The role of psychiatric symptoms and parenting stress Postpartum psychosis: which are the symptoms and which women are more at risk Postpartum psychosis is the most severe mental illness that can occur in the postpartum period, so that it is considered a psychiatric emergency and requires urgent treatment and, in most cases, hospitalisation. Postpartum psychosis usually develops very soon after childbirth and symptoms include elation, depression, with rapid fluctuations, as well as psychotic symptoms (delusions and hallucinations), often centred on the baby, and disorganized behaviour. Maternal Mental Health Alliance Luckily, contrary to postpartum depression, postpartum psychosis is relatively rare, occurring in 1–2 per 1000 deliveries in the general population. However, some women are more at risk to develop this illness, and these are women with a diagnosis of bipolar disorder, schizoaffective disorder and those who have already experienced postpartum psychosis with a previous delivery. Although these women are more at risk to develop the illness, we know very little about why some women considered at risk become unwell after delivery while others remain completely well. Some of the most significant risk factors reported in the studies include sleep deprivation, having experienced psychiatric symptoms during pregnancy and being a first-time mother. However, many other factors remain to be investigated. The little amount of research in postpartum psychosis is in contrast with the numerous known risk factors for antenatal and postnatal depression. I am a postdoctoral researcher working in perinatal psychiatry at the Institute of Psychiatry, Psychology and Neuroscience and I have talked about risk factors for antenatal depression in a previous piece. We need to better understand which factors increase a mother's risk of developing postpartum psychosis. As we have recently read in my fellow colleague Katie’s blog, our research (the Psychiatry Research and Motherhood Study — the PRAM Study) has studied a number of possible risk factors. Our aim is to eventually identify, early on -in pregnancy, which women are more likely to develop an episode so that preventive interventions can be put in place. Our research has found that maternal experience of childhood maltreatment, high perceived stress and cortisol are important risk factors. Mother-infant relationship As much as we know little on why some women considered at risk of postpartum psychosis will eventually become unwell after delivery while others will remain completely well, we know even less about the mother-infant relationship in women at risk of/with postpartum psychosis. Photo by William Fortunato from Pexels This is surprising considering that we know that postnatal depression can represent a risk for the mother-infant relationship and infant development, particularly when the illness is severe and persists over time, with no treatment provided. Considering the severity of postpartum psychosis, it is essential to establish whether this illness can also have negative effects on the mother-infant relationship so that interventions can be put in place to protect the dyad in the long term. Maternal perceived bonding towards the infant is an important aspect of the mother-infant relationship as it is the emotional response towards the baby i.e., how the mother feels towards and in the relationship with the baby. It is very much subjective as it represents how the woman perceives herself as a mother, her baby and their relationship. Family Services We know that maternal bonding does not start when the baby is born, but much before then -when the mother is pregnant. It is during this time that the mother starts to develop a relationship with her baby, which is comprised of her feelings, thoughts and behaviours directed to the fetus. This relationship represents the basis of the mother’s future relationship with her child, although, of course, it will also be shaped by lots of other factors that will come about postnatally, including maternal mental illness, the involvement of the father, maternal experiences of being parented during childhood, social support, social and environmental circumstances, parenting stress. Our study And this is where my work comes in. I have a particular interest in the mother-infant relationship and infant development in the first years of life. Since 2013 I have worked on the PRAM Study, which recruited a group of women at increased risk of postpartum psychosis and followed them (and their children) from pregnancy to 12 months postpartum. As part of this study, we investigated maternal emotional bonding towards the baby during the perinatal period in women at risk of postpartum psychosis and in those at risk who then become unwell (with depressive, manic or psychotic symptoms) in the early postpartum period (within 4 weeks after delivery). This work was recently published in the Journal of Affective Disorders. So, what did we find? We found that women at risk of postpartum psychosis who became unwell within 4-weeks after delivery reported a more negative affective experience towards their infants (i.e., more negative feelings) during pregnancy, compared to women at risk who remained well during that time. However, these differences in bonding evident in pregnancy were not present anymore in the postpartum period. Indeed, in the first 12-months postpartum, women at risk of postpartum psychosis who became unwell within 4-weeks after delivery reported similar bonding to women at risk who had stayed well during that time. However, women at risk of postpartum psychosis as a group i.e. regardless of whether they had developed an episode within 4-weeks postpartum showed a more negative affective experience towards their babies compared to healthy control women (women not considered at risk of postpartum psychosis), and this remained the same throughout the first year postpartum. What do these results mean? The role of maternal psychiatric symptoms We found that this difference in bonding between pregnancy and postpartum was explained by the same underlying mechanism-maternal psychiatric symptoms-which had a negative impact on bonding. In other words, psychiatric symptoms affected the emotional relationship women experienced towards their babies, both in pregnancy and in the postpartum