internal behavior of worrying.
Speaker 1: So when we think about all these different panic disorders,
Speaker 1: how common is this?
Speaker 2: Very common?
Speaker 3: I think the anxiety disorders are the most common of
Speaker 3: the mental health categories.
Speaker 1: So what are we talking like twelve percent of the population.
Speaker 3: It's pretty high. Yeah, And so I can't name them
Speaker 3: off the top of my head. But generalized anxiety disorder,
Speaker 3: for example, tends to peak in mid adulthood, which is
Speaker 3: kind of interesting, but it seems to be on the
Speaker 3: rise in general.
Speaker 1: And mid adulthood is what, oh, forties. Okay, so people
Speaker 1: have been living a life without it and then they
Speaker 1: start feeling really anxious about something. Give us an example
Speaker 1: of a patient walks into your psychiatry practice and starts
Speaker 1: talking to you, and you figure out this person has
Speaker 1: generalized anxiety disorder.
Speaker 3: I'm thinking of a particular patient, we'll call him Dave,
Speaker 3: who walked into my office at the age of forty.
Speaker 3: He walks in the door, he looks pretty anxious. Right,
Speaker 3: Sometimes you can just tell that somebody is anxious, like,
Speaker 3: what do you pick up? Oh, there's this vibe to it.
Speaker 3: You know, I don't want to make this sound gloo woo.
Speaker 3: But there's a lot of work actually on emotional contagion
Speaker 3: and social contagion. You know, somebody walks into the room
Speaker 3: and they're really angry, and everybody can feel that anger
Speaker 3: kind of radiating off of them.
Speaker 2: The same is true with anxiety.
Speaker 3: So you can probably see it in their eyes, you
Speaker 3: can see it in their face, you can see how
Speaker 3: they carried themselves. But then give them a second they'll
Speaker 3: tell you exactly what it's like. So this guy in particular,
Speaker 3: had he started getting panic attacks probably in fifth grade,
Speaker 3: I think, so about three decades before he started seeing
Speaker 3: me and had general and he was just worrying all
Speaker 3: the time, and so he met the criteria both for
Speaker 3: panic disorder, where you know, the key to panic disorder
Speaker 3: is not just the panic.
Speaker 2: Attacks, but it's it's being worried about.
Speaker 3: Having a future panic attack and kind of organizing your
Speaker 3: life around avoiding those things. So this gentleman in particular
Speaker 3: had gotten panic attacks driving on the highway, and so
Speaker 3: he was very afraid to drive even on local roads
Speaker 3: like Providence, Rhode Islands, pretty small roads anyway, I think
Speaker 3: anybody gets a little nervous driving on those roads, but
Speaker 3: he in particular was really struggling even driving a couple
Speaker 3: of miles to my office.
Speaker 1: Because he was worried about getting an accent or about
Speaker 1: hitting somebody else.
Speaker 3: Well, he was in particular worried about having a panic attack.
Speaker 3: Oh I see, yeah, so there's the panic piece. He
Speaker 3: also he got a twofer in life, unfortunately, where he
Speaker 3: was so worried all the time and feeling so anxious
Speaker 3: all the time that he met the criteria for generalized
Speaker 3: anxiety as disorder.
Speaker 2: So he was he was just NonStop anxiety and worry.
Speaker 1: And generally when a patient walks into your office. Do
Speaker 1: they have a particular target of their anxiety? I mean,
Speaker 1: in this guy Dave's case, it sounds like he was
Speaker 1: worried about having another panic attack. But do other people
Speaker 1: worry about very specific things?
Speaker 3: There can be Phobia's a lot of you know, spider
Speaker 3: with phobia is a common one. So people can certainly
Speaker 3: have fears of particular things. And I you know, I
Speaker 3: would say, for example, people that generalize anxiety disorder, they
Speaker 3: just look around and they find something to worry about.
Speaker 1: Got it? As in, am I gonna say the right
Speaker 1: thing at this party? Am I going to get this
Speaker 1: work deadline?
Speaker 3: Met?
Speaker 1: Stuff like that. There's always something to worry about.
Speaker 3: Yes, And if you think about this as fear of
Speaker 3: the future, you know, whatever is up ahead of them,
Speaker 3: they're going to turn that into a worry fest.
Speaker 1: And is it because they are simulating possible futures? As
Speaker 1: we know this is the major job of the brain
Speaker 1: is to simulate possible futures and evaluate them. Is it
Speaker 1: that they're simulating bleak futures or future that are embarrassing
Speaker 1: to them or averse of in some way, and then
Speaker 1: evaluating those and feeling those feelings.
Speaker 3: That's my sense, and I don't think you know, these
Speaker 3: generative models. I think that's a good way to look
Speaker 3: at it. What I mean by that is, you know,
Speaker 3: we have this this world view, and then we're going
Speaker 3: to bias what we see now to meet that worldview.
Speaker 3: And so you know, this is where a confirmation bias
Speaker 3: comes in. So somebody, somebody with general as anxiety disorder,
Speaker 3: for example, might see an upcuping trip that they're planning
Speaker 3: very differently than somebody that doesn't have a lot of worries. So,
Speaker 3: you know, they all they have to book their tickets,
Speaker 3: they've got a book, hotels, whatever the trip is. And
Speaker 3: somebody without the generalised anxiety disorder might say, okay, we're
Speaker 3: going to do this. We're going to do this. They
Speaker 3: might check their you know, their itinerary a couple of times,
Speaker 3: make sure they haven't missed anything. Somebody with worry will
Speaker 3: do that planning, but they'll add on top of it like,
Speaker 3: oh maybe this could go wrong?
Speaker 2: What about this? What about this?
Speaker 3: So they start catastrophizing. One way to kind of get
Speaker 3: a sense for whether this is happening is asking somebody like,
Speaker 3: how many times have you gone over this trip in
Speaker 3: your head. So planning a couple of times to make
Speaker 3: sure you haven't missed anything makes sense. But when it
Speaker 3: goes to four and then fourteen and then forty four,
Speaker 3: that's debt generally tripping into the area of worrying and catastrophizing.
Speaker 1: Do you make a distinction between let's call it adaptive
Speaker 1: anxiety and maladaptive No.
Speaker 3: The nice thing here is there's a lot of stuff
Speaker 3: that's not clear in the science and the clinical realm.
Speaker 3: This one's pretty clear. Okay, there's no adaptive anxiety, got it,
Speaker 3: full stop. So there's good research and actually this is
Speaker 3: worth unpacking a little bit because there's a lot of
Speaker 3: mythology on the internet about this. There's good data showing
Speaker 3: that there's an inverse relationship between anxiety and performance, for example,
Speaker 3: at work performance. So the more anxious somebody is, the
Speaker 3: worse they do. And they say that because there's a
Speaker 3: curious if you've heard this the yerk's Dodson law, no good,
Speaker 3: don't go look it up. Okay on the internet the
Speaker 3: yer Dodson Law talks about this inverted you shaped curve
Speaker 3: around performance anxiety, and the idea is, if you have
Speaker 3: very you know very little anxiety, you're not going to
Speaker 3: perform well. And you if you have too much, you're
Speaker 3: going to be deer in the headlights and not perform well.
Speaker 1: Righty.
