E67: The Emotional Domain of Stress

Kirtly: I am so stressed out. But what does that really mean? Is it an emotional state or a physiological state, or both? I am "Stressed Out Dr. Kirtly Parker Jones," and we're going to be working on the topic of stress through the lens of the "7 Domains of Women's Health."

Today, we talk about the emotional domain of stress. And with me in the virtual Scope studio is Dr. Katie Ward. She is a nurse practitioner in women's health and a certified midlife women's health clinician. She has a doctorate in nursing practice and also has a focus on anthropology.

I'm a reproductive endocrinologist. I do hormones and have an interest in how stress affects reproduction.

Both Katie and I will take our research and our clinical interests in stress to help us think about how the emotional domain affects women's health.

So what is this stressed-out thing? Is it an emotion? Is it a physical state? If you're feeling stressed out, you probably have a physical sense of tension, muscle tension, headache, increased pulse, maybe an upset tummy. Yeah, I know I still use the word tummy, sorry.

The physical sense is similar to that of anxiety, and that's an emotion. Picking apart why you feel this way is really important in trying to get a handle on how to help yourself feel better.

The National Institutes of Mental Health actually have a handout entitled "I'm So Stressed Out!" And you could google that.

So is it stress or is it anxiety? Stress is usually from an external stressor. Physical sensations can be the same in terms of anxiety and stress, but usually stress is a response to an external cause. It can be a flight or a fight or a difficult family issue. It can be a big test coming up. It can be bills that you need to pay, but you don't have enough money to do it. It can be the physiological stress of climbing a big mountain.

It can be worth trying to identify these external causes for why you feel stressed so you can take some actions to resolve them. In fact, it's possible in some cases, once you know what your stressors are, to say "I'm going to let go of that," or, "I'm not going to do this one thing." And then you'll feel better.

Now, is it anxiety that you're feeling? Anxiety is internal. It's a feeling of dread or fear that doesn't go away. It isn't always easy to pin down a cause, though there are maybe triggers for anxiety or an anxiety attack that can be external.

So, Katie, help me here. What are your thoughts?

Katie: I mean, I think this is where the words we use to describe this really matter. That precision helps us really make sure that we're talking about the same thing.

I've had patients come in to see me and they're asking for treatment for an anxiety disorder. They're telling me they have anxiety. And when I ask them about what's going on, the issues are sort of right here in front of them, exactly what you said. They have a test coming up. They have a job. They're the breadwinner. They can't work less because they provide the insurance for the family and they have so many things going on. And I'm like, "That's not anxiety. That's not an anxiety disorder. That's the real-life stress in front of you."

So we talked about this in the physical domain episode. And if you haven't listened to that, I recommend you go back and catch the physical domain episode of this podcast. But your body has a stress response. That's the thing you feel and that's what gets called the fight or flight or freeze.

Kirtly: Oh, hold it. Hold it. I just want to interject, because you know me, I'm the biologist. Possums actually freeze. When they're stressed, they lay down and play dead. And you can't actually get a heartbeat. They look like they're dead. The phrase is, "Oh, you're playing possum," meaning you're just laying down and playing dead. Well, that's what possums do. That's their stress response. Sorry, I just had to add that in there.

Katie: No, it's important. And I think that this comes up for women too. There are times when bad things happen, and maybe you don't not get a heartbeat, but freezing and not knowing what to do and sort of being passive in that moment might be part of that stress response. It might be your best course of action and your biology knows that.

There's also a special breed of fainting goats. If you want to google something fun to watch, fainting goats. They occur very rarely in nature, but people have been specially breeding them just because they're entertaining.

Kirtly: Well, getting back to anxiety.

Katie: Okay. Anyway, the stress response that triggers you to be a fainting goat or fight or just freeze or run away.

Kirtly: I'm not feeling stressed anymore. Laughing makes me feel so much better. Go for it.

Katie: Well, let's put that on the list of ways to deal with your stress response.

So, as you were saying, anxiety is usually not right now in the moment. Anxiety is more future-oriented. You're kind of thinking about the what-if. It could involve one thing like a phobia, or it can be generalized, but it's usually more being afraid of something that's not actually happening.

For example, lots of people are afraid of flying. Odds are they've never been in a plane crash and will never be, because planes are actually very safe. But because we see those images, they're everywhere and we're capable of imagining that, the idea of getting on a plane just causes that stress response.

So there's the response, how your body is dealing with it. And then the stress sort of being more how you're responding to the things that actually are threats, whether they're physical threats or existential threats.

I think that that's such an important distinction, and it's the thing that I'm looking for when I'm talking to patients, or assessing my own life for that matter. "Is this a real thing that's right here and now and that's a stressor, or am I imagining . . ."

