Ep. 229 Ways to Reduce Anxiety and Better Understand your Brain and Body

Cynthia: Welcome to Everyday Wellness Podcast. I’m your host, nurse practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

Today, I had the honor of connecting with Dr. Ellen Vora. She’s a board-certified psychiatrist, acupuncturist, and yoga teacher. She is also the author of the bestselling book, The Anatomy of Anxiety. It is absolutely one of my go-to resources on mental health. She also takes a functional medicine approach to mental health considering the whole person and addressing the imbalance at the root. Today, we talked about some of the limits of traditional modalities, the impact of the pandemic and the collective trauma, root causes of substance abuse, promiscuity, alcohol, and the avoidance of uncomfortable feelings, the impact of resiliency and the subjective experiences over the last several years, the physiology of the brain and the gut, food addictions and gender differences as it pertains with an emphasis on the impact of synthetic oral contraceptives on inflammation, micronutrient depletion, changes in the gut microbiome, and blunts to libido, as well as changes that occur in our bodies in perimenopause and menopause. I loved this discussion with Dr. Vora. If you’re not already following her on social media, you definitely should be, and definitely check out her book, The Anatomy of Anxiety. 

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Dr. Vora, it’s so nice to connect with you. I really enjoy your body of work, and it’s such an honor to bring you on the podcast, and talk about real world issues that are ongoing from a provider’s perspective, another human’s perspective.

Ellen: Yeah, Cynthia, I am truly honored to be here and so excited to talk about this, which is on so many of our minds these days.

Cynthia: Absolutely. So, over the past several years, we, as a society have really experienced a lot of loss and stress, and obviously, this has tremendous impact on our mental and emotional health. And so, what are some of the patterns that you have seen evolving with your patients and talking to love ones over the past two years in particular, because I really think if we’re going to have a conversation about anxiety, we have to talk about the elephant in the room. And on a lot of levels, watching the process of the past two years through the eyes of my children who are actually teenagers has been very enlightening. And I think it’s a sign of what a lot of families and adults, and children have gone through. So, what are some of the common themes that you’ve been seeing with your patients, some of the concerns, symptoms, etc.?

Ellen: Yeah. It’s definitely multifactorial. I think an interesting phenomenon happened at the very beginning of the pandemic. We’re talking March 2020 or even going a month back, February of 2020. I saw this peak in anxiety in several of my patients, and I didn’t know how to explain it. I remember trying to come up with a way to make sense of why everyone was suddenly feeling this peak of anxiety. I couldn’t explain it. I was really grasping at straws. And then when the pandemic really came and just turned life upside down, in an instant, it started to feel like, “Oh.” I almost think that these are my [unintelligible [00:03:39] patients and they were tuning into something. 

And so, in a tiny way, there was almost this– It’s not quite a relief, certainly, because it was this collective trauma and it was so tragic. I’m in New York, where things were really heavy. But there was this feeling of, “Okay, that helps me make sense of what I’m feeling.” And then that, of course, has evolved over time where it’s been such a collective trauma. This is the premise of the second half of my book is this idea of true anxiety that when we’re viscerally connected to what’s going on in the world, we feel that. And that’s not something to pathologize and it’s not really something we can suppress or eliminate all that effectively. 

Definitely don’t go gluten free and stop feeling anxious when the world is tumbling towards certain disaster. But it is something to feel and to expand our vocabulary for identifying what’s coming up in us and to really just, I think, you feel it and process it, you let that move through you. And I think it’s especially your perspective with having teenage sons, is that right? 

Cynthia: That is correct. 

Ellen: We can go into that, but it’s tough to be young right now and they’re really, viscerally connected to the suffering in the world. It will hopefully, I have to hope, save us all, but it’s a higher calling, but it’s a hard role to play.

Cynthia: And It’s interesting. My older son was a high school freshman, heading eighth-grade into ninth-grade. Eighth grade, everything shut down in March, and at the time we lived in Washington, D.C. And my older son is my introvert. And so, for March of 2020 to March of 2021, it was all a virtual classroom. He never had all those eighth-grade milestones. And being the introvert, I don’t think it bothered him quite as much as his extroverted brother. But now as I’m realizing, he’s now a rising junior, and my youngest is heading into high school, and how different my youngest son’s freshman year is, because he’s in person, he’s had a very different high school experience than his brother. And although they don’t articulate it, I know that there was this regression that went on. They had this whole lack of socialization for an entire year, other than virtually through computers and conversations. And I think for even parents, all of us were like, “We’ve never lived through this before.” 

Although I wasn’t in New York City, I was in the Washington DC suburbs. And for me, where we were, it was very conservative and masking everywhere you went. And so, we were very diligent about– we only went to the grocery store and how little we saw of other human beings other than virtually. And I think as adults, maybe, we’ve processing these experiences. I’m curious to imagine what it will be for our children as they continue to grow up with this kind of arrested development period. I’m obviously not a child psychiatrist or psychologist, but I wonder in subsequent generations or other stages of life, if we’re going to see things that will crop up for them. 

Again, like I mentioned, my introvert, I think was completely fine. Being a little more isolated, the extrovert was the one who struggled the most. And so, we were very creative in trying to find ways that he could socialize in a safe way. But there were many, many months, where it was just the four of us and two dogs, and trying to navigate this new normal. I know so many of us did.

