EPI 247: Overcoming Anxiety Without Medication & Living Your Best Life. With Psychiatrist Dr. Ellen Vora

Welcome back to another episode of the Peak Performance Life podcast. Today, I am very excited to introduce you to Dr. Ellen Vora. She is a board certified psychiatrist, acupuncturist and yoga teacher and the author of the Anatomy of Anxiety, understanding and overcoming the body's fear response. So that's a book that we're going to talk about today as well as many of the other things. She takes a functional medicine approach to mental health. I absolutely love that. She considers the whole person and addressing imbalance at the root. Dr. Vora received her BA from Yale University and her MD from Columbia University. Dr. Vora, thank you so much for joining us here today. Thank you so much for having me, Talor. Yeah, I'm really excited to jump into this. We've kind of done a couple episodes recently on mental health and things of that nature. We've recorded almost 250 podcast episodes here, and we've talked a lot about fitness and losing weight and health and all that strength training and all that kind of stuff. But I always say that mental health is the most important part. And there's also kind of something that I always think about is if we all know what to do, why aren't we doing it? And so the psychology behind that and being in a good mental health where you're motivated, feeling good, have a desire to live life and do things and accomplish things. So I'm really excited for this conversation here today. Already in what you've said, I have so much to say. Yes, well, let's, well, I want to jump into it. Why don't we start with just a real quick background to bring people up to speed and how you got interested in the work that you're doing today in the book that you wrote? Sure. I started on a very conventional path. I was in med school and psychiatry residency, but anybody who ends up taking a sharp left turn into the functional world or any kind of holistic approach to medicine, it's usually some combination of a personal story or some big moment of disenchantment. And I had a lot of both along the journey of my training, but on the one hand, I was myself really unwell. And I was thinking, I know how to do everything right because here I am in medical school. So I'm running long distances and eating skinless chicken breast and low fat dairy. And yet why am I getting sicker and sicker? And it didn't really make sense. And so I had my own personal journey happening in parallel with a lot of disenchantment that I experienced through my training. And there were just different head scratching moments, but it was really when I started to study Chinese medicine and acupuncture in my last year of med school. And where you see these Eastern modalities that see the whole body as an interconnected web, rather than the way we see things in Western medicine as these isolated, separate, discreet organs. And to me, that felt like, oh, we just got it wrong. And yet in Western medicine, we are getting increasingly hyper specialized. And I often like to joke that your gastroenterologist or your gut and your brain are talking to each other, even if your gastroenterologist and your psychiatrist are not. And so that was an aha moment for me, was to understand the body as an interconnected system, rather than isolated organs. We're never going to look at just the brain because it's embedded within a system where everything happening in the physical body is directly impacting our brain and therefore our mental health. Yes, yes, very well said. I'm curious, and many listeners may be as well, we hear Chinese medicine or Eastern medicine and acupuncture. Tell us a little bit, what did you learn when you went from those fields of health? It would be hard to summarize that, but it's basically, I mean, I think some general takeaways are the, even the yin yang, that ancient Taoist symbol, that alone is a lifetime of study and understanding of how we have this dynamic equilibrium between these two opposing energies. And yang, the basics are that this is more masculine sun energy, it's action, it's doing its productivity. It's the part that our world is obsessed with. So we love yang here. And then you also have this pesky other 50% of the overall way, which is yin, which is moon, feminine energy, rest, receptivity, surrender, non-doing. And I think that's where we get tripped up as modern humans, is that we don't value yin, we don't carve out time or permission to be in the yin. And anytime we do happen to touch a yin aspect of our lives, we usually have negative self-talk about it afterward. We're like, let's say you relaxed all day, then later we'd say, I was so lazy, I wasn't productive, I didn't accomplish anything today. So we don't just recognize the inherent value of rest and non-doing. And that's where we've become very much human doings rather than human beings. I love that. I've never heard anyone explain it like that. So I really am happy to hear that. And I do, I've seen that as well. The people who can have a good balance between those two, and be able to do things in the real world, but also stay calm, have practices that help ground them and do things like that. I think it's a really important distinction there that you mentioned. So great. So we talked a little bit about that in your background. Now, let's talk a little bit about your book and the issues with anxieties. Obviously, never been a bigger topic than it is today. I guess maybe what are some of the reasons that anxiety has become more and more has grown so much, it seems like it doesn't seem like we had it quite as much many years ago, or even when I was growing up, I don't know if electronics or just this constant feeding of news and information is contributing to it. But we'd love to get into what's been contributing to it. And then we'll get into what we can do about it. Yeah, I think of anxiety as what I call the pH of our age. Like if you dropped a litmus strip into this stew that we're operating in, the pH is one of anxiety. That's where we go when we feel subjectively not at ease. And I think that there's a lot that goes into it. And it'd be hard to describe my reasoning