Transcript for Fear Less

I remember actually one of my first encounters with serious fear. It's this experience. I was a child I think around 10 years old and I got up this ladder to a balcony with my mom. My mom was basically over seeing building a house. And it was going from one level to another level. There was no stairs, so we used this ladder to go up there. It wasn't much of a height. It was like about two, three meters, but going up was much easier because I wasn't looking down. I was just looking up forward. So I didn't even register that it's scary. I just went up easily and cheerfully and then tried to come down. It was tough. And we went up there and did what we were about to do. And then as we come down, she comes down first because she wanted to be able to watch me from below. So she comes down. And then I get on the edge of the balcony. I look down and I'm terrified. And it took a while for me to overcome the shaking my knees and the feeling of terror inside my heart. And of course, my mom's kind and encouraging face helped me. But yeah, that was my first encounter with this feeling realizing that I'm afraid of heights.

Absolutely, yeah, yeah, you're right. And that is the toughest part. The anticipation is the toughest part.

I remember if let's say we went for a hiking, I would really avoid any edge that could expose me to being able to see below if the decline was not gradual. Or when I came to America and I bought my house, of course, our addicts here. We didn't have addicts in my house in Iran, but here I couldn't go up the ladder to go to the attic or trying to replace light bulb was a big challenge for me. And so it stayed with me. I have a member probably about 10 years ago. I was with the friend. We were jogging in Ann Arbor and we were alongside the river. And then she basically wanted to show me this little tiny island in the river where there was a tree log connecting the mainland to that tiny island. Probably like a 10 feet long. She just ran over on it, like because so, and she was on the island. And again, it was a reminder to me that I am afraid of heights. And the water below me was probably again 8 to 10 feet below, but I needed a lot of encouragement to get to the other side.

Embarrassingly I was basically on my four limbs. I was crawling on this lock to get to the other side.

So the school shooting was happening in the sound of gun going off was coming out and one of the security officers who was at the school, he was very slow and kind of paralyzed and responding to the threat was outside the building and ended up not taking action in a timely manner.

Yeah, that's correct. And of course, I was not in the head of this person, but I could just imagine if I go on what's going to happen to me, what's going to happen to the kids? Will I by mistake shoot someone else? Do I know what I should be doing? Will I be judging criticize afterwards? And of course, all the bodily reactions we shot there at the sight of the terror. And it goes back to the biology and psychology fear. This is a very, very strong force and energy within us is one of our deepest and most primitive emotions which functions at many different levels from very basic primitive animal theory which is now gunshot, loud noise danger to the highest level of human processing and there's a lot of thoughts, plastic biology at play at the moment.

Yeah, so right after college, this bright kid immediately gets a job, he enjoys a job, he has a circle of friends, mostly work related, they hang out together, and then he's laid off. So then he searches for work a little bit and he finds a job that he can do from home and remotely. And gradually he starts losing some of his social skills. He loses the circle of friends. He doesn't have other people outside. And then he loses this job also. And starts a full period of self-doubt. And then panic attack start. And panic the way it works is just totally out of a blue. There is a full storm of fear, extreme form of fear someone can experience in their mind and in the body, heart pounding. Breathing is difficult, so it's very terrifying to people especially if they don't know what's happening and this happened to coincide with driving. So then he's brain associated driving with danger, slowed down on driving and at some point stopped driving. Then he started to have panic attacks in social situations, started avoiding going to a place as first places which were more crowded, and then more and more, basically generalized situations even like a grocery store. And let's say another time had a panic attack while showering. And now, brain associated, the shopping in the shower with the panic attacks, so it started basically Increased intervals of his showers, and then now hygiene is not great, so that was another layer of lowering self-esteem and not going out. So by the time I met this person in his mid 40s, he was basically housebound, this functional spending all his day on the couch.

So this happened early in medical school. We were near the University Hospital with a few of my classmates. We were getting ready to go to funeral of one of our classmates mother. And all of a sudden, this motorcycle writing very fast just plows through the driver's side door and I'm so happy nobody was injured luckily and miraculously but basically the two doors on the left were just totally damaged but what I remember was It's as if I'm seeing this slow motion movie. And right now, 20 some years later, you and I are talking, I see the image right in front of me. And I see how slowly that bike is coming towards me, basically slow motion with full attention. And then I saw, even I remember the guys face as the bike was getting closer and the hit the door on my side.