Speaker 3: For this, this was based on a nineteen o eight
Speaker 3: study of Japanese dancing mice, for which they didn't even
Speaker 3: report their statistics. Oh so, first off, Japanese dancing mice,
Speaker 3: you can't exactly ask them how anxious they are. Right,
Speaker 3: They did find that there was even though their statistics
Speaker 3: weren't really reported. These were like groups of like two
Speaker 3: or three mice.
Speaker 2: So take that all that with a grain of salt.
Speaker 3: But they were finding that there's a level of arousal
Speaker 3: that correlates with performance, which makes sense, like if you're asleep,
Speaker 3: you're not going to perform well. If you're freaked out,
Speaker 3: you're not going to perform well, whether you're a mouse
Speaker 3: or a person. Right, right, So this has been mythologized
Speaker 3: on the internet to this inverted you shaped Yerks Dodson
Speaker 3: law that you need a certain amount of anxiety form Well,
Speaker 3: this is total correlation at best in humans where people
Speaker 3: my sense is that they're holding onto this story that oh,
Speaker 3: my anxiety is good for me. I get to keep
Speaker 3: it as compared to actually, if you look at the data,
Speaker 3: your anxiety is not helping you, and holding onto that
Speaker 3: story is making it even worse.
Speaker 1: But just to push it on this for one second,
Speaker 1: is it useful to say, Okay, I'm going on this
Speaker 1: big trip to the Antarctic, and I really do want
Speaker 1: to make certain that I've packed this and I'm ready
Speaker 1: for this eventuality and this possibility over here and so on.
Speaker 1: Let me ask you, this is the your Dodson law.
Speaker 1: Do you think there's something about it that caught on
Speaker 1: because it points towards something directionally or it's totally wrong.
Speaker 3: I would say there are a couple of things that
Speaker 3: give it this govitas that people have given it. One
Speaker 3: is that it fits with people's experience. And so this
Speaker 3: is where the more mythology right. Correlation does not equal causation.
Speaker 3: So somebody's anxious, true, and they perform well. True, They
Speaker 3: can start to correlate being anxious with performing well. Another
Speaker 3: good research line has shown that people correlate, or they
Speaker 3: basically correlate problem solving with anxiety. Well, somebody has generalized
Speaker 3: anxiety disorder and they're anxious all day, and they solve
Speaker 3: a problem guess what correlation, right, So the likelihood that
Speaker 3: you're going to associate the two is pretty high if
Speaker 3: you're worrying all day. So I think those pieces play
Speaker 3: a huge role here. And the other is that it's
Speaker 3: hard for people to let go of really being identified
Speaker 3: with anxiety.
Speaker 2: I see this a lot.
Speaker 3: A pilot tester for one of our early anxiety programs
Speaker 3: who wrote me an email is so stunning.
Speaker 2: The way she wrote this.
Speaker 3: She said, you know, I feel like I have this
Speaker 3: deep edged in my bones anxiety. This is how identified
Speaker 3: she was with her anxiety. So here, I think the
Speaker 3: identification piece and anxiety is not unique.
Speaker 1: Here.
Speaker 3: We get identified with anything from you know, I like
Speaker 3: this type of coffee or chocolate, to I like surfing
Speaker 3: to whatever, you know, like we see ourselves a certain way. Well,
Speaker 3: this is also true with the psychiatric conditions, where somebody
Speaker 3: is like, oh, you know, I have ADHD, I have anxiety,
Speaker 3: you know, like I'm an anxious person. That's actually limiting
Speaker 3: for people because they kind of box themselves in, but
Speaker 3: the identification gives them this comfort zone where they feel
Speaker 3: comfortable because they've lived there so long. For example, my
Speaker 3: patient that I described earlier when we were working together
Speaker 3: and he was starting to have periods where he.
Speaker 2: Wasn't having anxiety and he comes in one day.
Speaker 3: I still remember this because he's like, you know, I
Speaker 3: have these periods where I'm just not worrying anymore, and
Speaker 3: he goes, Then I start to worry that I'm not worrying, oh,
Speaker 3: because it was such a habit and it was The
Speaker 3: way I think of this is we move out of
Speaker 3: our comfort zone, even if our comfort zone is discomfort,
Speaker 3: but our brain is saying, hey, this is different, is
Speaker 3: a dangerous and the first thing our brain's going to
Speaker 3: check for is danger. Well, if we can train people no,
Speaker 3: you're moving to your growth zone, You're moving somewhere else
Speaker 3: that's better, then they can learn that that new space
Speaker 3: is the new normal, which is a wonderful sign, but
Speaker 3: it can be scary for people.
Speaker 1: Was he worrying about not worrying because he thought I
Speaker 1: won't be prepared for work tomorrow or for the.
Speaker 2: It was just that it was so different for him.
Speaker 1: Yeah, okay, okay. So a lot of people have anxiety
Speaker 1: of some sort and the question is what are the
Speaker 1: things that they can do about it? So there are
Speaker 1: pharmaceutical interventions, there are cognitive interventions, and we're also going
Speaker 1: to spend a lot of time talking about what you've done.
Speaker 1: Incredible work. So let's start with the pharmaceutical medications.
Speaker 3: Sure, so, as a psychiatrist, the best medications that we
Speaker 3: have out there the selective serotonin reuptake and have SSRIs.
Speaker 3: That number needed to treat, which is just a fancy
Speaker 3: term for like how many people you need to give
Speaker 3: a treatment to before one person shows a significant reduction
Speaker 3: in symptoms. That number needed to treat as five point two.
Speaker 3: So basically, for every five patients that walk in my door,
Speaker 3: one of them is going to show significant reduction in
Speaker 3: symptoms with the medication. The my psychiatric crystal ball is
Speaker 3: kind of broken, so I don't know which one of
Speaker 3: those five is going to benefit.
Speaker 2: And on top of that, you know.
Speaker 3: I can joke that I get anxious as a psychiatrist
Speaker 3: because I don't know what to do with the other
Speaker 3: four who haven't you know, won the genetic lottery or
Speaker 3: whatever and are benefiting. So for me, it's like I
Speaker 3: can get anxious because I'm not sure if I'm limited
Speaker 3: to only prescribing medications.
Speaker 1: And are there many different SSRIs and you try people
Speaker 1: on different ones.
Speaker 3: Yes, yes, and unfortunately it becomes more of a placebo
Speaker 3: game than actual benefit game with anxiety. You know, because
Speaker 3: they with they're all within the same class. They have
Speaker 3: largely the same mechanism of action. They might have slightly
Speaker 3: different side effect profiles and half lives things like you know,
Speaker 3: how long they stand in the body and whatnot, but
Speaker 3: in terms of what they're actually doing in the brain,
Speaker 3: you know, there might be slight variations, but it's really
Speaker 3: you know, once you get past one or two, it's
Speaker 3: it's largely a losing game unfortunately.
Speaker 1: Okay, So besides the pharmaceutical interventions, people have also thought about,
Speaker 1: hey can we do cognitive interventions, the most famous probably
Speaker 1: being cognitive behavioral therapy.
Speaker 2: So explain to us what that is, how that works.
Speaker 3: Cognitive behavioral therapy in a nutshell, So I was formally
Speaker 3: trained during my psychiatry residency and CBT.
Speaker 2: The idea behind.