period. The more the psychiatric symptoms experienced, the more negative was the quality of the emotional bonding. This finding is in line with what we would have expected as we know that mood symptoms impact the woman’s feelings towards herself, her environment, and her relationships, and therefore, also the relationship with the baby. Also, this confirms previous studies in depression that have shown that bonding during the perinatal period is affected by symptoms of depression, even if they are only sub-clinical (they don’t reach the level necessary for a diagnosis). Women’s Mental Health Let me explain this in more detail. In pregnancy, women at risk of postpartum psychosis who then went on and developed a postpartum episode already experienced more psychiatric symptoms than those who then stayed well postnatally and this negatively affected the bonding women experienced towards their unborn babies. However, by 8-weeks and 12-months postpartum, when bonding was evaluated, other women at risk of postpartum psychosis who had stayed well within 4-weeks postpartum, developed psychiatric symptoms. Therefore, by this time, women at risk of postpartum psychosis with and without an early postnatal relapse were not so clearly identifiable as before in terms of the levels of psychiatric symptoms, while women at risk of postpartum psychosis reported as a group more symptoms than healthy control women. As a result of the effect of psychiatric symptoms on bonding, in the postpartum period, women at risk as a group reported a more negative bonding quality compared to controls. The role of parenting stress Family Services Another important finding of the study was that parenting stress, the stress the woman experiences in her role as the mother, for example feeling inadequate as a mother, restrictions on other life dimensions, conflict with a partner, a child not meeting expectations, child perceived as difficult to manage etc. was higher in women at risk of postpartum psychosis compared to women not at risk, and this remained the same throughout the first year postpartum. Interestingly, the more stress women experienced in their parenting role, the more negative was their bonding with their baby, a finding that has previously been reported in depression. Indeed, we found that parenting stress, similarly to psychiatric symptoms, was an important predictor of the quality of bonding women reported towards their babies. Therefore, in summary, we found that both psychiatric symptoms and parenting stress negatively affected the emotional relationship women experienced towards their babies. Of course, it is important to mention that this was not the case for all women at risk. Indeed, not all of them experienced psychiatric symptoms, high levels of parenting stress nor a more negative emotional bonding towards their babies. As in every study, we talk about a percentage of women, not all of them. Why these results are important We know that both psychiatric symptoms and parenting stress can have an impact not only on the mother-infant relationship but also on the infant development in the long term. Therefore, these findings tell us that it is absolutely important to think of preventive interventions from pregnancy throughout the first postpartum year to support women at risk of postpartum psychosis to reduce parenting stress, as well as psychiatric symptoms and to improve the emotional bonding with their babies, specifically in view on the fact that bonding and parenting stress remained the same during the first year postpartum. We expect that supporting women to improve their mood symptoms and reduce parenting stress will have positive effects not only on their emotional bonding towards their babies but also on the quality of the mother-infant interaction and on the development of the infant in the long term.

Co-written by Katie Hazelgrove. This is the third week of our Maternal Mental Health series, and it is dedicated to Postpartum Psychosis — a rare but extremely severe postnatal mental illness, which must be treated as a medical and psychiatric emergency to protect the safety of the mother and baby. This week we are publishing two blogs: one by Eve Canavan on her personal experience, and another by researchers Alessandra Biaggi and Katie Hazelgrove from King’s College London, focusing on what is known about the illness and what further research is needed to help the women affected and their children. What is postpartum psychosis? Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. It is so severe that it is considered a psychiatric emergency, requiring specialist care and, in most cases, hospitalisation. As we have read in Eve Canavan’s blog about her experience, postpartum psychosis typically develops soon after childbirth, often within days or weeks of the delivery. Symptoms include mania (feeling elated/high), depression, or rapid fluctuations between manic and depressed moods. As a result, women may be more talkative and active than usual or restless and agitated, or they might be more withdrawn, tearful and anxious, or a mixture of all of these. They may also have difficulty sleeping or feel like they don’t need any sleep. As the name suggests, women may experience psychotic symptoms in the form of delusions (unusual thoughts or beliefs that are unlikely to be true) and hallucinations (seeing, hearing, smelling or feeling things that are not there). Confusion is also common, and women may appear not to know who or where they are. They may also behave in ways that are out of character. Photo by Sarah Chai from Pexels Which women are at risk of postpartum psychosis? Postpartum psychosis is relatively rare, occurring in 1–2 women per 1000 deliveries in the general population. However, some women are at greater risk. Indeed, research has shown that up to 50% of women with a diagnosis of bipolar disorder or schizoaffective disorder, and most of those who have experienced an episode of postpartum psychosis following a previous delivery, will experience an episode of the illness after giving birth. It is therefore important for women at increased risk to be closely monitored throughout pregnancy and the postnatal period. Several other risk factors have also been proposed, including becoming a mother for the first time (primiparity), sleep disturbance, and the dramatic fluctuation