We surgeons are trained, through our culture and our experience in residency and practice, to tolerate high levels of stress. The key word in that sentence is "tolerate" or endure. Endurance and grit are incredible superpowers that can transform our ability to grow, learn, and adapt. But like all good things, they are good until they are not. As someone who grew up in miserable circumstances, and as a surgical resident and surgeon, I came to believe that I was nearly impervious to stress, as if I was a piece of human Teflon. Reality, as it always does, catches up with all of us at some point, and it caught up with me when I found myself overwhelmed with too much on my plate, a dwindling sense of meaning in my work, all exacerbated by social isolation and lack of connections. Andrew Huberman shows us how we can better manage acute stress with something other than just enduring, using science-backed techniques for breath work and social connection that can have a profound effect on what Andrew says is our "ability to dance with stress." There is a lot to this episode, so I will break it down into more than one post, with this first one covering physiologic sighs for moments of acute stress.
- A physiologic sigh is a deliberate process of taking a deep inhalation, throught the nose, followed by one more very short inhalation to expand the lungs, and then slowly breathing out through the mouth with the lips slightly pursed. The key is that the exhalation is more longer and more vigorous than the inhalation phase.
- This recruits alveoli that are collapsed from the shallow breathing of an acute stress event or from being wired up and frazzled from a long string of stresses in a day.
- The alveolar recruitment blows off the CO2 build-up from shallow breathing, and since CO2 build-up leads to anxiety and jitteriness, you get calm but stay alert.
- Physiologic Sighs induce a calm and alert state and they are perfect for:
- Acute stress episodes - think give a talk, conflicts, a complication, any acute stressor.
- When you are wired or frazzled at the end of a long case or day of work.
- When you are tired and still wired up, ruminating, and you can't fall asleep.
- Before you walk in the door at home (or anywhere - meetings, operating room, wherever) when you are stressed, so you don’t drag your stress and emotions in and pollute other people with your emotional contagion.
Summary and Thoughts
When we are engaged in anything, be it writing a paper, driving a car, having a conversation with someone, there is a profound link between the external experience and our internal experience, and as the two converge emotions are created, and this is particularly true for stress. The key idea here is that we don't have to be a slave to our external experiences and the stress they can create in our bodies, as there are scientifically proven ways to manage stress, both on the fly in our daily lives, and on a ongoing basis, especially in the management of chronic stress, the pernicious killer.
First off, the stress response is generic. It does not give a damn if it comes from outside of us, or from inside our heads and our thinking - in other words psychological stress. The body deals with both in the same way with a generic stress response. The generic stress response involves activation of the autonomic nervous system to get us to "do something, to move," and the movement can either be literally moving or saying something (that you may well regret later), all driven by activation of the sympathetic nervous system with release of epinephrine and all of its effects - pupil dilation, blood vessel constriction, shuttling of blood away from organs like the gut to the muscles and heart.
The parasympathetic system is the key lever we can pull in the face of acute stressors. The parasympathetic nervous system controls the muscles of our face and eyes and to some extent our trachea, and it also has a major highway of nerve fibers in the vagus nerve, a two-way highway that has massive influences on the control of our mood, digestion, and heart rate - and it sends all of this info from the body to the brain via afferent fibers. So the setup is clear: the sympathetic nervous system is there to get us to take action with a threat, whereas the parasympathetic system is a huge feedback highway of information that profoundly affects many aspects of our wellbeing, and it also counters the sympathetic nervous system's effects.
First up: acute stress. You are about to go up on stage at a meeting to give a keynote, or you have just had an argument with a loved one, or a case went poorly and there was a complication. What does not work is telling yourself or anyone else to "calm the f#@^ down." My dear wife used to be fond of telling me to "just get over it," and even recalling her saying that stresses me. So here is what you do in an acute stress situation like the one I am experiencing right now: a Physiologic Sigh.
It works as follows. Whenever you inhale, the diaphragm descends, expanding the volume of the chest, and the heart increases in size a bit, so the blood moves a bit slower, signaling the sinoatrial node to tell the brain letting it know about the slower flow. The brain then sends a signal to the heart to speed up a bit for God's sake. What this means practically is that if you want to speed up your heart and blood flow, inhale longer, and more deeply than your exhales. The key is that the inhales need to be more vigorous than the exhales.
Conversely, when you exhale, the diaphragm moves up, the heart gets smaller, and blood flow speeds up, and the sinoatrial node signals the brain about the higher flow, activating the parasympathetic nervous system (vagus) which slows the heart down.
The beauty here is that we can control our diaphragms with breathing. And we can control or blunt our acute stress responses with physiologic sighs. If you have ever been in a real crying fest where the tears and emotions are coming out of the spigots - this is particularly common to see in kids when they are upset - there is a natural physiologic sigh that happens automatically as a way of calming the system. They suddenly stop sobbing, take a huge deep breath, and then another one or several small ones after as they try to recover air or calm down, and then they breathe out slowly.
But instead of crying uncontrollably, you can do a physiologic sigh by doing a double inhalation by first taking a deep inhalation, followed by a smaller one stacked on top of the big one, followed by a slower and long exhalation with the lips slightly pursed. So there is a bit of a paradox here since you take a deep breath in, which activates the sympathetic system. The reason is that when we are stressed, our breaths are shallow, and we accumulate CO2. By taking a big inhale followed by a little one you open more alveoli and blow off CO2, which is a good thing since CO2 buildup induces anxiety and jitteriness. Now the long exhale is much more efficient at blowing off CO2, which relaxes one quickly.
Huberman makes the great point that a physiologic sigh is not just fantastic for those acute stress situations like I mentioned above but also for calming down whenever we find ourselves in a state of heightened activation - ie you feel all wired up and tense, perhaps after a long hard case or after a long day. It is very hard, if not impossible often, to control the mind and how you feel, but a physiologic sigh is a powerful lever to use in those two circumstances - acute stress events and when you feel frazzled and wired.
A physiologic sigh is also a great technique to use on the way home or before you go in the door to your loved ones. In my piece on the How To Score the Winning Point When You Come Home, the steps were:
- Reflect on your day - and specifically ask yourself what went well, what did I achieve, and how did I get better.
- Rest - gain presence and calmness.
- Reset - and decide how you will show up at home by setting an intention and deciding how you will behave.
Step 2 - rest - is the perfect spot for some physiologic sighs.
Here is a video of Andrew doing a physiologic sigh - and he makes the point that it may take several in a row to get you to the sweet spot which is calm and alert.
One caveat that I need to throw in is for the doubters. I used to be a doubter of all of these "wo wo" sorts of things, but no longer. I was ignorant of the power of small actions like physiologic sighs, gratitude, meditation, and connection with others as I had fallen into the trap of viewing and treating myself like a machine.
I was wrong.