Category Archives: stress management

Susceptible

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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.

Sensing and Feeling

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“Where do you feel it in your body?”

What a revelation, the first time Coach Christine asked me this during a session. It had never occurred to me to tune in to body signs of anything other than hunger, thirst, fatigue, and pain. In this conversation, c.2005, Christine asked me to locate peace, connection, and knowing. Almost 20 years later, the answer now is still the same: deep and central, between my diaphragm and navel but toward the back–where rhythmically mobile and unsung, stable body parts meet and coexist in dynamic balance–huh, I have never thought to describe it this way before.

“What are your body signs of stress?”
“What do you actually feel, physically?”
“How would your loved ones answer this question for you?”

I make these queries during clinical interviews to help patients recognize how their anxiety, fear, and agitation manifest. Often the physical signs arise before conscious awareness of their origins. It occurs to me now that localizing joy, love, connection, and confidence would also be useful. My inner peace and knowing reside at my center of gravity, now that I think about it. I feel it as a weight, though not a heaviness. It feels solid, centered, grounded, and stable–a substantive, resilient nucleus. I have used ‘unassailable’ multiple times to describe its quality–when that perception occurs, I know I’ve tapped into something important and profound, and good things often result soon after.

Our culture does not often facilitate or value this organic, instinctual attunement to body signals.  We look to devices to tell us—how we slept, how much we moved—before we query and trust our own natural knowing.  How ironic, that we seek intrinsic information and knowledge from extrinsic sources, without questioning the devices’ precision, accuracy, and ultimate relevance. More importantly, the frenetic chaos of modern life, coupled with the siloed and and non-integrated nature of ‘data’ from any given source, can pull us unknowingly into a vortex of statistics without synthesis. I see it as an epidemic of dis-integration. How much more self-aware and -regulated might we be, how much simpler and better our quality of life, if we just slowed down, got still and quiet, and asked/answered the questions above more regularly and frequently? That investment of time, energy, and connection could yield high returns, no?

What do I feel?
Where do I feel it?
What does this correlate with?
What’s going on with me/us/my world right now?
What does this all tell me?
How do I best respond?

How do you relate physical sensations to emotions? This is the intersection of ‘sensing’ and ‘feeling’, in all senses (ha!) of both words. Fear causes an agitated vibration in my chest, a shrill buzzing, and makes me want to discharge it with mindless, moderately intense activity, like on the treadmill or ellipitical. Anger also vibrates, but at a much lower frequency (more of a thunder rumble) and lower in the body, in my abdomen. Relief comes from slower, heavier, stronger movement–lower body lifting and lumberjack/throwing motions. Love and connection feel light–both in photons and mass–my visual perceptions are brighter; my chest lifts forward and up; I feel lighter on my feet. In these moments, often after an Ethos workout or quality time with friends, I hear music in my mind, songs like River and and Granted by Josh Groban, Hallelujah and Amazing Grace by The Tenors, and Say It to Me by AHI. Listening to my Agape playlist while in this state sustains both the physical sensations and the psychological feeling of connection and love, giving me mental space and time to revel and reflect. Blog post ideas often emerge in this setting, the words flowing forth in torents of values synthesis and integration.

So this is what I wish for us all, my friends: That we see the value in attuning to our innate sensations, that we practice connecting them effectively with emotions and relationship, that we may trust our intuitive assessments and use this important information to regulate how we show up–to ourselves and one another. I wish for a confidence, an inner peace that emanates from that deep, quiet, grounded, unassailable place that makes us present, open, loving, resilient, and connected.

When/where/how does this already happen for you?
How could you get more of it?
What would that be like?

Oxytocin: There Is. No. Substitute.

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Photo by Tobias Baumgaertner, Melbourne, 2020 https://www.bbc.com/news/in-pictures-55416365

“Tell me about your emotional support network,” I ask patients every year at their annual exam.

Our relationships kill us or save us, I am still convinced. 