in hormones that occurs during pregnancy and the early postnatal period. We also know that genetic factors are likely to play a role, as women whose mother or sister have experienced postpartum psychosis are at increased risk of having an episode themselves. Our own research, which we have previously discussed in Inspire the Mind, has shown that stress might also be an important factor, particularly for those women already at high risk for postpartum psychosis. It is likely that there are many factors involved in determining whether or not women will develop postpartum psychosis, and much more research is needed to better understand exactly which factors play a role. How is postpartum psychosis different from other mental health problems that occur during the postnatal period? It is extremely common for women to experience mood symptoms during the postnatal period. Indeed, up to 80% of new mothers will experience the ‘Baby Blues’, a normal condition that is thought to occur due to the hormonal changes that happen after childbirth. Symptoms of the Baby Blues include fluctuating mood, and feeling tearful or anxious. Although these can appear similar to the early signs of postpartum psychosis, symptoms of the Baby Blues resolve without treatment, while those of postpartum psychosis escalate very quickly and soon become severe. It is also important that postpartum psychosis is not confused with postnatal depression, which is much more common than postpartum psychosis, affecting 10–15% of women after they give birth. Symptoms of postnatal depression include low mood, sadness, and a loss of interest and enjoyment, but not the manic and psychotic symptoms and confusion that women with postpartum psychosis typically experience. Furthermore, unlike postpartum psychosis, which often begins within the first couple of weeks from delivery, postnatal depression usually starts later in the postnatal period, typically around two or three months from delivery. What about treatment, prognosis, and prevention? Considering the severity of postpartum psychosis, treatment with medications and, in most cases, admission to hospital are necessary. When possible, it is always preferable for women to be admitted to a specialist “Mother and Baby Unit” (MBU) rather than a general psychiatry ward. MBUs are specialised inpatient units for treatment of psychiatric disorders during pregnancy and in the postpartum period and are considered the ideal option for women developing postpartum psychosis. HRH The Duchess of Cambridge visiting the MBU at the South London and Maudsley NHS Trust; Credit Hannah McKay/PA In fact, these units prevent the separation of mother and baby and offer specific interventions aimed at promoting mother-infant relationship, supporting the family and informing about the illness. Furthermore, women admitted to MBUs generally report higher satisfaction in the service than women admitted to general psychiatric wards, as we have also heard from Eve’s experience. Despite postpartum psychosis being among the most severe psychiatric disorders, the prognosis is usually good. In fact, with appropriate treatment, most women can recover within a fairly short period of time, usually within two months, although some women may develop depression afterwards, so full recovery may take 12 months or more. However, for women who have experienced an episode of postpartum psychosis, the risk for future episodes during or outside the perinatal period remains high and, therefore, it is important to implement adequate psycho-education about the illness, as well as appropriate monitoring of the woman, particularly in case of a new pregnancy. What are the potential consequences for mother and baby? Considering the severity of postpartum psychosis, it is very important that women are identified early on and that adequate treatment is provided, to avoid potential negative outcomes for women and their babies. The postpartum period is a time of increased risk for maternal suicide and, according to the Confidential Enquiries into Maternal and Child Health, suicide represents the leading cause of maternal death within the first year postpartum. There is evidence that the majority of women who commit suicide are experiencing a severe depressive illness or an episode of postpartum psychosis. Indeed, until the creation of the national charity Action on Postpartum Psychosis (APP), aimed at supporting women and families, training health professionals, supporting research in the field, and disseminating information about the illness, half of suicides within the first year postpartum were of women experiencing postpartum psychosis. Nowadays, this percentage is much reduced. Photo by Sarah Chai from Pexels Considering the severe alteration in mental state and behaviour that can be present during an episode of postpartum psychosis, there is also a risk that the mother will not be able to attend to the baby’s care and, in very rare cases, of infanticide. Although these episodes are not frequent, postpartum psychosis represents a psychiatric emergency and it is paramount to protect the safety of the mother and the baby. Many studies have documented that perinatal depression, particularly if severe and left untreated, can have a negative impact on the mother-infant relationship and on infant development. On the contrary, only a few studies have to-date been conducted to understand whether this could also be observed in postpartum psychosis. Some studies, including our own longitudinal study, reassuringly suggest an absence of a negative impact of the postpartum psychosis episode on the mother-infant relationship and on infant development. You can read about it in our blog here. These results are promising and may be explained by the fact that acute symptoms of postpartum psychosis tend to resolve within a fairly short period of time, resulting in a limited time of exposure for the child. However, other studies suggest that postpartum psychosis or a severe postnatal mental illness can have a negative impact on the mother-infant relationship. Therefore, more studies are needed to clarify whether postpartum psychosis can be associated with difficulties in the mother-infant relationship and in infant development so that, if necessary, interventions can be developed to protect both mother and baby in the long term.

