The Expert in High Intensity Training and Fitness Medicine

Benefits of High Intensity Exercise

Cognitive Dissonance Has a Physical Sensation

My recent fascination with myokines has made me much more aware that skeletal muscles performing hard work signals for beneficial adaptations in all of the tissues of the body.  The brain and nervous system are no exception.  In the recent past, I have become much more aware of this fact.

In my professional life as an emergency physician, the recent years have heralded an almost exponential increase in the stressors faced by emergency physicians.  At baseline, it is amongst the most cognitively demanding landscapes imaginable.  High stakes situations present without warning and many times at a pace that is not manageable (picture the I Love Lucy episode where Lucy and Ethel get a job in the chocolate factory).  Major decisions must be made rapidly with little to no information and in an environment that tolerates no mistakes.  Now, due to signal disruptions from political and economic forces, even more is being diverted to the ER as it is the sole entry point into the healthcare system for almost any situation.

Over the course of the past few years, I have shifted my focus from trying to change the system or rebelling against the situation to one of adaptation.  I came to realize that my stressors in life, and in the ER, will never decrease.  If I want things to be better, I could not rely on changing my external environment.  Instead, I would have to focus on improving my internal environment.  I needed to handle stress better.  I simply had to get tougher.

In the context of cognitive processing, working in a fast-paced environment involves fast decision-making based on intuition and past experience.  For the well-trained and/or experienced emergency physician it works well to use what Daniel Kahneman (author of  Thinking Fast and Slow ( System 1 thinking.  However, there are times where our System 1 thinking will betray us and lead us to a wrong conclusion.  All sorts of cognitive biases can lead us astray (premature closure, anchoring, recency bias, diagnostic momentum or just plain exhaustion).  When this situation occurs, we need to switch to a System 2 thinking strategy…one that relies on asking disconcerting questions, rooting out the cognitive biases that may be at play and methodically thinking “what else could be at play here”.

This all sounds well and good, but one must ask:  if System 1 depends upon intuition and subconscious processes, how do we recognize when it is about to fail us.  Enter Cognitive Dissonance.  Cognitive Dissonance is commonly defined as the mental discomfort or psychological stress that one feels when someone holds two contradictory beliefs, ideas or values.  However, my personal experience also shows that it occurs when you reach a System 1 conclusion that is contradicted by System 2 data points that are present but not consciously acknowledged.  The mental discomfort, however is much less intense than what is experienced under the formal definition.  As such, it is much easier to have “slips”, especially when the pace of the work does not allow the empty space to be in touch with more subtle emotions.

Here is where I venture into the “land of Woo” a little bit, but bear with me.  I found that I was unearthing these System 1 errors at two very specific times, usually hours or days after the actual decision event.  The first was during deep stages of sleep when I would awake with the answer and experience a slight sense of “flight or fight” that may or may not be linked to a dream or a nightmare.  The second incidence would occur during my workout, usually fairly deep into a set, somewhere between the bogging down of speed and failure.  Also, it would occur deeper in the workout and during significant metabolic stress.  Several of these instances have resulted in my calling a patient hours or days later to come back for a recheck and further workup that revealed the true problem.

As I paid particular attention to these events, I began to notice a particular pattern in the experiencing this sort of cognitive dissonance.  The pattern that emerged was that what heralded my recognition of the System 1 error and the cognitive dissonance was a physical sensation.  I cannot really describe the sensation, and probably shouldn’t attempt to do so, because it is probably different for each individual.  It was the same sensation if the realization came during the workout, or if it occurred during sleep or elsewhere.  Most importantly, it is a sensation that I have come to experience every time I do a high intensity workout.

The physical sensation seemed to correlate with the same sensation that I have previously referred to as the pop-up timer.  I used this term to describe the sensation I would have when I new I was reaching the appropriate level of fatigue or inroad.  This heralded a level of effort and concentration that was sufficient to trigger an adaptive response.  Also, it served as a warning of when I was about to venture into territory that would would result in overtraining or a degree of stimulus that was so severe as to be disproportionately difficult to recover from.   Over time, I developed a sense of this transition zone between optimal stimulus and a damaging one and came to recognize it easily.

