Podcast: Go From Stressed Worrier to Stress Warrior

In this episode, Christopher M. Palmer, MD, provides tips on stress management, ways to reshape our stress reactions, explains the impact of stress and anxiety on our lives, and answers related questions from the McLean community.

Dr. Palmer is the director of the Department of Postgraduate and Continuing Education at McLean Hospital and specializes in treatment-resistant mental illness and the use of the ketogenic diet in psychiatry.

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Episode Transcript

Jenn: Hey everyone, welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Alright. Folks, we are just about ready to get started. So first and foremost, thank you so much for joining us today. And I hope wherever you are in the world, you are doing well.

I would like to introduce myself. I’m Jenn Kearney, and I am a digital communications manager for McLean Hospital. Today’s session, all about stress. And yeah, I’m going to acknowledge right now, some stress is actually good. We even have clinical exams that are called stress tests that literally provide us with benchmarks of health. So not all stress is bad. Our flight or fight response is actually a really good thing to have to do. But when stress is hard to manage, it’s out of our control or it’s just really over the top. And if you’ve made it through the pandemic thus far, it’s been pretty over the top, so things can get pretty messy. And that’s why we’re here today to talk all about it.

So during this session, Dr. Chris Palmer is going to answer all kinds of questions about stress in all quantities, how it impacts our mental health and how we can keep our stress more even keel so that it doesn’t become harmful to our health.

Before I hand it over to Chris, if you are unfamiliar with him, you are in for a real treat. Dr. Palmer is internationally known for pioneering the use of the ketogenic diet in psychiatry, especially in treatment resistant cases of mood and psychotic disorders. And he is currently serving as the director of the Department of Postgraduate and Continuing Education here at McLean Hospital.

So, Chris, hi. I’m super excited that you’re here today. So, thank you so much for joining me for another session. I don’t know if you want us to talk a little bit about stress before we start asking you just all types of questions.

Chris: Yeah. So, it’s great to be here. Thank you, Jenn. And thanks for that kind introduction. And I think I do want to kind of just say a few words just to set the stage for people.

And so, as a psychiatrist, mental health professional who uses medications also does psychotherapy, does a wide range of treatments, stress is kind of a bread and butter complaint that I hear from people. And one of, I think my pet peeves as a psychiatrist is that all too often, especially in the media, stress ends up getting reduced to a cliche, and then there are three or four solutions or three or four steps that you can take to relieve stress in your life. And the reality is that for some people, stress can be that simple and the solutions can be that simple. And I’m all for it. If you can do some simple solutions and it relieves your stress and allows you to live a relatively tranquil stress-free life, that’s awesome.

My guess is that a lot of you who’ve joined us today that’s not the case. Because a lot of the kind of well-known treatments everybody kind of knows them already. And usually a lot of people have already tried them and for some people, and I would argue even for a significant number of people, they aren’t enough, they don’t work.

And so, one of the things that I think gets me kind of upset about this topic and the simplistic ways that people talk about it is because it can lead to a lot of shame. It can lead to this thing of, oh, are you feeling stressed? Well, don’t worry. Just stop worrying, stop. Just stop. Just take some deep breaths and stop. Or you just relax. Why don’t you relax. If you just worked a little harder to relax, everything would be fine. You know that stress is really going to cause you to have a heart attack, stop doing what you’re doing. But in reality, again, those solutions, although they can work for some people, and I’m all for them when they do work for you, they don’t work for everybody because stress ends up being actually really complicated.

So, stress affects not only mental health. It actually affects physical health. We know that stress, people who have chronic levels of stress tend to have higher rates of cardiovascular disease, diabetes. They are at a greater risk for being overweight or obese. And those kinds of metabolic disorders, confer risk for all sorts of other disorders, including cancers and Alzheimer’s disease and all sorts of things. So, it actually really is important to try to manage your stress.

But one of the problems with this simplistic view is that everybody assumes that there’s clear trigger. You have a test coming up, or you have a work project coming up, and you’re worrying too much about it. And the way to manage your stress is you need to stop worrying so much, take some deep breaths, do some yoga, and then there, a problem solved. Everything will be fine. But in fact, it doesn’t work that way for everybody.

So, one of the really interesting things that I’ve observed as a mental health professional is that yes, stressful life events can absolutely cause stress and can cause people to have a fight or flight response that can actually lead to poor health outcome.

But interestingly, some people can develop what I would consider an abnormal stress response. That actually makes them feel stressed much more often than they really should. And the easiest example of this is that when people get clinically depressed, even if it’s just mild depression, almost universally people with depression will feel more stressed. But one of the things is that they actually kind of have a decreased coping capacity so that when life becomes adverse in some way, they have a project due, somebody reprimanded them, somebody cut them off in traffic, whatever. That those things end up upsetting them a lot more than they ever did before they were depressed.