Photo by Bonnie Kittle on Unsplash I can tell you now, that being completely prepared for the arrival of a new baby is impossible! However, lots can be done to arrive as prepared and organised as possible, with the right information and without unrealistic expectations. The transition to parenthood is associated with many changes and challenges and, as a result, parents have to deal with high levels of stress. Therefore, it is not surprising that mental health problems are common during this period. It is therefore important for parents to reduce their levels of stress, to protect their wellbeing and their baby’s too, as stress during pregnancy and postnatally can also have negative effects on the infant's development. To reduce stress, it is important to start thinking about possible strategies that can help deal with the changes and meet the requests of this period. Practical examples include: building a network of support for the family to receive help and avoid loneliness delegating house tasks so you can sleep when the baby sleeps reducing unnecessary commitments being flexible and self-compassionate about what is feasible to do with a newborn baby include some time for self-care. Below I will discuss some of the aspects that would be helpful to consider, based on my experience as a mum and my work as a psychologist. The importance of self-care and social support We said it already: taking care of a baby is a 24-hour job, with no breaks or holidays. This is why mothers (and fathers) can feel exhausted, but often carry on doing everything by themselves and don’t ask for help. This is partly due to the fact that it is not culturally recognised that parenting can be very tiring. It is not uncommon to hear things like, "Why are you always so tired? You are at home all day!" It is important to recognise that taking care of a baby alone is challenging, and asking for help does not mean you are a bad parent. Indeed, receiving emotional and practical support is an important protective factor for the mother's wellbeing, and therefore, for the baby’s wellbeing too. If a mother has been emotionally supported and has time to rest or do something for herself, she will have more energy for the baby and will be more likely to take care of them in a sensitive way. In contrast, mothers who are lonely and overloaded are at increased risk of developing mental health problems, such as depression, and to experience relationship difficulties with their baby. Remember that taking care of ourselves as mothers means taking care of our baby too. Photo on Freepik The needs of the new-born baby As we have discussed previously, babies don’t have bad habits but have actual needs that have to be met. Therefore, it is important to be aware of these needs and think of possible strategies that can be implemented to help you meet these needs. For example, newborn babies often require lots of physical contact with the caregiver and can manage very limited time on their own. A possibility to satisfy this need is baby-wearing, which leaves you hand-free for other things. Furthermore, often babies need to be fed frequently, not only because their stomach is small, but also because sucking doesn’t satisfy only hunger but also helps the infant to calm down, receive reassurance, alleviate pain, connect with the mother, and sleep. This behaviour is referred to as "comfort nursing". There is growing evidence on the importance of "responsive" feeding — also called "baby-led" or "on-demand" feeding, regardless of whether it is breastfeeding or formula feeding. This means following the baby’s cues for feeding rather than timings. This is associated with a number of positive effects for the baby, even in the long term, such as better infant cognitive development. Last but not least, babies don’t only need sleep and feeding, but lots of other things too, such as adequate stimulation with a caregiver who treats them as individuals with minds of their own. Building a relationship with the baby As with any other relationship, the parent-infant relationship is a "building process", which requires time and effort, as parent and infant need to get to know each other. For some parents, the development of the relationship with their baby is fairly straightforward, while for others it takes more time. There is no right or wrong. Photo by Thiago Borges on Pexels However, as the relationship with the baby starts in pregnancy, it can be useful to start creating "a space in the mind for the baby" during this period, which means starting to build an emotional connection with the baby. Examples of what you could do include: talking with the baby, listening to music with them, focusing on their movements and how they may feel at the moment, touching the belly, and thinking about what you could be doing together once the baby is born. After delivery, you will slowly get to know each other and you will gradually start understanding their cues and signals, and the relationship will build up day-by-day. It is not always easy to understand what the baby is telling us and what they need, and this requires time. We will talk more about this in the next blog. Remember that every baby is different! Once again, it is easier for you to build a healthy relationship with the baby if you receive support from the people around you. The cultural views and expectations with regard to parenthood There are many cultural, unrealistic expectations that surround parenthood. For example, it is a general thought that becoming parents is only characterised by joy. However, parents can feel stressed, frustrated, and bored. This is normal, considering the amount of effort required. Also, becoming parents is a learning process and it is important