Speaker 3: Kyo behavioral therapy is catch it.
Speaker 2: Check it, change it.
Speaker 3: I don't want it to sound oversimplified because it's a
Speaker 3: very you know, complex and nuanced treatment, but ideally is
Speaker 3: the idea is to catch what the cognition is, right,
Speaker 3: That's why it's cognitive behavioral.
Speaker 1: And what I'm thinking at this moment when I'm feeling anxious.
Speaker 3: Right, And it's often described as a maladaptive cognition. Right,
Speaker 3: So they catch it. You've got to figure out what
Speaker 3: that maladaptive cognition is. And there are a number of
Speaker 3: categories there.
Speaker 1: Give us a specific example.
Speaker 3: Uh, catastrophizing, okay, right, so or all you know, black
Speaker 3: and white thinking all their none type of things. So
Speaker 3: it's like, oh, it's always like this or it's never
Speaker 3: like this. That's probably a simple one to think about.
Speaker 3: So you can catch that because you know, nothing is
Speaker 3: always like this. You know that's not how the world works.
Speaker 3: But people's brains can set up these generative models around
Speaker 3: oh yeah, this is how it always is, and then
Speaker 3: they only see those cases and kind of minimize the
Speaker 3: other cases. So it does seem like that's the case.
Speaker 3: So you catch that cognition, you check it is this true?
Speaker 3: And then so this is where you can find examples
Speaker 3: where it's not true and kind of have a debate
Speaker 3: with the brain about like, oh, is this really too well,
Speaker 3: here's some evidence to the you know, to the contrary.
Speaker 3: And we'll even have people do homework where they go
Speaker 3: find evidence you know that something is not always true.
Speaker 3: So let's use an example of a workplace anxiety. So
Speaker 3: if somebody has this idea that a coworker is always
Speaker 3: judging them for exait sample, and so they start to worry,
Speaker 3: Oh no, this person thinks I'm not very good at
Speaker 3: work or they don't like me or something like this.
Speaker 2: They're gonna, you know, I all are you know? All
Speaker 2: are non.
Speaker 3: Basically, it's like they always think I do a bad job.
Speaker 3: Let's just use that as a simple example. And then
Speaker 3: so they're gonna their brain's gonna be looking for those
Speaker 3: instances and they're going to get stuck in this anxiety
Speaker 3: like oh, I'm never good enough to do this job
Speaker 3: for my boss or my cowork or whatever. So that's
Speaker 3: where they have to catch that cognition. They check it
Speaker 3: to see if it's true, right, so rarely is that
Speaker 3: the case? And then the change it. That's the last piece.
Speaker 3: Catch it, check it, change it. So the idea is
Speaker 3: to change that cognition where it's like change the all
Speaker 3: or none thinking to something more adaptive.
Speaker 1: It's essentially saying, hey, I was going down this mental
Speaker 1: pathway here, but now that I see that i'm doing that,
Speaker 1: I'm gonna switch my viewpoint to this other thing. Okay,
Speaker 1: So you, as a psychiatrist, looked at pharmaceuticals, you looked
Speaker 1: at CBT, and you said, hey, maybe there's a different
Speaker 1: way of doing this. So you started thinking about anxiety
Speaker 1: as a habit. So tell us about that.
Speaker 3: Yes, so, as I was getting anxious about how to
Speaker 3: put help my patients with anxiety. And some of this
Speaker 3: has to do with the pharmaceuticals that we talked about.
Speaker 3: But even with cognitive therapy, there's not a lot of
Speaker 3: good neuroscience showing that the pathways to change. For example,
Speaker 3: there are some things that are correlated with CBT, but
Speaker 3: most of those seem to be centered in the prefronal cortex,
Speaker 3: the forward part of the brain, and the preferal cortex,
Speaker 3: from an evolutionary perspective, is both the youngest and the
Speaker 3: weakest part of the brain, so it's the first that
Speaker 3: goes offline when we get anxious.
Speaker 1: So preferal cortex right behind our forehead allows us to
Speaker 1: simulate possible futures and think about all the stuff that
Speaker 1: humans do so well. But as soon as stuff starts
Speaker 1: hitting the fan, that decreases and we're operating on more
Speaker 1: basic circuitry.
Speaker 2: Yes, and guess what you need to catch it, check.
Speaker 3: It, change it.
Speaker 1: Yes.
Speaker 3: Yeah. So unfortunately, the funnel cortex may not be available
Speaker 3: to us when we need it most. So those were
Speaker 3: some of the struggles and challenges I was working with
Speaker 3: in my clinic, and so as a habit change researcher.
Speaker 3: So I'd been studying habit change for a while, and
Speaker 3: we'd done some work with smoking and gotten good results
Speaker 3: in those studies. We've done work with overeating, for example,
Speaker 3: and gotten pretty good results in that area. And so
Speaker 3: I happened upon this nineteen eighty five or mid eighties
Speaker 3: paper by a guy named Thomas Borkovik. It was like
Speaker 3: two pages, very humble, and he basically said, oh, why
Speaker 3: aren't we thinking about anxiety through the lens of negative reinforcement?
Speaker 3: And that paper got buried in the promise of Prozac
Speaker 3: because project came out right around then, and so he
Speaker 3: was like, Oh, we don't need to think about neuroscience.
Speaker 3: We can just give people this magic bullet and it
Speaker 3: ended up not being so magic unfortunately.
Speaker 1: And so what does it mean to think about it
Speaker 1: as negative reinforcement?
Speaker 2: Yes?
Speaker 3: So negative reinforcement, and so that's in the category of
Speaker 3: enforcement learning. The idea here is and this is evolutionarily
Speaker 3: conserved all the way back to the ceaseluck. So Eric
Speaker 3: Kendall got the Nobel Prize showing that this is how
Speaker 3: memory forms back in the year around year two thousand
Speaker 3: and The idea is that if we do a behavior
Speaker 3: then and we get a certain result of that behavior,
Speaker 3: that result is going to drive future behavior. So if
Speaker 3: the result is positive, then that's called positive reinforcement.
Speaker 2: Our brain learns, oh, do that again.
Speaker 3: If the result is negative, our brain learns, oh, don't
Speaker 3: do that again. And so with negative reinforcement. It's interesting
Speaker 3: because I hadn't really thought about worrying, even though it's
Speaker 3: the primary aspect of anxiety. I hadn't really thought about
Speaker 3: it much as a mental behavior, you know. I've mostly
Speaker 3: been working with the behaviors that you can see physical
Speaker 3: ones like smoking and eating. You can see how much
Speaker 3: somebody smokes or eats. So it was really interesting to
Speaker 3: think about it from that lens. And the idea is
Speaker 3: that the feeling of anxiety, that feeling of nerve business,
Speaker 3: that feeling of worry, can drive the mental behavior of worrying,
Speaker 3: and that mental behavior can give us this illusion of control.
Speaker 3: You know a few things about illusions, right, it can
Speaker 3: give us the solution of control, or at least distract
Speaker 3: us from that negative feel that embodied feeling of anxiety itself.
Speaker 3: So it becomes negatively reinforced because it distracts us from
Speaker 3: the feeling of anxiety or makes us feel like we're
Speaker 3: in control.
Speaker 1: Great, So I want to really zoom in on that.
