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