And so, when they end up with clinical depression, some people would still say, well, they need to take deep breaths. They need to not let everything bother them. But in fact, I would say the reason that they’re stressed is actually because their brain is kind of having an exaggerated stress response. And deep breathing, if it works, that’s great. But I can tell you for far too many people, deep breathing doesn’t work to treat clinical depression.

Now some of you might think, well, why are you talking about clinical depression, we’re here to talk about stress? Well, one of the most common things in society today right now is this thing that we call burnout. And usually when we talk about burnout, people think about work stress. Burnout is actually now a diagnosis. It’s not a diagnosis recognized in DSM-5, but it is a diagnosis recognized internationally in this kind of diagnostic code called ICD-11. And it turns out that there’s a fine line between what we call burnout and what we call depression. So, people who have mild burnout are actually three times more likely than other people to have clinical depression. But if you score severe on the burnout scale, you’re actually 46 times more likely to have clinical depression. People with high levels of burnout have a higher suicide rate.

And so, a lot of people who will say, I’m not depressed, I’m just burned out. And why are you burned out? Well, because of all the stress in my life. We have strong reason to believe that a lot of those people are actually probably clinically depressed and telling them to take deep breaths or take a yoga class may not be an effective intervention for those people.

And just to share a couple of quick statistics with you on how prevalent this is. So, this is pre pandemic in 2018. The Gallup organization did a poll. 23% of Americans reported feeling burned out often or always. So, they were always burned out or they were often burned out. That’s a quarter of Americans. And 44% of all Americans said they were at least sometimes burned out.

Now we all know this pandemic has taken an astronomical toll on people’s stress levels, on people’s mental health. And so, we can only assume that the rates of burnout and the rates of stress are much higher.

So one of the reasons that I bring this up is because when we think about stress in this way, we can think about stress as, yes you’re having some adverse life events and they’re causing you to have a stress reaction, but I want you to think of it almost in the reverse. I want you to think can some people have what we might call burnout or what we might call a mental illness, or at least a challenge in terms of their mental health. And can that challenge, can that illness actually cause them to feel stressed all the time, can that cause them to have less reserve, to be less resilient, to kind of be more stressed by everyday things that they used to be able to manage really well.

And as soon as we start to think about it in these different terms, the reason that I like to think about it in these different terms is that it offers a whole range of solutions. And it’s not all about take some deep breaths or try yoga.

It’s interesting because in the clinical realm, when we deal with people who are stressed, so we’re talking about people who have anxiety disorders. We’re talking about people who have clinical depression. We’re talking about people who have post-traumatic stress disorder. When we deal with people with clinical problems, there are some kind of therapeutic camps that will say these stress reduction strategies can be really helpful. So, yoga, mindfulness, meditation, deep breathing, those things can all be really helpful for people when they are stressed. But again, that makes the assumption that those things are going to work. And so, we want to find something that works for you.

And again, I’m all for those, if those things work for you, great, do them, keep doing them. If you’ve never tried them, really give them a try, they’re worth at least giving a try to. But what the mental health field has found over the last 20 to 30 years in particular, is that for a lot of people who have what we call depression or anxiety disorders, or post-traumatic stress disorder, that actually asking them to take deep breaths and try to get rid of the stress actually sometimes makes their stress worse. And it can actually make their ruminations worse.

And so that’s one of the reasons I’m so kind of, I get so upset about this sometimes is because not only can it shame and stigmatize people like it should be working for you, you must not be doing it right. Why don’t you just do it better. Like take deeper breaths. Like clearly this works for everybody except you. So, there must be something wrong with you or the way you’re doing it. Well, we know in a mental health field, that’s actually not true at all, but on top of that, we might actually be making things worse.

And so, there are whole range of treatments now where when people are really stressed or anxious, we actually do exactly the opposite of what you would think. We ask them to face their fears. We ask them to face situations that we know will make them stressed. We ask them to like lean into it, go into it, and then tolerate it. And do it over and over and over again, and just tolerate it. Don’t deep breathe your way through it. Don’t try to meditate through it. Like actually feel it. Feel how overwhelming it is, feel how awful it is, feel how painful it is, feel your heart racing, feel how it makes you maybe nauseous and want to throw up. And if you do that over and over again, in a controlled way, usually with a therapist, this usually needs to be done with a therapist, but when you do it in that kind of a controlled way, it can actually have dramatic effects on your stress or anxiety levels. And people can actually learn to manage their stress much more effectively.

So, I’m kind of all over the place. So, stress can be caused by bad life events that causes stress reaction, but stress can also be caused by your brain just being hypersensitive to anything that will stress it. And then when we talk about treatments or solutions, it’s all over the map. It might be deep breath your way through it, try to relax, but it also might be, do the exact opposite. The exact opposite of that. Face those fears. Like even though they’re going to make you really stressed, just face them over and over again. Again, usually with a therapist in this case. So, there’s a wide range of ways to think about stress and there’s a wide range of treatment options.