Speaker 1: So let's start with smoking as an example, and then
Speaker 1: let's tie that back to worrying, because smoking is a
Speaker 1: habit that we can really understand. Okay, that's a physical
Speaker 1: habit that you're doing, So what do you do with that?
Speaker 3: I think that's a good example to start with. So
Speaker 3: my patients who come in who smoke, you know, often
Speaker 3: they've started smoking the age of twelve or thirteen, and
Speaker 3: it becomes reinforced because not because smoking is great, you know,
Speaker 3: nicotine is a pretty toxic substance, and so people feel
Speaker 3: nauseated the first dame they smoke because their bodies saying,
Speaker 3: why are you jesting poison? You know, is this a
Speaker 3: good thing to do? But the thing that is more reinforcing,
Speaker 3: is there whatever the social status is, so whether it's
Speaker 3: being cool at school, rebelling against the parents, seeing somebody
Speaker 3: that you look up to something is more positive than
Speaker 3: the negative effects from the smoking itself.
Speaker 2: So people become addicted to cigarettes.
Speaker 3: So when they come to see me, they've typically been smoking,
Speaker 3: you know, packa day, which's like twenty cigarettes a day
Speaker 3: for decades. Yeah, and well, one patient's been smoking forty years.
Speaker 3: We calculated that he'd smoked roughly like two hundred and
Speaker 3: ninety three thousand cigarettes. Yeah, yeah, so he'd reinforced that
Speaker 3: a lot. So if you look at smoking, typically it's
Speaker 3: stress or habit where it's just automatic like I get
Speaker 3: in the car and I smoke, or it's the withdrawal
Speaker 3: from nicotines. So nicotine has got a pretty short half life,
Speaker 3: meaning that it goes out of your blood system pretty quickly,
Speaker 3: about two hours. So you'll see people who are addicted
Speaker 3: to cigarettes, they'll roughly smoke every two hours just because
Speaker 3: their body is saying, hey, I need more nicotine in
Speaker 3: my system. So if you think of it that way,
Speaker 3: that unpleasant sensation of stress or withdrawal or whatever leads
Speaker 3: to the behavior smoking, which then makes that feel a
Speaker 3: little bit better and then they repeat the cycle.
Speaker 1: Got it, So that's a habit. So they're doing that habit.
Speaker 1: And then how did you in your work, how did
Speaker 1: you get people to stop smoking?
Speaker 2: It is something very unorthodox.
Speaker 3: Are you ready?
Speaker 1: I'm ready?
Speaker 2: So I told people to smoke.
Speaker 3: And this is probably the first time that many of
Speaker 3: my patients had had their doctor tell them to smoke. So,
Speaker 3: for the record, I'm not encouraging people to start smoking.
Speaker 3: What I'm encouraging them to do is to pay attention
Speaker 3: as they go ahead and smoke, because they're coming to
Speaker 3: me because they can't stop smoking.
Speaker 2: And so we really brought in started bringing.
Speaker 3: In these mindfulness practices to have people really pay attention
Speaker 3: to what that cigarette tastes like, what the smoke felt
Speaker 3: like going into their lungs, what that smoke smelled like
Speaker 3: coming out of their mouth or nose. And you know,
Speaker 3: one of my patients put it as smells like stinky
Speaker 3: cheese and taste like chemicals.
Speaker 2: Yuck.
Speaker 3: Right, And so no patient of mind has ever come
Speaker 3: back and thanked me for helping them smoke mindfully be
Speaker 3: you know, like, oh, I didn't realize how delicious a
Speaker 3: cigarette is, you know, not a single one and people
Speaker 3: who haven't smoked are a little flabbergasted by that, but
Speaker 3: you know, not encouraging them to go try a cigarette.
Speaker 3: Cigarettes don't taste very good, right, That's why people use
Speaker 3: menthol That's why the vaping has come into vegue because
Speaker 3: you can mask a lot of the negative effects that
Speaker 3: come with that which make it particularly addictive. But the
Speaker 3: long story short is like, that's how we started exploring
Speaker 3: this territory of bringing awareness in to actually leverage the
Speaker 3: reinforcement learning process itself.
Speaker 1: Okay, so people think, hey, I'm addicted to smoking. This
Speaker 1: is cool. But when you get them to stop doing
Speaker 1: it unconsciously and really attend to what the feelings aren't,
Speaker 1: they realize, oh, that's kind of disgusting, and then that
Speaker 1: that breaks that loop of the habit.
Speaker 3: In our first randomized controlled trial where we compared cognitive
Speaker 3: therapy to this mindfulness training, we actually got five times
Speaker 3: better quit rates with having people pay attention as they
Speaker 3: smoked as compared to the usual you know, just try
Speaker 3: to distract yourself or do something else.
Speaker 1: Great. So now back to anxiety. What is the parallel.
Speaker 3: The parallel here is, you know, if you look at
Speaker 3: any habit, you need a trigger, a behavior, and a result. Right,
Speaker 3: So we talked about smoking. You feel stressed, there's the trigger,
Speaker 3: the behavior's smoke, and then you feel better. There's the result.
Speaker 3: From a neuroscience standpoint, there's some reward there. Otherwise you
Speaker 3: wouldn't keep doing something with anxiety. It's interesting because the
Speaker 3: feeling of anxiety drives the mental behavior of worrying, and
Speaker 3: then the result is that somebody distracts themselves or they
Speaker 3: feel like they're in control, or as some of my
Speaker 3: patients put it, it's better than doing nothing.
Speaker 1: Oh fascinating. They feel in control by worrying about the.
Speaker 2: Thing because they're doing something.
Speaker 3: Yeah, I see, But you can be spinning your wheels
Speaker 3: if you're stuck in sand, not going anywhere, burning gas,
Speaker 3: but you're doing something.
Speaker 1: I see. Okay, So you thought, can we treat anxiety
Speaker 1: in the same way as a physical habit like smoking? Okay?
Speaker 1: What's the analogy to get them to attend to the
Speaker 1: taste of the cigarette?
Speaker 3: So this gets into some of the neuroscience. So back
Speaker 3: in the nineteen seventies, these two researchers named Rascolet and
Speaker 3: Wagner came up with this formula for reinforcement learning, and
Speaker 3: they suggested this is how habits form. Something's rewarding, you're
Speaker 3: going to keep doing it, and then you're going to
Speaker 3: lay it down as a habit, where your brain's going
Speaker 3: to shift from certain parts of the brain called the
Speaker 3: ventral to another part of the brain called the dorsal
Speaker 3: strite it which is more involved in habit. And that
Speaker 3: makes sense. With habits, we don't want to have to
Speaker 3: be relearning everything every day. I think if it is
Speaker 3: set and forget right, you set a habit, you forget
Speaker 3: about the details, and so you can do these things automatically.
Speaker 3: And that's important because what we're doing automatically is smoking
Speaker 3: a cigarette, for example, and not paying attention to how
Speaker 3: rewarding it is or how not rewarding it is.
Speaker 2: So we can do the same thing with eating.
Speaker 3: Just giving a quick eating example, we did a study
Speaker 3: where we had people really pay attention as they over ate,
Speaker 3: and it took very little time, like five to fifteen
Speaker 3: times of ever eating for somebody to realize that overeating
Speaker 3: actually feels very.
Speaker 2: Bad in their body.
