Stress Management: Strategies and Tactics15 minute read

In mental health, stress management by Steven Kornweiss, MDLeave a Comment

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In this article, I discuss three different types of stress: panic, anxiety, and disappointment. I will address causes for each, and treatments that I have found helpful.

Intro: Mind vs. Body

The concepts of health and well-being can be divided into two categories: physical and mental.

I have spent most of my time as a doctor learning to treat the physical aspects of health. However, it strikes me that people are much more capable of coping with physical ailments than mental or psychological ailments. In fact, it often seems to me that the worst part of being physically ill is the uncertainty and fear that come with physical illness.

I learned this first hand after my recent experience with appendicitis. I was in pain after surgery. The pain itself was easy to deal with. However, the idea that the pain could indicate a complication was frightening. I imagined the worst case scenarios. This worrying made me feel mentally and physically exhausted, and I was unproductive for a week as a result.

Even in the absence of true physical illness, mental and psychological stress alone can cause physical symptoms such as pain and fatigue. This is called somatization. In severe cases, patients can even suffer stroke-like symptoms or seizure-like activity due to the conversion of psychological stress into physical symptoms. This is known as "conversion disorder."

It’s clear that mental and physical health are inseparable. The human body and mind are not two separate entities, but one integrated whole. I’ve decided, therefore, to spend more time understanding and addressing the mental and psychological aspects of health.

In my past efforts to alleviate stress and anxiety, I have learned various skills and implemented several systems to help me deal with common stressors. I would like to share a few of these with you right now.

Acute Stress / Panic

We have to dispense with panic before we can deal with anxiety or disappointment.

Panic, or acute stress, is a cognitive and psychological state in which our entire mental content is occupied by an emotional response. It is a state in which no thinking can take place. Instead of clear, linear, rational thinking, our minds flash from one fragment of an idea to another. We can’t grab onto any one of these ideas because we are overwhelmed. This state of stress is so mentally disorienting, that it is common to have physical symptoms along with it: a feeling of being in a fog, heart palpitations, dizziness, or even nausea, shaking, and sweating. The essential emotion that underlies such an episode is fear. Our bodies respond physiologically to fear by increasing the tone of the sympathetic nervous system.

In order to think straight, the first thing that must be done is to shut off the fear response.

The best technique that I have found for doing this is called "tactical breathing." Tactical breathing is a technique taught to soldiers who must perform mentally and physically under the threat of death in combat. I use this technique in my practice of emergency medicine when I must perform quickly and effectively for patients who are critically ill. I also use this technique when I feel overwhelmed by a writing project or a mountain of tasks. It works equally well in all of these scenarios.

Tactical Breathing


There are various methods of tactical breathing, but the one I prefer is simple and effective and takes only 64 seconds.

  • Inhale slowly and deeply for 4 seconds.
  • Hold your breath for 4 seconds.
  • Exhale slowly and completely for 4 seconds.
  • Hold your breath out for 4 seconds.
  • Repeat this process 4 times.

This technique accomplishes two things. First, it gives you an achievable task that will move you in the right direction. Second, the technique has physiologic effects on your autonomic nervous system. It will slow your breathing and your heart rate. You’ll stop shaking. You can test this sometime even if you’re not in a panic. Look at your Apple Watch or FitBit or any device that shows you a real-time heart rate. Sit down and breathe normally. Watch your heart rate. Then perform tactical breathing. You’ll see your heart rate come down by at least a few beats per minute or more.

Note: It’s normal for the heart rate to vary throughout the respiratory cycle.

Once the acute stress has been reduced or eliminated, it should be possible to focus on the task at hand.

Anxiety and Confusion

Being unfocused causes anxiety, and being anxious makes it hard to focus.

In order to be focused, we need the following:

  1. A purpose or goal to focus on
  2. A next step to take towards our goal
  3. A clear mind

Let’s assume for the purposes of this article that we have a purpose or goal already. In fact, we likely have many. When we have many goals, we end up with many ideas and tasks. Eventually, these tasks lead to a state of mental overload, and it becomes unclear what should be done next. We may try to do more than one thing at a time. When we try to think about and do many things at once, we end up feeling scattered and overloaded.

If this state of overload continues, eventually we will forget something important. This mistake reinforces our fear and causes a further feeling of anxiety.