And I’m going to stop there and really open it up. ‘Cause I have no idea where any of you are at. So, some of you might just need some everyday tips. You’re relatively healthy, doing great. And others of you might be overwhelmed by stress. So, I really want to just open the door for questions and set that stage so that people can hopefully be more upfront and honest. And hopefully this will be a shame free environment. If deep breathing doesn’t work for you, that’s okay. And we will try to come up with other possible things to try.

Jenn: I think it’s super important to one of the big like key takeaways from what you just said was that a lot of the ways that people address stress is almost by shaming others, even when it’s unintentional, like, oh, just take some deep breaths and you’ll be fine. It’s incredibly dismissive. And it can make you feel almost like invalidated in what you’re feeling and how you’re feeling it. And I think that’s, as we continue to strive to de-stigmatize mental health conditions, I think it’s really important to acknowledge how much our words can matter to other people.

But I do want to kick off the questions. Someone asked, stress and anxiety are often used interchangeably. Can you please define the difference between stress and anxiety?

Chris: Great question. And there really, I kind of alluded to that and I think depending on who you ask, there is no difference whatsoever.

So, the way that I would maybe try to come up with more of a medical explanation. So, I think when you’re just reading lay press like articles, blogs, whatever, internet stuff, they are used interchangeably, no question about it. As a medical professional I think the way that I would distinguish them is that this, we do know physiologically biologically, there is a stress response. So, whenever people or any animal actually are challenged or threatened, but it doesn’t have to be a threat to your safety. It can just be a challenge. Like I need to do this test, but it’s a really hard test, or I need to figure out how to open up this box in order to get the food, but it’s really difficult to figure it out. So, whenever people are stressed in any of those ways, there is a physiological response that involves all sorts of hormones, stress hormones, neurotransmitters, other things. And those things activate the fight or flight response.

But the interesting thing is that most of the time people don’t fight or flee when they have a stress response, they stay right where they’re at and they absorb that extra energy. They absorb that heart rate, they absorb all of that. And then they have to do something with it. And that’s where the problems can develop for some people.

Now that extra energy, all those stress hormones can be really helpful if you do something productive with them. So, if you do fight, that’s great. If you do run away, that’s great. If you use that extra energy to solve the problem and figure it out, that’s great. But what if you just become paralyzed? What if you don’t know what to do? What if you just become overwhelmed or sad? Then that’s bad.

Anxiety on the other hand, I think some people would refer to it as just kind of worrying about the future. So, something in the future and you’re worrying about it. And it could be a test. It could be a project. It could be relationship oriented. It could be anything. But it’s rule of thumb, I think they’re interchangeable terms.

Jenn: So, I know you’ve talked a lot about burnout and its relation to depression more than anything. How can we best determine if we are experiencing burnout? Are there any key questions that would lead us to know whether burnout might be an issue we should bring up with a provider?

Chris: Yeah, so great question. So, if you Google burnout, burnout screening questionnaire. So, this is actually a concept, like I said, it’s actually in the ICD-11. So, you can Google ICD-11 burnout and you can actually see the diagnostic criteria for it. But researchers have been studying this for at least a few decades. And there are all sorts of short screening questionnaires around burnout. So, you can easily find those. And like I said, assess whether you have mild, moderate or severe burnout.

As I said, the statistics that I shared with you, if you have mild burnout, you’re three times more likely to also at the same time meet criteria for clinical depression. If you score severe on burnout, you’re 46 times more likely to have clinical depression. And I think that’s one of the reasons DSM-5 doesn’t include it as a separate disorder because there’s a lot of debate in the field. But some people, some mental health professionals strongly believe that it’s really kind of a form of depression that’s centered more around workplace or school environments, or just being hyper scheduled in some way, but that the end result is similar.

Jenn: So, I know you’ve mentioned a lot about workplace and a lot of people are in situations where their family lives are being challenged or up ended, but also are trying to juggle being in a stressful work environment too. Do you have any advice for how to alleviate and help manage stress regarding types of situations where we don’t have control over whether we’re in them or not?

Chris: So, it’s a great question. I think there are billions, literally billions of people on the planet right now who at least feel some degree of that. That what happened, I’m not a work from home kind of person, or I never signed up for work from home or I didn’t sign up for my kids to be home schooled, or I certainly didn’t sign up to get laid off from my waitress, or waiter job or my hotel job, or whatever. So, I think countless people right now have been forced into situations that they didn’t voluntarily sign up for, but they’re stuck with them. And I think that depending on the situation and who I’m talking to and what they’re really struggling with, there’s a limitless number of solutions and a limitless number of problems.

