Avoidance of Risky Substances:

Steps to Help Patients Reduce

Anxiety, Overeating,
and Smoking
Judson A. Brewer, MD, PhD
doi: 10.12788/jfp.0244

CASE STUDY with either of these conditions, busy physicians have only a few
A 40-year-old white man presented to my office with the chief minutes in which to counsel patients about stress reduction or
complaint of anxiety. He described how, a few months ear- lifestyle modification practices (and prescribe medications as
lier, when he was driving on the highway, he suddenly had the appropriate). Patients who present with both (as my patient did)
thought, “Oh, no, I’m in a speeding bullet. I might kill someone.” can be challenging for the most seasoned family physicians.
This was accompanied by the sudden onset of racing heart, In medical school and residency, I learned the nuts and
sweating, and shortness of breath. Similar episodes followed bolts of how to treat anxiety (eg, selective serotonin reup-
and, despite the fact that he had never been in a car accident, he take inhibitors [SSRIs] are still first-line treatment, number
now avoided driving on the highway and even felt a bit nervous needed to treat = 5.15),4 and the straightforward theory of
driving on local roadways. weight loss (more calories out than in). But I found it pretty
A full history revealed that the patient met criteria for both unsatisfying to have to prescribe an SSRI to more than
panic disorder and generalized anxiety disorder. Of note, he also 5 patients to see a significant response in 1 of them, and all of
had hypertension, steatohepatitis, obstructive sleep apnea, and my patients knew the calories in/out formula walking in the
a body mass index (BMI) > 40. door—they just could not always follow it.
So, I started studying habit change in my laboratory to
see what I had missed. There are simple principles of posi-
BACKGROUND tive and negative reinforcement that are at the root of form-
Anxiety disorders are the most common mental illnesses in the ing any habit, and they break down to this: if a behavior is
United States,1 with an estimated 31.1% of adults experiencing rewarding, we will keep doing it. To form a habit, we only
an anxiety disorder at some time in their life.2 According to the need a trigger, a behavior, and a reward. For example, with
Centers for Disease Control and Prevention, the prevalence of positive reinforcement, if we see a piece of cake (trigger), eat
obesity was 42.4% in 2017-2018.3 Yet, for patients who present it (behavior), and it tastes good (reward), we learn to repeat
the behavior through dopamine firing in the reward centers
Judson A. Brewer, MD, PhD in our brain. The same is true for negative reinforcement: if
we are stressed, eat a piece of cake, and feel better, we learn to
AUTHOR AFFILIATIONS
repeat that behavior as well, because we distracted ourselves
Mindfulness Center, Providence, RI; Department of Behavioral
and Social Sciences, Brown University School of Public Health, and/or enjoyed eating the cake, which reduced the nega-
Providence, RI; Department of Psychiatry, Warren Alpert School of tive feeling of the stress. In a nutshell, positive reinforcement
Medicine at Brown University, Providence, RI helps us learn to repeat behaviors that feel good (ie, have pos-
itive outcomes) and negative reinforcement helps us learn to
DISCLOSURE
repeat behaviors that reduce bad feelings (ie, reduce negative
Dr. Brewer owns stock in, and serves as a paid consultant for,
Sharecare Inc., the company that owns the mindfulness apps outcomes). Both positive and negative reinforcement form
described in this manuscript. “habit loops” that people repeat over and over.5-7 The term

Supplement to The Journal of Family Practice | Vol 71, No 1 | JANUARY/FEBRUARY 2022 S35
REDUCING ANXIETY, OVEREATING, AND SMOKING

