Module 5. Working with stress and anxiety
Confession: I used to get full blown panic attacks when I was in residency. How do I know they were genuine panic attacks? I happened to be training to be a psychiatrist. I would suddenly wake up in the middle of the night with all of the symptoms, cold clammy hands, sweating, racing heart, shallow breathing, tunnel vision. The works. I even had those thoughts that I was dying. At that moment, I literally thought I was dying. Fortunately, that was about 10 years after I started a mindfulness practice, because my mind kicked into mental survival mode. By this, I mean that my mindfulness practice kicked in on cue. Remember that naming or noting practice that I taught you as a way to work with intrusive thoughts. Well it works. Really well. Imagine this as an intrusive thought: I’m dying! I’m dying. Imagine your panicked brain waking you from a dead sleep, screaming at you that you’re dying. It doesn’t get much more intrusive than that.
When my panicked brain started sounding the alarm, fortunately my survival brain kicked in. When we are panicked, we fall back to our old habits. That’s why we do all sorts of things that we later regret, because our thinking brain has shut down and run for cover. The good news is that after a bit of practice, I had developed the habit of noting my thoughts, emotions and body sensations. So even while my prefrontal cortex was still asleep, I started noting all of my signs and symptoms. I don’t know how long my first panic attack lasted, but after the dust settled, my habit brain handed my thinking brain–which was now wide awake–a list of what it had noticed. “Oh, wow, this looks like the diagnostic checklist for a panic attack” I thought to myself. I didn’t see anything on the list that indicated that I should add myocardial infarction, pulmonary embolus, stroke, or anything else that would indicate that I should get myself to the Emergency Department, so being a sleep-deprived resident, I went back to sleep. My next panic attack was shorter because my brain already knew what this was, and eventually I stopped having them altogether.
I bring this story up for two reasons. (1) This sh*t works! (2) The onset of my panic attacks might teach you something important about your brain. And this might help you not burn out and even live a happier, healthier life. So let’s dive in.
#1. Sorry about the earlier expletive. There is plenty of neuroscience data showing that what we do with our attention matters. I’m not quite sure how else to convey how powerful this is to learn how to work with your mind to change your brain so that you can have it work for you. Yes, even when the five alarm panic fire breaks out in your head. If you are thinking that this is just some crazy psychiatrist making stuff up to justify to himself all of the hours he spent navel gazing, hey I get you. That’s why I’m also a scientist. Science helps us cut through the crap and see what is real.
Here’s some science. Our brains don’t like uncertainty. More accurately, uncertainty triggers a survival mechanism that signals to our brains that they have to take action. This comes in two main flavors that relate to the approach or avoid reaction: curiosity and fear. We approach when we’re curious. We run when we’re afraid.
For example, let’s say it is the middle of the day. You are in your bedroom taking a well-deserved nap. You hear a noise at your front door that wakes you up. You might be curious, “hmmm, I wonder if I just got mail or a package delivered?” You go and take a look. When you see the package or your mail, you're now pretty certain as to what caused the noise. Now let’s say that it is the middle of the night. That exact same noise at your front door wakes you up. Because it is an unexpected event, instead of curiosity, the noise elicits a fear response. Are you just going turn over or and going back to sleep? Nope. Your brain won’t let you. That uncertainty fires up the danger signals in your brain. Fear kicks in. You go on high alert, get out of bed and figure out what it was that made the noise. Only when you are certain–or as certain as you can be–of what caused that noise can your brain be reassured that you can turn off the alarm in your head and go back to bed.
How does anxiety fit in here? Fear and anxiety can be distinguished based on timeframe. Uncertainty in the form of a potential threat in the present moment elicits fear. Possible future threat elicits anxiety and worry. Can you see the difference? If the potential threat is happening right now, our fear response kicks in. If the potential threat was completely predictable, we might fear and/or plan for it. It’s that unpredictability, the uncertainty that drives anxiety and worry. In other words, when we worry about the future, we get a taste of fear in the present: we feel anxious. In fact anxiety is defined as a feeling of worry, nervousness or unease typically about something with an uncertain outcome. Research psychologists have added that this feeling is “in response to uncertainty about a potential future threat.” I think of the difference between fear and anxiety in this way: fear is helpful for survival right now. Planning for the future is also helpful. When you mix fear and future–and the future is always going to be uncertain to some degree–you get anxiety. In this way, we can simplify the definitions of anxiety to this: anxiety is fear of the future. Ironically, anxiety is an anti-survival strategy. Why? Because it makes it harder to think right now, and it makes harder to plan for the future. It’s also not good for our mental or physical health.