for why it's increased without taking a step back and really talking about the central thesis of my book. And so my book, The Anatomy of Anxiety, I really believe that how I was trained to think about anxiety has done a disservice to my patients. And I don't think it's actually been the most useful way to navigate treatment decisions. And so I was taught to think about anxiety as there's obsessive compulsive disorder, there's generalized anxiety, panic disorder with or without a goryphobia and all of these different classifications. What I've come to observe in my practice is that the meaningful categorization, the one that changes management is whether somebody has what I call false anxiety or true anxiety. And those terms I recognize now can be a little invalidating and triggering. There's nothing false anxiety is perfectly real. It's it's a very life altering, strong experience. The reason I call it false is that it doesn't need to be happening. It's a result of physical imbalance and so much of anxiety. Is the result of physical imbalance. And if we can identify what's got the body out of balance and if we address it on that level of the physical body, then we can eliminate all of this unnecessary suffering. So that's our false anxiety. And that's, of course, increasing in the modern world. And we have our true anxiety on the other hand, which is completely different. And that's could also be thought of sometimes I call false anxiety, avoidable anxiety. Sometimes I call true anxiety, purposeful anxiety. This is not because our blood sugar is crashing or we're breathing through the mouth and sleep deprived. This is our inner compass nudging us and it's saying something's out of balance. Whether that's in our personal lives, our communities, the world at large. This is a part of us that's nudging and saying something's out of alignment. You need to show up and help course correct. And that's where the question is no longer, how can I stop feeling so anxious? And the question changes to what is my anxiety telling me? What do I do with that information? Once we start to let that fuel purposeful action, once we're mobilized, we don't feel so stuck in the feeling of anxiety anymore. Then we're imbued with purpose where we're cooking with gas at that point. I love that. I absolutely love that. Let's let's jump into the false anxiety. Right. Because this is something that could potentially someone listening to this podcast right now. By the end of this episode, maybe they learn something where they can change that and get rid of that false anxiety. So we'd love to hear about like what are the most common things that are causing this false anxiety and what are some things we can do to kind of change that? Yeah. So I can't help myself, but take two steps back also and just say with the way we've taught, we've been taught to think about mental health. We're very focused on the neck up. We talk about serotonin. We think of mental health conditions like depression, like anxiety, as genetic chemical imbalances. And I think we got that largely wrong. And a reframe is to recognize mental health is physical health for the most part. We still have our unresolved trauma. We still have our social issues. We still have our true anxiety, but so many of the ways that we suffer in our mental health is related to the physical body. And even these conditions like depression, like anxiety, I don't think of that as a diagnosis. Those are symptoms. Those are the ways the body is communicating in balance. And I think of anxiety as it's not the final verdict. It's the beginning of the inquiry. And so when someone's anxious, I'm thinking about how is their physical body out of balance? And it can there are a few very common ones that I see all the time. Blood sugar regulation is an enormous factor when it comes to anxiety. And we come by this honestly, because in the modern landscape, a lot of us are dysglycemic, where our bodies have a hard time managing blood sugar. And our food landscape is one of refined carbohydrates and coffee drinks that are secretly milkshakes and rose all day. So we're on this blood sugar roller coaster. And when it spikes, we end up crashes. And then because of the insulin effects and then in that crash, it generates a stress response. And that stress response can feel identical to what we call anxiety. It can even feel identical to a panic attack. And I have had endless patients where they're having life altering anxiety. It's incredibly negatively impacting their quality of life. And the salve for it has been managing their blood sugar. And they can walk away from sometimes a decade of panic disorder just by stabilizing blood sugar. So it's that it's always where I start. Because when that does happen to be the silver bullet for someone, it's life changing. It's quick. It's generally free and it is so impactful. So that's one common one I see. Yeah, that's huge. It's so huge. You know, I have a teenage daughter and I've realized not to try to have any deep and meaningful conversation with her on the ride home from school until after she's eaten. Right. I noticed that like, you know, she can. There's certainly something there when and so in that case, maybe her blood sugar is low, probably for adults, most people's blood sugar too high, either way, balancing it and having, you know, feeling kind of that consistent good energy throughout the day is really important. So what tips do you have for people? I would say for adults, it's probably more of the higher, although again, if you don't eat for a long time and you're not really well adapted to going long periods of time without food or you're eating a lot of carbohydrates and, you know, you maybe can't go 10, 12 hours without eating and that could be a problem as well. But I guess balancing blood sugar, what have you seen as some keys for balancing blood sugar that you've seen help your patients? Yeah. So ultimately you want to build towards a place where your fuel sources are your meals are anchored with protein and anchored with healthy fats, where the blood sugar isn't swinging wildly, where you're not in a state of insulin resistance. And even where you train your body to have