I think the general advice I would give you is this though, I would kind of take a step back and just ask yourself, is the way that I’m living my life right now, the way that I’m doing work and home life and managing kids or friends or what, is this okay? Am I like at least okay? And if you can say you’re okay right now, you’re actually probably doing pretty damn good. Just keep it up. Keep doing it. ‘Cause we’ve all had major changes. If the answer to that is no, I’m really not doing okay. Try to get more granular. In what ways are you not doing okay? Are you working longer hours? Are you not getting good sleep? Are you overeating, or over drinking to deal with the stress? Are you starting to feel depressed? Like in what ways are things not working out, or what ways are things not okay? And then depending on what kind of granular problems you can identify, sometimes you can start to come up with solutions to those.

The big picture is to try to figure out, well, which aspects of your life can you control? And I wanted to just kind of say, I want to give you permission to then control them. So, one of the things that gets in the way is kind of guilt about, I’m supposed to be whatever. Whatever follows that I’m supposed to. Whatever follows that is probably a huge obstacle standing in the way between a stressful life and an okay life. And I’m really not even shooting for good and harmonious and like that, that’s probably too much to ask right now in the middle of the pandemic with masks and major disruptions to society, everybody’s going to be stressed. When we go to war as a nation, everybody should feel some degree of stress. That is the normal human response. And I don’t think people should meditate their way out of that stress because if you truly meditated your way out of that stress, it would mean that you were naive or oblivious to reality. And I don’t want people to be oblivious to reality. Like you’ve got to face the fact that there are stressors in life right now.

But I think that when people start to look for ways that they can control things and then give themselves permission, the easiest way to give yourself permission I think, is to recognize that if I keep going on like this, I really am going to burn out. Or if I keep going on like this, my kids are going to suffer ‘cause I’m so irritable with them these days. Or if I keep going on like this, I may not stay with my girlfriend or boyfriend because I’m so irritable with that person. And they’re not going to put up with this much longer. And when you start to recognize serious consequences like that, that can be the motivation to how can I achieve a better balance in my life?

Like this is not going to work out. I don’t want to lose this important relationship, or I don’t want my kids having poor self-esteem ‘cause I’m yelling at them all the time. I don’t want my stress to affect the people that I love and care about in these ways. And so, recognizing that maybe I have a problem, I’m trying to do too much. I’m putting too much pressure on myself to keep up, because of these statements I should, I should be able to do everything, well, if you’re not able to do everything, just admit it, just be compassionate to yourself. Like it’s okay. It really is okay if you can’t do everything right now.

And then figure out, well, what can I change? Could I try to force myself to stop working at 5:00 pm every day? If you need to put an out of office, if people are emailing you expecting, maybe an out of office message at 5:00 pm. I’m not checking email after 5:00 pm today. I’ll check it first thing tomorrow morning, whenever that is, and I’ll respond as soon as possible. And maybe that can alleviate some of your guilt or some of your, whatever, like the obsessiveness to like, oh, I need to check it. I need to check it. I need to do more work. And maybe that will free you up to then spend some better time either with self-care.

Maybe then you’re going to take a walk or you’re going to exercise, or you’re going to take a bubble bath or whatever will help you kind of unwind and kind of treat yourself or whatever, or maybe spend some time with these people that you love and care about. Even if it’s over Zoom or a phone call to really take care of other parts of your life. It’s always important to try to figure out what are all of the important buckets in my life? And am I giving enough attention to all of them? And as a rule of thumb, if people are giving enough attention to all of the major buckets in their life, hopefully they feel okay. Hopefully they feel at least okay.

Jenn: And I feel like after you talked about putting up an out of office message at 5:00 pm, I feel like I should publicly apologize for never emailing you within like the constraints of a real work day, , as soon as you saw that I was like, “Oh no, I emailed him yesterday.”

Chris: That’s not a thing for me. So, I’m okay with that.

Jenn: Oh, well that’s a relief. So, we had someone ask, how does stress affect our breathing? And if we feel stressed and notice a difference in our breathing, what can we do about it?

Chris: So, stress can definitely affect breathing in some people, it doesn’t in everyone, but it can in some people. So, if you’re really stressed, so if somebody terrifies you or threatens you, you are likely going to start breathing much faster. And that is being driven by all of the hormones and neurotransmitters and other things that are being secreted by your body. And that is a normal human response. It’s just important to acknowledge that. And it’s important to recognize that your body’s actually preparing you to fight or flee

And so, some people will start breathing faster and usually more shallowly. So, it’s just faster kind of breathing. If they’re doing that, if you think that that is contributing to your stress response. So, for a lot of people it is, and that’s why a lot of people talk about deep breathing, slow deep breathing as a way to slow that down. So you’re counteracting that kind of more rapid, shallow breathing pattern of the stress response and what you’re trying to do with slow deep breathing is you’re trying to activate the parasympathetic nervous system, which if you expand your diaphragm and if you do really slow deep breaths, for some people, not for everyone, but for some people that can be helpful. It can slow their heart rate down and it can slow that breathing pattern down, which then feeds back to that stress response and can calm that stress response.