I do this a lot. I'll imagine a conversation I need to have with somebody. It's not really happening, but that's anxiety, right? And these two things can coexist. So I may have stress about some things in my life and anxiety about other things.

So that's why I think the vocabulary is important, because it's like, "How is my body responding and what can I do to calm my body's response down?" The laughing and the other things we've talked about in the last episode. But what are the things I can deal with and what are the things that are just causing me anxiety?

I think the tricky part is how my body reacts to these things is pretty much the same. I've got a system of neurotransmitters that we talked about last time that trigger the same chemical messengers running the same program in my body. So it raises the heart rate, it raises the blood pressure, it narrows my focus. I'm just on this one thing that's important, and I'm shunting all that physiologic effort from the other stuff, digestion, fighting infection, regulating my reproduction.

Whether it's stress or whether it's anxiety, the net effect on you is it's making you sick, or at least disrupted in your normal kind of regulation.

So everything we can do to treat both stress and anxiety is important, because left untreated that effort is going to lead to loss of physical health and loss of mental health.

Kirtly: For me, I've certainly been stressed out, but the causes have always been external and I write them down. I say, "Have I internalized anxiety so that I now have an anxiety disorder and would be helped by medication? Or these are external things that are really happening to me, and where is the nexus of control in my life? Do I own the nexus of control for some of these things?" And often I do. And writing them down isn't always comfortable, but it gives me an action plan.

Now, feeling stressed and overwhelmed and anxious can lead to depression. That's an emotion and it can be reinforcing a negative loop. "I'm stressed out. I'm not good enough to do this. I'm not good enough, period," and down we go. Depression is an emotion that has profound physical effects, sleeplessness, or having too much laying in bed, or overeating, or not eating, or eating the wrong things, or stress eating.

Now, my stress eating is salt, crunch, and fat in some combination. Yours, Katie?

Katie: Butter. Butter on potatoes. Butter on popcorn. Pretty much anything you can put butter on. My kids think I really love potatoes, but, honestly, it's the butter.

Kirtly: Oh, potatoes are so boring. But if I put sour cream on potatoes, I still want the butter underneath that. It's got to have butter in the foundation. And then you've got to put salt. So if mine is salt and fat and crunch, I'm right in there with you.

So depression, Katie?

Katie: I mean, it's complicated, right? It's a bio, psycho, social phenomenon. Lots of things that we can't really see. There are biological underpinnings, and those might be your genes and how your brain is assembled, and where does it store information, and how you're hardwired in receptor sites and neurotransmitters and all kinds of complicated brain chemistry. But if you look at brains, you don't know where the depression is housed.

So there's the biology of it, and then there's what lands on top of our genes, the epigenetics, what happened to your parents and your grandparents even, the choices they made that created the events in your life that shaped your own life, and how then that affects your biology.

And then there's the part that we kind of think about when we think about treating depression, which is figuring out how you think about the things you think about. It's that stuff you were saying, Kirtly. The self-talk, like, "I'm not good enough," and the sort of learned responses. What insight do you have into those thoughts? And then also, the bigger thing, the meaning you ascribe to that.

Kirtly: Right. My brain lies to me in my own voice. I've heard that phrase from a wise woman. "My brain lies to me in my own voice."

Katie: Yes, that's beautiful. Or it's sad, but it's beautiful in its eloquence.

Then I think we're going to talk about this a lot more in the next episode in terms of the social domain of stress, but depression as well, the social part of that is if you're depressed for a long time, that starts to really affect your relationships and how you're interacting with the people in your life and how you show up in the roles in your life.

It becomes a very complicated thing to unpack. But I think what we want to talk about with this episode is really that not dealing with the stress, the here-and-now things that you can control, really can lead to depression, a more complicated condition.

Kirtly: Right. How do we stop this cascade of things? And I'm a fan of the RULER project to help kids and adults. It helps you who are feeling depressed or stressed or anxious become more in tune to your emotions.

R stands for recognize. "I don't feel so good emotionally. I just don't feel so good."

Understand what's making you feel this way. "Gosh, I had a big fight," or, "Gosh, I just can't pay my bills," or, "I don't know why I feel that way."

Label it. Is it stress? Is it anxiety? Is it depression? Is it anger? I think of anger as being more of a guy thing, but certainly women can hold on to a lot of anger for a long time, although it usually drives them into depression. So label it. You've got to label it.

Express it. That's the E part of RULER. Tell someone you love and the people around who you love how you're feeling.

And then regulate it. So how can you regulate your stress and the emotional consequences?

Well, I'm going to go back to a quote from Viktor Frankl that I used in the physical domain. Viktor Frankl was a psychiatrist who survived the horrors, read: stress, of the concentration camp. He said, "Between the stimulus and the response, there is a space. And in that space is our power to choose our response. And our response is our growth and our freedom."