Absolutely. I couldn't do anything. The car wasn't even on and I just saw a scared face and then boom. That was all I saw, but in a very slow motion and being aware of all the even the colors of what's going on around. What time of the day was basically my brain registered all the context and accused that Werler.

So fear has a very long story with us. And we have to understand the context within which it evolved. And the context within which fear evolved was a context of physical threats. We had to worry about a predator or another human attacking us or falling rock or natural disaster. So the system is designed to react very fast to the dangers that are around us. And when the system is activated, The brain regions involved in fear of crossing, including the amygdala and the sympathetic nervous system. Basically, it was not that the environment slowed down. I sped up. So my processing speeds up. My attention becomes hyper focused and the memory becomes stronger. So you register such experience as even more crisp and more strongly and that by itself has an evolutionary purpose because if something is dangerous, if something is a threat, I should register and learn it so well that the next time if this is about to happen let's say and stuff, the motorcycle approaching me very fast, it was a grizzly bird. And I was attacked by a bird as a tribal human 50,000 years ago, it would be very dumb for me for the second time to go try to pet the next grizzly bird that I met. So it registers in my brain so well that this is dangerous, you gotta be careful and also learn whatever skill you need to avoid at the next time.

And that's another amazing aspect of fear. So we have the fights, response, flight response and the freeze response. Freeze response has been seen mostly in animals which are prey. For example, a rapid spots a hawk. And the rapid freeze is because it doesn't want to be seen. So basically the brain paralyzes the system. So the motion is minimal for humans. We are more of the predatory animal, and that's why freeze response is less often observed. But when there is no other option, you try to basically minimize the risks and minimize the resources and minimize the chances of more harm by freezing. And we see this reaction a lot of horrible situations where humans are stuck like rape and assault and torture that they cannot do anything else. So the best option is to not do anything. to at least, let's say, going back to the evolutionary context, reduce the amount of bleeding.

Absolutely. We talked about how this system has evolved to react to very physical situations of danger. But what you are coming to now is that in the modern life, majority of the threats that we are perceiving are so abstract. a few years ago we were talking about this virus which is spreading from China to Europe and gradually coming to America. It's a virus. We don't even see it. We just hear the news and we have to make decisions based on that. So system gets confused a lot of times, but also there are situations that you pause to be able to process more. You pause because you cannot do anything else. Or it's a better self-preservation to not make a move when you do not know what is the move to make.

Fourth of July. So this generalization of fear is again an evolutionary advantage. As you said, a grizzly bear attacks me or one of my tribe mates now. I avoid not only grizzly bears but also black bears. Or a wolf attacks me now. I avoid all different kinds of wolves. And for people who have been in war or near explosions or gone violence or shootings, the loud noise is associated with something horrific and dangerous. And now, any unpredictable loud noise can create the same response and the brain over generalizes the fear response to any loud noise, whether it's a slamming door or the fireworks. And that's why a lot of veterans and survivors of convalence day are terrified of Fourth of July and they try to where headphones go to the basement because they logically know They are safe. This is not the war environment or this is not the shooting context. The problem is that we are talking about the illogical part of the brain, which basically learns fear through association. And I've had even veterans that during the Fourth of July when a viral goes off to just drop on the floor.

Yeah, so when something dangerous happens, these highly dangerous painful situations are very strongly registered. So for this person, when the robbing happened, they were in the gas station, they were just about to get in their car, somebody comes pointing the gun at them and then takes their money. This was very terrifying and now this brain wants to prevent this from happening again, right? The same story as the Grizzlybird. I don't want to be attacked by Grizzlybird again and lose another limb to them. So now the brain tries to collect not only data about the bear, but also about the context in what context this happened. That corner of the woods, the bears there, I shouldn't go there anymore. The same applies here. It was a gas station. It was at this time of the day. So the associations becomes the gas stations here for this person. Avoiding gas stations, finding it very difficult, going there, and it's automatic. Logically, they know that the guy with the gun is not at this gas station. Now, there may even be cops nearby, but they find it difficult gradually they can't expand to convenience stores or that time of the day for a lot of people is the time of the day or the time of the year that this happened that the anxiety increases because amazingly the context is not just the physical context but also social context but also temporal context.