habit loop was first described by Charles Duhigg, and will be reduction in craving-related eating with app-based mindful-
used in this article from this point forward.8 ness training (Eat Right Now).17 Furthermore, a recent study
Reinforcement learning is also critical for changing hab- of app-based mindfulness training for anxiety (Unwinding
its (including worrying, which is a key component of anxi- Anxiety) demonstrated a 57% reduction in Generalized Anxi-
ety and can be negatively reinforced due to the rewarding ety Disorder-7 (GAD-7) scores in anxious physicians,28 and
sense of being in control or problem solving—even if one a randomized controlled trial of the same program showed
is not truly in control).9-11 In particular, the reward value of a 67% reduction in GAD-7 scores in people diagnosed with
a behavior gets laid down in our brain so that, when given a generalized anxiety disorder.29
choice between 2 behaviors, we can easily decide which one
to pick—or more accurately—we habitually pick the behavior INTERVENTION
that has a higher reward value. For example, if children are In the clinic, patients can follow a simple 3-step process
served broccoli and cake at the same time at dinner, which based on the research described above.20
one they’ll pick is a no-brainer.
This reward value hierarchy is the key to breaking STEP 1: Recognize habit loops. Map out the trigger,
unhealthy habits.12 To reduce the likelihood of overeating or behavior, reward (or result if the behavior is not rewarding
smoking (or even worrying), one needs to reduce the reward anymore) sequence so that you can see the cause-and-effect
value of the unhealthy behavior—the corollary is true for relationship that reinforces the behavior. Free worksheets
increasing healthy habits. This process has been studied from that briefly describe what a habit loop is and how to map it
bench to bedside: neuroscience research has identified key can be downloaded at www.mapmyhabit.com or clinicians
brain regions and networks (eg, the orbitofrontal cortex) that and patients can collaboratively write this down on a piece
lay down and store the reward value of behaviors,12-15 includ- of paper.
ing relatively recent clinical studies16-18 that have linked brain
and behavioral mechanisms.12,19 STEP 2: Update reward value. Focus on the result of
Importantly, changing reward value is not an intellectual the behavior. Notice what it feels like in your body when you
process. We cannot think our way out of anxiety or into better overeat or eat junk food. Notice what a cigarette tastes and
health. To update the reward value of a habit, we must be very smells like. Ask yourself, “What do I get from this?”
clearly aware of how rewarding the behavior is right now, not
when it was first laid down (eg, the reward value of eating lots STEP 3: Find the bigger, better offer (BBO).
of cake was reinforced with every birthday party we attended There are many BBOs when it comes to unhealthy habits. As
as a kid). And reward value is relative. So, the reward hierar- mentioned above, curiosity feels better than cravings and can
chy can be changed in 2 ways: decreasing the reward value of be trained to be used in situations when strong urges come
the old behavior or comparing it with other behaviors that are on. When it comes to eating, you can compare what it is like
more rewarding. One can think of the more rewarding behav- to stop when full vs overeating or to eat healthy foods vs pro-
iors as “bigger, better offers” that our brains will pick if given cessed food, to see which one feels better both immediately
a choice. For example, curiosity feels better than a craving or and afterward (eg, which one leads to lethargy, indigestion,
worry.20 When someone has a craving for cake or a cigarette, mood swings, etc).
they can get curious about what that urge feels like in their
body, which not only brings curiosity to the front of awareness, CHALLENGES
but also helps individuals see that their cravings do not last Busy physicians may find it challenging to spend any extra
forever. By simply being curious about the cravings, people time in clinic visits providing psychoeducation. Additionally,
can ride them out without smoking or eating cake.21 if a physician is more comfortable with prescribing medi-
Fortunately, there are specific ways to train awareness cations and/or a patient is expecting a prescription, trying
to help with this process, such as mindfulness training, and out a new approach can feel uncomfortable, as one or both
the evidence base is building, suggesting that it can help participants may be moving out of their comfort zones (eg,
with habit change.6,7,20,22-24 Mindfulness can be operationally the expectation to prescribe/receive medication). Fortu-
defined as bringing awareness and curiosity/nonjudgment nately, extra time can be billed, and the above-stated 3-step
to present-moment experience.25,26 For example, studies have process can begin with just the few minutes it takes to map
found that mindfulness training outperforms cognitive ther- out a habit loop together with a patient in the clinic. Then,
apy 5-fold in helping people quit smoking and targets specific instruct the patient to start mapping these habit loops out
neural pathways for its effects.18,27 Another study found a 40% in daily life while asking themselves the question, “What do

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 REDUCING ANXIETY, OVEREATING, AND SMOKING

I get from this?” Additionally, with a small amount of prac- REFERENCES

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