Speaker 3: And what that does is it re engages this reinforcement
Speaker 3: learning system. So we can have what's called a positive
Speaker 3: prediction error which is just a fancy term for it. Oh,
Speaker 3: that was better than expected. So if something is better,
Speaker 3: we're going to actually do it more. But we can
Speaker 3: also have a negative prediction error where we expect something
Speaker 3: to be a certain way, a certain level of reward,
Speaker 3: and it's not as rewarding. So with smoking, when something
Speaker 3: tastes like crap, they get a negative predictionairey and they
Speaker 3: can't unsee that.
Speaker 2: Their brain pays attention.
Speaker 3: They get this dopamine sprits and they learn, hey, cigarettes
Speaker 3: don't taste that great. That helps them become disenchant with
Speaker 3: the behavior. We see the same thing with overeating. Oh
Speaker 3: this gut bomb isn't actually very good. With anxiety, it's
Speaker 3: particularly interesting because people have this assumption that worries going
Speaker 3: to help them, or they read about the Dodson myth
Speaker 3: on the internet or whatever, you know, and they're like, oh,
Speaker 3: I'm attached. You know, worrying's got to be helping me
Speaker 3: because that's just what I do. Well, people realize pretty
Speaker 3: quickly the worryings actually just making them more anxious, and
Speaker 3: it's not solving problems. It's burning mental energy that they
Speaker 3: could be using elsewhere, like actual planning or getting on
Speaker 3: with their day or being present with you, whoever they're
Speaker 3: having a conversation with us compared to like being lost
Speaker 3: in their stories, and so they become disenchanted with that behavior.
Speaker 3: That disenchantment is key because it's not about changing anything,
Speaker 3: you know, it's not about changing a cognition. It's about
Speaker 3: seeing how this habit pattern is so unhelpful that we
Speaker 3: naturally are not excited to do it.
Speaker 1: Now. One of the ways that you've talked about this,
Speaker 1: which I love, is about getting curious. So tell us
Speaker 1: what you mean about curiosity here.
Speaker 3: I think of curiosity as a superpower, right, and it's
Speaker 3: kind of baked into some of the definitions of mindfulness.
Speaker 1: Right.
Speaker 3: We're bringing this curious attitude to our experience rather than
Speaker 3: prejudging what's going to happen. So with curiosity, the idea is, well,
Speaker 3: let's tick worry as an example. When somebody worries, they
Speaker 3: tend to have this mental some flavor of oh no, right,
Speaker 3: oh no, am I going to They wake up in
Speaker 3: the morning, they start to worry, am I going to
Speaker 3: be anxious?
Speaker 1: All day?
Speaker 3: Which of course makes them moren anxious and keeps that
Speaker 3: anxiety loop going. So we have people recognize that worry
Speaker 3: behave as a mental behavior oh no, and we have
Speaker 3: them bring in curiosity. So here's something that's also somewhat
Speaker 3: on our orthodox. A lot of my patients get stuck
Speaker 3: in the why, like why am I anxious? Because they
Speaker 3: think if they can figure out why they're anxious, they
Speaker 3: can avoid it or change it or whatever. But the
Speaker 3: why doesn't actually drive the habit loop. It's the what
Speaker 3: what are they doing right now? So the what is
Speaker 3: that worrying? Is that mental behavior? So we have them
Speaker 3: get curious and flip from oh no to oh, what
Speaker 3: does this feel like in my body right now? So
Speaker 3: instead of getting lost in a story or trying to
Speaker 3: solve or fix or figure out why they paid you
Speaker 3: money for fifteen years of psychotherapy and aren't better yet, you.
Speaker 2: Know, we go right into the body.
Speaker 3: And the interesting piece here is that often because something's unpleasant,
Speaker 3: we train ourselves to run away from it, right That's natural.
Speaker 2: You touch on stove, you're going to pull away.
Speaker 3: So if something emotionally feels unpleasant, we're going to find
Speaker 3: ways to distract ourselves or pull away or do whatever.
Speaker 3: That's where the worrying gets stuck in it as a cycle.
Speaker 3: So instead we train people to be curious and run
Speaker 3: towards their experience and they learn a few things that
Speaker 3: are really interesting. One is that these are physical sensations
Speaker 3: that make up anxiety. They're not as scary as they
Speaker 3: thought when they get up close and personal with them,
Speaker 3: and they tend to get scared when we move toward them. Right,
Speaker 3: So it's like our emotions and body sensations are king
Speaker 3: and that kind of take roost, and you take hold
Speaker 3: and kind of rule the house. When we turn back
Speaker 3: and look at them, it's like, you know, it's like cockroaches.
Speaker 3: You flip on the lights and they scurry.
Speaker 1: Right.
Speaker 3: They start to change, They evolve, and they're not something
Speaker 3: that lasts forever. They change, which gives us tremendous amount
Speaker 3: of power and the ability to develop distress tolerance. Oh
Speaker 3: this is unpleasant, but it's not terrible. I can actually
Speaker 3: be with this, and the more I learn to be
Speaker 3: with it and turn toward it, the stronger I get.
Speaker 1: So, just to tie this back to cigarettes, the idea
Speaker 1: of really getting curious about what does this taste like?
Speaker 1: What is the feeling? Because what does it smell like?
Speaker 1: That's an example of getting curious instead of popping a
Speaker 1: cigarette in automatically. Yes, absolutely, yeah, okay, And so when
Speaker 1: people start doing that with their anxiety, what's the equivalent
Speaker 1: to the yuck that your patient felt.
Speaker 3: Well, one of the I get this very often. They
Speaker 3: my faces come back to me and they say, I'm
Speaker 3: not getting anything from worrying. Am I missing something? And
Speaker 3: I say, congratulations, you are not missing anything.
Speaker 1: It's just a habit, by which they mean they're not
Speaker 1: getting anything from the from running the loop and so on.
Speaker 1: But what does it feel like? What's the Yeah, what's
Speaker 1: the equivalent of the chemical smell and taste and that
Speaker 1: sort of thing.
Speaker 3: Well, that's where they see and feel more directly that
Speaker 3: the worrying, the mental behavior worrying is actually driving more anxiety.
Speaker 3: So the worry feeds the anxiety. So then it gets
Speaker 3: back to these sensations that we talked about, the tightness, tension,
Speaker 3: they heat, the restlessness, and of course their mind gets
Speaker 3: filled up with worrying, which makes it very hard to
Speaker 3: do anything else.
Speaker 1: So here's a question for you. Okay, so you've really
Speaker 1: pioneered this treating anxiety like a habit and seeing if
Speaker 1: you can break the loop of it. So if somebody
Speaker 1: is listening to this podcast and has anxiety, what can
Speaker 1: they do today to start breaking the loop for themselves.
Speaker 3: So it's a great question and what we've worked out
Speaker 3: in our studies. So we've done randomized controlled trials here
Speaker 3: where we actually train people to be curious and just
Speaker 3: to give the data behind this in case if it
Speaker 3: helps people that actually try this.
Speaker 2: We did a randomized control trial.
Speaker 3: We got a sixty seven percent reduction in anxiety and
Speaker 3: people generalized anxiety disorder. That was compared to fourteen percent
Speaker 3: in people who got the usual clinical care, which is medication,
Speaker 3: psychotherapy or both. So this seems to work pretty well
Speaker 3: if we get pragmatic here, there's a three step process
Speaker 3: and I outline this and I've read book called Unwinding Anxiety.