So how do you get to serenity? I'm not sure Viktor Frankl was serene in the concentration camp, but he certainly has a lot of wisdom about what to do to challenge yourself to come to serenity or come to calm in the face of a lot of stress.

So I'm a fan of the serenity prayer, and that is, "God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference." And whether it's God or your higher power or just, "Out there, please grant me . . ." Don't say God if you don't feel comfortable. "Please grant me the serenity to accept the things I cannot change."

So that's something that I remind myself of, like, "Okay. I cannot change this. So how am I going to respond to it? What can I change? Can I get out and really make a difference? And do I have the wisdom to know the difference?"

Katie: Yeah, I think that's where help is valuable. I use a metaphor with my patients, and I'd like to say I totally invented this, but somebody planted this seed in my brain and I'm not sure who to give credit to exactly, but it's become a metaphor that I use a lot and I like it.

I think when I'm talking to people about how to deal with depression, in particular, but anxiety, it's things for which we have treatments. And so no matter where it comes from, whether it's secondary to anxiety or stress or coming from some other source, the picture I use is to say, "It's like you're in a river. You're in depression. You're in this river. It's all around you. You're swimming in it. It's got rapids and rocks and eddies and it's cold and it's overwhelming. Your job is to get through this."

And so navigating this river is going to take both learning to swim and recognizing the obstacles and the triggers, the things you need to move away from, and the safe places that you need to move toward. So it requires learning.

And this water might be calm sometimes and it might be rough and rapid other times. How you approach a rough patch has a lot to do with what you learned in the last rapid and the last rough patch.

And to get through all this, you just might need a life preserver, something that holds your head above water while you're learning how to navigate all of this. Maybe you figure it out with trial and error and you get along fine without a life preserver, but at a minimum, you need a teacher.

So, in my metaphor, medications are like the life preserver. They hold your head up. But there's still work to be done to navigate the river.

Kirtly: I love that metaphor, Katie. That's great.

Katie: Yeah, thank you.

Kirtly: I love that. I'm a swimmer on a river and I love that.

Katie: I mean, I think it's helpful because at least what comes up for me a lot in my practice is people kind of come in and by the time they've waited to see me for six months and been thinking about what their problem is, they're sure that I'm going to give them a cure, whether it's an antidepressant or an anti-anxiety medication or a hormone of some sort, and that's going to fix everything.

So I like this metaphor to talk about, "I can maybe hold your head above water while you do the other work in therapy." And that's sort of the metaphor of learning to swim and having a teacher to teach you.

There's often some undoing. So there's the understanding why it is. And I think this discussion we've been having about differentiating stress and anxiety . . . because maybe it's anxiety. Maybe you're worrying about things that haven't happened or aren't really happening or that are not even that likely.

But maybe it's stress. Maybe it really is situations in your life that you do have some control over. And while long-term control over those things might not be something you have today, you can often control your stress response. You can do some things to change how your body is reacting.

Kirtly: Right. I think it's important if you can label what's causing your stress. "What can you change?" or "What can you let go of?" And importantly, "What can you forgive?" People can spend a lot of time going down the rabbit hole of anger and then depression over something. Can you forgive and move on and change the channel?

So my recommendation is when you're in the middle of it, try to recognize it and try to understand it and try to label it. You can try, and when you get to regulate, change the channel.

Exercise hard. That takes your mind off it. Or do something and exercise with a lot of focus, like yoga or tai chi. It is really hard with some of those yoga poses to be thinking about your bills or thinking about how much you're angry at your mom or whatever it might be because you're going to fall over or whatever, or tai chi.

Get together with friends, because your friends will give you emotional support and they'll make you laugh. And for an urgent fix, like right now, my heart is pounding, I'm really feeling bad, I go back to deep breathing.

But don't make it worse. Try to keep a steady sleep schedule if you can. Shift work is a well-known cause of stress and subsequent anxiety and difficulty dealing. So try to keep a sleep schedule. Make good sleep habits a priority. It can be a hot bath, a cool room, no screen time one hour before bedtime, no caffeine in the afternoon, no alcohol except tiny bits.

So, Katie, what's a tiny bit to you?

Katie: The tiny bit for me has probably changed as I've gotten older. So the older I get, any alcohol really impacts my sleep. But surprise, I do like a buttery Chardonnay. Sometimes I choose to drink and I just am like, "If I have one, I might as well have a large because I'm not going to sleep."

Kirtly: Oh, no. That's not worth it to me anymore. I want to sleep.

Katie: Right? But I'm making a decision of saying, "All right. Can I afford to not sleep tonight? What's on the schedule for tomorrow?"

