Amanda: Hey guys. Welcome back to the podcast. I'm Amanda.
Laura: I'm Laura.
Kendra: And I'm Kendra.
Amanda: And today we wanted to finish a conversation that we started with Dr. Shideh Shafie last week about stress. She told us so many great things, but when she hung up immediately I started thinking of all the things that I wish I would've said. So, we're gonna make it an entire podcast instead. So the first thing is I wanted to make sure that we all understood what we're talking about when we're talking about stressors versus stress. Stressors are the things that cause you stress. Stress itself is a cycle that happens in your body. It's the neurochemical cascade of fight or flight, freeze or fawn, or whatever happens to you when you're under stress. And I'm not sure if we made it clear or not, but that cycle, in order to get back to homeostasis, has to complete itself. There is an end to the stress cycle, and that is something that we as adults tend to stop midway and never do finish the stress cycle, which means that it's harder for us and our bodies to get back to homeostasis. Again, like Shideh said, not all stress is bad. Eustress is positive stress, the, you know, the jitters and everything that you use to motivate you to get up on stage or to go do the hard thing. Negative stress, though, is the opposite of that. And the thing about modern times is that your body can't tell the difference between a lion attacking you and you getting frustrated because you're stuck in traffic. So, we just wanted to talk more about things. Shideh had talked about, you know, shaking it out for a song and we had talked about a couple of things that you can do to go ahead and finish the stress cycle. But there's so many other things that, if that's not your thing, there are so many other options and we just wanted to give you those things.
Laura: One other thing that I thought about that I wanted to add to our discussion of stress is stress that we maybe have packed in and accumulated over our lifetime. And it will have a link in the show notes to a Psychology Today article about stress. And I wanted to share just a couple of quotes from that article because we all as emergency physicians, if you're not an emergency physician, you also deal with residual trauma from a variety of different exposures. But emergency physicians in particular deal with a lot of residual trauma just from things that we're exposed to at work. And this article says people living with residual trauma are continually getting ready for the next attack or life altering event. I'm gonna read that one again. People living with residual trauma are continually getting ready for the next attack or life-threatening event. I think that many of us can relate to this feeling of waiting for the other shoe to drop, waiting for the next ambulance to roll in with CPR in progress, waiting for the next level one trauma, we can feel it in our bodies and it definitely has an effect on us. The article goes on to say, “When someone is preoccupied with a real or imagined threat, the resulting fear, rage, or disappointment will be reflected in the body. Research shows that trauma survivors suffer more illnesses”. I personally experience this. I know many of you do as well. It says, “For example, the Adverse Childhood Experience Study”, and if you're not familiar with adverse childhood experiences, I encourage you to look that up. It talks about specific experiences that children may witness or experience during their upbringing that increase the risk for physical and mental illness later in life. So the adverse childhood experience study found that “survivors of childhood trauma are some 5000% more likely to use drugs, attempt suicide, and suffer an eating disorder. Muscle tension, disease and injury are physical, are also physical manifestations of this preoccupation”. We know we feel that. I wish, man, I wish we had a little on staff masseuse. That would be amazing! Like maybe just a chair massage? Just a chair massage would even help. Trauma has such a severe impact because of the way it affects and ultimately rewires the brain. When the brain goes into stress or is stuck in stress, it leads to physical changes and a complicated ripple of life altering symptoms. I think that this information is super helpful, not only for us as co-trauma experiencers, co-trauma survivors, but also our patients. When we see these people come in with issues with drug addiction, alcoholism, suicide attempts. I see a substantial amount of eating disorders and in peds as well. It helps us to be more curious about them and less judgmental when we think about the stressors that they have experienced that have led to what we're seeing in front of us and develop more compassion for ourselves if there are any of these issues that we ourselves struggle with. It just is helpful to be curious about what were the things, what are the things that we continue to experience and witness that are contributing to these issues?
