In the ED, we often see patients presenting amid an emotional crisis – whether it’s a panic attack, or a period of extreme anxiety or stress, or a feeling of being overwhelmed. In fact, it is not just patients. We as humans can experience this too, finding ourselves in situations where we feel overwhelmed, unable to deal with our emotions, and not knowing what to do next. For this reason, I wanted to provide some tips on coping with an emotional crisis, that I learned during my psychiatry rotation. In psychiatry, we called these “distress tolerance skills”, which is a component of Dialectical Behavioural Therapy. 

One distress tolerance skill is TIPP – which stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation. 

1. Temperature: During a crisis, our body may feel hot. So, it can be helpful to come into contact with something COLD. This can include eating/drinking something cold, tapping a cool cloth on yourself, splashing cold water on your skin, standing out in the cold or front of an air conditioner, or holding an ice cube. Whatever is convenient! This will “cool” you down both literally and emotionally.
2. Intense Exercise: At times, feelings become overwhelming, and you may become full of anxious energy. Performing intense exercise on a daily basis can act as an outlet to release negative emotions and energy and can decrease stress levels. This can be any form of intense exercise, including jogging on the spot, doing jumping jacks, going on a run, or going to the gym. 
3. Paced Breathing: This is a technique of taking slow, deep breaths. It can heighten performance and concentration while also being a powerful stress reliever with a soothing effect. One way of doing this is box breathing, which actually has evidence for regulating the autonomic nervous system. Here are the steps for box breathing:
   1. Close your eyes. Inhale through your nose while slowly counting to four.
   2. Now, hold your breath inside while counting slowly to four again. Try not to clamp your mouth or nose shut. 
   3. Begin to slowly exhale for 4 seconds.
   4. Now, hold your breath there while counting slowly to four again. 
   5. Repeat these steps multiple times daily, for 5 minutes at a time. 
4. Progressive Muscle Relaxation: This is a technique that helps to slow down your heart rate and breathing, while also releasing the muscle tension that often accompanies anxious feelings. To perform this, you first tense particular muscle groups in your body, such as clenching your fist, while you slowly inhale. Next, you release this tension, e.g. slowly unclench your fist, while you slowly exhale. 

Focus on what helps you, and encourage patients to focus on what helps them. This may involve identifying problematic ways of coping with anxiety that end up exacerbating anxiety in the long term, such as resorting to alcohol. Other daily things that may be helpful include meditation, yoga, exercise, and getting adequate sleep. Maintaining a routine can be beneficial. Any relaxation exercise of your preference, that helps you be more present in the moment and slow down your thoughts, will help in times of an emotional crisis. Many people find it helpful to keep a journal on a daily basis to collect their thoughts, and to keep up hobbies they enjoy such as sports, hiking, walking, spending time with loved ones, cooking, and so on. I hope you found this blog post helpful, not just for ways to help patients going through an emotional crisis, but yourself too. Feel free to leave a comment below with additional strategies you have found helpful to cope with an emotional crisis!