Kirtly: Well, it makes me uninhibited enough that I can really have a great laugh with my buddies and it's worth it.

Katie: Yeah, sometimes that is worth it. But I think anything you're doing that's there helping you avoid dealing with problems itself can be a problem. Like a friend of mine used to say, "Whatever is your strength, when taken to an extreme, becomes a weakness." This is from the lady who should have been cleaning her data and I was cleaning my house, or avoiding a hard job I needed to do.

Kirtly: The place underneath my sink is always the cleanest when I'm the most postponing, when I'm procrastinating a writing deadline.

Katie: Exactly. And I think that's exactly the kind of thing in managing stress before it gets out of control and leads to depression, is to start to think about those things that you do that make it worse.

My biggest stressor really is that I'm always rushing to get things done. I'm rushing and I'm worrying that I'm not doing a good job. And then at the same time, I'm kind of wasting time cleaning my house and then feeling panicked that I didn't get to the place I wanted to get to in my goals and my work.

My stress management is to look at my schedule and say, "All right. I'm going to schedule in some time for TV or looking at social media, but creating a schedule where I do get my work done." And I recognize that I need that downtime and I'm going to put it in the places that allow me to . . .

Kirtly: You have to be so disciplined, though, to limit your time there. When I'm stressed out, I read junk novels. I read mysteries and thrillers. I'm not into romance. That's just too goofy. Although it is the most popular genre in the reading world. However, it's hard for me to say, "Okay, I read my chapter." It's like, "What do you mean I read my chapter?"

Katie: Right. "I've got to keep going."

Kirtly: "I've got to go to the next chapter. I've got to keep going."

"Well, Kirtly, you said you were going to write a chapter for this book or you're going to go do this work." "Well, what about the next chapter?" I have this inner dialogue when I'm trying to deal with my stress about dealing with my stress.

Katie: I do the same thing. And I think the other thing that's really pernicious is that one way we're all dealing with stress or just filling the voids is social media, the endless scroll on social media. And then what you see in there is comparing yourself to unimaginable standards, and that in itself becomes a source of relaxation and a source of stress. It's a complicated world.

Kirtly: Yeah, it is.

Katie: So we've talked about a lot of interrelated, complicated things here in this emotional domain of stress, but I think I want to review just a little bit.

If you're feeling stressed and you've been stressed for a long time, you're not wrong. That exaggerated or chronic stress response, whether it's caused by stressors, things that are in the here-and-now and that we can take a look at and do something about, or things that are in the future, sort of imagined that maybe aren't quite so tied to reality, they still can lead to a loss of physical health.

So high blood pressure, risk of heart disease, tummy aches, Kirtly, heart attacks, susceptibility to infections, all the things we've listed. And it can lead to a loss of your mental health.

So no matter what's happening, whether it's stress, anxiety, depression, a visit to your healthcare provider is a good place to start. And I know it's sometimes hard. I know people wait a long time to see me or to see any clinician. But I think making sure you're seeing a bonafide healthcare provider is a good place to start.

What I see a lot in my practice is people, maybe while they're waiting, have ended up with a lot of misinformation or being sold a lot of ineffective or maybe even dangerous treatments.

And there's a lot of that out there. There are a lot of people that want to make money off of your stress and anxiety and concerns about mental health.

And so my advice always to sort of slice through the good information/the bad information is that if somebody doesn't take your insurance for a healthcare issue, if they're asking you to pay cash, hold off, wait, and talk to the person that's covered by your insurance, and then you can think about it.

Kirtly: Well, I worry about influencers. So there are people on social media who will tell you how to deal with your anxiety or depression one way or the other, but they're being paid. They are being paid by whoever makes this thing that they're pushing. And so I think it's very difficult to have someone who's quite influential, but not very real. They're not very real people. And I think if you can get to your clinician and get a referral . . . Although, Katie, you mentioned there is a crisis line wherever you are.

Katie: Yes. So wherever you're listening to our podcast across the country, 988 is the crisis line across the entire United States. That is available 24 hours a day. It's available in English and Spanish. It's a phone call where you can talk to a real person, or if you prefer a text, it's actually available as a text service. So 988.

Kirtly: This is government-sponsored, so this is run by the U.S. government, this crisis line.

Katie: Yes. Staffed by trained providers.

Kirtly: So take a deep breath. I know these are stressful times. We can't change everything out there and we spend too much time reading about it, but we can change things under our power, and therein lies wisdom. It's worth pursuing that.

Thank you all for listening. If this has been interesting or helpful, share it with a friend or use it as a start of a conversation with somebody you know and love.

We'll be working on stress in all of the seven domains. And you can listen to all "7 Domains of Women's Health" wherever you get your podcasts, or at womens7.com. Take a deep breath again.