Amanda: Yeah, so I was a zoology major. That was pre-med, for that was the most direct pre-med course, and I loved zoology at OU. But if you want a real example, if you ever watch the Nature Channel or something like that, and you see a gazelle narrowly escape a lion attack or tiger attack or whatever. What happens next is they go over and lay like in a bush or something like that, and then a shaking spell happens over their entire body and it lasts several minutes. Then they get up and run off. The same thing happens, or can happen to humans, however we stop it. The main time that I've ever seen this in humans is repeatedly after car accidents when people come in and they have that shake. I would always be like, that's something that I need to give them an Ativan for or something to relax them. That is the opposite. That is literally the body, the limbic system telling the body that the stressor is gone. We are now safe and it's serving a purpose to physically reset the body and I didn't even know what that was, but it's the exact same thing that the Gazelle does. But humans tend, and especially adults, tend to stop mid cycle and not complete it and not ever get that reset or, you know, move back to homeostasis. So then we're accumulating days and days and months and months and months and months of stress in our system. Right, because we never do discharge the extra energy. Have you guys seen that too? The uncontrolled shaking. I thought that it, just cracks me up, that I thought that that like needed to be stopped. It's the body knows what it wants to do. Okay. So we're gonna give a few more ways that you can complete your own stress cycle. That comes from the book, “Burnout: The Secret to Unlocking The Stress Cycle'' by Emily and Amelia Nagoski. I don't know if I'm saying that correctly. They also have a podcast that you can check this out, but the first one she had already talked about is physical exertion, literally discharging the extra energy that's pent up in your body. It's that movement that tells the body that it's in a safe place. And that's the exact same basis behind Optic Flow, which is the basis for EMDR. A psychologist, I wish I would've written it down, back in the day realized that her patients could access their memories and could be treated better when they were walking.
And so she ended up, when you are walking out in nature, your eye normally will follow things as they pass. It's called optic flow. When you are super stressed, your pupils are constricted. Your focus is singularly on one thing. When you are relaxed, your peripheral vision expands. You are taking in all of the things. So if you know that you need to finish a stress cycle. One great thing to do is go outside and walk or some sort of forward movement. It would be even better than being on a treadmill because you would get the benefit of this optic flow. The trees moving past you. All the things. So that's one way to hack. The next one is neurogenic tremor. Which I'm super excited because in January I'm going to a conference and there's a specific talk on neurogenic tremor. I can't say it, but it is reenacting the shaking that the gazelle has or the motor vehicle crash victim has. It is re-mimicking that in a special way in your psoas muscle to close the stress cycle. And I will put a link to that cuz there's just a really easy video that you can watch and do it for yourself. It's the same sensation if you took a barre class and you're, you know, standing on your toes for a long time and your legs start gently shaking. It's that, it forces that to happen in the psoas muscle to release all the extra energy.
Another thing that you can do is music that's concordant with the feeling. Most of us like to turn on, and I'm guilty of it too, turn on like a happy song to kind of run away from the negative feelings that we had. But if you were truly trying to finish your stress cycle and you had cut off being angry in the middle of it, what you would wanna do is put on some raging kind of music and just get that energy out. Same thing if you cut off a sad stress cycle. You could put on really sad music and, you know, in effect, get that to complete the cycle.
The last thing is that, and I don't know if this has ever happened to you guys either, but sleep is actually a very excellent way of closing a stress cycle. REM sleep is where you process your experiences. David and I went to Mexico. I've never been in a hurricane before. But we ended up getting in a hurricane and then we signed some papers that turned out we were like refugees. And anyway, it was super stressful for me. We finally found an inland hotel and got to it, and the second I got to the room, it was seven o'clock at night and I had to go to bed. Like all of the adrenaline crashed and I should have stayed awake. I was in Mexico on vacation, like I should have stayed up longer. But everything in my body was like, just go to sleep. So that is another way that you can close the stress cycle if you're not into the previous ones. All of these options are just options. You pick whatever works for you, you don't have to do any of them or you know, If somebody's telling you that physical exertion is the best one, you don't have to, you can pick something else.
Laura: And the reason to do this, correct me if I'm wrong, is to keep us from packing away like hoarders all of this negative stress. So that it becomes overwhelming to us later and causes physical illness.
Amanda: And I don't wanna get too woo out there, but you know, if you listen to our very first podcast, I would get hives at work and I'm 100% certain because that was I am a professional bufferer. I was great at not even reacting. I had no emotion whatsoever. I mean, obviously I had some, but I would shove it down and so it stayed in there and eventually came out as psychosomatic hives. Which was unbelievably embarrassing to me at the time because of course I was not gonna be loving to myself.
Laura: No, you have to shame yourself for your hives.
Amanda: Exactly. And the weirdest thing you guys, is that I've had since second grade asthma and I just do not require the medications that I used to. And anxiety is very attached to asthma many times and I just wonder if some of this work, I like to think it's that I'm eating better, but if I'm honest, I really am not. So maybe it is this work that has helped me. Now, I'm coughing like crazy right now cuz I just had the flu. But I don't know. I think there's something to this stuff.
Laura: Oh, definitely there is.