Speaker 3: The first step is mapping out a habit loop. So
Speaker 3: I'll give you an Example's the person that I was
Speaker 3: talking about, Dave. We mapped out his habit loops. What
Speaker 3: we wrote out that day was trigger behavior result on
Speaker 3: a piece of paper, and so the trigger for him
Speaker 3: were feeling anxious, The behavior was worrying, and then the result, well,
Speaker 3: he wasn't exactly sure what that result was, so that
Speaker 3: was his charge for the first two weeks of treatment,
Speaker 3: you know, sent him home to go map out these
Speaker 3: habit loops. So that's what anybody can do, is find
Speaker 3: what the trigger is. The behavior tends to be worrying
Speaker 3: or some flavor of that, but it can also be
Speaker 3: procrastination or avoidance or other or stress eating or whatever,
Speaker 3: and then seeing what the result is. But we'll get
Speaker 3: into the result more with the second step. So he
Speaker 3: comes back two weeks later, and in fact, I didn't
Speaker 3: mention this. He was also four hundred pounds when he
Speaker 3: came to see me, and he had a lot of
Speaker 3: health anxiety because he had high blood pressure, he had
Speaker 3: been obstructive sleep appening. Basically he was having troubles sleeping
Speaker 3: that was related to his unhealthy weight. And also he
Speaker 3: had basically patat his liver because he was addicted to
Speaker 3: eating fast food as a way to numb himself from
Speaker 3: his anxiety or avoid it. Okay, So he comes back
Speaker 3: two weeks later and the first thing he says to
Speaker 3: me is, hey, Doc, I lost fourteen pounds. And I
Speaker 3: looked at him because I swore that we had not
Speaker 3: talked about weight loss yet.
Speaker 2: We were just going to start to.
Speaker 3: Map out his habit loops around anxiety, and he said, yeah, okay,
Speaker 3: here's my habit loop. Feel anxious, eat fast food, and
Speaker 3: actually feel more anxious because he had a lot of
Speaker 3: health anxiety, right, and so he's like, oh, this is
Speaker 3: not helping me. This fast food is not helping me
Speaker 3: at all, and so he became disenchanted with that behavior
Speaker 3: right eating fast food to the point where he had
Speaker 3: basically stopped eating fast food. Like that was a very
Speaker 3: easy he said it was the easiest weight loss he'd
Speaker 3: ever had. He lost fourteen pounds. He actually went on
Speaker 3: to lose over one hundred pounds and still maintain those losses.
Speaker 1: So the loop in this case was when he's feeling anxious,
Speaker 1: he goes to fast food and the result of the
Speaker 1: fast food is more anxiety. And that's why it's a loop.
Speaker 2: Yes, that was just one of many loops that he
Speaker 2: ended up mapping out.
Speaker 1: So when people have these loops, it's that they eat
Speaker 1: the fast food and they think that it's somehow it's
Speaker 1: solving something, but in fact it's just putting them in
Speaker 1: the loop.
Speaker 3: Yes, it gives them this brief relief because they're avoiding
Speaker 3: the feeling of anxiety, and the same is true for worries.
Speaker 3: So Dave had a worry habit loop that was just
Speaker 3: as strong as his fast food eating habit loop, which
Speaker 3: was feel anxious, and he'd worry, oh, now what do
Speaker 3: I need to do?
Speaker 1: And the worrying somehow made him feel like he was
Speaker 1: solving something, but it just made him more anxious. Exactly,
Speaker 1: got it?
Speaker 3: Ye?
Speaker 1: Okay? So once once Dave recognizes what the loop is,
Speaker 1: then he's able to say, look, the short term relief
Speaker 1: I'm getting from something is clearly not worth it, because
Speaker 1: it's just a reinforcement loop, and I'm going to get
Speaker 1: curious about how, in this case, how the fast food
Speaker 1: makes them feel, or getting curious about what the consequences are.
Speaker 3: The simple question that I have patients ask themselves in
Speaker 3: the second step is what am I getting from this?
Speaker 1: Right?
Speaker 3: Importantly, it's not just cognitive, it's an embodied experience.
Speaker 1: Right.
Speaker 3: So when somebody is worrying, asking that question what I'm
Speaker 3: getting from this?
Speaker 1: Right?
Speaker 3: Is it keeping my family member safe? Is it solving
Speaker 3: the problem? Is it really helping me plan? So they
Speaker 3: can look at that cognitively, but they see that it's
Speaker 3: not actually helping and then when they dive into their body,
Speaker 3: they realize.
Speaker 2: That it's making them more anxious.
Speaker 3: And that's critical because that's where they get these negative
Speaker 3: predictionaries where they see that worryings actually not solving anything,
Speaker 3: it's not helping them, and is actually making them feel
Speaker 3: more anxious.
Speaker 2: So that's critical.
Speaker 3: And the way I think of this is our feeling
Speaker 3: body is much stronger than our thinking brain. Right, if
Speaker 3: our thinking brain really worked that, well, my clinic would
Speaker 3: be very different.
Speaker 2: Patients would walk in. I just say stop.
Speaker 3: You know, there's this great Bob Newhart skit that I
Speaker 3: highly recommend anybody watch called Stop It, where he's playing
Speaker 3: a psychologist and women comes in. It's it's absolutely worth
Speaker 3: the five minutes. But he's highlighting this back in the
Speaker 3: nineteen seventies, he was pointing at like, oh, does CBT
Speaker 3: really work? You know, if it did, this is what
Speaker 3: it would look like. You know, stop it and you
Speaker 3: can get the idea from this.
Speaker 1: Git.
Speaker 3: So, our feeling body is really what drives behavior, and
Speaker 3: this is where reinforcement learning comes in. If something's if
Speaker 3: something feels rewarding, we're going to do it again. So
Speaker 3: when people ask the question, what am I getting from
Speaker 3: this and they see that it doesn't feel rewarding, they
Speaker 3: become disenchanted. Unfortunately, Dad doesn't rely on any amount of willpower.
Speaker 3: It's absolutely willpower agnostic.
Speaker 1: Oh that's wonderful. Why doesn't it work for everybody?
Speaker 3: So in that study, the remission rate was about sixty
Speaker 3: four percent versus three percent, So this highlighted that, you know,
Speaker 3: it wasn't every single person that was benefiting. And in fact,
Speaker 3: we could break this down. We did some further analysis.
Speaker 3: We could actually find different categories just based on these
Speaker 3: simple self reports, and there seem to be three categories
Speaker 3: of people. Interestingly, the people with the highest anxiety scores
Speaker 3: did the best, which is great news, right, so you
Speaker 3: know that if you're happy to know it, clap your hands.
Speaker 3: I think if you're really anxious and you know it,
Speaker 3: clap your hands because you're going to do really well.
Speaker 3: And then people with moderate levels also did extremely well
Speaker 3: or both of these very different than the control group.
Speaker 3: There was a third group of people, about a third
Speaker 3: of people who were barely you know, not statistically significantly
Speaker 3: different from the active control group. And what our data
Speaker 3: suggests is that these people may be more experientially avoidant,
Speaker 3: where there just really don't want to go near their bodies.