So if we avoid a grizzly bird in the woods, every time we avoid it, it's a benefit. But the challenge is a lot of these fears that we have learned our context dependent, allowed noise just in the war zone or in the shooting environment is a dangerous thing, right? On the Fourth of July, it's a fun experience. The problem is that sometimes this thing that we are avoiding, for instance, now in this example, new other gas stations. It's not dangerous. But the way it works is that I see it, I freak out because the brain says, this is dangerous, we shouldn't go there. You don't go there, nothing bad happens. The brain says, you see, you avoid it, nothing bad happens. So you should keep avoiding. So now it will become harder and harder and harder and it keeps expanding and generalizing and consolidating the field and becomes stronger and I've seen it and other examples of patients how like a plague it expands through their life and in generalizes to other more and more and more and more conditions.

So I see this actually a lot in first responders. I work a lot with cops and firefighters and emergency personnel. And I didn't know how tough their lives are until I started working with them. There's a ton of stress. There's a lot of unpredictable dangers happening in their lives. And if you're a police officer, you go to deal with the shooting that has happened or there's been domestic violence abuse. You're a firefighter. You go to where there's been called car crash, have to pull people out of a burning car. And the difference they have, let's say, with veterans is that the veteran goes through war zone and then they come back to the safe civilian environment. For first responders, the same environment where they live is the same environment they are exposed to the worst of what humans do to each other and to themselves. So their brain automatically goes to the state of fine and flight constantly screening for danger. And they could have arrested or done a CPR on someone in the same rest or now they want to go through their family. So when they go to the place, a lot of them go at the time that there are many people there. And if they go, they will sit somewhere with the back to the wall where they can watch everything and watch the exits. And so it's basically becomes an automatic safety behavior.

So a lot of times, fear, as you said, distorts our attention. So when I'm scared, let me just bring an example. I go to a class that I'm teaching, and I already am terrified that I may not be a good speaker, I may not be a good professor, or I already have some fear of public speaking, and I have actually had this in a lot of my patients. So I go into this class, And I already feel less confident. My heart is pounding. My breathing is difficult. I might be a little bit sweaty. My tension is a little bit distracted and distorted. And then the amazing thing about it is that my brain is in fine and flight mode and thread detection. So my attention is focused on any signal and cue from the environment. That might suggest that things are not going well. Let's say for one of my students is on their phone. I will think that they are texting another student about how bad of the teacher I am. If another one is under computer even though if they are taking notes from my speech, I may think that they are bored. If someone is sitting with their arms crossed, I think they are now guarded. So that makes me become less confident in myself. And my reaction to them may become awkward. And they start thinking what's wrong with this guy. Why is he acting awkward? They encourage really this basically creates a self-fulfilling prophecy cycle. Because we already set the expectation that this world and this environment is dangerous. And these other people, and we see this actually the example I brought up a lot of times in people with social anxiety, for example. They go out thinking everyone out there is tried to judge them. And anytime they see any sign that other people appreciate them, they brain-basically screens this out as noise. But any sign that can be interpreted, even neutral signs as there's something dangerous or some people are judging me or they don't like me or I did something dumb and they didn't like it. That will affect basically my perception of other people and my perception of myself and my own behavior.

So, bravery and courage are defined in situations which are difficult and challenging for the person But the person is able to overcome that primitive animal reaction and take their right action. Sometimes it's basically a self-sacrifice, which could be logical. The case I remember is there was a firefighter who was stuck with this partner with his colleagues inside the building. And this person decides that the other two should go first and pushes them out and helps them out of the building and he dies. So this is a brave action, but then there are a lot of actions that might sound brave from outside, but could just be an impulsive action, right?

No, it's not. Actually, to be fearless, basically one needs to not have a make-dollar, basically brain damage, leads to inability to experience fear. Otherwise, all of us, normal humans, do experience fear the same way we experience pain. Of course, there are things that help us be stronger, be more prepared. So accurate threat perception, right? I see a snake, I freak out. Someone as uologist sees that snake and they're like, well, we are Michigan, Michigan, the prevalence of poison venomous snakes is very low and then of course I'm looking at this snake and I know this snake is not venomous. So they look very brave to me but what is happening here is that they just have knowledge or someone has training someone has a sense of control or a sense of purpose so there's so many different aspects that come into a brave action.