Kendra: So a few other examples might be crying. So we all know that sometimes in a stressful event at the end, you take a deep breath and sometimes burst out into tears and seemingly for no reason. But actually your body may give a huge release of all of that sympathomimetic surge that is going on and then you burst out in a full on cry. I remember one case I had in residency actually. One of the unit secretaries that worked on the floor, but she would come down to the ER sometimes on a PRN basis and so I got to know her really nice gal my same age. And it was the day after or the day before Thanksgiving, and she had gotten sick and had gone home like two days before this. And she didn't come in until that night and it was my shift. And she came in by ambulance, like extremely air hungry, tachycardic in the 160’s, just really, really sick. And when she hit the door, I knew exactly what she had, most likely a PE. But anyways, it was a very difficult situation. And she ended up coding and we could not get her back. And so the whole time was like business, you know, you're working up, putting all the lines in, doing all of the things, and then, you know, she coded in the ER. So you know, it was an extended resuscitation. And I remember not wanting to give up, but then when my attending was like, okay, you know, gave the question to the team, “Anybody have any other recommendations?” And then when her time of death was called, like I just stood there. And then went outside and I just lost my mind. Like I absolutely lost control. Like I don't even know where it came from, but it was just so close to home. I mean, I just talked to her two days before. She's my same age. She just got married, like all the things, and then I just busted out. I remember my attending saying, “This is our job. You are going to have to learn how to control this”. And I was like, okay. And like, so it was like, dry your face and get back in there. And I'm like, okay, okay, okay. I got this, I got this. But you know, back then you didn't know. You didn't know what that was. But you know, when you think about events that you've had or these reactions to cases in the ED or whatever. Even going home in the car, I was just trying, my body was just trying to healthfully, I don't know what you wanna say, but complete my stress cycle. So crying, let it all out.
Laura: What'd you say, Amanda?
Amanda: I said, God forbid you be human and be allowed to have a human experience, you know?
Kendra: Well, yeah. And that's the biggest thing is, especially in that podcast, the twins were talking about, you know, don't just cry to cry. Like if you bust out crying, don't interrupt it, let it finish. Most of the time it's gonna be a minute and a half to two minutes of like that real good cry and go from there. But anyway, it's just an idea.
Amanda: Another good thing they said, you know, a lot of us, when we are crying, we're also, I think what you're getting at, is we are also judging ourselves and trying to keep ourselves from crying. But the point would be to fully lean into the cry. You're doing it on purpose. It serves a purpose to release that pent up energy.
Laura: Yeah. And we are not just talking to the women here. Men, you get so much cred if you just let it out and sometimes you just need to, to be human. And our job requires it sometimes.
Kendra: And another human factor is connection. We were born to connect. That is what makes us human. That’s what makes us individual and unique to like a mammalian species is that we were made to connect. So sometimes another way to finish that stress cycle is to connect. Not always is it just to our friends and family because sometimes maybe they don't understand and maybe, so you wanna have like an intentional connection where maybe sometimes you just kinda let it all out and you just need some ears to hear and to listen to you. And then once you get it all out, then you feel better. Sometimes it's a two-way conversation. But anyways, whatever it is for you, connection is real. And if it's not to people, sometimes it's to your pets. I mean, the reason there's pet therapy is because there's something to a connection with, you know, usually it's a dog or horses that they feel you, you feel them. Your body rhythms become one and the same. They just connect with you on a different level and it's unconditional. Most of the time people, when they have dogs and you're mates for life because they're just unconditionally loyal to you. And there's just something about that connection.
Then something that's important to me is that connection spiritually. There's been many times when I have been in an active case in ED and I just take a deep breath and I'm like, “Lord, I need you”. And like just even the connection in the moment helps me and then when I decompress on the ride home, there is something that there is a bigger purpose out there that's bigger than me, the universe, whatever you call it, there is something bigger than me that is in control and everything's gonna be okay. And so this is one of the ways I frequently finish my stress cycle is the vulnerability that you feel when you're in prayer or when you're just in there and you're just speaking in the silence and you say words and you become vulnerable and you know that there's a bigger something out there that's listening and that cares. That is a huge way that you can not only complete the stress cycle, but realize that there are many things in this world we're not gonna control. Even with all the education we have as physicians, some are gonna make it and some aren't, and that is something we have actually zero control over either way.