So, I guess I would stop there and just say, if you’re noticing a change in your breathing and you can counteract that change with these kinds of deliberate slow deep breaths, that’s great. If slow deep breathing doesn’t work for you then really anything, there are so many other strategies that people can use to try to counteract the stress response.

So, kind of going along with it, like I said, so when people have a stress response, usually we’re supposed to fight or flee, but the majority of time when we’re stressed, we do neither. Sometimes actually fighting or fleeing with your body can be really helpful.

So, I don’t want you to fight, I don’t want you to get into a fight, but nowadays we call that exercise. And so for some people, if you really are having an intense stress response, and you’re not able to calm it down or control it through mindfulness or deep breathing or something else, you can actually work with it, and get your body to do what it wants you to do anyway, your body wants you to flee, and that means run. Run as fast as you can to dissipate that energy. And if you can dissipate that energy, the stress response will go down and more than likely the adverse effects of that stress response will go down. Then you’ll use up a lot of that energy and it won’t be fueling your worry and the ruminations to just kind of keep going over and over again.

But there are lots of other strategies, I’m going to stop there with those couple of suggestions, ‘cause I could go on forever just on this topic. So, if those don’t work for you, that’s okay.

Jenn: You actually teed up my next question because a couple of folks have been saying other tips for stress management that aren’t yoga or deep breathing, and I guess this should include exercise in there as well too, since you’ve mentioned that.

Chris: So, exercise, absolutely. So, for some people, again I think, as I think about recommendations, so I, as a clinician, I come back to, well, I want to know what’s causing this stress to begin with. So is the person actually truly reacting to chaotic, stressful, threatening, challenging situations in their life. Or is the person having an exaggerated stress response due to burnout, due to depression, due to an anxiety disorder or something else.

So, I just want to reiterate that. It really depends on what’s causing this stress response. And depending on which of those things I just said, and then the countless others that could also be causing it, there are different treatment strategies. So that’s the big picture that I really want you to hear. But I’ll give some generic answers.

So, some generic answers, if you’re truly stressed by kind of adverse life events, let’s say you’re on the front line in a hospital working with COVID patients. Those people are stressed. They are. They’re in masks and seals, and it’s uncomfortable and they’re putting their lives on the line. And hopefully with the vaccine now that’s going to be less of a concern. But that is a stressful environment. They’re dealing with people who are dying every day, that’s stressful.

And so, for those people, I would say compassionate self-care is critical. Really check in with yourself, how much of this can I do? How much of this can I take? And just recognize life is a marathon, it’s not a sprint. And you have to stay in the race. And so, you got to pace yourself.

And again, this is where this, I should, other people are doing it so I should be able to do it too. I should be able to keep up with them. My boss says I should be able to do all, well, whatever. If it’s like, if you can’t or if you’re really struggling, have some compassion, recognize that this is a really horrible situation, whatever it is, whether you’re on the front line or whether, again, whether you’ve just got a busy job, whether you’re stuck working at home, you’ve got three kids who are being homeschooled and they’re all yelling and screaming and messing up the house. And you don’t have any time to yourself. Like whatever those real-life stressors are, just check in with yourself.

And then figure out what can I do to more appropriately pace myself? How can I pace myself? Can I take breaks? Do I need to talk with my boss? If this is a work thing. And just let that person know that I’m kind of barely holding on right now and I’m doing my best. I’m here. I want to do this work. This is what I signed up for, but is there any way I could work shorter shifts? Is there any way I could have a break in the middle of my shift? Just to get outside and get away from it all, just to clear my head so that I can come back.

Talk to people in your life, supports, a significant other, children, parents, friends, whoever, let them know my life sucks right now. Please help. Like can I talk to you? Can I unload on you? Every now and then I’ll try not to do it too much, but can you be a support for me because I’ve got this chaos in my life and I can’t do it. Reaching out to people, opening up, talking about it can be immensely helpful, can really relieve. Even if the people don’t have any practical advice to give you. If only they can just listen and absorb it and be with you and hopefully show some, at least a tiny bit of empathy, like, oh my God, that sucks. How awful, like kudos to you for hanging in there. Like you’re doing such good work and people are dying. So, I hope you can keep doing this, but let me know if I can help. And just the moral support, just knowing that people are behind you. People recognize that you’re human, can go such a long way.