This is one of the most important aspects of dealing with fear. In normal usual scary situations, yes, that is the sense of control that allows me to feel I can do something about it. Let's say when the pandemic started, we didn't know anything about how we can protect ourselves. Then some came and said, okay, there's a mask here. There's a vaccine here that reduces the chance of getting sick. And we started feeling a lot more confident because now we had some control. We could do things that could help us protect ourselves against the danger. And the one way of gaining the sensor control is gaining the knowledge to prepare, educate, learn ways we can deal with the situations we are afraid of.

So this person loved the swimming and surfing and they would love to go to California and go on the beach and do surfing and swimming. But they were so terrified of sharks. And interestingly, this fear started when they were younger and they watched the movie Jaws. And of course, these fears are not logical. The person even comes to my office and says, I know it's stupid, but I'm afraid of this or that. To which I answer, it's not stupid. It's illogical. We have a logical way of processing and we have the illogical or associated way. How about we start learning about sharks? How about we learn about which ones are done? Because not all sharks are dangerous to humans, which ones are dangerous, which ones are not. There are those dangerous sharks. What are the chances and the beach here that I go there are more and less of them? So not only learning about that environment, allowed him to be more comfortable. Okay, the kind of shark that is dangerous is never spotted on this beach. So I can probably go here. While also, it becomes a kind of a curious interest. which helped him every time engage and incorporate basically cognitive brain to, and every time we bring the cognitive logic called brain, whether it's through paying attention to things around us or doing something mindful or learning something or even labeling the emotions, the intensity of the emotions declines.

Yeah, and this happens a lot in anxious people with more abstract forms of fear experiences. For instance, how scary is failing an exam or not grading well on an exam or failing a job evaluation or failing an interview I've done, right? For a lot of people who are anxious, you ask them how which part was the most scary? They said anticipation. So a lot of times I say look back in the past and see the past on average what percent you overshoot the danger. And then I say cognitively try to bring it down. That's one way, basically knowing myself and knowing how scared I usually am compared to the reality, let's look at the statistics. And utilizing all of these cognitive resources and tools allows us basically control and leash that animal field response.

So boxing started in my life when a friend of mine probably about 10 years ago dragged me to this fitness boxing gym. I first thought it's such a stupid thing to just stand there and hit a bag, but I just fell in love. It first felt it was fitness boxing. Just hitting the bag, I found it a very good discharge after a lot of tension, being focused, and of course, good workout. Basically, I have a trainer, Reggie, is a boxer himself, and we have started basically sparring training, but we don't hit each other hard. So, after so many years, ten years of fitness boxing, I knew all the moves, I, and I'm not bad, I glove up, and I'm standing in front of him. All of a sudden, it's just like I time travel to whenever in school, standing in front of a bully. As a kid, I was never fit, I was never athletic or a smaller, so I was bullied a few times, so I see myself right in front of this bully. And I was like, wow Reggie, I'm just experiencing the whole my whole body experience that fear. And he said, imagine if that child you were once, was here today. How proud of you he would be. He basically made a beautiful connection. I time traveled there and he made a bridge between there and now.

I absolutely, it's such a beautiful way of saying it. And a lot of times we do this with patients in treatment that they're stuck in the past. Part of our animal brain doesn't understand time. Doesn't understand The distinction between one happened there and then what happens here and here and now, right? The person with let's say post-traumatic stress disorder, they have a flashback of the memory and now they have a panic attack. And one of the things we do in treatment is to put those memories in the context. That's in the past, now we are here. What did I learn? And now I'm a different person than that other person. I'm making basically these connections. You said it very beautifully.