The state of being unfocused is called distraction. Distraction is caused by mental overload. There are external distractors like text messages and social media, but these are easily dealt with by silencing devices and closing browser windows. What about the distraction that comes from within? Consider how difficult it is to focus on your work when you know that your car needs to be serviced, the bills need to be paid, and you have to shop for groceries and cook dinner. Or, what about the problem of trying to write an article about focusing while trying to incorporate too many ideas about focusing all at once?

Jean Moroney is a consultant who runs a business called Thinking Directions. She writes articles on her blog by the same name. In one of her articles, she tells the following story:

”The earliest known discussion of the problem of mental overload includes a memorable story about a crow. It comes from a paper by Sir John Lubbock published in Nature in 1885.

A hunter wanted to shoot a crow, which he considered a nuisance. It turns out the crow was too savvy. If the hunter came to the area, the crow hid until he left. Yes, he was playing “Hide and Go Seek” with a bird.

Thinking to outsmart the crow, two hunters came. The bird hid. Then one hunter left, and one stayed behind, hoping the crow would come out so he could get it. But the crow wasn’t fooled. It stayed hidden. The hunters tried again with more people. Ultimately, they needed to send in 5 hunters, then have 4 leave, in order to fool the crow into thinking it was safe to come out.

The crow had exceeded its psycho-epistemological capacity. It couldn’t tell the difference between a group of 4 or a group of 5 hunters. It saw only that many hunters came in, and many left. Just as with humans, when overloaded, the crow Can’t Really Operate Well."

The point of the story is clear: working memory is limited. Once the capacity is reached, we cannot bring in a new idea without letting an old one go.

Fortunately, there is a solution. In his book How to Take Smart Notes, Sönke Ahrens tells the following story about Soviet psychologist Bluma Zeigarnik.

“The story goes that she went for lunch with her colleagues and was very impressed by the waiter’s ability to remember correctly who ordered what without the need to write anything down. It is said that she had to go back to the restaurant to get the jacket she left there. Much to her surprise, the waiter she admired just minutes ago for his great memory didn’t even recognize her.

Questioned about what seemed to her a contradiction, he explained that all the waiters had no problem remembering the orders and matching them with the guests at the table. But the very second diners left the restaurant, the waiters all forgot them completely and focused on the next group.

Zeigarnik successfully reproduced what is now known as the Zeigarnik effect: Open tasks tend to occupy our short-term memory – until they are done. That is why we get so easily distracted by thoughts of unfinished tasks, regardless of their importance.

But thanks to Zeigarnik’s follow-up research, we also know that we don’t actually have to finish tasks to convince our brains to stop thinking about them. All we have to do is to write them down in a way that convinces us that it will be taken care of.

That’s right: The brain doesn’t distinguish between an actual finished task and one that is postponed by taking a note. By writing something down, we literally get it out of our heads. This is why David Allen’s “Getting things done” system works: The secret to have a “mind like water” is to get all the little stuff out of our short-term memory.” (Location 1301)"

According to Ahrens, Zeigarnik, and David Allen, in order to have a clear and focused mind, and thus one free of anxiety, we must get these important, but currently extraneous and distracting ideas out of our heads.

Take Notes and Make Lists

We must trust that these important but currently irrelevant ideas and tasks will be dealt with later, even though we are dispensing with them now.

We must have a system of note taking that allows us to externalize unfinished but currently irrelevant tasks and ideas so that we have more mental space to focus on the task at hand.

There are many methods of keeping notes ranging from the simplest – a list on a piece of paper, to the most complex – a “slip-box” or zettelkasten.

Getting Things Done

For more information on task lists, and creating a system of getting things done, the book Getting Things Done, by David Allen is widely considered to be the bible.

Zettelkasten or “slip-box” method of note taking

For more information on the “slip-box” or zettelkasten, read How to Take Smart Notes by Sönke Ahrens. For a brief overview of zettelkasten, I recommend this article.

The following passage is about German sociologist Niklas Luhmann and his zettelkasten method of note taking:

“During his almost 40 years of research, he published more than 70 books and over 400 scholarly articles on a wide variety of subjects, connecting sociology with such diverse topics as biology, mathematics, cybernetics, and computer science. That’s more than seven books every four years for his whole career — in addition to a boatload of articles. And those books are no hastily thrown together nonsense. They are classics that made him one of the most important sociologists of the twentieth century.

His productivity is even more impressive considering how old school he was. Shortly before his death, in a radio interview with Wolfgang Hagen, he revealed that he used no computers, only pen and paper and a typewriter, which he operated using hunt and peck typing.