For other people, distracting can be really helpful. So, for some people that can be distraction with anything. So, it could be throwing yourself into work, throwing yourself into a project at home. If you’ve held off on organizing your basement or your garage or that closet or that dresser or whatever, if you’re coming home completely overwhelmed, ruminating, your head won’t stop. And you just want to watch TV, drink, eat, whatever, to escape, but those aren’t really working all that well. Distracting yourself with something else.

So, getting out of the environment, taking a walk. But it could just be, I’m going to organize my dresser drawer and I’m going to give those clothes, the old clothes that I never wear to Goodwill. And why is that helpful? Well, you’re doing something, so it’s physical, there’s a physical aspect. And that again is kind of getting rid of some of this energy of this fight or flight thing, which is good, but you’re also accomplishing something that’s important to you. And so, at the end of the day, even though you’re burned out, you’re going to open that drawer and you’re going to be like, “Oh, it’s like so uncluttered now.” And like, “Oh, this is great.” And you’ll have a sense of accomplishment and that’s something that you could control.

So that’s something that you took control of and you mastered it and you accomplished it. And that alone will give you a sense of when I put my mind to it, when I come up with a plan, I can be effective, I can get stuff done. Because I think one of the dangers of people who are really overwhelmed with a stress response is learned helplessness. That they can just feel beaten down, beaten down, and it can get to the point where they just feel like whatever I do, it’s not enough. It’s never good enough. No matter how hard I try, I’m just so tired, I’m just so exhausted. Nothing I do matters. Nothing I do is working.

That is a really dangerous situation to be in. It certainly pushes people into depression. It can push people to drink more than they should or use other substances or eat more than they should, or be irritable with people they love.

And again, so one remedy of many remedies, I don’t mean this to be like a one size fits all thing, but if you can get some degree of mastery over something that’s important to you, it doesn’t matter what it is. It could be household or work thing. It could be a fun thing. It could be a hobby. It doesn’t really matter. Just something that you decide this is important to me just to focus on, in addition to all the chaos in my life, it’s all out of control and all hell’s breaking loose. I’m going to do this one thing for myself to get it done. And sometimes I can go a long way. I’ll stop there. You can tell I could go on forever, but.

Jenn: It’s okay. It’s all really helpful information. We’ve had a lot of clinicians write in asking, how can we better help our clients lean into their fears? And in addition, is there a name for the therapy regarding facing stressors with a therapist?

Chris: Yeah. So as a rule of thumb, it’s usually called exposure therapy. So, there are different types of exposure therapy. Exposure therapy has been around for decades.

So, for people with anxiety disorders, something like panic disorder, social anxiety disorder, generalized anxiety disorder, any of those kind of anxiety disorders, some type of exposure therapy can be really helpful. And it’s actually important to do it in a graded way.

So, you don’t start off necessarily with something that is impossible for the person to do. You want to do it in a staged way. You want to come up with interventions that will lead to success. That is the number one rule of exposure therapy. The person has to succeed because if you give them tasks that they fail at and they do that two or three times, you’re actually making their anxiety disorder worse. You’re basically letting them know they aren’t capable of facing their fears. They aren’t capable of.

So that’s why I kind of gave the caution that it’s really important to do this with a therapist, ‘cause if you try this on your own and you fail a few times, you’re actually going to reinforce your fears and your anxiety, and it’s probably going to make it worse.

So, exposure therapy, there is exposure and response prevention therapy ERP for OCD. That’s a specific therapy. And then there’s prolonged exposure therapy, which is an evidence-based treatment, probably the best evidence-based treatment, even over medications for post-traumatic stress disorder. So those are three examples, but most, most of them have exposure in their name.

There are lots of other variations of different kinds of exposure therapy, but it really is about facing the fears, not deep breathing, not trying to mitigate that stress response, actually letting that stress response come on, just bring it on. I’m going to feel it. It’s awful. It’s awful to feel it. But if they do that over and over and over again, they actually start to learn, oh my God, it’s not killing me, number one. Oh my gosh, I can actually tolerate it. Oh my gosh, I’m tougher than I thought I was. And then finally, that’s not stressful anymore.

Like whatever, I’ve done that 20 times. And I lived through it each time and it doesn’t even bother me anymore. Why was I stressing so much about that? Like, what was I stressing about? Like, I can do that.

Interestingly, if you do exposure therapy even around, like so if you take somebody with generalized anxiety disorder who has fears of 100 different things, you actually don’t have to do the exposure therapy for all the 100 things. If you do the exposure therapy for one or two of those things, a lot of times people kind of learn the pattern of what needs to happen to extinguish their anxiety. And they start to notice a dramatic decrease in anxiety across the board, across all of the other things, because they start learning that I can do that. I’ll stop there.

