Abstract
It seems that fear has never been more prevalent today among people in the United States, and people often bring their thoughts about what scares them to a doctor's attention. But perhaps as clinicians, we too often assume that patients simply should learn to live with their fears. On the contrary, research suggests that there are ways to help individuals deal with persistent and intense fears about their health and their future. In fact, such fears are important to address because they can negatively impact both physical and mental health, contributing to cardiovascular disease, immune dysfunction, chronic illness, depression, and anxiety. Helping patients address their fear through mindfulness skills is plausible and important for our patients' health.
The State of Fear
Unfortunately, today, it seems the opportunity to become fearful is ubiquitous in society. In the 2018 Chapman University Survey of American Fears, the top five fears of Americans included fear of corrupt government officials; pollution of oceans, rivers, and lakes; pollution of drinking water; not having enough money for the future; and fear of a loved one becoming seriously ill. 1 Other fears making the list included global warming, high medical bills, extinction of plants and animals, and fear of cancer.
Dr. Mary D. Moller, DNP, ARNP, PMHCNS-BC, CPRP, FAAN, associate professor and coordinator of the Psychiatric-Mental Health Doctor of Nursing Practice program at Pacific Lutheran University School of Nursing, Tacoma, Washington, commented in an interview on the significance of fear in our society and said, “We are bombarded on a daily basis both from a visual and auditory standpoint with bad ‘breaking’ news. When talking with people, there seems to be an increasing overarching sense of doom and waiting for the other shoe to fall—everything seems to have a negative spin from the weather to education to finances and the stock market to health care and of course, to politics. This has set up a sense of uncertainty and generalized angst, which translates into worry which translates into fear for many individuals.”
Unchecked, fear can ultimately contribute to wear and tear on the hypothalamic-pituitary-adrenal axis leading to fatigue and breakdown of body systems governed by the autonomic nervous system, according to Moller. Specifically, Greeson and Brantley described the psychobiological nature of fear and how it sets off an alarm reaction that “descends from the limbic system through the brainstem, spinal cord, and peripheral nervous system, ultimately activating a broad-spectrum physiological response throughout the body.” 2 Moller stated, “Fear can cause headaches to become migraines, an upset stomach to become gastroesophageal reflux disease, muscle aches to become fibromyalgia, body aches to become chronic pain, general nervousness to become panic attacks, and the list goes on.”
Fear is a complex term with many ways of interpretation; however, Adolphs in an article on the biology of fear stated that “fear is what links sets of stimuli to patterns of behaviors.” 3 In its simplest form, fear is that which makes us afraid. In addition, there are a variety of fear states, and LeDoux reported in an article, “What ties together all instance of fear is an awareness, based on the raw materials available, that danger is near or possible.” 4 LeDoux continued, “Emotions emerge from nonemotional ingredients, events that exist in the brain and body as part of being a living organism of a particular type (e.g., survival circuit activity, brain arousal, body responses and feedback, memories, thoughts, predictions). No one ingredient is essential to fear. Variation in the kind and amount of ingredients determines whether you feel fear, as opposed to some other emotion, and also determines the variant of fear you feel.” 4
Addressing Fear with Our Patients
It is important to point out, of course, that not all fear is bad. In fact, fear is essential to our survival and often should be followed as a means of protection. Fear often moves us toward taking beneficial action in our lives. However, when fear becomes intense and persistent—interfering with daily life—it needs to be addressed. So what can be done to help patients with their fears?
First of all, Moller recommends that clinicians develop a therapeutic relationship based on mutual trust and respect. She said, “Begin to explore the etiology of the particular and/or generalized fears.” Other of Moller's recommendations included: conducting a qualitative timeline in which the patient identifies key life events that may contribute to the etiology of fear; evaluate for substance use; recommend psychotherapy that focuses on targeted cognitive behavioral therapy (CBT) for anxiety, depression, and trauma as appropriate; find an appropriate support group; and schedule appointments to allow for enough time for the patient to explore fears. Important laboratory assessments, according to Moller, may include ordering a morning cortisol level to evaluate adrenal function; a complete thyroid panel including Free T3 and Free T4, Total T3 and Total T4, thyroid antibodies in addition to thyroid stimulating hormone; and a comprehensive metabolic panel, lipid profile, immunoglobulins, and liver function tests to evaluate baseline medical status.
