How do you assess risk?

For a long while now I have thought of risk in terms of intrinsic and extrinsic factors. For any given challenge, any individual (or collective) may have certain baseline predispositions for a certain consequence or outcome. The intersection of those innate properties with the external environment and conditions then create the actual outcome(s). This post is about self-awareness and self-regulation in service of mitigating risk in two situations: Infection and severe mental stress.

Infection

When was your last COVID vaccine? There have now been two booster vaccines available after the initial doses back in 2021. In the current endemic state of the virus, repeated vaccination feels less urgent than before. Some will continue to say ‘always’ or ‘never,’ but most of my patients want to discern more thoughtfully. I advise situationally. The following applies not just to COVID, but for any infection we may contract in the wild:

Intrinsic risk: What is your overall state of health? How many risk factors for infection and complication do you have (eg advanced age, respiratory illness, diabetes, other immune compromise)? What are your nutrition, exercise, and sleep habits, generally and now, and do they protect you or make you vulnerable (sleep deprivation and high mental stress increase risk)?

Extrinsic risk: What is your likelihood of exposure, in terms of intensity, duration, and novelty? What is your access to healthcare in case of severe illness? How would infection impact your function, livelihood, and the health and function of those around you (and what are their intrinsic risks, if you were to expose them)?

I did not get my second COVID booster until right before I traveled to Taiwan last month, even though it’s been available since last fall. It was mostly due to inconvenience, though I also did not want to spend a whole day in bed (my reaction to this vaccine), and I assessed my risk of infection and complication to be low. Then Husband got infected at the same time that Friend told me all about her severe and prolonged experience with long COVID, and I learned that cases in Taiwan were still fruequent and severe. I would be traveling alone with Daughter, who has asthma, spending 20+ hours each way and all days in country in crowded airports and public spaces. So while I had no overt intrinsic health risks, I was moved to vaccinate by both subjective and objective extrinsic factors.
I prioritized sleep the week before and all through traveling. I minimized caffeine intake. We wore KN95 masks in all public spaces throughout the trip and washed hands vigilantly. COVID infection during international travel is no joke, and we took no chances. Thankfully, we arrived back home uninfected and healthy.

When thinking about any infectious disease, I consider goals and trade offs. How important is it to avoid this illness, in general and right now? What are we willing to do and not do to prevent infection? What are the real costs of prevention and potential costs of illness? How can I minimize my susceptibility in a realistic, pragmatic, and balanced way? As a physician, I must consider infection impact not just on an individual’s health, but on public health as well.

Severe Mental Stress

In recent years, I have added a slide on distress tolerance to my wellness presentations. Practices like cold water to the face, paced breathing, and progressive muscle relaxation can help de-escalate us in the throes of acute emotional hijack, helping us get back from fight or flight to thinking clearly and acting reasonably. We have all encountered situations when we feel overwhelmed, out of control, and powerless. We each have our own unique triggers and reaction patterns, whether it’s performance anxiety, phobia, vicarious trauma, or simply rage, sadness, shame, etc.

Intrinsic risks for severe acute mental stress include history of trauma, tendency to avoid uncomfortable feelings, difficulty managing and expressing feelings or thoughts, and baseline anxiety, depression, etc.

Extrinsic risks for emotional hijack include inciting events that trigger past trauma reactions, often subconsciously. This could be anything from seeing someone else experience the harm you endured, to simply entering an environment similar to one in which you felt unsafe before. Certain words or gestures can trigger us–it can literally be anything. We each have a different threshold in any given situation, depending on the intersection of our current state, baseline traits, and real time conditions.

Susceptibility to mental stress, however, goes beyond simply passive innate attributes coming in contact with inciting circumstances. We all have our stress tendencies, many of which we can only partially control, if at all. Here is where our daily patterns, habits, and practices can really save us. Sleep deprivation and dehydration make everything feel exponentially worse, in my observation. Regular physical activity regulates the autonomic nervous system and improves sleep quality. Moderation of caffeine and alcohol help mitigate these substances’ disruptive effects on brain and body. Consistent self-assessment of mood and energy, what affects them, and anticipating challenges and threats on the horizon can increase confidence in our ability to meet them. Practices such as mindfulness, prayer, and communion with loving others also boost resilience–both mental and physical. And we cannot overestimate the profound importance of healthy, strong, and loving relationships to hold us up through anything life may bring.

For mental stress, while intrinsic psychological risks matter, our strong and consistent habits in the 5 reciprocal domains of health can (sleep, exercise, nutrition, stress management, and relationships) combine in synergy to minimize (or at least mitigate) our susceptibility to acute emotional hijack. Mindset, self-talk, communication skills, and attunement to others in daily life can set us up generally to encounter adversity feeling grounded and solid or vulnerable and insecure.

Thus, in addition to intrinsic and extrinsic risks, intrinsic assets also matter. The more we strengthen them when things are easy, the more easily we can call them forth when things get really hard.

I remind myself that though dividing risk into intrinsic and extrinsic is clear and helpful, it is also an oversimplification. History of trauma is not innate to me as a person, but the experience is integrated into my nervous system. Repeated subjective experiences accumulate and integrate further. I have, one could argue, adapted to it all in a way that protects me from recurrent harm in the future by alarming my system, mind and body, to similar threats, perceived and real. And while I practice my centering, grounding, inner peace methods, it also behooves me to honor and embrace my natural, un-peaceful tendencies. My best outcomes occur when I hold these all in dynamic balance, with nonjudgmental awareness and self-regulation. Anticipation, preparedness, and seeking support from trusted others also help mitigate my susceptibility to adverse outcomes and suffering.

In the end, I wish for all of us to live more peaceful, self-aware, self-efficacious lives. I want us all to move through good fortune with joy, and through adversity with fortitude and confidence, even while we allow ourselves to fully feel fear and distress. As an advanced practice in this domain, the better we understand our own intrinsic vulnerabilities and the conditions which expose them, and manage them effectively, the more likely we may recognize the unique struggles of others. We may all suffer less when these skills help us see, hear, and understand one another more empathically, compassionately, intimately, and lovingly.
We can, if we choose, help minimize one another’s susceptibility to pain and suffering.