metabolic flexibility so it can handle some low blood sugar without creating anger or what I call anxiety. And, but then in the near term, before you're able to definitively solve this at, you know, bringing everything down to the studs, what I want people to do is have little quick hacks for giving them a safety net of blood sugar. So I have patients who are in no position to overhaul their diet. That's not happening. It's they don't feel like they have capacity right now. But just having them bring a jar of almond butter to their desk at work or even in their backpack at school and almond butter is probably not a good idea for a school environment where there's a lot of nut allergies, but sesame, sesame seed butter can also work. But then and then also having it on the bedside table where you take a spoonful before you're anticipating a predictable blood sugar crash. So I have a lot of patients who a high risk time for them with their anxiety is their commute home. And they're on their way home. They're freestanding on the subway. I'm based in New York City, so it's a lot of subway commuting. And that's where they start to feel that brewing, crescendoing sense of dread. And suddenly their heart is racing and they're sweating and they're feeling like it's going zero to 60. And that is often triggered by a blood sugar crash and just taking a spoonful of almond butter, a sip of water before they leave the office gives them a safety net of blood sugar. It's like the floor is only so low then and they can make it home, start chopping onion, make dinner without going into a full blown panic or without picking a fight with their partner when they walk in the door. So that's very impactful and doing the same thing right before bed because ultimately you want to get to a point where someone can manage their blood sugar overnight. But at least in the near term, I love for someone to take a spoonful of that sip of water right before they brush their teeth so that their blood sugar stays solid overnight and they can sleep through the night. Interesting. Yeah. So I've heard of that, but I haven't heard too many people talk about that. So healthy fats at night can kind of, especially if you're hungry for me, if I'm very, very hungry, it's a little harder for me to kind of fall asleep and have a good night's sleep. Whereas just having a little bit of some healthy fat in there can help kind of stabilize throughout the night. I like that. That's right. Yeah. You don't want to, and some people can even start to recognize there's different types of insomnia. There's different reasons the body is awake in the middle of the night. And especially my perimenopausal female population, there's a unique low progesterone, luteal phase, middle of the night, wake up that it's its own quality of insomnia. But there's a different feeling to a blood sugar crash induced insomnia. And there's a feeling of uneasiness and almost like a, we would call it acathesia and psychiatry, but like a wanting to jump out of your skin a little bit, like your body's antsy. And if you notice that in the middle of the night, you might even want to ask yourself the question, like, am I hungry? And if your body's like, actually, yes, like a bacon cheeseburger, it sounds great right now. Then you just take a spoonful of something and it can be almond butter. It could be even a little bit of ghee or a handful of nuts. It could be a hard boiled egg, yogurt. It can, I often use honey, manuka honey, which is sort of runs counter to the overall thought of stick to protein and fat. But I find that honey is actually a really useful overnight source of stable blood sugar. Yeah. So most of the things you mentioned, by the way, I'm a big fan of manuka honey as well. It's probably one of my only sources of like sugar and carbs that I really take in. And it is kind of counterintuitive because it is high sugar, high carb, but it doesn't seem to have the same blood sugar spiking effects as, as, you know, actual sugar or carbs or things of that nature. Right. That's what I find in my practice. And so I can't exactly point to the science of why is this not problematic and sending us on a blood sugar roller coaster. But I find that it's a very useful tool for supporting sleep. Yeah. Yeah. Everything else you mentioned, just to be clear for the listeners, because it might be counter to many of the things they're saying, right, everyone's saying, don't eat for three, four hours before bed, whatever the case may be. And so we're not saying to eat anything that's specifically, especially high carb. You don't want to go eat a bowl of pasta. You probably don't even want to eat, you know, bananas or, or, or things like that for the most part, carbs and things like that. Because that's not going to, it's the healthy fats that can help you keep kind of the state won't spike your blood sugar. Right. And that's kind of why you're focusing on the fats at night if you're going to eat something. Right. That's right. And this is not something that's going to pull a lot of blood flow to the digestive tract. This is something very light and small and even honey uniquely has a different behavior with the portohepatic circulation. So it's even burdening your body less than something healthy, fat and proteinaceous. But it's really just giving you that stable blood sugar overnight in a way that's not the forever solution. But it is a very helpful tool to use upfront while you're getting rid the Alice like training your body to have that metabolic flexibility. And, and we're just all so different. I think for male physiology, training the body to not eat for three hours before bedtime is a worthy goal. And I almost always work towards that. For women of reproductive age, I have an entirely different and more nuanced set of goals. And in the luteal phase, especially if someone gets more perimenopausal or especially if they're in any state of depletion, that's not the goal for me at all. And I still don't want a big, heavy stomach or refined carbohydrate effect overnight. But I'm really looking to create a signal of abundance and safety in that female physiology to provide for better sleep. So I think it's a different