Ellen: Yeah, I wonder the same. I think that so many new pressures have been put on this generation. It’s been put on all of us. But when you’re at a formidable age, it’s clearly going to have an impact on development. I don’t think it’s entirely bad. I don’t mean to spin anything positive from the pandemic, but I have to believe that it has been a pressure that can help build towards resilience, if handled properly. But I think there’s also this really upsetting idea, which is that the disparity, it was really a stark difference based on what kind of resources a family had. If you could afford to have some kind of pod to support your child’s education and socialization, then that kid might have been way better off, and experiencing fewer language delays, and less of an impact on their socialization. Whereas, if this was just a household just trying to barely stay afloat, then I think that that put a lot more burden on the kids. 

I think the other thing that I really observed, and I’m not a child psychiatrist, I’m an adult psychiatrist. But I came up against very often how parents were holding the experience for their kids. What I kept seeing over and over was parents feeling almost one of two extremes. One would be really creating an atmosphere of anxiety and angst in the household. I’m not sure that that was always necessary or helpful for young kids. And then you saw on the other hand, parents that almost tried to plaster on a smile and everything is okay. And there, it makes a lot of sense to me to push back and say, “Kids are incredibly sophisticated social creatures. They read our truth, whether or not we are portraying it in our poorly acted facial expressions.” 

And so, I think that to just recognize that we don’t have to fake anything for our kids. We certainly, I think we can both show them how we’re doing and then also model for them and here’s how I’m working through that. Take them on the whole journey of here’s what’s challenging, here are my coping strategies, here’s what I’m worried about, here’s what I’m hopeful about, here’s what we’re doing to keep you safe and to keep everything okay, as much as possible. And I think that this has really asked a lot of parents to get a quick education on how to move through our feelings in the presence of our kids.

Cynthia: Well, I think it’s hard as a parent to be fully transparent. I try to be very as honest and forthright as I can be, especially about when we’re talking about circumstances related to extended family or things that are going on. But I would imagine most of us are trying to find a reframe all the time, so that if we appear to be calm, our children would be calm and they wouldn’t pick up on– even if we were intrinsically feeling stress or anxiety about the uncertainty of what was evolving. My husband’s probably the most positive person in the world. And so, there were definitely moments where we would look to him, “Hopefully there’s an end to all of this, so that we can get back to some degree of normalcy.” 

But when we talk about the capability of people being resilient, are their identifiers, are there things that make us more prone to resilience than others. I know you mentioned, some of it can be socioeconomic. So, let’s be very transparent. There are some people who were really, really struggling on every level during the past two years and then there are other people that were in a very different position. But intrinsically, are there resilient genes, are there resilient personality traits that can help us work through challenging times?

Ellen: Yeah, that’s a great question. I think resilience is incredibly multifactorial. There’s a lot that goes into it. The way I think about it is that when I’m working with patients and they’re going through something difficult, I do try to help them arrive at some narrative that helps them make meaning of the challenges in their life. And it’s certainly not the spiritual bypass of, “Oh, everything happens for a reason,” or, “It’s all good.” This world is not all good, but I think that when we go through a challenge, when we experience a serious loss, when there’s something really dropping us to our knees in our lives, I think it is actually helpful to say, “Well, here’s how I am making meaning of this.” 

And I think from my own life, I think about when I lost my mom, which was in 2015 and it at once really drew upon my burgeoning at the time spirituality in my worldview. It really made me skeptical of it, but it also at the same time ended up galvanizing it and really made me have to stop and say, “I don’t know, [unintelligible [00:11:50] really knows.” But here’s how I choose to make sense of the unfolding events of my life. And that has helped me immensely. It gives me comfort and it helps me make meaning of challenges and losses. I think that I try to support my patients in a very agnostic way. I don’t have a horse in this game. There’s no answer that’s right. It has to be what feels true for any given individual. But to see the events of our lives as building towards growth or building towards meaning. I think there’s an underappreciated role in resilience to our physiology. 

When I go into companies and talk about emotional intelligence and cultivating resilience, I’ll talk about the regular talking points and expanding our emotional literacy, I think is really incredible, and the work of Marc Brackett is really wonderful. His book, Permission to Feel, Brené Brown’s Atlas of the Heart. But then I love supporting physiology. I think that when we’re sleeping well, when our brain actually gets an opportunity to have good glymphatic flow at night and a true reset, I think that supports resilience. And I think that keeping our blood sugar stable and being less inflamed, it sounds so small and material, but I think it actually does play a dramatic role in our ability to resilient we cope with challenges. 

And the last piece is just, I mean, I’m a psychiatrist. So, I’m biased, but we have to talk. I think we have to process what we’re going through. I think that we are culturally due for a rebranding around crying, where we need permission to cry and not to cry small, where we suck it back in and say, “I’m sorry, I’m sorry,” and really try to wrap it up as quickly as possible, but to actually give ourselves permission to dive in, and have a big messy cry, and let it feel complete. And I think that is the best free therapy that we all have access to.

Cynthia: I think that’s really important and this ties in beautifully with my next focus. What happens when we avoid uncomfortable feelings or processing our feelings? Because I know certainly my generation, the way that my parents spoke to me, it was suck it up. Tomorrow’s a new day, it will get better, it was always those trying to be helpful. But what happens to us during our development if we don’t articulate or process those uncomfortable feelings? Because I feel what I’m starting to see is, if you don’t process it and you don’t deal with it, it will eventually come back and you’ll have to deal with it, probably in a very ugly way. So, how does that process actually evolve or how do we stay in this kind of arrested development?