Interestingly, I have started over the past few days doing this ice plunge. Basically, I got one of these buckets and there's ice in it. I mean, I was too lazy to put it outside on the back porch and Michigan's already very cold. So I don't recommend that 25 degrees, but I have been able to sit in it for 30 seconds. During that time, I'm just here and now in my body. I'm not anywhere else. And the idea is that when I do mindfulness practices with my patient I ask them Basically, at the moment, listen very carefully and tell me how many sounds are in your environment. Then I asked them to look around and tell me how many colors they're seeing around, and all shades of color, right now there's in front of me in my office. There's a picture that I took in a last skull, which has a mountain and beautiful water and trees, and there's so many colors in this. Then I asked them to feel their shoes, feel every inch of the shoe, where the for this more pressure, less pressure, where the food is touching the ground, where the food is not even touching the shoe. And then this very tiny practice after we've done and asked them how much did you think about the past or the future? The answer is no. The reality is that we as humans are capable of reflecting on the past and planning for the future, which is an amazing human capability that has made us very capable. But it has also plagued our lives because majority of the times We are not here, we are in the past or in the future. A mindfulness is a practice of bringing us to here and now because the reality is, the only true moment in our lives is this very moment which most of the times is the safest moment. So you can use practicing mindfulness to bring us to the here and now and ground us in the here. And a lot of times that could be our body. I use the example of this cold lunge because at that moment, really, I kind of think of anything else. And actually, that's one way, fear helps us. For me, with my fear of heights, if I stand on an edge of a rock and Grand Canyon, even though I'm safe, I cannot at that moment think about anything else.

So we talked earlier about how my brain associates something to ginger and every time I avoid it, I reconstructed the fear and the idea and the belief that that thing is dangerous. Explosion therapy is the opposite of that. That we gradually slowly introduce the feared situation to the person. Let's say I'm afraid of dogs. So we can sit here in my office and forward talk about how and why dogs are safe. It's not going to work. It's not going to teach the animal brain. Animal brain learns through experience. So we gradually introduce the feared situation whether it's a dog, whether it's height, whether it's a public speaking, whether it's being around other people. I get terrified. Nothing bad happens. I go in. I get terrified. Nothing bad happens. Gradually, gradually, I develop a new learning that in this environment, this context, I'm safe, which is paired with the sense of control. Because it's not forced upon the person, right? We don't throw a person with a dog in the room and close the door on them. It was their own agency, they took charge and did it. And of course, I, as a social safety cue, I'm there with them. And they gradually, this brain develops, then it's just no learning. Along with the sense of control, I could do it. And we say, you should keep doing it until it becomes boring or just annoying. And that's it.

some very excited about this technology we have created. So virtuality, you were these goggles during the different world. But augmented reality, you were these goggles as imagine you were in a pair of sunglasses. You see what is exactly around you and then all your desk, you see a spider. So we combine the real and unreal and they make it more real and immersive. So we started this for exposure therapy. Let's say I have people with fear of spiders. We put tiny spiders in their environment and gradually the spiders become bigger and more spiders more calls of spiders so we can generalize and of course it's not that easy in the beginning it's just One tiny spider in the very far corner in the air terrified is what's amazing is that we have found the subjective responses and brain autonomic responses to these virtual spiders are the same as a real spider. So then we gradual advance this to dogs and snakes and now for people will post my access disorder, they find it difficult to be around other people. Now I have someone in my office wearing the goggles, a virtual door opens on the wall, humans of different race sex, body type, behavior walking the room, starting tracking with the patient, and then the patient practices exposure. So we have been using this technology and it works so well.

That's good. That's very good. See if you can hold it like longer time.

This is actually the part that she was trying to slide her hand under this spider. How amazingly our brains perceive this, that she started to even feel it. She was like, oh, it's for warmer. It feels warmer here, while she was sliding her hand under this thing. It's one thing to be okay with some virtual augmented spiders, but we want this to have real life implications. So, after that, we have a live tranchula. My lab is stress trauma and anxiety research clinic stark with a C, and this tranchula is named Tony Stark. So they will see how close they can get after the treatment to Tony Stark. And actually, this patient was able to go ultimately half Tony in her hand, which is a large rose hair tarantula. And interesting, we have published this clinical trial. Everybody, we treated with this technology for free of spiders. In less than one hour one session treatment was able to touch Tony Stark or the tank containing Tony. And these are people who were like standing 15 meters away from Tony before treatment.