equation. Yeah, it makes a lot of sense. And I think there's even been a lot of recent studies showing how for women intermittent fasting, maybe you want to do for a shorter period if at all, right? Maybe going 18 hours for a woman is not the same as going 18 hours for a man, you know, without eating. So yeah, that's good, good, good points there. And I think intermittent fasting and cold plunging, if at all, it's a follicular phase activity for a postmenopausal woman. Go for it. I don't think it's something we need to sync up with. There isn't a cycle to sync it up with. But for reproductive age women, follicular phase, if at all. And you really want to listen for when is your body interpreting this as a signal of this is a time of scarcity. Because I think the female physiology is always scanning the physiologic horizon and looking for is this a good time to conceive? And part of the how it answers that question has to do with nutritional and caloric abundance. And when you're sending a signal of a fast for 18 hours, that's fine. It has other benefits, especially in this modern world with a super abundance of of calorically dense foods. But that's a body that's starting to see, OK, there is some scarcity right now. No problem. I'm just going to suppress ovulation so that we don't conceive right now. So the body has its checks and balances and its mechanisms. And it's how it protected us from conceiving on the savannah in times of nutritional scarcity. But in modern life, if you're lucky enough to not have nutritional scarcity, what that ends up meaning is your cycle starts getting wonky, your hormones start getting all over the place. It doesn't feel very good. And so most of us don't want to mess with ovulation. And part of how we do that is sending a signal of nutritional abundance. Yeah, good stuff. And the last thing I want to point out about what you just said before we move on is the importance of planning ahead, putting yourself in a situation where you can succeed. I see so many people, for example, they're like, oh, I'm traveling and I'm like me when I travel, I go to the airport. I bring my, you know, grass fed venison jerky sticks and my bag of macadamia nuts. And I know, like in my mind, I'm not eating at the airport because I haven't yet found anything healthy. Maybe maybe there's a couple of airports in the country that have one or two good things, but it's very rare. So I'm planning ahead. I'm bringing that stuff. I'm knowing, hey, okay, it's been five, six hours now since I've eaten. Maybe I'm going to have some nuts here and try to get ahead of this so I don't run into this situation. So I think it can't be understated how planning ahead and setting yourself up for success instead of failure is just a big, easy thing that people can do that many people just don't. Well, planning ahead is so good. But even that planning becomes another to do and another thing that we can get right or wrong. So I think you want to remove the friction even from the planning ahead. Part of what I've learned to do is buy in bulk bags of grass fed jerky that I deem good quality. And then I put them in my suitcase, even when they arrive from, you know, in the mail and then that's ready then. And it removes any step of like, oh, I have to remember this other thing. And it's just already ready. But I think that especially in an audience where people are being intentional about their nutrition, their health, their lifestyle, their habits, I always want to counterbalance. And like, we all deserve all of this information and we want to know how to be intentional with how we feed ourselves. But then there are going to be times when we can't do it properly. And that's when we need to switch our mindset out of like this orthorexic trigger of like, no, but it had to be perfect into our body is not that fragile. And sometimes we're going to have the burger at the airport and don't overthink it. And I think that that's an important tool to be able to pull out when necessary as well, which I wouldn't say to an audience that needs the information around how to plan ahead and eat well at the airport. But once in a while, I see that we swing too far in the other direction. And then we're white knuckling and the stress and fear and even the excessive concern about how to do this right can become its own source of putting a lot of cortisol in our bloodstream and not really doing us any favors. Yeah, I love that. I actually had someone who's he's also very into health. So I think he could say this, but he said to me something like we were he was he was in Vegas and and you know, there wasn't any real. He didn't have any of his own food or anything. He was eating out. And he said something like, look, he's like, I'm either eating healthy or it's hormesis. Right. That's the way he was looking at it. He's like, well, you know, I eat healthy most of the time. So today when I don't eat healthy, it's going to be hormesis and my body's going to be less fragile when I'm done with it. So I think that's a great way of looking at it. That's a perfect frame shift. Yes. Yes. Yeah, absolutely. So just what else are people for listeners right now? What are some again, like you mentioned, like the blood sugar crashing and things like that. In terms of diet, what are some of the things where you've seen, you know, people are not eating, I would imagine for women, maybe they're not eating enough protein, for example. Are there any other examples like that that you would point out as well? Yeah. So I think so with nutrition, it's money in the bank because most of us aren't doing it quite right. And your audience largely probably doing it pretty right. But what I see in the population is that there's so many quick wins. Often it's not enough protein. Often it's not enough fat. And I think we're living in the wake of decades where we were taught to say fat was the problem. I think that we were taught there and there was industry interest driving this conversation. But we were taught to think that the operative distinction in fat was between saturated fat and unsaturated fat. And I don't believe that that's true. I think the more meaningful distinction is between man made fat and