Ellen: Yeah, the way I think about it is that a moment of feeling. It’s almost like a unit of energy. There’s this little molecule of sadness and it needs to go somewhere. [chuckles] It can either bubble up and out in the form of talking, and crying, or journaling, or just letting the feeling move through you. Or, if we’re like, “Nope, nope, nope, I’m strong on that.” “I resist or refuse to feel that,” or, “My childhood did not make it safe. I was shamed for crying. I was said, ‘Just don’t cry. Don’t be so sensitive.'” If for whatever reason, we don’t let that up and out, I think it gets lodged inside our bodies, and I think it often shows up later as chronic digestive issues, chronic low back pain, headaches. 

And this is adjacent to this idea that the body keeps the score, but I think that no human emotion in the history of humanity has ever been successfully pushed under the rug. It doesn’t go away. It just goes somewhere else. And that’s why I think it does behoove us to just feel it in the first place and move through it. And if it’s a little late and it’s already lodged in our body, then to do somatic therapies, and yoga, and bodywork, and to really start to excavate that from our tissues, and let it up and out. And so, I agree with you completely.

Cynthia: Yeah, it’s interesting, because in working with patients and doing good physical exam and talking to them, examining relationships with alcohol, or illicit drugs, or if appropriate, if they were disclosing a history of promiscuity. And so, sometimes, understanding that those behaviors can be ways of coping. And, again, I’m not a clinical psychologist or a psychiatrist, but their coping mechanism for not dealing with those really uncomfortable behaviors. Maybe they’re not yet ready to deal with the traumas or there’s adverse childhood events that they experienced. 

For me, the one thing that I found really interesting about adverse childhood events in particular, again, just my evolution of just learning more about this, how much those traumas we experienced as a child or young adults impact our health? You mentioned, chronic pain, or digestive issues, or sleep issues, and just understand, this interplay is so important and so significant. And for many of us, if we’ve been in a traditional allopathic model and we’re working with someone, they may just see us through blinders. They may not be seeing that, “Oh, the pain is really not, because you’re playing tennis.” The pain is really because of all these other issues. And understanding that our bodies are all interrelated. You can’t put your blinders on and anticipate that that’s going to ensure that it’s just a musculoskeletal or orthopedic problem. It could be so much more than that.

Ellen: 100%. What I find myself saying in my practice all the time is, it’s always a both ends. It’s always both. And something can have a very physical basis. I had a patient I worked with yesterday. And she has old injuries in her lower back and her hips from college sports. The injuries are real. The scar tissue is real. There’s material basis. And when we really started to go on the jungle journey into what is really at the heart of this chronic pain, it relates to a miscarriage that she had, it relates to a very painful time in her life where it’s almost– because she didn’t have a container to process what she was going through. It got lodged in this particular place in her body. And so, it’s always both. There’s always a physical dimension, there’s always a psycho spiritual dimension, and I’m always happy to engage on both of those paths up the mountain of healing. And sometimes, it’s a little bit of a dance toggling between the two. 

I think the Eastern modalities, things like Chinese medicine, Ayurveda have understood for a very long time that blockage in the body is not just purely material. They recognize that it can be stagnation, it can be blockage of the flow of energy. And so, really, these are just more tools that we then have in our armamentarium to help someone who’s struggling with chronic pain. And I think just as you were describing, addiction. You had me thinking for the first time about, you have teenage kids, I have a six-year-old, so I’m not too far from the phase, where we were always in that dance of, “If she’s upset, do I give her comfort or do I help her develop her own skills of self-soothing?” 

I think that so often we don’t get the good enough parenting that we need and striking that right balance. And so much of addiction in adulthood is in a way seeking the comfort, not having a healthier way of self-soothing. I think about for me, my addiction was in my 20s in med school when I was binge eating. And it really had a quality of– On some very deep unconscious level and this is a psychiatrist way of thinking about this. I wanted to be a baby breastfeeding again, essentially. I wanted to be held in a mother’s arms, feeling loved and cherished and safe, while getting inputs of basically opiate rich breast milk. And that was what I was seeking when I felt really unmoored and unseen, and unlovable, and when I was hurting most. And I think that so much of addiction is seeking that grounded feeling of being back to the ultimate state of comfort.

Cynthia: It’s really interesting, because I have a family member that has a long-standing history of alcoholism. And at this stage in my life, I view them very compassionately. And sometimes, friends of mine who have known this individual my entire life are sometimes surprised by that. I just always explained that I believe their alcoholism is a byproduct of a very traumatic childhood. This was their compensatory way of dealing with those super uncomfortable feelings and processing information that I think even now, this individual is retired now, they’re still incapable of addressing those feelings. And so, I 100% agree with you. 

It’s been interesting, my impression of this person has shifted. The compassion piece, I view– I think a lot of it’s since becoming a parent, I just view people in a compassionate way. Not that I was not compassionate before, but in a degree in a way, because everyone is someone’s child. Every time I interact with people, I try to be kind, because I start to realize that is someone’s child. Even if their behaviors abhorrent and they’re obnoxious and they’re not making sense or saying nice things, it’s still someone’s child and they’re trying to make sense of an environment that for them may have been very challenging and painful. 

And so, as I’m navigating parenting teenagers, the one thing for me that I’ve had to struggle with is understand, in two years, one will be in college, the other will be in college in four years, and I have to let them struggle a little bit. I’ll give you an example. My youngest started high school and he got into a high school that requires quite a bit of busing to get to, and this is a high school he wanted to attend and got into. And yesterday, there were a lot of busing problems. It meant that his long commute turned into an even longer commute. By the time he came home, he was tired, probably, his blood sugar was low, he had been on the bus for a while. He was just grumpy, and it started with, “I hate my teachers, everyone at the school is strange.” I just let him bubble it all up. And so, I said to my husband, “He’s going to eat dinner, we’re going to give him some time, and sure enough, within an hour or two, he had processed these uncomfortable feelings and trying to explain to him.”  That happens a lot in life. 