I always say the only way beyond fear is through fear. at the end of the day, exposure matters. We got it through ourselves in it. Of course, we want to do it the way that we succeed. So gradually, one step at a time, and I recommend people, go to the minimum level I can do. Let's say I am afraid of go grocery shopping because of my anxieties. Just go to a grocery store, which is smaller, reach your most comfortable, at the time that there may be even two people at this store. Just go there, stay there. What matters most is stay with that scary situation. Whether it's the date, whether it's the grocery store, stay with that little tiny bit, keep repeating, repeating, repeating until I mastered that stage. Now I have a sense of autonomy. I've learned my own limits. I've learned how my brain and my body responds to this. Then go to the next level. Then go to the next level. Then go to the next level. And I've seen a lot of good responses from people who do this.

Yeah, so this happened. I still laugh every time I think about it. many years ago I was doing my residency and I had a week of vacation I had to use in December. One of my friends who was very adventurous tells me that hey go to Grand Canyon, there's this mural right down the bottom of the canyon, it's beautiful. And I was so naive. I didn't think for a second that I'm afraid of heights. So I signed up for this thing. I go there six a.m. in the morning in December. Very cold. Everybody's wearing several layers. Sitting on this huge mules. And that was the first time I saw what Grand Canyon is. You look down and you see the bottom. It was terrifying, and we were told, if listen, if you're afraid, you can leave now, but you have to leave now, when we start moving, you cannot back up. And I'm like thinking, should I stop, should I not, looking around, seeing all these kids and older people are very comfortable having fun, I was embarrassed, I'm like, okay, we'll do it. And these mules, day, tend to walk on the edge of the canyon and it was icy and slippery sometimes just slipped and when they make it and the trails are narrow and when they make it you turn you just see the bottom of the canyon you your meals head is off the canyon basically so it was very terrifying for me But knowing the what are the principles of this exposure I try to basically do as much as I could looking at others getting so seeing other people are having fun remembering the fact they told us that they were running this business for a hundred years and nobody has been injured or died No mural has been killed so basically utilizing all my cognitive and not cognitive resources we went down to the canyon and the next day we come back up and that basically not that I recommend this as a way of overcoming your fears but that was it for me and I overcame my fear of heights actually a couple weeks ago I was back In Grand Canyon, I stood on the edge of that cliff, of course, in the safe way. I felt the tingling in my knees, but I could do it. And another amazing experience that came out of this, besides the overcoming my fear of heights, was, for the next few days, I realized I'm not experiencing my usual anxieties of daily life. And I started thinking about what is the source. I mean, one theory I came up with was that maybe we need some occasional experiences of real fear to exercise the fear system in a normal way. The same way we exercise our bodies to be healthy because our lives are so sudden to read these days. The other thing I realized was that When we experience such real fears, because at that moment I'm standing on the edge of that cliff on that mule, what is my fear? My fear is if I fall, I'm dead. So now I'm facing a real fear. Now, in compared to this fear, how much does it matter that things that are going on at work, or the paper that got rejected, or this disagreement that I have divided this other person, basically these kind of fears, put other anxieties in context?

Absolutely. And that's why a lot of people, I mean, we did talk a lot about the trauma in, let's say, first spawn is police firefighters veterans, but the other side of it is that people who have seen the real danger of situations who have experienced the, what's really matters. A lot of them have grown to the point that they find other anxieties that bother the rest of us meaningless.

And that's for an amazing thing about our humans. that fear capable of overcoming a lot of terrifying situations that we even did not know we were capable of. What I found in my career is that the meaning we create for our experiences transcends a lot of our fears and can help us basically protect us against fear.

So I was in the emergency room and there was a car accident. There was a mom on the stretcher with a very pale face and there's a dad and a couple of kids probably five, six years old. And I remember this woman's son was next to the stretcher terrified crying worried about his mom. And mom was basically so calmly Such a soothing way saying, it's okay. I'm all right. Nothing bad has happened. It's okay. And then we unwrap her arm, which was wrapped in a sheet or towel. I don't exactly remember. And I saw the worst injury crushed bones on her arm. and was just amazed by this is crushing pain. And she knows she has a high chance of losing this arm, but for her the priority is to make sure her child is okay and not terrified and not hurting. And this was one of the most amazing examples of selflessness and bravery I've seen.