to not have high and rigid expectations about it. When a baby is born, a new mother and father are also born. Furthermore, no matter what mothers do, it is likely they will receive some criticism. In fact, it is not uncommon to hear things like, "Have you not come back to work yet? The baby is grown up now". Or the opposite: "Why did you come back to work so early? The baby is still little and needs you". Or "you should work part-time to have more time for the baby", or "if you worked full-time you could earn more money". Remember that nobody else knows better than you what’s best to do in your circumstances for you, your baby, and your family. In addition, in our society, mothers are often expected "to work as they were not mothers and be mothers as they were not working". Obviously, this is very difficult as it is challenging to perform each of these tasks as though the other one does not exist. Photo from Getty Images Mothers also often suffer from what is commonly called the "mental load of motherhood", meaning that often they are those responsible for hundreds of baby- and house-related tasks, with the consequence that their brains are constantly occupied by pressing thoughts of things that need to be done. "Are we running out of nappies? What can we eat for dinner? I need to book the baby health check. I need to buy winter clothes". It is easy to understand how these constant thoughts can affect the mother's energy and ability to concentrate and perform at work. It is important to make a plan to allocate tasks between different family members and off-load the mother as much as possible. Picture by MommysBundle on Instagram Breastfeeding is a competence that needs to be learned We all know that breastfeeding is beneficial as it provides nutrients and antibodies for the baby, promotes mother-infant attachment, and protects the mother from some diseases. However, breastfeeding is not always easy, and a competence that needs to be learned and, in fact, many women need some support with it. Also, women need to do what’s best for them. Breastfeeding is important but is more important that women are happy and don’t feel forced to do something they don’t want to do. Babies need an emotional connection, a caregiver that is there for them, and this can be achieved regardless of the type of feeding chosen. It seems a slogan, but it is actually true: when a mother is happy, her baby is too! In summary, becoming parents is associated with many changes and challenges in many aspects of our lives including our identity, our couple relationship, and our sleep. Our way of thinking and priorities also change. It is therefore important to be as prepared as possible while not having unrealistic expectations. Pregnancy is a good opportunity to start preparing and then when the baby arrives, there will be a further gradual process of mutual adaptation. For our wellbeing, it is important to do what we think is best for us and our baby, reduce stress, and have some time for ourselves. This will help us to have the mental and emotional space for our baby.

My Journey Towards Healing the Bodymind The term hysteria has earned a bad rap for good reasons. Coined as a diagnosis to refer to physical symptoms without an identifiable cause, it was originally considered as a female malady caused by a “wandering uterus”. Image Source: Simran Sood on Unsplash Although hysteria ultimately became a dismissive and misogynistic label used to pathologise women’s emotional experiences, the original diagnosis behind this popular term – now known as conversion disorder or functional neurological disorder - is far more complex and deserving of attention. I am a former educator and freelance writer who has experienced physical symptoms without an apparent cause. As a writer, I initially turned to my journal for answers to those unruly symptoms; writing has always helped me connect what is happening in my body with what is happening in my mind. In trying to make sense of these experiences, I learnt about conversion disorder, which offered me deeper insight into my somatic symptoms and a greater sense of agency in managing them. Through this reflection, I hope to shed light on an often misunderstood condition and help others navigating a similar journey with their own healing. Listening to My Body Before the COVID pandemic started, I experienced inexplicable physical complaints. I vomited upon waking – after menopause. When I entered stressful environments, my body would often object…loudly. Sudden, blinding headaches would prevent participation in certain events. Sometimes, muscle tension would seize up so severely that a hot Epsom salt soak and an early bedtime were my only options. When I sought answers from my primary care physician, I was met with alarm. She appeared visibly distressed as she offered a battery of in-patient tests, in case something terrible lurked in my system. I knew my body was communicating, but I also knew I wasn’t sick in a strictly medical sense, and neither required nor desired invasive procedures. My doctor agreed. She just didn’t know what else to do. Image Source: Curated Lifestyle on Unsplash+ Initially, I found relief through alternative means: myofascial massage, acupuncture, and saunas helped immensely. As I focused more on breath work, meditation and somatic yoga, my health steadily improved. However, when I accepted invitations to certain events or agreed to extra responsibilities at work, ailments returned. Once I recognised the pattern, I began to suspect the root lay in unprocessed emotional and mental distress. This led me to research the relationship between chronic pain and trauma. What I found surprised, and ultimately, empowered me. From Historical Roots