Sometimes, we just have to accept that things are outside of our control and you’re in a circumstance where you were in a safe environment, I wasn’t concerned about you. But that’s life. Sometimes, things just don’t work out the way that we want them to. Now, if he had been younger, it would have been a lot more cuddling and hugging, and he just didn’t want that. And his body language said that it’s like, let him process. My husband and I were privately giggling about how grumpy he was. And I said, “Just let him process what he’s going through.” Because I think a lot of us as parents, we want to solve everything. Sometimes, we have to let our kids work through it, because it’s not going to serve him well when he gets to college, or has his first job, or has some life setback of some sort. It’s really enabling him to ultimately be a strong independent adult at some point as much as it crushes my soul to imagine being an empty nester. I know that is coming. It’s not a question of if, but when. But I think for anyone that’s listening, it’s the acknowledgement that these processes, we sometimes have to sit back and let our children work through this on their own in a safe way.

Ellen: There’s an amazing Alain de Botton quote. He is a pseudo philosopher. I’ll butcher it slightly, but basically, “It’s not to dismiss the gravity of the human experience to say that ‘Sometimes despair is just low blood sugar and exhaustion.'” 

Cynthia: [laughs] 

Ellen: This is the premise of the first half of my book is basically that so much of these really big feelings that we can experience are sometimes avoidable and related to a straightforward physiologic stress response that can be precipitated by all of these common habits in modern life, like low blood sugar and inflammation, and chronic sleep deprivation. And an extra-long bus commute one day, and you didn’t get a snack in time, and your body’s like– 

Cynthia: [laughs] 

Ellen: This is our hard wiring from when having enough to eat really was a common life or death issue that would come up. And so, the body goes into an all-out five alarm fire and thinks, everything is terrible. It was originally designed to create some urgency to go forage for food, but it gets put through the modern lens. It’s not to deny what comes forth in that moment. Maybe some of the teachers are not great and maybe some of the people to school are weird. Probably, we’re all weird. And so, there’s probably still a kernel of truth. But our ability to cope within work with the things that aren’t great in our lives, it’s so much less when our blood sugar was crashing and so much more when we’re in a state of balance.

Cynthia: I couldn’t agree more. When we’re talking about blood sugar dysregulation and the impact of nutrition, it goes without saying that most, if not all of us, are not metabolically healthy. And so, this blood sugar dysregulation and hypoglycemia or high blood sugar and insulin resistance, let’s unpack how that impacts our behavior, because I think this is an important distinction. The interrelations between key hormones in the body and our gut health– For many of us, we don’t even realize the foods that we eat influence that insulin sensitivity, it influences our behavior, our neurotransmitters. I love everything about the gut microbiome. I find it effortlessly and endlessly fascinating. So, I’d love to touch on how that interplays with our behavior and our feelings.

Ellen: Yeah, this question and my desire to answer it in an hour and a half TED talk is-

Cynthia: [laughs] 

Ellen: -very indicative of the fact that it’s a web of interconnections. I remember when I was wrestling with my chapter on inflammation and gut health and how that pertains to anxiety, it’s really hard to say, here’s the beginning of this story, because it’s many interconnections. But let’s start with the premise that absolutely what we eat impacts our physical health, which in turn impacts our mental health. And the state of our gut health is keenly interconnected with the functioning in our brain. And the fact of the matter is in modern life, both of these are really in– There’s a bad state of affairs going on. Modern life makes a broad assault against the health of our digestive tract, whether it’s multiple courses of antibiotics or the fact that our tap water has chlorine and pesticide residues, and our foods are covered in Roundup, and we exist on a diet of refined carbohydrates, and sugar, and alcohol, and then we’re chronically stressed. These are the perfect conditions to have an unhealthy gut, and many of us do. And we’re also not consuming fermented foods as part of a daily cultural given. 

And so, a lot of us have really unhealthy guts, whether we have a decimated gut flora, and we don’t have that diverse ecosystem of beneficial bacteria, and fungi, and parasites, and viruses that help train our immune system to recognize the difference between friend and foe or it’s that we have an unhealthy gut lining. Some of us are genetically very susceptible to having disruptions to our gut lining from certain pesticides in our foods, most of all, Roundup. But other things in our foods too. Things like carotene. All of this creates a lot of different pathways to worse mental health. One of them is the fact that the gut is involved with the manufacturing of certain neurotransmitters and we’re starting to talk about that. People know that gut is the second brain. 

There’s even a growing awareness that more of our serotonin is physically located in the gut and the brain. I actually think we overplay that concept, because the body is a multitasker with certain chemicals. But it is to say that our gut health does impact our serotonin functioning in our brain. And that’s not the only neurotransmitter impacted by our gut. GABA, our primary inhibitory neurotransmitter in the central nervous system, the one that I think is so relevant to anxiety and panic is also manufactured by gut bacteria. If we take a course of antibiotics and we decimate our Bacteroides species, we might not be making our homegrown GABA and then it becomes really difficult to feel calm and hopeful. 