Speaker 3: And so the good news there is we can identify
Speaker 3: those even at baseline.
Speaker 1: Right.
Speaker 3: Oh, you might struggle with this training and give them
Speaker 3: kind of a booster shot before they get into the
Speaker 3: main training.
Speaker 1: Okay, so this is a side note. What I find
Speaker 1: interesting is that some people, let's say one out of five,
Speaker 1: respond to medications, some people respond well to cognitive behavioral therapy.
Speaker 1: A number of people, but not everybody respond well to
Speaker 1: your therapy about treating anxiety as a habit. You mentioned
Speaker 1: earlier that you don't have a crystal ball as a
Speaker 1: psychiatrist when someone walks in, How do you know which
Speaker 1: path to take with people?
Speaker 3: One way that I approached this is I think for
Speaker 3: some people, right, medications are really helpful, right those one
Speaker 3: in five For everyone, we haven't found a single patient
Speaker 3: who hasn't benefited to some degree from learning how their
Speaker 3: mind works. And the nice thing about that is it's
Speaker 3: very straightforward to train somebody to map out these habit loops.
Speaker 3: We even have a free habit mapper That URL is
Speaker 3: just mapmihabit dot com, right, so anybody can download this
Speaker 3: and use this to map out their anxiety or eating
Speaker 3: or procrastination or any type of habit loops. So that's
Speaker 3: nice because it's free, it's relatively straightforward, and it doesn't
Speaker 3: take very long to train. I train patient in this
Speaker 3: in a minute, right, really didn't take fre you long.
Speaker 3: So I would say everyone would benefit from learning how
Speaker 3: their brain works.
Speaker 1: That's actually what got me into neuroscience. So I'd taken
Speaker 1: a lot of philosophy courses, and you know, we're trying
Speaker 1: to figure out all the stuff, and you end up
Speaker 1: spinning yourself into these quagmires where there's sort of no answer.
Speaker 1: And I thought, God, if we could understand the perceptual
Speaker 1: machinery by which we're viewing the world, we could really
Speaker 1: make progress. So I couldn't agree more that this is
Speaker 1: one of the best things we can do as humans,
Speaker 1: is trying to understand our own thinking, our own brains,
Speaker 1: and that helps us a lot in moving forward. Okay, great,
Speaker 1: So we talked about step one, which is mapping out
Speaker 1: your habit, and then step two, which is asking what
Speaker 1: am I getting from this? What is step three?
Speaker 3: So step three is leveraging that same reinforcement learning process
Speaker 3: but finding these positive prediction errors. So what am I
Speaker 3: getting from this helps us leverage these negative prediction errors.
Speaker 3: Seeing that worrying isn't getting us anything and that's making
Speaker 3: us more anxious. We can take that and flip it,
Speaker 3: which is really nice. And I think of this as
Speaker 3: the flip clinically, so that oh no, that comes that
Speaker 3: with that voice of worry, we can get curious. And
Speaker 3: we actually talked about this a little bit already. That's
Speaker 3: really what step three is all about, is getting curious,
Speaker 3: Oh what does this feel.
Speaker 2: Like in my body?
Speaker 3: And that's literally the flip, noticing that oh no, right,
Speaker 3: where we feel this closed and contracted quality of experience
Speaker 3: and flipping that to oh what does this feel like
Speaker 3: in my body? There's a poet James Stevens. I think
Speaker 3: he wrote, curiosity will conquer fear even more than bravery well. Right,
Speaker 3: Oh yeah, so if you think of that anxiety as
Speaker 3: fear of the future, curiosity will conquer fear even more.
Speaker 2: Than bravery well.
Speaker 1: Right.
Speaker 3: So if we run toward our experience, we a couple
Speaker 3: of things happen. One is that we learned that it's
Speaker 3: not so scary, and two is we develop curiosity as
Speaker 3: a habit. I'll give a personal example I used to
Speaker 3: get panic attacks in residency. Okay, talk about conditions for
Speaker 3: having right. So, as a resident, I'm expected to know everything,
Speaker 3: and I've just graduated from medical school. I mean, you're
Speaker 3: a doctor now and you're expected to know everything, even
Speaker 3: though you were just a medical student one day before. Right,
Speaker 3: So as a resident, all that you know and you
Speaker 3: actually have power where you can, you know, ideally heal people,
Speaker 3: but you can.
Speaker 2: Also do harm.
Speaker 3: So it's pretty stressful and pretty you know, you've got
Speaker 3: to be pretty responsible there, even though you don't know anything. Right,
Speaker 3: So let me add to that sleep deprivation. Right, so
Speaker 3: you put all these conditions together, you shake up the bottle.
Speaker 3: Of course, I was getting panic attacks during residency. Now,
Speaker 3: fortunately two things. One, I was a psychiatry residence, so
Speaker 3: I knew exactly what was happening. But two, I could
Speaker 3: only know what was happening because I'd been meditating myself
Speaker 3: since the beginning of medical school. So I've been doing
Speaker 3: this type of noting practice where you just note your
Speaker 3: physical sensations and your you know what you're seeing, what
Speaker 3: you're hearing, and all this from moment to moment, which
Speaker 3: helps bring in this this Hawthorne or this observer of
Speaker 3: effect where you know, think of our thoughts, right, if
Speaker 3: we're identified with this th I was like, oh, no,
Speaker 3: they take us for a ride. But the noting practice
Speaker 3: helps us give this perspective because you can't be identified
Speaker 3: with and observing something at the same time. So I
Speaker 3: could start to see oh and was I remember being
Speaker 3: fascinated because I really had thoughts that I was dying,
Speaker 3: and I was like, oh, that is really true.
Speaker 2: I was having these back thoughts, couldn't breathe.
Speaker 3: Tunnel vision, the whole works, right, So one I could
Speaker 3: empathize with my patients more too, I knew exactly what
Speaker 3: was happening. But I could only know what was happening
Speaker 3: because I was bringing this observer effect in and I
Speaker 3: could observe it.
Speaker 2: So I remember the first time, you know, I.
Speaker 3: Had this panic attack and I was doing this noting
Speaker 3: practice and it just kicked in because that was my habit.
Speaker 3: I was practicing it a lot, and I went chicchick, Oh,
Speaker 3: I just had a panic attack, and that oh came
Speaker 3: in because I was like, oh, this is really interesting.
Speaker 3: It's compared to Oh, no, I had a panic attack.
Speaker 3: This is going to ruin my cure career. Can I
Speaker 3: be a psychiatrist? Am I going to have more of these?
Speaker 3: You know, that's the mental proliferate that races off into
Speaker 3: the future and sees us ending up as a failure
Speaker 3: and you know, destitute and lonely and you know whatever,
Speaker 3: when in fact, that's just our mind racing off. So
Speaker 3: I could watch that mind race off and not follow
Speaker 3: it and not chase it. That's the idea is bringing
Speaker 3: that curiosity in. And I've had a number of patients
Speaker 3: and folks in our We have this program called Going
Speaker 3: Beyond Anxiety where people report having panic attacks and their
Speaker 3: automatic response is being curious, going oh, and then looking
Speaker 3: at one person put it like looking at what was
Speaker 3: happening as compared to getting stuck in the why is
Speaker 3: this happening?