Beyond that, Moller stated that the recent explosion of information related to the Polyvagal Theory by Dr. Stephen Porges, Distinguished University Scientist, Indiana University Bloomington and Professor, Department of Psychiatry, University of North Carolina at Chapel Hill, has “revolutionized clinicians' understanding of the 3rd nervous system—the relationship of the dorsal and ventral vagal system in activating/deactivating the social engagement system.” Moller commented, “Complementary and alternative medicine (CAM) therapies can be essential in this area and particularly mindfulness skills and relaxation techniques. This theory and research helps to explain the physiology behind the effectiveness of mindfulness based approaches and interventions along with basic breath work to help a person be present and focused and what such therapies truly do to quell the fires of fear that are often raging deep inside a person, just waiting for a trigger to explode. Instead of dissolving into dissociation, we now possess the physiological knowledge to help our patients stay present and experience our awesomely human social engagement system.”
Mindfulness and Fear
With >15 million cancer survivors in the United States today, 5 doctors are likely to hear patients discuss their fear of cancer recurrence (FCR). This is significant and needs to be addressed, as Luberto et al. reported that FCR is associated with “poorer outcomes for survivors and their caregivers, and many oncology mental health providers find it difficult to treat.” 6 Luberto et al. offered that mindfulness practice and CBT skills are effective means to treat FCR. Specifically, these authors described a case study using mindfulness-based cognitive therapy (MBCT) targeted to FCR. The MBCT protocol included 8 weekly 50-minute sessions with homework, which included learning various practices such as the body scan, awareness of breath meditation, 3-minute breathing space, mindful yoga, meditation, and utilizing an MBCT workbook. Learning “new ways of relating to thoughts rather than challenging the content of thoughts” was also a key aspect of treatment. 6 The authors recommended that MBCT for FCR should also “focus on teaching patients skills for coping effectively with upcoming medical visits that are likely to be triggering, and emphasize skills for living a meaningful life despite the potential for cancer recurrence.” 6 Results showed that the case study participant became less anxious/worried, less fearful of cancer recurrence, less stressed, and acquired an improved ability to decenter from anxious thoughts. Secondarily, the participant also experienced improvements in work, relationships, and sleep. The authors of the study recommend further research in this important area of work.
Fear may also exacerbate the conditions that our patients suffer from. For example, people with chronic pain often experience greater distress and decreased functioning when they experience more fear and anxiety symptoms. 7 Mindfulness and present moment awareness practices can help to attenuate these fears and anxiety, which ultimately may help decrease symptoms, avoid worsening of conditions, and decrease the need for pain or other medications.
Greeson and Brantely commented that mindfulness can complement established psychotherapeutic approaches to fear and anxiety and stated, “Taken together, mindfulness practice appears to offer a healthy and effective means of relating to one's inner experience of fear and anxiety, in part through cultivating the ability to pay attention on purpose with an open, curious, and accepting attitude toward oneself and one's outer world. This ‘wise relationship’ offered by mindfulness practice may help ease the suffering of excessive fear, anxiety or panic by encouraging an individual to ‘reperceive’ the transient conditions of internal discomfort by maintaining equanimity as one's experience unfolds, moment by moment.”
Finally, as clinicians, we must be ever aware of how we can directly contribute to patients' fears. We can cause fear in our patients by sharing too much too soon, using frightening terminology, overcommunicating perceived health risks, and using scare tactics to convince a patient to change—all of which can then cause terror in our patients. Speaking with patients in a mindful way that reduces rather than causes fear is important.
Conclusion
Moller stated that in 1956, when Hans Selye wrote his now famous book, The Stress of Life, Selye was ostracized by most. Moller commented, “Now we know his work was seminal in describing the effects of chronic stress as causative in the wear and tear on our bodies.” To that end, helping connect patients with mindfulness-based programs and groups with pertinent content and a focus related to their fears can be very effective in helping our patients. There are many innovative efforts today in the field of mindfulness, offered in academic institutions, other medical facilities, and community settings, all of which help to address fears related to chronic illness, trauma, stress, and many other topics for which fear is inherent. Clinicians should make an effort to connect with both practitioners and leaders of mindfulness programs so that referrals are at the ready.▪