Think of it this way: information is like food for your brain. Your stomach signals when you need calories and urges you into the kitchen. Well, your brain does the same thing: uncertainty signals that you are low on information and urges you into action. You could be driven to get that information by curiosity or by fear. Bringing this back to the example of severe anxiety in the form of panic, if I hadn’t learned what a panic attack was, or how to work with it, my danger signals may have sent me to the emergency department to get checked out. Thoughts like “I’m dying” are pretty compelling for dialing 911 when you don’t know what the hell is going on. But knowing these helped reduce my uncertainty, so there wasn’t a need to worry.
Here’s a fun fact in case you slept through your psychiatry lectures in school: having a panic attack isn’t enough to get you the panic disorder diagnosis. Having a million panic attacks doesn’t do it either, especially if you know what they are and could predict when they were going to happen–notice how the uncertainty goes to zero here, so there’s nothing to be anxious about. If you do exactly when they're coming on you know how they’re unpleasant, but tolerable because you know that they aren’t dangerous, and will end relatively quickly. In order to get a diagnosis of panic disorder you have to be worried about having future panic attacks enough that it affects how you live your day to day life.
That’s right, if your brain doesn’t know what caused your panic attack, it is going to start worrying about when you’ll have the next one. Uncertain of what to do, you start avoiding situations that you’ve associated with your last attack. For example, I’ve had a number of patients who have their first panic attack while driving. They end up in my office, often via the bus or a saintly family member driving them, because they avoid driving at all costs. Yes, uncertainty can suck, especially if you're driving your car and you're worried to have a panic attack
So why was the onset of my panic attacks so important? Well, for one thing, residency is an ocean of uncertainty. Remember your first day of internship or clinical training ? As a newly minted MD (or healthcare professional), you’re suddenly supposed to be an authority, and know how to take care of your patients. If you’ve moved to a new town or started a rotation or residency at an unfamiliar hospital, think of all of the uncertainties of everyday life. And those are on top of not knowing when you are going to get paged next, or what dumpster fire your team is going to get signed out at night, if you are lucky enough to have a team, and not be the only person on call that night. You get the idea. In healthcare uncertainty abounds. As a reminder, fear is a helpful survival mechanism. Planning for the future is a helpful survival mechanism. But you need information in order to plan. So when you stir fear + uncertainty together your brain gets all mixed up. Fear makes it hard for you to think. When you add planning into the mix, your brain gets even more mixed up. That’s when you switch to that anti-survival mechanism called anxiety. Yes, fear of the future is gunpowder for your brain. Uncertainty lights that match in your brain. At best you get that slow hot burn of anxiety. At worst, your head explodes in a panic attack. Pure suckage.
If you are past clinical training, you have your license or certification, you’re all set right? No more uncertainty. No more anxiety. Right. If only life was that simple. Well, what in life can you guarantee with 100% certainty? If your answer was uncertainty, good job!
So if uncertainty is one of the few certain things in life, how can you work with it? Ready for some more science? Well, as we were talking about, one way that uncertainty shows up in the healthcare field is in anxiety. We are a very anxious profession. In 2021, one study showed that the prevalence of anxiety among all healthcare providers ranged from 22.2% to 33.0%. This is certainly an increase due to the COVID-19 pandemic, but anxiety was already at high levels pre-pandemic.
My lab develops and studies anxiety treatments. Did you know that anxiety operates like any other habit loop? I never learned this in my medical school and residency. I stumbled across this important fact when I was struggling to help my own patients with their anxiety. I was struggling because anxiety medications dont help everyone. With selective serotonin reuptake inhibitors, SSRIs, the number needed to treat for generalized anxiety disorder is 5.2. Talk about uncertainty. That number needed to treat the number 5.2 means I don’t know which 1 of the next 5 patients I prescribe an SSRI for will benefit. And what do I do with the other 4? More uncertainty.
So my lab developed an app, called Unwinding Anxiety that focuses on anxiety as a habit. It targets the mechanism of negative reinforcement. Here’s the Anxiety habit loop: Anxiety triggers worry as a mental behavior. Worrying makes us feel in control–or at least like we are doing something–which is enough of a reward for our brain to learn it as a habit. For my patients with panic disorder related to driving, thoughts of having a panic attack triggered them to avoid driving. I’m guessing that you can name a number of patient or work related worry habit loops of your own. Here are some of the loops clinicians in this program reported:
Trigger: fear of being late for patients or not being able to get home on time to be with my family
Behavior: worry, incessant planning, bringing work home
Result: feeling tight and closed off to the world which is exhausting
Here's another one.