And then the gut has this two-way street with the brain by way of the vagus nerve. I think we’re at a moment culturally where we understand the top-down communication. We know that if we’re stressed, this will impact IBS or if we’re anxious before a big presentation, maybe we have nervous diarrhea. We get that the brain is communicating to the gut. But the part we’re not yet talking enough about is that the gut is also communicating back up to the brain. And so, if everything is great and healthy in your gut, it can send a memo up to your brain like, “Everything’s copacetic down here. Go have a great day.” But if your gut flora is decimated, if it’s full of inflammation, if the gut lining is permeable, this is sending a really different communication up to the brain. And it’s basically saying, “Things are not okay down here.” Feel unwell. And that’s not just to make us suffer. It’s designed to make us make different choices. Maybe then we’ll rest, maybe we’ll eat something soothing, maybe we won’t eat something irritating. But many of us are going through our lives in a state of this chronic gut inflammation and disorder and then it’s creating states of chronic low-grade mood and chronic anxiety. 

And then, of course, the last piece is just the role of our gut overall state of inflammation in our body. And if our gut is inflamed, our body’s inflamed, and we’re more systemically inflamed, our brain is inflamed. And that can show up as depression, anxiety, bipolar OCD. And so, it’s so keenly connected to every aspect of our mental health. I find that to be hopeful news, because our thinking that mental health is the neck up and you just need to be on the psychotherapist couch for seven years to talk through your problems. Well, I’ll admit like, I’ll be the first to say, I think they’re benefits to therapy. I’m a therapist. But you can heal your gut in a matter of weeks, months, and that’s easier. And then you can walk away from some diagnoses that felt like a fixed part of your identity.

Cynthia: I think it’s really reassuring to understand that there is a very conscientious interrelationship between our gut microbiome, and our digestive health, and our brain health. And I think a lot about inflammatory foods in particular, the one that I think is most challenging for people to do on an elimination diet, in particular, I find dairy is the one that people struggle with the most. And certainly, gluten is another one. And there are specific properties in these foods that light up areas of our brain that make us feel good. And so, it’s this complex in a relationship. I think a lot about serotonin and how we know there are specific foods that will boost serotonin that are probably also not going to be great for our blood sugar support. 

And then also thinking about, as you mentioned, these toxins we get exposed to in the environment that can exacerbate a lot of what’s going on in the gut. I would love to touch on eating less often, because I know this is a shared strategy that we both enjoy and enjoy talking about. And I think it can’t go be understated that this chronic habitual have three snacks a day and these mini meals and stoke your metabolism. I certainly was trained during the time when we were talking about heart healthy grains, and very little protein, and far too much of the wrong types of fats. And I feel this is the stepping stone into why we’re seeing so much metabolic health issues and that translates into mental health issues as well.

Ellen: Yeah. And just to touch on something you said a second ago, with gluten and dairy, these were my drugs of choice continue to be really, and even though, I don’t eat them. It is interesting to learn that they can both break down into opiate like substances. With gluten, it’s gluteal morphine, with dairy, It’s Casomorphin. And in the state of leaky gut, these improper partial digestion of these proteins, you can have gluteal morphine and casomorphin in your bloodstream, their lipophilic, they’re crossing the blood brain barrier, and they’re acting on opiate receptors. So, it’s no wonder– Well, first of all, that we feel fuzzy after we have a really me dairy meal, but also that we crave it, and also that we get irritable when we’re coming down from it. 

And so, it’s not as strong as morphine, but this is not nothing. It’s part of why in when I talk to patients around issues like eating disorders, binge eating disorder, I do think that there’s a role for food addiction and how these drug-like foods which are gluten, dairy, for some people, sugar and for some people, all of the Frankenfoods, like the processed foods with their flavor crystals, how they can hijack a brain and really looping into an addictive cycle. I think that to answer your other question, which was–

Cynthia: Talking about fasting.

Ellen: Thank you. I look it, in many ways, I’m taking one step backwards in that. When I’m working with someone who I suspect blood sugar is playing a role in their anxiety, I actually don’t start with fasting. I start with– it’s like, let’s just start to get some of the water out of the sinking boat before we patch up the holes. And so, the way I do that with someone with panic disorder or really significant anxiety is actually really trying to stabilize their blood sugar one of two ways. I always suss out, what is someone ready for? If they’re willing to work with me on overhauling their diet and building towards more metabolic flexibility, then we go there, and then I’m thinking about like, “Let’s not eat so much refined carbohydrates and sugar, and booze. Let’s eat more protein and healthy fats, get your carbohydrates from starchy tubers, make sure you’re eating that alongside healthy fats.” If that’s what someone’s up for, I’m like, “Great, let’s go there.” And then we’d start playing around with intermittent fasting and really just helping them be not so much on that blood sugar rollercoaster, but much more metabolically flexible. 

If that makes someone’s eyes roll to the back of their head and they’re just not ready for that, it’s 180-degree departure from the fact that they’re currently having nachos for dinner, then what I do instead is, I encourage someone to use something like almond butter or coconut oil and take a spoonful of that at regular intervals to give them this safety net of stable blood sugar that can then blunt any superimposed crash. This is not the definitive long-term solution. But, man, is it a supportive hack that has pulled many of my patients out of really frequent panic attacks. So, it’s all speaking to the same truth, which is that blood sugar is critical to the functioning of our brain, critical to whether or not we’re dropping into unnecessary stress responses, creating anxiety and panic. 

And for some people, the inability to pay attention, it can relate to hyperactivity and certainly insomnia and depression, but how I approach, it depends on where someone’s at and what they’re ready for. And the fact of the matter is, a lot of my patients aren’t ready to embark on the intermittent fasting journey. I’m curious what you have found and I think probably, you have people that are coming to exactly because they’re ready for that.