When asked how he published so much, Luhmann used to answer “I’m not thinking everything on my own. Much of it happens in my Zettelkasten. My productivity is largely explained by the Zettelkasten method” (original in German).” – (David B. Clear, source)

Sometimes off-loading tasks is not enough to gain focus and clarity. Even a single problem can have many parts to it and can be difficult to sort through at first.

The best way to clarify your thoughts is to make them whole and to deal with one at a time. Sometimes I think I should be able to do this in my mind without writing, but this always proves difficult. According to this interesting article, many famous intellectuals kept notebooks including: Mark Twain, George S. Patton, Thomas Jefferson, Charles Darwin, Beethoven, Hemingway, Benjamin Franklin, Rockefeller, Edison, Newton, and of course Leonardo da Vinci. These are just a few examples. These geniuses obviously knew that writing is essential to clear and focused thinking.

Because writing facilitates clear and focused thinking, which in turn is required to eliminate stress and anxiety, writing is an essential tool for managing stress and anxiety.

Thinking on Paper

Briefly, thinking on paper is the process of writing your thoughts in full sentences. Since a sentence represents a unit of thought—an entity and its action—writing in full sentences causes you to focus on one idea at a time. If you’re unable to form a full sentence (a full thought), it becomes obvious that you are missing something. As you write out multiple thoughts, it’s easier to notice contradictions and connections.

The process of writing facilitates the identification of the issues at hand and promotes step by step causal thinking. In other words, writing facilitates the process of reason, and reason leads to clarity.

As you write your ideas, you can identify the relationships between them. For instance, I was not sure what to write about in this issue of the newsletter. I read journals, books, and articles on many topics this past week, and they were all swimming around in my mind. The night before I wrote this draft, I first attempted to summarize what I’ve been learning and thinking about. After a few sentences, I saw a pattern emerging. I realized that I could write about mental health. Upon reflection, I know this idea was in my mind earlier in the week, but I couldn’t grasp it until it was concretized on paper.

Ridding your mind of irrelevant tasks and ideas gives you space to think. When thinking still doesn’t work, think on paper. This can help clarify thoughts.

Thus far I’ve presented tactical breathing, task lists, and thinking on paper as effective tactics that can help us turn panic into calm, anxiety into focus, and confusion into clarity.

Disappointment

Even the calmest, most focused, people can still suffer from yet another more insidious type of stress: disappointment.

disappointment: the state or feeling of being depressed or discouraged by the failure of one’s hopes or expectations.

  • The Random House Dictionary of the English Language, College Edition, 1969

Unfortunately, many people who appear remarkably successful fail to experience a feeling of success.

Guy Winch, Ph.D., a clinical psychologist recently appeared on Peter Attia’s podcast, The Drive. Guy and Peter discussed a variety of mental health topics. The episode is worth a full listen. One of their discussions was about individuals who do not enjoy their own success. You can read a transcript of the excerpt below, or click here to listen to the clip.

Peter: You’ve talked extensively about the impact of failure on our emotional health. A lot of what you just described can be viewed as a failure, right: by definition, if you’re willing to compare yourself to a broad enough array, you’re a failure. I mean, there’s always someone who is smarter, better looking, richer, more popular. There’s no metric by which I couldn’t in 30 seconds come up with 10 people who are better than me. So what is the antidote to that misery that comes from comparison?

Guy: First of all, it’s a true misery, and the issue is that, for example, I work with a lot of successful people. They don’t think of themselves as failures. It’s more painful. They just don’t think of themselves as successful because they’ve only made 20 million and they’re looking at the person who made 50. There’s something extraordinarily tragic about someone who went from nothing to $20 million and doesn’t think of it as a success, right? I mean, that’s just unfortunate that you would spend so much effort to get somewhere and have zero appreciation for the fact that you’re there.

I worked with somebody once who tried to climb Everest and only made it to base camp, and I was like, "Oh, my god, you made it to base camp?" They were like, "yeah but I didn’t get to the top of Everest." I’m like, "again, you made it to base camp?" In other words, that’s actually impressive. It’s not that simple. It’s not that easy.

If you keep looking up, you will never, ever be satisfied you will never, ever be happy.