naturally occurring fats that humans have consumed for millennia. And we're all a little different. We have different ancestry, so I don't think it's one size fits all. But for the most part, if there is a fat out there, even if it's a saturated fat that your ancestors were consuming, your body probably does pretty well with it. Within reason, you don't necessarily need to like melt down and drink it by the gallon. But I usually encourage people to be more liberal with and I say healthy fats. But when I use that term, I know people are envisioning olive oil and avocado. And I mean a much broader list that includes red meat, that includes eating the fat on the chicken or on the fish, that includes grass, fed, butter and ghee. And so it's a very delicious approach to healthy eating. And I think a lot of people are missing micronutrients. This is really common in anxiety. And sometimes it's folate or B12. Sometimes it's zinc or magnesium. And we're also living in, I think, a pretty dysfunctional understanding of food. And we're always trying to do things like maintain lower weight or eat what's cheap and available. And there's just all these different ways that we've lost connection to. Every bite is an opportunity to check some boxes on that nutritional scavenger hunt. We want nutrient density and we want a variety of different nutrient dense foods. And so I think, you know, if we had our great-great-great-great-great-great-great-grandmothers feeding us, they would say, yes, eat this part of the animal and balance it with this type of tuber. And they're really thinking about balance and nutrient density. So we're missing a lot of micronutrients. And I'll throw out there, I also see a lot of anxiety from people that are underweight. And I think that we have a cultural message that tells us, here's what a desirable body looks like. and people can sometimes do heroics to work against gravity and work against nature and get their body to that state. And then they've achieved it. It's a very high effort state to be in. It's not a default setting. It requires a lot of restriction. But they're anxious as a result because even though they might think to themselves, I look good and I fit into these pants that I wanted to fit into, what their body is thinking is, we're in a danger territory. This is like we need more padding to know that we're safe. So I think often it's really just chronic anxiety as a result of effortfully keeping the body in a way that we think looks good, but isn't where the body wants to be. Yeah, I completely agree with that. I'm thinking back to when I was in high school and college and just being everyone was obsessed with like how ripped you could be or something like that. And these days when someone's like, oh, like, wouldn't you want to get down to like, you know, seven, eight percent body fat or something like that. And I'm like, you know, I'm pretty happy at 10. You know, feels good, feels right. You know, I eat when I'm hungry. I'm not starving myself. I feel good. And that's for men, obviously for women, it's going to be much different in terms of body fat percentages and things like that. But yeah, it's like, I don't need to be extremely super ripped when it's going to be, again, so kind of demanding from both a physical and a mental standpoint to do that to my body. And you mentioned something else right before that, which was really good as well is the deficiencies. And so would you recommend, and we haven't really got into like antidepressants and things like that, but like before someone was to go on an antidepressant, would you recommend they get a blood test and see if there's something that they're clearly kind of deficient in? Yeah, there's a lot of things I want someone to do before they start an antidepressant. But I think that it's yes and no. I think I hate putting barriers to someone just taking the steps that we know are going to be beneficial. So you could read a book and start feeding yourself better today, and you don't need any blood work to know that eating real food, avoiding fake food, reaching for nutrient-dense foods is going to be a good thing to do. It'll have benefits with your physical and mental health. But if you're feeling stuck, if you feel like you were doing it right, but something's still not working, I think blood work can be a really useful step in a mental health journey, because maybe you have an MTHFR mutation, maybe there's some way that a regular healthy diet isn't perfectly working for your body. Maybe it's leaky gut and your diet is good, but there's old damage to the gut lining that needs more concentrated, focused healing before you can even absorb the nutrients of your good diet. So I think that you start with the fundamentals first, no barrier to entry. And then if you feel like you do need to go deeper, a little basic blood work, looking at folate, B12, high sensitivity CRP, homocysteine, magnesium, zinc levels, and a CBC and a BMP, just throw in the basics and how your body's managing and slitting. Blood sugar are all useful things to look at. But I think that that's a further down the process step, and many of my patients don't even need to get to that point. Just by eating a balanced nutrient dense diet, they're addressing those micronutrient deficiencies, whether or not we actually objectively demonstrate that you can tell and how they feel. Yeah. Yeah. So what are some of the foods specifically that you would avoid? Or you would have someone potentially avoid? Or let's say someone comes into your office, they're a first time patient, they say, look, I've been feeling depressed, haven't been feeling good. I have some anxiety. Where would you start and what kind of things would you look to eliminate if they had it in their diet first? Well, I mean, the political thing to say here is ultra-processed foods and that alone. And then if someone is a vegetarian or a vegan because they believe it's the healthy choice, I usually want to disabuse them of that notion. Now, if someone's a vegetarian or a vegan for ethical reasons, environmental considerations, religious reasons, like I don't touch that, I honor that. But if they have a belief that this is the healthiest