to Modern Understanding of Conversion Disorder Coined by psychoanalyst Sigmund Freud and his mentor (Josef Breuer, a physician), conversion disorder originally referred to the somatic expression of repressed experiences, such as trauma. According to Freud and Breuer, what the mind cannot handle will eventually express itself physically. While controversy swirls around this idea today, largely due to the historical misuse of the diagnosis to pathologise people’s emotional experiences, there is value in the concept. Conversion disorder assumes the close interrelationship of body and mind, which far better reflects my experiences than what I had encountered in mainstream medicine. In modern medicine, conversion disorder (also known as functional neurological disorder) refers to neurological symptoms not explained by identifiable organic causes. Image source: Alex Shuper on Unsplash The brain and body present intact in exams, nevertheless patients experience acute and involuntary symptoms, including seizures, paralysis, fatigue, and/or chronic pain. Somatoform disorders emerge from a complex interplay of factors, including nervous system regulation, personal history, and environmental causes, as such they may present differently in different people. The Bodymind Concept Advocates in the disability justice movement have pushed this idea further by suggesting the term bodymind to help us recognise our multifaceted experience of health and illness. The merging of two words is intentional here. From the philosopher Rene Descartes, we have inherited a sense that the mind and body are separate, distinct entities. Yet, that duality does not necessarily reflect reality. Bodymind is meant to heal this Cartesian split. According to medical anthropologist Emily Mendenhall in her 2026 study, Invisible Illness: A History from Hysteria to Long COVID, this term characterises human health as an “integrated whole” which sees as foundational the “intersectional interrelatedness of mind and body.” Bodymind made good sense to me. Why the Hysteria over Hysteria? Further research into the bodymind led me to the acclaimed 2025 podcast Hysterical, in which host Dan Taberski investigated an unexplained outbreak at the LeRoy Middle/High School in 2013. Twenty girls experienced involuntary tics similar to Tourette’s Syndrome. Families wanted answers. In the meantime, rumours about a toxic chemical spill from forty years earlier brought environmental advocate Erin Brockovich to the scene. The more attention on the inexplicable symptoms and the more fervent the demand for someone to explain them, the worse the girls’ condition. Eventually, doctors there arrived at the conclusion that this instance of conversion disorder had developed into a mass psychogenic illness, or hysteria. Not unlike the frenzy during the Salem witch trials, or in the famous dancing plague of 1518, individuals experienced real symptoms expressed collectively in the body of the community. Distinct lines between person and group, body and mind, heart and soul, simply collapsed. One particular scene from the podcast stood out. A young girl during a town hall meeting shouted down her doctors, finger stabbing the air: “You are not doing your job. You are not doing your job at all.” This young woman’s reaction highlighted for me how difficult it can be to accept the legitimacy of somatic experiences. Your Body’s Innate Intelligence Unexplained ill-health led me on this integrative journey in which I learned to honor my body’s intelligence, to observe symptoms and find root causes within the totality of my lived experience. Somatic discomfort required me to seek answers beyond a purely physical framework, engaging in honest conversation with my mind and body, heart and soul all seated at the same table. Image Source: Ruthson Zimmerman on Unsplash It also required me to ask for help along the way. I turned to new friends for deep conversation; I sought healers from traditions other than my own; I said yes to interventions others might dismiss. In the process, I discovered the healthiest version of myself… so far. While I would never suggest ignoring sound medical advice, the more I trusted in my body’s signals and responded accordingly, the clearer my path toward vitality. My physical symptoms were no less, and no more, real than someone suffering from a structural ailment. While my body taught me how to heal myself, it was my good fortune to find practitioners who facilitated this delicate conversation. I wasn’t expecting to benefit immediately from any single treatment, no matter how nourishing it felt or grateful I was for it, but by showing up every day and investing in integrative, holistic care, over time I have learned what excellent health feels like from the inside out. And it starts with self-trust. Embracing Bodymind Doesn’t Erase Reality While many people reject labels that suggest a psychological component to physical distress, I found wisdom in welcoming them. Accepting the mysterious relationship between internal experience and external embodiment does not negate reality. It doesn’t mean your symptoms are “all in your head.” It does mean they are within you. For me, this is actually good news. It means that while not everything is within our control, we can support and care for our bodies from the inside out. Exploring this unknown territory of bodymind with curiosity and discernment offered me an empowering route to wellness by way of self-trust, on my own terms. This article has been sponsored by the Psychiatry Research Trust, who are dedicated to supporting young scientists in their groundbreaking research efforts within the field of mental health. If you wish to support their work, please consider donating.