Jenn: It’s fascinating because you hear people say that the mind is a muscle. And then when you hear things like that when it comes to people with generalized anxiety that their brain starts to pick up the patterns that just reinforces that yeah, it’s a muscle, that’s muscle memory. It knows what’s going to happen. Would you be able to provide an example of facing and tolerating a stress trigger?

Chris: Yeah. So, the easiest one is in post-traumatic stress disorder, we’ll just do that. So, for somebody who’s been traumatized, they can have lots of triggers. And sometimes those triggers can be anything that reminds them of the abuse. And so a lot of people have been abused multiple times in multiple different ways, so it can become very cloudy and murky and sometimes they don’t even remember what all their traumas were and what all the triggers are, but let’s take an easy example, one trauma with clear triggers.

So, if it was a person who was wearing a certain cologne, every time the person smells that cologne, they get triggered in a major way, they have an intense fear response. Their heart is racing, they become overwhelmed, they’re sweating, they’re almost like ready to curl up into a fetal position on the ground, or run, or yell, or fight, or something, they’re like that triggers them because it reminds them very specifically of that.

And so an exposure therapy with that person, especially if this is a cologne that for whatever reason they smell, like let’s say they work in a department store, they work in a mall and they have to kind of walk through some stores where they’re going to smell different perfumes or colognes, and every now and then even if it’s a new cologne, it kind of reminds them of that and it triggers this response.

So, with that person, you could imagine doing a whole series of kind of exposures. Those exposures could be in the office, but then you could also assign homework to the patient to have them do some of those exposures at the mall or somewhere else where they’re going to gradually over time, expose themselves to these smells over and over again until that stimulus extinguishes. And what I mean by that is until they get to the point where it’s like it doesn’t automatically trigger that stress response anymore.

And why would it not trigger it? Well, because now you’ve smelled it, you’ve smelled those smells like 100 different times in 100 different contexts, and it’s not specific to the trauma anymore. You’ve also learned that when I smell that smell, it doesn’t automatically mean I get abused. And it also doesn’t automatically mean I have a panic attack or a fear response. I’ve learned how to smell that smell and be okay. So that would be an easy example.

Jenn: We did have an individual write in saying that they’re sometimes in a position where they speak in front of a room full of people, but unfortunately I’ve had more than one panic attack while doing so. Do you have any suggestions for when people find themselves in situations like this?

Chris: Yeah. It’s a good question. Panic disorder is a disorder unto itself. And there are people who have panic disorder, who can have panic attacks completely out of the blue. They can be sitting in the safety and comfort of their home, watching TV, having a stress-free evening, and out of the blue, their body goes into panic mode. And for those people, I think those people need a slightly different treatment, and which might include medications or other types of psychotherapy or other types of interventions.

So, the example that you gave me, I’m going to assume, so the reason I said that is because if this assumption is wrong, then don’t listen to it or take it with a grain of salt. If the panic attacks only happen when you are speaking publicly, sometimes you’re able to do it, but sometimes you’re not. And sometimes you have a panic attack. Then I would assume that you may in fact have kind of a fear of public speaking. This is a very common thing. So, lots of people do not like to be in front of audiences. And she says in front of like 400 people.

Jenn: Why do you think I like doing webinars so much? It’s just me and one other person.

Chris: There you go. So, fear of public speaking, really common trigger, a lot of people will have panic attacks. And there are a couple of ways to think about managing it. So, some people will take medication, some people, plain and simple, if they only have panic attacks in very defined and specific ways.

So, there are a lot of like talented musicians, for instance, who will have panic attacks when their orchestra is performing a major event or something, or when they have to do an audition. And some people will use a medication called a beta blocker. And it’s very clear and specific. They only use it in the situation that they know will provoke the panic. And sometimes that alone can be enough ‘cause a beta blocker will reduce your heart rate and will prevent that stress response from kind of feeding on itself. Obviously you need a prescription for that. And if you want to try something like that, I strongly recommend trying it before you have a real, like stressful thing that you need to perform in, ‘cause the medication can affect different people in different ways. And obviously if the medication, if you have an adverse reaction, if it makes you drowsy, if it makes you not on your game, that may not be a good strategy for you.

Other people will use anti-anxiety medicines in a similar way. If it’s happening on a really frequent basis, sometimes people will use medications in those ways, but exposure therapy can actually be helpful for something like that too.

So, you could consider, depending on how frequently it happens, you could consider working with a therapist and doing kind of a very short, targeted intervention around exposure for that specific event. And that can actually have a really powerful effect.

A lot of people have what are called simple phobias. So, it’s basically having panic or anxiety symptoms in very specified situations. So, fear of flying, fear of spiders, fear of heights, whatever, and fear of public speaking goes into that. And honestly, exposure therapy can be amazing because it can get rid of the problem once and for all.