way to support their body, I usually want to show them a different way to think about that. I am a bit of a walking cliche in that I think most of us in the United States don't do great with conventional gluten. Some people do okay with it. Some people have found a healthy balance where they're consuming the farmer's market organic bougie long fermented sardo. And if that's really how you're consuming your gluten, good for you. But for the most part, you almost have to be mentally one-zero about gluten or else it slips in everywhere. And so if you are not gluten-free, then you're going to be at an event and there'll be past order and that's not such good quality gluten. Or you'll be at a kid's birthday party or wherever and it comes through and conventional gluten I think does set people down some bad physical and mental paths pretty quickly, both in how it's disruptive to our gut flora and to our gut lining, ceding the conditions for leaky gut, even in many ways ceding the conditions for an immune response against gluten, which then can make us more reactive to it down the road because it's a bit of a one-two punch of here's the gluten packaged with Roundup that creates the leaky gut so it gets into our bloodstream and then now we have antibodies against it. So a lot of us don't do well with gluten, conventional gluten in the United States, but I won't say I take it away from everyone because I've learned the hard way. I'm playing the long game and if I just come at everybody right away saying, okay, you're gluten-free now, I don't keep people along for the whole ride. Yeah, yeah, I've yet to hear a compelling argument as to why we should, the benefits of eating gluten. So yeah, gotta agree with you there. So we're getting rid of ultra-processed foods ideally, getting rid of gluten ideally, but not being so forceful with it or whatever with your clients, obviously playing the long game here. I know you've mentioned caffeine before. I've heard you talk about caffeine and sleep as two important things and I agree as well. I mean, personally, I drink one big cup of coffee in the morning, but that's it for the day and I started to notice that in the afternoons previously, even a cup of decaf, for me, I'm very sensitive to it. Even a cup of decaf, I could feel tightness in my jaw sometimes. I could feel a little bit like I'm a little antsy and so I've just completely now gotten to the point where I've completely cut it out, but your opinions on caffeine and sleep. Yeah, so caffeine, nuance. Basically I'm no longer, I used to be a little bit more aggressive about it. I'm not taking caffeine away from people. I want to open people's eyes to the fact that this is having a real impact on your anxiety levels. But you might give me anxiety if you say I can't have caffeine, sir. Exactly the problem. So we're always delicately playing the long game. I think that there's benefit to a cup of coffee in the morning. Coffee is a source of magnesium and antioxidants. There is really compelling data about risk for type 2 diabetes and Parkinson's and even suicide going down with coffee consumption. Coffee has its own polyphenols and benefits. So I'm not anti these substances and we're all just so different in how we metabolize them. There are some rapid metabolizers out there who can have the decaf or even the calf in the afternoon and be fine. And then someone like you or me, like I'm very sensitive, a slow metabolizer. If I had coffee yesterday afternoon, I'm still acting like I'm on cocaine talking about it and not sleeping tonight. So we just need to know ourselves, but for all of us it has a decently long half life of around five to seven hours. So cutting it off around 11 a.m. maybe noon is a great rule of thumb for most of us because we don't realize that we are effectively having half of a cup of coffee at 9 p.m. if we're having it at 3 p.m. And so just to be empowered with that information, keep the coffee, keep the ritual, keep the joy, but just manage the caffeine milligram that you're consuming and when. So for me, I use the Purity brand and I use their two thirds cup and then I mean it's pretty intense, but in the morning I use one scoop of two third caffeinated coffee and one scoop of decaf and that's my cup of coffee in the morning. And I love it and it gives me all the benefits of coffee, but it's not a lot of caffeine and that has been a happy medium for me. So I just want people to look with an eye towards what's the right amount of caffeine while we keep that ritual. Sleep which connects to this. Sleep is the place I start because really nothing can work properly in the physical health and the mental health without good sleep. And most of us know we subjectively we want to sleep better, we want it to come more easily and to be more efficient and to wake up rested, but for the most part we don't know how to do that and I think light is one of the most impactful places to start and it's just recognizing that that's the design. We have a clock in our brain, the super charismatic nucleus and it's not connected to a cell tower, that's not how it knows what time of day it is, it's just connected to our eyeballs. So it's our internal clock is being queued by the light coming in through our eyes and on the proverbial savannah of evolution that was foolproof, we couldn't get that wrong. But these days evolution didn't anticipate the plot twist which is that we were going to harness electricity and invent the light bulb and eventually the iPhone and then now none of us can sleep anymore. And so the solution is just to try to approximate more savannah light cues in our modern world and that's not completely easy to do, it's not impossible. We generally want a circadian walk first thing in the morning, getting some kind of sunshine into our eyeballs, starts the clock, makes us feel awake and alert during the day but then also ticks in the background setting us up to get tired at night. And then everything after sunset I think matters a lot. We want flux on our computers and night shift mode on our phones but I think it's also worth wearing a pair of blue blocking glasses in the evening so that we're not taking in blue spectrum light, suppressing