Image Source: Getty Images on Unsplash+ We have an extraordinary ability to imagine. Our imagination lets us revisit the past, rehearse the future, create entirely new experiences and worlds... all within our minds. But are we always in control of what we see in our minds? My name is Eman, I’m a PhD candidate at the Institute of Psychiatry, Psychology and Neuroscience at the Imagine Better Lab. My research explores why young people with low mood and depression might experience upsetting images playing in their minds, even when they don’t want them to. Since starting my PhD, I’ve spoken to many young people about their experiences of intrusive images, and their rich experiences of mental imagery have left me with more questions than answers. What makes our imagination so powerful, and how can we harness this power of imagination? Well, researchers and research participants in the field of mental imagery are already beginning to unravel these very questions. Mental Time Travel What would you do if you could step inside a time machine? Is there a moment in the past you would return to or somewhere in the future you would project yourself forward to? What would you change? Would you believe me if I told you that time-travelling is something we can already do, and in fact, something many of us do often? But not in the physical world, but rather within our inner mental worlds. Mental Time Travel was a concept first proposed by Endel Tulving in 1985. It describes our ability to bring past experiences, our memories, back into our minds and re-live them, and to project ourselves forward to the future and pre-live experiences, like rehearsing a conversation in our minds. As I write this piece, nothing will change before my eyes, but within my mind I can travel back in time to many different places, have conversations with many different people – like my parents, who are halfway across the world – but in my imagination I can see them clearly with my mind’s eye. The mind’s eye is our ability to generate and experience visual mental imagery in the absence of any direct sensory input. We often think of mental imagery as visual, but the images created in our imagination can be multisensory, encompassing experiences of smell, taste and sound, all without the presence of any external stimuli. Take a moment here, can you bring to mind the smell of roses? (I only have the experience of a faint smell, neither here nor there, but somewhere). What if I asked you to bring to mind the laughter of someone you love? (I can hear this loud and clear). Our mental experiences can vary considerably, but we know little about these differences. It is through this rich inner mental landscape that mental time travel might become possible. Image Source: Getty Images on Unsplash+ The Real Power of Imagination Have you ever found yourself lost in a daydream and felt your heart race or noticed your mood shift, even though nothing around you had changed? Research on the brain suggests that we may experience imagination as if something is happening in the here and now. Your imagination sends signals to the brain similar to those triggered by real perception. We may process mental images experienced internally, in our minds, similar to how we experience external stimuli in the physical world. Because of this overlap, neuroscientists describe imagination as ‘weak perception.’ This might be one reason why mental imagery can be more emotionally intense than verbal thoughts. When we imagine emotional mental images, we may be activating the same brain areas as if we were experiencing an emotional experience in reality. For example, replaying vivid scenes from a good day yesterday, in your mind, might generate more positive emotions than simply thinking “I had a good day yesterday,” according to research. A Double-Edged Sword On one hand, memories which we remember positively can make us feel happy, nostalgic, and loved, and images of the future can fill us with motivation or hope. But on the other hand, memories or images of the future can also be negative, upsetting and distressing. For some, negative images can become persistent, uncontrollable and intrusive. Often, these images play on repeat, shaping how people see themselves, the world around them and their future. One young person with lived experience described it like the chorus of a song stuck in their head on loop. Many people think of Post Traumatic Stress Disorder (PTSD) when they think of intrusive memories. But research suggests both intrusive memories and images of the future may play a role in a range of mental health difficulties. Vivid, emotional, and upsetting mental images that intrude in people’s minds are increasingly recognised as an important, yet poorly understood feature in mental health difficulties such as anxiety and depression. Someone with depression might be tormented by vivid memories of being bullied and these are experienced as if they are happening in the here and now. Like a time machine, pulling them back to the past whether they want to go or not. Reimagining Imagination Researchers are exploring how imagination itself might offer a way forward to reduce the power of intrusive images. One therapeutic approach, Imagery Rescripting, is showing signs of early promise. Imagery rescripting is an approach which helps people revisit, process and reshape these intrusive images using their imagination. It offers an intervention where a more acceptable or positive outcome is imagined. If the brain really is processing imagination similar to what we experience in reality, then we have reason to think that imagining something can be a powerful experience in itself. While we can’t rewrite the past, we may be able to rewrite how it exists in our imagination and in doing so, reduce its power. And so perhaps, William Blake, painter and poet, writing in the 1800s, might have been onto something when he said: “The imagination is not a state, it is the human existence itself.”