Trigger: abnormal lab work from a cancer survivor who had an ill-defined complaint that doesn’t point to a clear next step
Behavior: Worry that I should have done more tests, and worry what to do next
Result: Take the worry home with me
And here’s one more.
Trigger: Feeling overworked
Behavior: Tell colleagues how hard this is. Wouldn’t anyone feel this way?
Result: Get validation.
Can you relate to these habit loops? The good news is that if these can be learned, they can be unlearned. My lab did our first study with one of the most challenging populations I could think of. Yes, physicians. Let’s just say There are plenty of anxious physicians in the New England area. In fact it only took a single email from the CEO of our hospital system to recruit all of the anxious physicians that we needed for our study. In the study, at baseline, we found a very strong correlation between anxiety and burnout. Remember that self-protection habit loop from earlier? Yes, cynicism was highly correlated with anxiety. The good news is that within 3 months, these docs showed a 57% reduction in Generalized Anxiety Disorder-7 scores. On top of this, they showed a 50% reduction in cynicism. That was without even mentioning the word burnout in the training. When you learn how your brain works, you can extend that learning beyond the original target. Neat brain trick.
Now this was a single arm trial without a control group. So we followed up that study with another population that really struggles: people with generalized anxiety disorder. In this randomized controlled trial we got a 67% reduction in GAD-7 scores when the Unwinding Anxiety app was added to treatment as usual. Treatment as usual results were parallel to the medicine numbers: anxiety dropped 14% which is in line with a number needed to treat of 5.2. As a comparison, that 67% reduction equated to a number needed to treat of 1.6. Not bad for an app.
So if you need evidence to show you that treating anxiety like a habit works, there you have it. You probably don’t need any science to convince you that stress and anxiety habit loops are real, whether they are your own, your family members, your friends or your colleagues. As long as humans have brains and uncertainty, there will be anxiety. If you get excessively stressed or have anxiety, the good news is that you can use the same tools that you’ve already been learning in this course to work with your own mind.
Here’s an example from someone using the program:
“Last week I was doing a telehealth visit with a patient who has a lot of psychiatric diagnoses and I was feeling like I am not equipped to help her as she has had these issues for much longer than she has known me. I was dreading the fact that she was on my schedule, thinking, "I will never get through the visit". Many of our previous visits both virtual and on site have left me feeling inadequate. But last week I sat back and really listened and felt very connected to her. She did not choose to have these issues. I used the tools of the program and I was able to really support her. I just let the visit move at its own pace. I was open and without a plan--just ready to meet her where she was. it was pretty cool ...
So try this today: when you notice stress, worry, or another habit related to trying to control what is happening coming up, take a moment to map it out. For example, is uncertainty spinning into an anxiety habit loop? Then ask yourself, “what am I getting from this?” and check to see if there is actually anything rewarding about it. Is anxiety helping you think, plan or reduce uncertainty? Feel into your body when you ask this question. Intellectual answers don’t change behavior so they don’t really count. Your feeling body is much stronger than your thinking brain, so stay with the wisdom of your body. Let it help you get disenchanted with that old habit. Then get curious. When you mapped out and see how rewarding or unrewarding it is, then get curious. Tuning into your bodily sensations, ask “what does anxiety feel like in my body right now?” See if you can note the sensations from moment to moment, using the same noting technique that you learned to work with intrusive thoughts. Yes, the same noting I used to ride out my own panic attacks.
Onward! I will see you in the next module.
References:
Fernandez, R., Sikhosana, N., Green, H., Halcomb, E. J., Middleton, R., Alananzeh, I., Trakis, S., & Moxham, L. (2021). Anxiety and depression among healthcare workers during the COVID-19 pandemic: A systematic umbrella review of the global evidence. In BMJ Open (Vol. 11, Issue 9). BMJ Publishing Group. https://doi.org/10.1136/bmjopen-2021-054528
Roy, A., Druker, S., Hoge, E. A., & Brewer, J. A. (2020). Physician anxiety and burnout: Symptom correlates and a prospective pilot study of app-delivered mindfulness training. JMIR MHealth and UHealth, 8(4).
https://doi.org/10.2196/15608
Gong Y, Han T, Chen W, Dib HH, Yang G, et al. (2014) Prevalence of Anxiety and Depressive Symptoms and Related Risk Factors among Physicians in China: A Cross-Sectional Study. PLoS ONE 9(7): e103242. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0103242
Ruitenburg, M.M., Frings-Dresen, M.H. & Sluiter, J.K. The prevalence of common mental disorders among hospital physicians and their association with self-reported work ability: a cross-sectional study. BMC Health Serv Res 12, 292 (2012). https://doi.org/10.1186/1472-6963-12-292