our melatonin and making it really difficult to get tired at the right time. And I would say the only other thing that I want all my patients to do is not keep their phone in their bedroom at night. And if someone pushes back and they're like, but, but, but I need to like even just keeping it in ear shot but not arms reach makes a big difference. Yeah, yeah, really good pieces of advice. And I definitely have a morning routine where I like to get out. Luckily I live in Vegas so I get a lot of sunlight pretty much all year round. I like to go outside every morning and get some sunlight early in the morning before 9am. And I can see it just not only for my sleep. I've been sleeping great. I've had great sleep scores the last year, but just I don't know. I feel better. My mood just when I get a little bit of sunlight when I get outdoors when I, you know, I can't imagine just waking up and you know, having turning all the lights on and it being all dark like I want to wake up when the sun rises. I want to open all the shades and get natural light. I want to go outside and get some sunlight on me. And it just for me, it does something for my mood as well. I can't explain it. I don't know if we know exactly what it does, but certainly all the advice you gave there and then yeah, blue light blocking glasses as well. These days when I don't have my blue light blocking glasses at night, I'm like, oh, it's so bright. Can we turn down the lights? So I've kind of got used to them and certainly agree that those help at night as well. Yeah. I think we're kindred spirits with all these different practices. Yes, yes. So what else do you talk about in your book? I know we don't have too much time left, but I want to make sure people kind of get a full picture here of kind of what they'll learn about when they go through your book. Yeah. So that false anxiety, first half of the book, we talk about what we've already covered and then there is a discussion about the gut and the immune system and inflammation in general and movement. But then the second half of the book where I focus on true anxiety and purposeful anxiety, that's a whole other approach. That's where on the one hand I'm looking at unresolved trauma and looking at trauma-focused therapies and how we can bring that to resolution, but also these fundamental psychospiritual needs that we have as human beings that often go unmet in the modern environment. We need community. We know this from long-term meta-analyses that human happiness tracks with the quality of our relationships, full stop, but our lives are often not set up for that. So how do we prioritize that? And orient our lives around that being the first thing is that we live in community and we know how to identify the people that enrich our lives that are affirming that are filling our cup and how we make sure that our life actually has that on a daily basis, which is hard to do. And then we have needs for purpose, for meaning, for feeling that we're being of service and making our unique contribution. I think we just need to acknowledge that in mental health. And there's a conversation to be had around spirituality as well. For me, this connects to what I call the inherent fragility of walking this earth in a human body, the fact that this whole thing is impermanent, that we do lose the people that we love, that we do the way our lives unfold. We don't always get what we want. And we need some relationship to that that ends up being a protective and stabilizing mental outlook. And I'm not here to proselytize any one particular view of that. But I think we all deserve to at least spend some time with those questions. For me, I know I've needed to, in the wake of grief, I've really needed to have a relationship of trust and surrender to the unfoldings of life rather than the feeling of I'm in resistance to reality. For me, grief actually ended up exploding a whole new world view where I started to see this universe as vastly beyond our comprehension and quite charmed and a little bit magical. So that's been really helpful for me. That's given me meaning and comfort and guidance and reason for less fear and less need for control. So that's my second book, which comes out in October, which is completely different from the Anatomy of Anxiety. But this book that's coming out soon is called Season of the Witch. And it's really about that experience of grappling with these more spiritual questions. Yeah, I absolutely love that. Everything you said there, community, spirituality. For me, when I lost someone that was very close to me, I literally, the thing that got me through it probably more than anything was saying the word acceptance over and over, acceptance. Accepting, you know, just I have to accept there's nothing I can do. It's over. It's done. How I have to accept this. And so obviously it takes time. But but yeah, I think that's that's something that's that's very important as well. Is there any type of therapy that you find that you maybe gravitate to or use more in your practice? Like I know there's a lot of studies on cognitive behavioral therapy or is there one particular type that you like or recommend to patients? So what I'm supposed to say is that, you know, the more evidence based modalities like cognitive behavioral therapy, but I actually am kind of the problem child in mental health and that free form psychiatry, like free form psychotherapy is actually where it's certainly how I practice and it's not anything reproducible. You can't really study it in the same way. So it's the Wild Wild West and I recognize how that comes with a lot of problems. But to me, the most critical thing that's happening in therapy is the relationship. It's the container. It's the opportunity for a reparative experience. And and it's the ongoing, steady relationship where you matter to somebody where somebody matters to you. And I think that's ultimately what's most therapeutic about it. So and with CBT, cognitive behavioral therapy, it made me think about a book I read by an author named Holly Whitaker and she wrote a book called Quit Like a Woman. And it was about how many things, but for her, it's her journey to sobriety and how she