The other thing is breathing. So this kind of goes along with what I was saying with the connection and the spiritual connection. Sometimes people call it meditation. But they all, there's always a component of breathing and what is good about breathing is you really activate that parasympathetic system because obviously when you're in that high stress, it's a very sympathetic surge. And so what is common in most breathing or guided exercises for breathing is there's, you know, a period of time you inhale, you usually hold the breath for a period of time, and then you exhale. And the focus really is on the exhale. And you can have kind of like a mantra that you say on the exhale, like, you're letting all of the stress out, you're letting all your cares and worries out. Whatever that you say to yourself on the inhale, you're really being present on that inhale, and then when you're holding it, you're centering. Then that exhale is really just a release of all of that and it activates that parasympathetic. So you're just not in that totally unopposed sympathetic surge for a great deal of time. But it really centers you, it gets you present in the moment. And like I said, all of these are ideas that we're just throwing out there. You can use a combination of these, one or the other, or none. But these are just ways that have been very confidently and commonly used to help finish your stress cycle.
Amanda: There's a whole study of breath with yoga where, you know, we always are talking about focus on the exhale and have your exhale longer than your inhale to specifically access the parasympathetic. You can absolutely do the opposite with pranayama to do short, quick inhales to give you energy too. But for this purpose, you are hacking your parasympathetic tone to get back to homeostasis.
Laura: Yeah. So just a few last ideas for you to help to complete that stress cycle. You can use your imagination. Sometimes, hopefully this doesn't trigger anyone, but I do get some kids in the ED who have been abused and specifically like if I get a sexual abuse case, I feel so much rage. So one of the things we can use is your imagination. Sometimes my imagination just goes to karma for whoever did that to that poor kid. You can think about crushing whatever stressor it is in that moment. That would be the pedophile, but you can think about ways to soothe yourself through your imagination. Imagine yourself in one of your favorite places and you're drinking a fruity drink and relaxing. You can play a movie in your mind of what happened and kind of analyze it that way so that you can complete the stress of that situation in a way that your brain and body can understand. Using self-expression, I wanna just testify here that if you're not an artist, but have an interest in being an artist, art is something that you can learn. It's a learnable skill. So you can learn to draw if you don't already, but if you enjoy art, art definitely can help complete the stress cycle. Writing. Either writing creatively or writing as a thought download or a thought dump. This is something we use and recommend for our clients all the time. So much information can be gleaned by just writing down what's in our brains and what our brains are saying. Once we get it on the paper, it's so much easier to assess what's going on and use the rational part of our brain to process it and make sense out of it.
Belly laughter. I love, I think we all do love a good belly laugh and so that can be something that happens with your kids at home. You're playing with your kids and get a good belly laugh. You can watch a comedian. If you haven't checked out Nate Bargatze, he's my, he's my favorite current. I'm so excited we're going to see him in person tomorrow night, but he's hysterical. Watch a comedian that you love, or just do something silly and fun with members of your family or friends to help get that belly laughter going. Be mindful and intentionally self-compassionate.
One thing that Mel Robbins recommends that people do, she does this first thing in the morning. She's dealt with a lot of anxiety and she says this is something that's helped her calm herself, is put her hand on her heart and she inhales. And while she exhales, she says whatever thing it is she most needs to hear. For her it is, “I'm okay. I'm safe. I'm loved”. She does this every morning. Or it might be, “It's just okay to rest, or it's okay, or I did my best today, or I made a difference today”. Whatever that thing is, being self-compassionate is really crucial. I don't know. In my opinion, it's probably the most important thing out of all of this. When we're dealing with stressors, we must have our own back. We must be kind to ourselves and recognize that we are doing the best we can with the knowledge that we have. Because if we are not kind to ourselves, then we are becoming a stressor to ourselves and it's gonna be impossible to process all this trauma and stress that we endure. So be kind to yourself.
Amanda: One of the funny things that the Nagoski sisters say is if your imagination could cause you stress, you know, with the worries and anxieties and all of this sort of stuff. It absolutely can be used, just like you just said, Laura, to complete the stress cycle too. If the stress's coming from your brain, you definitely can use your brain, you know, with the imagination or the mindful self-compassion or those sorts of things to finish it too. I liked that.
Kendra: We are so grateful that you joined us today in this second of two podcasts on stress and the stress cycle and many examples of how we can do good to ourselves by completing the stress cycle in many creative ways. We want you to stay connected to us, so go to our website, www.thewholephysician.com, to sign up for our weekly well check that's delivered right to your inbox. We have a live CME course that is eligible for up to 30 AMA credits. So head over to the website and check it out. Until next time, you are whole, you are a gift to medicine and the work you do matters.