How is your emotional support network? If you’re really honest: How secure are you in your relationships? How truly connected do you feel to the people in your life? In my mind, secure and connected relationships make up the core of our health and well-being. They are what give us deepest meaning and purpose, and what hold us up through any and all adversity.

This feeling of closeness, the ineffable sense of connection that inspires the most timeless and evocative poetry, that moves us to heroic acts, and that inexorably bonds lovers, friends, and especially mothers and children, is mediated in large part by oxytocin, the so-called love hormone. In the body it facilitates childbirth and lactation by contracting smooth muscle in the uterus and milk ducts. It plays a role in sexual arousal and orgasm. In the brain it promotes feelings of relaxation, trust, and belonging. It may even make us better at attuning to one another’s emotional cues. Levels rise when we connect with others, such as when hugging, dancing, and even reading or hearing stories. Interestingly, oxytocin also increases in times of stress, such as when we are separated from loved ones and feeling anxious. How fascinating and protective–I LOVE how nature works! The research seems new, but it may be that when cortisol rose under threat stress (of which social isolation is one of the most severe and dangerous), our ancestors whose oxytocin levels also rose survived better because it caused them to seek reconnection with the tribe, to stay close despite the drive to separate. Like so many things in nature and the body, the dynamic balance of opposing instincts gives us amazingly effective elasticity, flexibility, and adaptiveness–not only for survival but to really thrive.

Like other neurotransmitters, oxytocin’s presence in tissues is transient, stimulated and cleared in the course of normal cellular function. That said, the frequency, intensity, and consistency of tissue exposure to oxytocin has important consequences. More oxytocin correlates with improved mood, more secure attachment, and even increased pro-social behavior such as donating to charity and helping others in need. So how can we get more of this life-enhancing hormone in our systems? It’s about relationships, duh.

“She understood now. Treasure wasn’t something that could be picked up and carried off, that could be owned. Whatever happened here… could only happen here, and after it happened, it lived on inside you.”
—The Conquering of Tate the Pious, Sierra Simone

Multitple times a week, I think my brain must be positively swimming in oxytocin. Ethos workouts with Jacob, Pam, Tim, Kasey, and now Andrew and Hailey stimulate it, for sure. I schedule regular meals and calls with close friends, and that always lifts me. These interpersonal contact highs defy verbal expression, truly. When I meet someone new I listen for their stories, engage my most sincere curiosity, and ask open ended questions to learn more about the very interesting person in front of me. We inevitably find something fascinating to share and expound on. I make these connections all the time, and the benefits last.

So therein lies the treasure. There simply is no substitute for the time and attention required to connect meaningfully in relationship with our fellow humans. Pictures in albums and shared on social media are great to commemorate, but they only matter because they bring back the feelings we had in communion–that warm and fuzzy, settled yet giddy, glad and joyous sense of true togetherness and connection. 

And it doesn’t necessarily need to be in person. Phone, video, letters–OMG letters! Read how The World Showed Up For Steven through www.moreloveletters.com, a website that allows people to request snail mail for their loved ones going through a hard time. Steven was widowed after 64 years of marriage and his daughter thought she could get maybe a dozen people to drop him a note. He received hundreds of letters, some that also included gifts of books, drawings, and invitations to Zoom meals. You are not alone. If that doesn’t raise someone’s oxytocin levels, I don’t know what does.

Cards, gestures, messages, collages, stories; hugging, laughing, crying, cuddling, making love–sharing love–that’s what it’s about, my friends. And it’s all kinds of love: romantic, platonic, fraternal, familial, collegial–Agape. Just the act of giving it heals us, even if we don’t necessarily get it back. *sigh*

I bet writing this post has elevated my oxytocin levels! As I think of my amazing friends, my loved ones, my patients, colleagues, and all of you readers–we are all connected! I feel it in my chest the most–full and calm–comforted the way a soft, heavy blanket feels on a cold night. If you want an oxytocin boost and blogging isn’t your thing, try these 12 suggestions. Or just do what the meme below says. Regardless, I hope you’re getting all the connection you need and want to live your best life, dear Reader. It’s what I wish for us all.

from Instagram