Cynthia: Yeah. I think bio-individuality, obviously, rules above all else and really assessing a patient’s readiness for change is critically important to get their bio-in, in terms of creating a personalized approach. I think the blood sugar stabilization is absolutely positively the first step. And on a lot of levels when I’m working with patients, the first thing is adjusting their macros, and maybe they’re eating too much carbohydrate. And let me be clear, I’m not anti-carb. I just like people to eat less processed carbs. The wrong types of fats, so seed oils in particular, I always say that’s a nonnegotiable. So, I encourage people to eat more protein, which will stabilize their blood sugar and help with satiety, and then start slowly deciding, “Can you go from dinner to breakfast without eating?” Because so many people, especially during the pandemic, we’re eating 24/7. They’re eating all night long. It wasn’t just a snack. It was multiple meals in the evening. And so, really seeing, are you at a point where we can go from dinner to breakfast without eating? Once they’ve hit that stride successfully and they feel good, then we can start working with for 12 hours as digestive rest. I say, once we’re doing digestive rest, that’s great. Then we start practicing a little bit more with opening up that window. 

Now, one thing I got a lot of questions about was your position on orthorexia. We talk about food addictions, it can also encompass binge eating and anorexia, and bulimia, but also I think about the Orthorexics. And sometimes, I see people, well-meaning people who pop up on social media and they’re so laser focused on being pristinely perfect all the time. And you have a really great quote in your book that I want to make sure that I mention. “Perfectionism is internalized oppression.” And I guess that was Gloria Steinem that actually said that but it really stuck with me. And so, when I see the Orthorexics in particular, it’s that perfectionistic tendencies. How do you work through that with your patients? Because I would imagine, that’s a really rigid mindset that’s challenging to work with.

Ellen: Yeah, this is central. It’s such a delicate balance that I’m looking to strike with my patients. And it’s born out of my own journey with this, where there were these years in med school when I was so unmoored, so isolated, didn’t really have good coping skills, and this combination of sadness and some degree of inflammation from gluten intolerance, and all of that, all came together. I was binging and I was really struggling to stop that behavior. 

On the one hand, cognitive behavioral therapy was helpful for me, but it wasn’t entirely helpful. And what I had to identify for myself and I didn’t really feel I had any mentor, anybody supporting me with this insight which for me ended up being the exit ramp was, I looked at the abstinent base recoveries. If you are trying to become sober from alcohol, you get to a point where you stop drinking and then there’s all of this supports that come up in your life to make sure that you can maintain that. But with food addiction, you can’t actually stop eating. And so, you have to engage with your addiction, minimum of about two or three times, maybe five times a day. Brené Brown, I think quoting someone else brings up this idea that, “Addiction is like a tiger living in a cage in your room.” And with the non-abstinent base recovery, you have to open that cage three times a day. And so, I was really struggling with that and I realized for myself that I wasn’t addicted to all food. I was addicted to those drug-like foods. For me, my triggers were gluten, dairy, sugar, processed foods. And then the times in my life when I’ve been vegetarian, actually, nut butters also come in as a source of addiction. 

And so, what I realized was that my exit ramp was to not avoid all food, but to avoid the drug-like foods. And abstinence from the drug-like foods actually created the space for me to stop binging. And it worked alongside, moderation, not moderation, but I almost can’t believe I said that, because I really stand in contradistinction to that concept. But it involve me normalizing, letting myself eat, not being so restrictive, and then doing all the psychospiritual healing around what was the real source of my addiction as well. But for me, the exit ramp from binging was avoiding the drug-like foods. And I started to bring that into my practice and helping my patients who were struggling with eating disorders and binge eating disorder to abstain from the foods that were triggering them. And it was really helpful for a lot of patients. 

Then, over time, it’s heavy and difficult to admit this, but I started to recognize that I was playing a role in creating an entirely new eating disorder, which was orthorexia. And that’s when my patients were starting to get obsessive about foods, about meal prep. They were starting to fear food, they were starting to feel their bodies were very fragile. It’s when I realized, “Shit, in trying to help and in helping someone move away from foods that were tricking them into addictive cycles, we’ve created an entirely new problem.” And so, now, I’m very conscious upfront to have this really broad conversation about what balance we’re trying to strike here, which is, if these foods are making your life harder, if they are preventing you from pooping, or from going through a day without a panic attack, or if you’re just always inflamed, or your foggy thinking, or it’s damaging your thyroid, it’s worth it to make these different difficult choices and actually abstain from these foods. But we want to do it with this loose grip, where it’s always coming from a place of self-love. It’s not coming from a place of self-negation or punishment, it’s not to make ourselves small or please the patriarchy. It is not about vanity. It’s really about how you feel. 

There are really difficult choices that come up, where sometimes doing everything “perfectly” and obsessively meal prepping and saying no to the dinner party. Once you’ve started getting that far down this path, it often has become counter therapeutic. And feeling obsessed about food, fearing food, feeling fragile, that’s going to make you feel more anxious, not less. And anyone you’re turning down social connection over food, you know you’ve gone too far, because that’s the real stuff of life. All of this is to say, wellness is not the ultimate goal. The whole goal here is live your fulfilling life and we want your physical health to recede into the background and simply serve as a foundation that makes it possible for you to lead a fulfilling life. If you need to change the way you eat in order to let your physical health recede into the background of your foundation, let’s get to work, but it can’t become a centerstage foreground of your life. It only ever has to be something that is in support of what really gives your life meaning.

