Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

TIPPS For Reducing Patients’ Anxiety


Helping patients engage in paced breathing and progressive muscle relaxation can be calming when they are feeling stressed.

“She’s getting more upset, can we please give her a dose of lorazepam?” This was the fourth page in two hours from Ms. S’s nurse.


“Sure, of course!” I really wanted to type this and return to my mountain of discharge summaries. I could have given her the dose. It was a totally reasonable option for her. She had no contraindications, the stakes were relatively low, she was distressed, and I was feeling the crunch to get through my work. However, I also knew in my heart that for Ms. S, the right answer wasn’t medication in that moment.


On admission, Ms. S openly conveyed that she struggled with stress and expected the same to be true with this surprise hospitalization. She self-deprecatingly commented, “I’m a handful and a mess.” However, she also voiced that she wanted to get better at managing her emotions, but she just wasn’t sure how. That night I promised her that we would get through it together if her anxiety bubbled over while she was in the hospital.


When I got to her room, she was visibly anxious and distressed. I examined her and verified there was no other medical reason for her distress. I sat down and suggested we try a few relaxation strategies, just to see how they might work for her. She looked at me doubtfully, but agreed.


Dialectical Based Therapy (DBT) has been praised as the gold standard treatment for borderline personality disorder. However, we’re slowly realizing that people without such diagnoses can also benefit by DBT skills in times of distress. The key idea behind the skills is that when people are overwhelmed with emotion, they need simple strategies to get them through. DBT skills are meant to calm the body and therefore the mind, allowing the storm of emotion to pass.


I ran through some basic DBT distress tolerance techniques with Ms. S. in her room, including  TIPP: Temperature modulation, Intense exercise, Paced breathing, and Progressive muscle relaxation. I explained that cold water on the face, traditionally taught as immersing one’s face into ice water (but can also be done through cold washcloths), slows one’s heart rate and can be a distraction from uncomfortable distress. Intense exercise increases heart rate to match the patient’s physical and mental activation. Then, as the body cools, the mind also cools down with it. Ms. S looked at me skeptically at this idea. I reassured her that the exercise could just be some arm punches in bed, not sprints down the hospital corridor. Last, I shared that paced breathing and progressive muscle relaxation both activate the parasympathetic nervous system, which leads the body to a more relaxed state.


In the end, Ms. S tried some ice packs on her neck and cheeks, as well as paced breathing and relaxing music. After about 10 minutes, she’d visibly relaxed. Ms. S voiced shock that something so simple could work. Perhaps even more surprising, the entire clinical encounter lasted no more than 15 minutes on my end with no prescriptions ordered.


The next morning on rounds, Ms. S shared with the team that she was planning on starting psychotherapy to help her continue using, practicing, and refining these skills. She joked that while she may have lost her gall bladder, she also gained some important tools to manage her stress. A few days later, instead of a benzodiazepine prescription on her discharge summary, I wrote a prescription for TIPP skills.



T: Temperature

Have the patient immerse their head in ice water, apply ice packs, or even just a cold washcloth to lower the patient’s heart rate and help them to gain a sense of calm.


I: Intense Exercise

This can be easily modified to fit the abilities of the patient. The goal is to get the heart rate up to distract the patient and then have the mind relax with the body during the rest period.


P: Paced Breathing

There are many different examples, but a common choice is inhaling for four seconds, holding for seven seconds, and breathing out for eight seconds. This ratio will activate the parasympathetic nervous system to promote a calming effect.


P: Progressive Muscle Relaxation

This can be done by focusing the mind on isolated muscle groups and releasing the tension in each. By relaxing the body in a focused way, the mind can also learn to relax.





This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.