Speaker 2: You know, huge change for this person?
Speaker 1: Oh amazing? Right? Is this the same thing as mindfulness
Speaker 1: when you talk about noting, which is you know, you're
Speaker 1: having some emotion and instead of feeling let's say the anger,
Speaker 1: you watch yourself and you say, oh, look, I'm having
Speaker 1: these bodily feelings and this is what's happening. Isn't that interesting?
Speaker 2: Yes? This is this is really like full on embodied.
Speaker 3: You know, often people think of mindfulness as like sitting
Speaker 3: down on a cushion and meditating. This is like in
Speaker 3: the trench's mindfulness, So when something's happening, somebody is noting
Speaker 3: their experience from moment to moment to moment. In fact,
Speaker 3: this was popularized by US Burmese meditation master named Mahasi
Speaker 3: Sayadaw I think back in the forties or fifties. So
Speaker 3: this is this is straight out of that Vipashi or
Speaker 3: Southeast Asian Travada meditation tradition.
Speaker 1: So it's sort of stepping outside yourself in a sense.
Speaker 1: Instead of you are your emotions, you are watching your emotions. Yeah, yeah,
Speaker 1: so zooming the camera back out. I'm just wondering, are
Speaker 1: do you think we're more anxious in the twenty first
Speaker 1: century than we were traditionally or do we just put
Speaker 1: a better name to it.
Speaker 2: It's a great question. It could be both.
Speaker 3: So certainly we've normalized mental health, which is a really
Speaker 3: important thing societally. Another thing is, you know, it's not
Speaker 3: like our brains have evolved that quickly in the last
Speaker 3: hundred years, but we've certainly evolved methodologies for capturing the
Speaker 3: brain's attention right, and all the dopaminergically driven things with
Speaker 3: social media to other attention grabbers that certainly doesn't help
Speaker 3: put us at ease. If you look at a lot
Speaker 3: of the work with adolescence, for example, there's all this
Speaker 3: social comparison and fear of missing out and all these
Speaker 3: things that are now embedded in society that weren't there
Speaker 3: before when we didn't have access to social media. So
Speaker 3: there are a lot of enablers, let's say, for anxiety
Speaker 3: that can kind of juice the system that was already
Speaker 3: that had already evolved a certain way. I think of
Speaker 3: anxiety as kind of an evolutionary bottleneck where fear is
Speaker 3: helpful right in the present moment, planning is helpful. But
Speaker 3: when you mush that present moment fear together with the
Speaker 3: future fear of the future, voila, you get anxiety, which
Speaker 3: doesn't help anything.
Speaker 1: And you have an app right tell us about that.
Speaker 3: Yeah, we have a program called Going Beyond Anxiety, And
Speaker 3: I love the program name because it highlights all the
Speaker 3: work that we've done over the last couple of decades
Speaker 3: where I can now in my clinic do a rapid
Speaker 3: induction of this three step methodology that we've talked about,
Speaker 3: and typically I would just discharge your patients, say okay, great,
Speaker 3: you know what anxiety, go home, and they say can
Speaker 3: we keep going? And I'm thinking, oh yeah, flourishing, thriving,
Speaker 3: there's a whole lot more to go here, and so
Speaker 3: we can use that new baseline as a springboard. And
Speaker 3: the idea here is we can get people back to
Speaker 3: baseline pretty quickly, and then we can use the same
Speaker 3: reinforcement learning process to help people thrive, so leverage gratitude, generosity, kindness,
Speaker 3: all these things that really give people the superpowers for
Speaker 3: developing not only distress tolerance, but thriving. So this Going
Speaker 3: around Anxiety program is a you know, stepwise methodology for
Speaker 3: people to use that where they you know, a couple
Speaker 3: of minutes a.
Speaker 2: Day podcast style lesson delivery.
Speaker 3: But also we pair that with learning assistance to make
Speaker 3: sure that people understand comprehendive concepts but also bring it
Speaker 3: into their lives through experiential education.
Speaker 1: That was my conversation with jud Brewer. We started with
Speaker 1: the question of what is anxiety and we saw it's
Speaker 1: not really that useful to think about anxiety as a
Speaker 1: feeling or a chemical imbalance. Instead, Jud found that he
Speaker 1: got the most leverage when he interpreted anxiety as a
Speaker 1: pattern that unfolds over time a loop. A trigger arises
Speaker 1: like some sensation or some thought or some situation, and
Speaker 1: so a person engages in a behavior like worrying or
Speaker 1: planning or rehearsing, and then there's a result, which can
Speaker 1: be a distraction or a brief sense of control, and
Speaker 1: then this loop tightens. So the idea is that this
Speaker 1: is the same reinforcement learning system that governs so much
Speaker 1: of our behavior, like when you learn to ride a
Speaker 1: bike or you check your phone without thinking. So these
Speaker 1: reinforcement mechanisms in your brain are constantly asking what worked,
Speaker 1: what didn't, what should I repeat, and sometimes it learns
Speaker 1: the wrong lesson. In the case of anxiety, the brain
Speaker 1: can learn that worrying is useful. It can learn that
Speaker 1: worrying keeps you safe and is something you should do,
Speaker 1: and it takes much closer inspection to figure out that
Speaker 1: it isn't helping at all. This model of habit loops
Speaker 1: has proven very helpful for Jud's patience because the loop
Speaker 1: can be put under the spotlight and examined, and that's
Speaker 1: the way to make it loosen and what we heard
Speaker 1: from Jud today is that all of this starts with awareness.
Speaker 1: You map the loop, you see the trigger, you recognize
Speaker 1: the behavior, and you ask what am I getting from this?
Speaker 1: And if it turns out you're not getting as much
Speaker 1: as you thought, the brain updates it expected one outcomic
Speaker 1: on another, and it learns from that gap. So the
Speaker 1: lesson from Jud's approach is be curious. Instead of running
Speaker 1: from anxiety, turn and toward it. What does that actually
Speaker 1: feel like in my body? Where is it located? This
Speaker 1: is the difference between being anxious and noticing anxiety, because
Speaker 1: when you do this, the thing that felt overwhelming can
Speaker 1: sometimes break apart into components and there's finally room to
Speaker 1: respond differently. Now, this isn't a magic switch that works
Speaker 1: instantly for everyone, and I want to be clear that
Speaker 1: different people respond to different approaches like medications, cognitive therapies,
Speaker 1: behavioral interventions. But I think it's a great question for
Speaker 1: us to all ask of ourselves. What loops are you
Speaker 1: running in your own mind? What patterns feel automatic and
Speaker 1: inevitable and unchangeable, And what would happen if, just for
Speaker 1: a moment you stepped back and got curious.
Speaker 2: You just observed.
Speaker 1: Because your brain is constantly learning, it's constantly updating based
Speaker 1: on what you notice and how you engage, and sometimes
Speaker 1: the first step toward changing your experience is simply to
Speaker 1: look at it more closely. Go to eagleman dot com
Speaker 1: slash podcast for more information and to find further reading.
Speaker 1: Join the weekly discussions on my substack, and check out
Speaker 1: and subscribe to Inner Cosmos on YouTube for videos of
Speaker 1: each episode and to leave comments until next time. I'm
Speaker 1: David Eagleman, and this is Inner Cosmos