Again, it’s a very unpleasant treatment though because you force yourself to face your fears and experience anxiety or experience even panic. And then just sit with it. And you’re not trying to get rid of it. You’re noticing, “Oh, here I go. I’m panicking. Oh, my heart feels like it’s going to burst out of my chest. Oh, I feel like I’m short of breath. I’m probably having a heart attack right now. Oh my God, I feel like I’m going to puke.” If you’re having extreme symptoms like that, that is what exposure therapy would entail, is you’re purposefully going into that zone. But doing it over and over again in a way.

One really cool thing that some people are doing now is virtual reality with virtual reality goggles and stuff, you can put yourself in some of these different situations. So, I could imagine putting yourself in front of a crowd of 6,000 people at some point. And getting yourself to give a talk in front of all of them, or even have some of them harass you or something. And learning to manage that fear.

As somebody I will tell you, so as a continuing ed director, I have to stand in front of people all the time and give talks. And I’ve given talks in front of thousands of people. And when I first started this job, oh my God, I would obsess the night before, like, “Oh, what am I going to say? Am I going to stutter? Am I going to say something wrong?” I have exposed myself to enough of these situations that I don’t even think twice about it anymore. It doesn’t flinch. So, I am a firsthand testament, exposure therapy really works.

Jenn: I think that’s a relief, given I have done a lot of these sessions that I still get anxious about them. So, it’s nice to know that continued exposure will help with that over time. I did want to ask, this one you’re going to love, how does diet affect stress?

Chris: So, we did an entire webinar on stress, diet and sleep. So, I’m going to plug the McLean Hospital website and some of the prior webinars on that. And I’m going to really encourage you to watch the whole thing.

In a nutshell, diet and stress are kind of in a bi-directional feedback loop. So, stress can make people overeat or under eat. And then overeating or under eating can actually cause more stress. So, you can be stuck in this vicious loop. People can get into that loop either way, they can get into the loop because stress starts it. They can actually get into the loop because they simply start overeating, for whatever reason.

They’re hanging out with the wrong crowd who are having parties and cookies and cakes all the time. And you just are going along with the crowd overeating, overeating, slowly but surely, your blood sugars are going up, your insulin is going up, you’re gaining weight. And at some point that can start to affect your sleep. And that can start to affect your stress levels. And people can get into a vicious loop and it can be challenging to get out of. It’s definitely doable and you can get out of it. But the first step is just recognizing that maybe you’re stuck in one of those loops.

Jenn: We have time for one more question. How do we address the people in our lives who tell us to just take a deep breath and move on? I don’t want to shame people, but at the same time, it would be nice if they were able to accept that their responses aren’t helpful.

Chris: Yeah. The way I heard this question is it’s from somebody who’s being told take a deep breath. And I think I would just let those people know you can refer them to this webinar and however you know, basically a lot of the stuff I’ve said will support what you’re going to tell them.

But you can just let them know, “I really appreciate your support. I appreciate the fact that you care about me, and that you’re trying to be helpful, but can I share some information with you? It doesn’t work. I wish it did. You have no idea how much I wish it did, but it doesn’t work for me. Taking deep breaths doesn’t work.”

Now, if they go on the path of, well, you’re not doing it right, you’re not doing it right. “Whoa. You have no idea, this stress or these panic attacks or whatever, these have plagued me, I have done it right. They don’t work for me. I wish they did. They don’t work for me. So when you keep telling me to just take deep breaths, even though that doesn’t work and it’s almost like you’re frustrated with me, like I’m not even trying, like I’m not even doing it, or like I don’t even want to get better. That just makes me frustrated. It makes me feel like you kind of maybe don’t care, or it makes me feel like you’re frustrated with me and that’s really not helpful. But I do want to find a way to manage my symptoms. I do want to find a way to feel happier, more tranquil.”

And if you’re open to other suggestions, you can say that to them, or you can just let them know “I’m working with someone else, a friend, or a therapist, or someone else on other strategies. And I really hope I’m going to find something soon. But if you could just back off on the deep breaths stuff, that would really help.”

Jenn: And if that doesn’t work, I had a friend advise me once that there are people that are close in her life, blood relatives and everything. She doesn’t want to take their advice to heart. So, she puts up what she calls the Teflon iron. And she just lets their words slide right off of them like Teflon. So that is always an option too.

This actually concludes the session because we have already gone over the hour. Chris, thank you so much. While so many people might be offering unhelpful responses in our day to day life, you have provided a wealth of knowledge to all of us and I cannot thank you enough.

So, thank you so much for joining and to everybody who joined us today, thank you all for joining and hopefully we’ll see you again soon. Until next time, be nice to yourself. And if a deep breath doesn’t work, you’ve got plenty of other options. Thank you so much. Take care.

Chris: Thanks.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to educate about, encourage compassion around, and reduce the stigma related to mental health and wellness. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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