In this conversation, Peter and Guy identify two separate reasons that cause people to feel inappropriately unsuccessful:

  1. Improper goal setting
  2. Improper measurement

Set Effort or Process Based Goals

The common error in goal setting is: setting an outcome based goal rather than an effort or process based goal.

In the example of the Everest climber, they set the goal of climbing to the top of Everest. This goal is a set up for feeling like a failure. A better goal would have been, "I will make my best effort to climb Everest." To be a success in this case, he must in fact make his best effort, but he need not actually make the summit.

Consider my medical practice as another example. An outcome based goal would be, "I will have a practice with X clients and Y revenue within the next year." Contrast this with an effort or processed based goal. For instance, my goal could be: "I am going to spend 10 hours per day building my business and providing as much value as I can to my clients."

For the climber, an avalanche, bad weather, an illness, or injury will make him a failure if he has the outcome of summiting as his goal. For me, a pandemic, financial collapse, or a few bad business ideas will make me a failure if I have an outcome based goal. But with the process based goals, consistent efforts make us successful no matter the outcome.

Aside: Of course in business you do also need quantitative measures of success, which eventually include profitability in some form or another. But in this context, we’re not talking about the success of a specific business, but whether an individual identifies themself as fundamentally successful or not.

Measure Success and Progress Against Your Past Self

The common errors in measuring success are:

  1. Measuring in comparison to others
  2. Measuring compared to your future self rather than to your past self

Both of these can be reduced to one mistake – comparing yourself to anyone other than your past self.

The millionaire in Peter Attia’s podcast measured his success in comparison to others instead of in comparison to his past self.

For another example, consider Alex Epstein. Alex is a writer, philosopher, and advocate of industrial progress. He talks about this exact mistake on his podcast, The Human Flourishing Project. He tells a story of when he was first starting out as a writer, but hadn’t yet made much money. Instead, he was losing money and going into debt. He saw himself as a failure. When he relayed his feelings to a close friend, this friend was dismayed. The friend pointed out the enormous amount of progress that Alex had already made, and the necessity of the hard work and debt that Alex was investing for future achievements. Alex says that this change in perspective was transformative for him. At first, all Alex could see was that he was still far away from his goals. After talking with his friend, though, Alex could see how far he had come from his starting point. This change in perspective enabled him to feel successful, and made him feel positive towards his work.

Interestingly, if we set an effort based goal instead of an outcome based goal, the only way to measure ourselves is to look at our past efforts. In this way, proper goal setting avoids all of the above problems.

Of course it’s also true that we have to be honest appraisers of our own efforts, and we may need to work harder, change course, try something new, or even change careers. None of these course corrections constitute failure in-and-of-themselves so long as we’re pursuing proper goals.

It’s also worth pointing out another possible pitfall: assuming that we know what our goals are. It’s easy to have some vague goal in the back of our mind, but the only way to know that we’ve constructed a proper goal is to make it explicit on paper.

To recapitulate, I believe a proper goal is explicit, self-referential, effort or process based, and is measured by looking backwards.

Summary and Review

Acute Stress / Panic

The first type of stress is acute stress, or panic. In its severe form, panic is both cognitive and physiologic, so you must do something that is both cognitive and physiologic to break away from it. My favorite technique that is battle tested and emergency medicine tested is called "tactical breathing." The method that I use is a 4 count method. First, you inhale deeply for 4 seconds to fill your lungs. Then, hold your breath for 4 seconds. Next, exhale for 4 seconds, and finally, hold your breath out for 4 seconds. Repeat this cycle 4 times. When this is complete, you should be mentally and physically calmed.

Anxiety and Confusion

Once you are calm, you should be able to perform. But, sometimes you may still feel anxiety because your mind is overloaded and scattered, and you don’t know what to do next. In this scenario, retrieve pen and paper and externalize ideas and tasks that are filling your mind but which can be dealt with later. Pick the one or two ideas or tasks that must be dealt with now, and trust that you will return to your list later to finish remaining tasks.

Now you know what to do, but you still may not know how to do it. When this happens, you can think on paper. Write your ideas in full sentences. Look for contradictions, inconsistencies, and holes. Find the relationships between your ideas. Consider following Jean Moroney’s "One-Minute Rule" for thinking on paper.

Disappointment

When you’re feeling disappointed in yourself, check your method of self-evaluation. Make sure your goals are explicit. This means writing them down on paper in full sentences. Make sure the goals are process or effort based. Measure your success not in comparison to others, but instead based on your own progress and effort.

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