Cynthia: I think that’s a really important message, because whether it’s a byproduct of social media or social conditioning that we now have, I recognized the things that we say and terminology that we use, and language is so important. We may think we’re being very clear and someone may interpret that message very differently. And so, being thoughtful and methodical in our language and how we have conversations about lifestyle and nutrition, and how we treat our bodies, and how we view our bodies, I think is so important. 

Now, I would be remiss, if we didn’t at least talk about some gender differences. I’m talking specifically about not just women who are still in their peak fertile years, but also changes that it can occur as women are getting older, perimenopause and menopause. And certainly, I’m the first person to say that I was on oral contraceptives for years. I think most women in my generation not realizing the full impact of said oral contraceptives and the net impact on our physiology and our health. And so, I’d love to start the conversation there, because there’s this growing awareness that some of these contraceptive choices, even if it’s not primarily used for contraception, it might be used to fix a wonky menstrual cycle, or mild PCOS, or whatever vernacular we’re really focusing on. But let’s start the conversation talking about the impact of these synthetic hormones on our physiology and our mental and emotional health.

Ellen: Yeah. It’s a whole thing. 

Cynthia: [laughs] 

Ellen: I also was on again and off again, the pill for so many years. And for one thing, it was a source of immense gaslighting in the medical world. You would go on a pill, and you would report to your gynecologist, your primary care doctor like, “I think I’m more emotionally and weepy on this thing.” And that was my real first taste of being medically gaslit, where the practitioner would say, “No, you’re not. You just think you are. There’s no evidence for that.” And absence of evidence is not evidence of absence. Why would the pharmaceutical industry test this, study this? But I think that we do need to sometimes trust patients when they are repeatedly reporting, “Here’s my subjective experience with this medication.” And so, we now have the data. 

Now, the medical literature supports what women have been saying forever, which is that this can contribute to depression and anxiety. We now know that these are exogenous hormones do that in an important way. The earlier in adolescence, you might go on these hormones, potentially even the more profound and enduring impact that that might have, which is pretty disconcerting. Not to mention its impact on libido, which we do know. We do know that it causes your liver to secrete more sex hormone binding globulin, which then can bind up your androgen or your male sex hormone, which is responsible for libido and other things, energy, mood. And so, the last I checked the medical literature basically at six months and one year follow up of discontinuing the pill, you still have higher rates of sex hormone binding globulin, you still have lower rates of androgen, and we don’t have further follow up beyond that. So, we don’t know. Maybe our libido is permanently altered from taking the pill. We don’t know. But that’s an unacceptable thing, especially to do without informed consent. 

What I have realized around the birth control is that there’s a bigger public health conversation that we have around contraception, around women’s liberation. This can be life saving for a woman to be able to control her fertility and I’m fully on board and in support of that. But we just need a very nuanced and patient-centered conversation around all of the relative pros and cons of our different options. And birth control is not free. It can impact your gut health, it can deplete you of certain B vitamins and zinc, it can contribute to states of inflammation, impact your liver health, impact your libido, impact your mood. These are really big impacts. The ramifications of those changes, especially if you’re taking this for decades at a time, it’s immeasurable. 

What I think is important is that we’re at least expanding the conversation to talk about things like fertility awareness method and the different types of IUDs. And to just broaden the conversation, fertility awareness method is a tricky pickle, because if you’re in high school, if you’re in college, do you have the responsibility at that point to really use this method to make sure that you’re not having an unwanted pregnancy? I’m not so sure. I wish I could say yes, but I don’t know if we’ve empowered our young people in that way. But I certainly really love it. At this point in my life, in my 40s, I’m married, it wouldn’t be the end of the world to have an unwanted pregnancy. But basically, it’s a way that I control my fertility without exogenous hormones and it helps me be much more attuned to my cycle and my body. 

Yeah, I’m in my 40s and I’m now aware of, “Well, hey, this is my follicular phase. Let me book my speaking engagements during this time. I feel social, I feel energetic, I want to be outward facing.” And now, I give myself so much more compassion and grace in my luteal phase rather than taking on this idea of, “I’m bitchy, I’m the problem.” I recognize like, “No, this is me in my luteal phase and this is an internal orientation of my energy. I want to be at home resting, journaling, taking a bath. I don’t want to be out in the world.” And that’s not something wrong with me. That’s something right with my cycle. And so, to just live in sync with that is really helpful. I think for the longest time I was and I see many women, we mold ourselves into this 24-hour workaday world, that’s really based on more of the male physiology. And we try to shape ourselves into that. And I now try to shape my life into what my body is naturally doing over the course of a month.

Cynthia: I think it’s really important. I always say that we need to stop apologizing for our physiology. I think we as women consistently feel we have to apologize, “Oh, I got my menstrual cycle.” “Oh, I’m sorry. I’m feeling I’ve seen PMs,” or, “I’m craving these crazy cravings.” And just acknowledging that our hormones until we go into menopause are fluctuating day to day, week to week throughout our menstrual cycle, if we’re not on synthetic hormones that are suppressing the normal communication pathways. And as it pertains to women in middle age, so women in perimenopause, depending on who you talk to 10 to 15 years before menopause, and lower levels of progesterone made by our ovaries, and the net impact that many women are starting to struggle with sleep, and they’re having more anxiety, and maybe some more depression, and they’re being told to be put on oral contraceptives, or an IUD, or an ablation, let’s just take everything out. 