realized for herself that AA was actually undermining her sobriety process a bit, that it the way she describes it. I'll never say it as well as she writes it in the book, but basically, AA telling her, you're not God, let me write size you take your ego out of this, surrender to a higher power. She's like, for men, that message was medicine. And she said, for her, it was more of the same expletive that made her sick in the first place. And so I think that we always just have to discern for whom is this the right medicine. And sometimes CBT is absolutely the right medicine to identify and really reconsider automatic assumptions and automatic thoughts and distorted beliefs. But I find that sometimes it's actually an undermining medicine where somebody is already feeling gaslit and dismissed for their feelings and their beliefs. And now we have a whole therapeutic modality that's effectively doing something similar. And I'm usually airing more on the side of even if we cannot yet objectively point to why you're feeling the way you're feeling. I really want to give people permission to fully feel their feelings. We don't necessarily need to ascribe so much meaning to the feelings, but to fully feel them without ever feeling like, well, your feelings are wrong. So that's my take as CBT. It's the right, it's the best or the worst medicine for someone depending on where they're coming from. Yeah, yeah, it's a great answer. Every person is different. Every situation is different. And everyone needs to find what works for them. One last question I have for you. I have to ask about your opinion on antidepressants, SSRIs. We know there's been a huge growth in the number of not only adults, but now many, many children taking them. Would love to hear your opinion on them. Do you use them at all? Sometimes never. Yeah, so very rarely I will start someone on an antidepressant. I'm not dogmatically a no. Like if someone's already on a medication and they want to continue it, I'll prescribe that for them. More often what I'm trying to do when I first meet someone, if they have not already started a medication, my belief is that their depression, their anxiety is not a genetic chemical imbalance. It's not that fixed trait or this low serotonin. We now have this large umbrella review of the evidence, which really shows us that serotonin model of depression was never the thing. That's not actually what's occurring here. So I don't subscribe to that belief and I don't see depression as a quote, lexaprodeficiency disorder. But that said, I'm always trying to identify what is the root cause? What is the physical imbalance or the unmet psychospiritual need or the unresolved trauma or the social situation that's weathering someone psychologically. And so it's usually more that I want to get someone to a place where they're fully healed and we don't need to reach for that because it's not ever barking up the right tree for how we're approaching depression or anxiety. I also find that that oath that we take in medicine first do no harm. I take that very seriously and I have some concerns about antidepressants in terms of can I confidently say I'm doing no harm because what I've witnessed is three things in particular. One is that some people experience what's called PSSD or this sort of post effect where someone's having sexual dysfunction and that can sometimes be lasting. There's a lot of shame. There's a lot of stigma. There's not a lot of research. There's not a lot of clarity on that. But I never want to do that to somebody. And what I've witnessed many times firsthand in my practice is that should somebody want to or need to get off of a psychiatric medication, that can be a very difficult process. We don't have a lot of instruction around how to safely off-ramp people from these medications, but there can be a pretty harrowing withdrawal. And so I factor that in in that initial decision of whether or not this is doing no harm and also in terms of the full informed consent where someone can understand these are all the trade-offs of all the different options they have at hand. And the last thing I'll just say is that there's also something called interdose withdrawal. And this is relevant more so with medications like benzodiazepines, things like Xanax. But basically sometimes you're setting someone up for a roller coaster of intoxication withdrawal, intoxication withdrawal, even when it's just taken as prescribed. And it can entrench certain mental health issues. It can create new mental health issues. And so I think these medications can be so helpful. They can be an arm that's outstretched and pulls someone out of a dark place. And they can create a lot of downsides as well. So patients just deserve to understand that full spectrum of possibilities and make a true cost-benefit decision. Very well put. Very well said. Dr. Vorra, thank you so much for joining us. Where can people follow you, find you, learn more? I think you've got an email list. You give away some free stuff if people sign up. And then they can maybe be notified when your upcoming book comes out as well. That's right. Yeah, so my website is ellanvorra.com. And that's where someone can sign up. And I tend to not email very much, but I will notify people of special opportunities around the book and all that. But then I'm pretty active on Instagram. I'm at EllenvorraMD. And are you still working directly one-on-one at all with clients? I am. I still see patients. I don't, I'm not taking new patients at the moment. But that's part of why I write books is get that message out there in the world and accessible. And then I come into corporations and give talks and go to conferences. So that's another way someone can kind of quote work with me as if they want to bring me into their company and work with them in that way. Amazing. Well, this has been very educational. I'm sure the listeners have learned a lot. And I encourage them to reach out to you and follow you if they want to learn more. Thank you so much for joining us. And I hope we can do this again sometime. I hope so too. Thanks for having me. Thank you. Thank you for listening. 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