Much has been made recently of the value of a meditative practice, and I find myself very much in agreement with this notion.  I believe this is largely a function of our evolutionary brain structure.  We are both the victim and beneficiary of a very rapid evolutionary increase in our brain size and capacity.  The result is a giant neocortex layered over a primitive brainstem.  Much of our behavior is dictated by the relatively automatic functioning of our more primitive brainstem.  For more complex and deliberate behaviors, we rely on our neocortex, especially our prefrontal cortex.  Most of the time, we carry out our lives with these two systems operating in tandem, but relatively separate from each other.  We are content to allow them to operate in a silo system.  However, if we want to function on the highest cognitive plane possible, we must integrate these two systems.  We must try to have conscious control over autonomic functions.  This is where meditation comes in.  It is incredibly simple…as simple consciously focusing on our breath.  This is commonly termed “mindfulness”.  As one becomes adept at this simple act (which is no easy task), they can then expand their mindfulness to other bodily sensations.  One can take note of the pressure of a chair on their body as they sit, or the sounds in their environment, but then return to the breath.  Once one becomes adept at this practice, they find that their mental performance improves in all kinds of tasks, simple and complex.  This is because they are becoming more adept at activating higher brain centers to focus on the task at hand and controlling autonomic responses that might affect performance.  Philosopher Ayn Rand once noted that the human animal is the only animal whose consciousness is not automatic.  Instead, it takes an act of volition to turn on consciousness and this act is perceived as effort.  In essence, all humans have ADHD…we naturally don’t pay attention, and we have to work to do it.

Meditation is an act of learning.  Initially, one pays attention to autonomic functions in order to later assume control of them.  At the beginning, you do something as simple as becoming aware of your breath.  Later, having developed this awareness you can try and control your breath.  As you progress, you will become adept at controlling other aspects of your physiology, and as you do so, you learning and awareness improve.  The real power of a meditative practice as it relates to learning and awareness really begins to express itself when the autonomic processes are more intense.

One person who has really married the concept of combining a meditative practice and intense physical experience is Wim Hof (  Hof combines breathing exercises and cold exposure to elevate the power of the meditative practice by combining it with intense physical experiences.  He uses cold exposure as a means of making the conscious control of autonomic functions both more challenging and to make the learning process more powerful.  While reading his articles and listening to him being interviewed– I was struck by how similar this sounded to Ken Hutchins description of the internalization process he recommends when training and how one should focus on the pain of exercise…to rush up on it and deliberately try to make it worse.  In so doing, he described it as being like a mirage, in that as you run up to it, it disappears.  The control over breathing, the relaxation of the face and the stoic focus on the task at hand had eerie parallels.

The ability to focus on bodily sensations and control autonomic functions while in quiet meditation is a challenging achievement.  Accomplishing this in conjunction with an intense experience is not just merely a higher achievement, it is an opportunity for a quantum leap in learning and awareness.   Learning during an intense experience can accelerate the learning process and greatly improve long term retention.

Dave Grossman, Author of the book “On Combat” ( has described this augmented learning as “limbic learning”.  The emotion of intense physical or emotional experience burns memories into our minds.  Learning to control intense autonomic events is not just a learning experience in itself, it is a way to learn new skills more effectively.  Being exposed to new material under stressful situations increases retention, especially when the stress is mitigated by a learner that has been taught how to have conscious control over autonomic functions.  One becomes familiar with their bodily sensations as they relate to the acquisition and retention of knowledge.  As more knowledge is accumulated, one becomes attuned to the bodily sensations that occur when acquired knowledge and new data are in conflict.  One begins to recognize the physical sensation of when something is not right.

So this brings me back to my original thought.  I think one of the benefits to intense exercise is the effect it has on cognition.  Done properly, it is an intense meditative practice that is elevated by the severe autonomic processes that are triggered and have to be overcome.  It is a practice that takes incredible concentration and focus.  The benefits are likely amplified by some kind of myokine signaling.  It has been my experience that these skills translate into other areas of your life where you expend intense cognitive effort and focus.  It is for this reason that I believe I am able to detect a cognitive bias while working in the ER by the very same physical sensation.

Ultimately, I know I have done a fairly poor job of articulating this experience, likely because I don’t yet fully understand it myself.  If you want to seek out this sort of experience yourself, I suggest the following steps.

  1. Adopt a meditative practice.  Using an app for guided meditation is a good starting point.  One of the most popular is the headspace app (
  2. Meditate immediately before your workout, and bring this meditative focus to your workout itself.  Rely on it to maintain an internal focus on what you are doing and to quell the autonomic storm that tries distract you from the task at hand.
  3. Rely on this state of mind in the other areas of your life that you are deeply engaged in.  Practice at work, with family and with sports.
  4. Be on the lookout for bodily sensations that alert you to important moments, danger or cognitive dissonance.

High intensity exercise offers so much more than just improved physical performance.  We are just beginning to scratch the surface of what is possible.

Copyright © 2019 by Dr. Doug McGuff. All rights reserved.