And I say this, because this happened to me, “But we’ll just take your uterus out. You don’t need it anymore.” And it’s so grateful that I completely, all four of those options were not an option. But understanding that as we are navigating different stages in our lives, women may experience more or less anxiety or depression or other types of uncomfortable feelings and I’m sure they probably see you for.

Ellen: Perimenopause is tricky. Part of the reason it’s tricky, with everything else in the body, I really operate from an ancestral lens of, we evolved under certain circumstances, we’re living in modern life in very different circumstances. If something’s broken in the body, let’s try to approximate those older circumstances and then the body knows what to do with that. Perimenopause is very different. It is by definition post reproductive. And so, there is no way to have had survival of the fittest and to have selected for beneficial adaptations to menopause, because if there was one woman who happened to have a lucky mutation, that meant she had a really lovely menopause. Well, that can’t be selected for, because it did not help her in her reproductive years. And so, it can’t be selected for.

It’s tricky, and there’s no way to fully fix our circumstances. I think it’s another case of rather than trying to shame ourselves, pathologize ourselves, feel like we’re the problem, can we recognize, this is a profound change happening in our body, happening infuriatingly unpredictable ways? Can we actually just give our have space in our lives to adapt to the changes? That sometimes means time for a nap during a day or time for being able to just do less. And sometimes, it means communicating to the people in our lives. “Hey, I’m not feeling myself right now. I’m feeling irritable. I apologize if I’m not the kindest version of myself. Give me some extra, maybe a little patience right now.” And I think that it is important to point out two things here. 

One is that, I think that whole PMS bitchiness, we have a real patriarchal cultural idea around like, “Oh, she’s out of her mind. She’s PMsing.” Let’s be clear. It does not actually affect our judgment. It just affects our ability to tolerate bullshit. And so, it’s not we’re suddenly saying things that aren’t true. We’re actually suddenly saying things that were always true, but we were so estrogenic in our follicular phase that we’re like, “Oh, that true injustice in my life? Yeah, no big deal.” In our PMS phase, like we are, it’s truth serum. We’re like, “You know what? Actually, this is not okay.” And so, it’s really something to honor and certainly not something to dismiss. 

And then I think with perimenopause, with the whole reproductive life of a woman’s cycle, in modern life, there is this, I think, biologic inevitability, which is that we have slightly higher estrogen levels because of all of our exposures to xenoestrogens from plastics, and pesticides, and birth control residue, and our tap water, and so on and so forth. And then we do have lowered levels of progesterone throughout our fertile years and perimenopause, partly because of pregnenolone steal, this concept that pregnenolone is the shared precursor for progesterone, but also cortisol, our stress hormone. For chronically stressed, every day, the body is saying, “You know what? Once again, have to triage this pregnenolone to go make cortisol. We have to deal with that. It’s a higher urgency.” And so, we have these higher estrogen levels and these lower progesterone levels, and I think all hell breaks loose as a result of that. So, it does make our perimenopausal years harder, and there are things we can do to support both, and it’s things your audience is familiar with. 

Trashing all of the endocrine disrupting substances and supporting our body’s ability to metabolize, the estrogen metabolites with things like dry skin brushing, and supporting liver health, and sweating in sauna, and maybe even a coffee enema, and then supporting progesterone through consuming cholesterol in the diet, and managing stress, and just all of the nutrient dense juiciness that we need to give ourselves, the raw materials to build these steroid based hormones. 

Cynthia: That’s really important. And one hormone in particular that I think of in that hormone hierarchy is oxytocin. I jokingly say, my kids are in an age where they don’t love the hugs, so my husband probably gets more and the dogs. But a little bit of oxytocin can help lower cortisol. When you’re feeling stressed and feeling overwhelmed, I just have to reflect on, what are the quick fixes I can make? And so, that something as simple as hugging someone you love, canine or otherwise can be very, very therapeutic, but it doesn’t last for very long. So, I would say, you have to get those hits throughout the day. I have one dog in particular who loves being snuggled with. And so, he gets a lot of snuggles during the day. 

Ellen: And pleasure has a role here. I think pleasure actually pertains to hormone balance in ways that I can’t biologically explain, but I think it’s true. I had a patient I was talking to yesterday. She was like, “You know what? If I get the career and if I’m in a good financial state, and then if, if, if, if, if, then I deserve a couple of minutes of pleasure.” And we arrived at this insight together. No, pleasure now, pleasure always. Pleasure for its own sake in its own right, we are inherently worthy of that. And so, whether that’s physical intimacy with a partner, or a self-pleasuring practice, or dancing, or chocolate, or opera, or whatever is your source of pleasure, and all of the above to make sure that that’s actually also part of our so-called wellness routine. And maybe take it out of that more sterile idea of like, “We’re not doing this in the name of self-care. We’re doing this in the name of self-love.”

Cynthia: Wow, that’s absolutely beautiful. I don’t think I could end the podcast any different light. Dr. Vora, let us know how we can connect with you on social media, where to get your book, which I highly recommend. I really, really enjoyed it, and I’m not just saying that because of interviewing you, I just thoroughly enjoyed the message and the language, and your approach to mental-emotional health from very unique lenses.

Ellen: Oh, thank you, Cynthia. On social media, I’m @ellenvoramd. And the book is called The Anatomy of Anxiety. And so, I hope that anybody who resonates with any of this message or struggling with anxiety can find it helpful.

Cynthia: Awesome. Thank you so much for your time. 

Ellen: Thank you. 

Cynthia: If you love this podcast episode, please leave a rating and review, subscribe, and tell a friend.