The Use of Natural Language Processing in Mental Health Research Language is at the heart of mental health. It is how clinicians describe what they observe, and how people express what they feel. But what happens when we ask AI to read it? Image Source: Nathaniel Shuman on Unsplash I am a clinical informatician at the CAMHS Digital Lab, South London and Maudsley NHS Foundation Trust and King's College London. My work sits at the intersection of artificial intelligence and child and adolescent mental health. I use Natural Language Processing (NLP), a methodology that allows us to extract meaning from clinical records using artificial intelligence (AI) and help translate findings from data back into clinical practice. Think of it as being a bridge between two very different – yet complementary - ways of thinking about the same problem. It is through this work that I have come to appreciate both the extraordinary potential of NLP in mental health, and the very unique considerations that come with it. Why Clinical Mental Health Text is Worth Reading at Scale In mental health services, clinicians write thousands of notes every day. These records capture how a patient is presenting, what they said in the room, how they seemed, and what happened next. For a long time, most of this information simply sat in electronic health records, unanalysed and inaccessible to researchers. NLP is changing that. NLP is a branch of artificial intelligence that enables computers to read and interpret human language. In mental health research, NLP can be used to analyse data from patients’ clinical notes. Platforms like the Clinical Record Interactive Search (CRIS) system at South London and Maudsley NHS Foundation Trust provide researchers access to millions of anonymised clinical records, showing what becomes possible when this technology is applied thoughtfully. Over a decade, NLP work within CRIS has enabled research at a scale that would have been impossible manually, supporting over 200 published research papers, drawing on records from over half a million patients. NLP has the significant ability to recognise patterns across thousands of clinical records, identify young people who might be at risk, and understand how presentations change over time. NLP does this by scanning large volumes of text and extracting structured, searchable information from language that would otherwise require a human to read note by note manually. What once took research teams months of manual review can now be done at scale, consistently, and across entire patient populations. In child and adolescent mental health, where demand for services continues to rise and early identification is critical, this has real implications. The sooner patterns in young people's presentations are recognised, the sooner care pathways can be improved. However, achieving that potential requires understanding what makes this particular type of text so demanding to work with and addressing these challenges. Image Source: Getty Images on Unsplash+ 1. Clinical Language is Deliberately Uncertain Clinicians frequently use phrases like "possible low mood" or "may be experiencing anxiety." This is not vagueness. It is responsible, careful clinical practice. Mental health presentations are rarely clear-cut, and a clinician may suspect something without yet having enough information to state it definitively. Writing with caution reflects that reality and protects young people from being prematurely assigned potentially inaccurate diagnoses. The problem is that NLP models require well-defined examples to learn to recognise patterns, and clinical uncertainty does not always map neatly onto the binary classifications these models prefer. This matters particularly in mental health, where language is inherently more ambiguous and contextual than in other clinical fields. Consider the phrase "she seemed low today"; for a clinician seeing this patient over several weeks, that sentence carries significant meaning. For an NLP model, it is difficult to classify without the surrounding context and clinical history that a human reader naturally draws on. Building a good NLP tool means making decisions about how to handle uncertainty upfront, not as an afterthought, because tools that misclassify uncertain language risk producing inaccurate findings or flagging the wrong patients entirely. 2. Define the Concept Before You Build the Tool This is the consideration that surprised me the most. Before any NLP tool can be built, the clinical concept it is looking for must be precisely defined. In mental health, that first step is harder than it sounds. Take something as seemingly straightforward as a "current episode." In one research context, it might mean the past week, in another it might mean the past six months. Clinicians use the same phrase to mean different things depending on the condition, the service, and the clinical context. If that ambiguity is not resolved before development begins, the tool is built on an unclear foundation regardless of how advanced the underlying model is. The technical work is only as good as the conceptual clarity that precedes it, and that clarity can come only if clinical practice and data science intersect. 3. Who is the Experiencer? A single clinical sentence can carry multiple voices. "Mother reports that he [the patient] has been aggressive at home" involves the patient as the subject, the mother as the reporter, and the clinician as the writer. Correctly identifying who is experiencing what, across thousands of notes, is a genuinely complex problem. It sits within a broader challenge of understanding temporal and contextual information in clinical text. More recent and advanced NLP approaches are beginning to address this. For example, a new AI tool called MedCAT has enabled the recognition of temporal information as well as the modelling of complex medical concepts from multiple keywords. 4. Most NLP Tools were not Built for Young People Other limitations of existing NLP research in mental health include poor generalisability across populations and a lack of linguistic diversity. Generalisability refers to how well a tool performs beyond the specific dataset it was developed and validated on. Most NLP tools in mental health were built using adult data, meaning they may not perform reliably when applied to children and young people, as they are fundamentally asked to interpret a different language. This ties very closely with the concept of linguistic diversity, which refers to the fact that different groups express thoughts, feelings, and experiences using different terms and styles of language. For example, a nine-year-old might not report low mood; instead, they might say everything feels grey, or that they do not want to do anything anymore. A teenager might describe anxiety as always waiting for something bad to happen, or they might say nothing at all, and the clinician's note will reflect that: "difficult to engage, kept looking at the floor." These are not incomplete descriptions, but when the language varies in this way, models trained on a different population may fail to recognise or correctly interpret patterns, underscoring the need for models validated on children and young people. The Common Thread: Collaboration Across all these considerations, one theme emerges consistently. Bridging clinical and computational expertise is critical for continued progress in applying NLP within mental health. The field broadly agrees on this in principle. Making it work in practice is the harder part. Image Source: Getty Images on Unsplash+ The clinicians who write notes understand things about the language that no dataset fully captures. Informaticians who understand the data can ask questions at a scale that no clinical team can do manually. Getting NLP right in mental health is not primarily a technical problem. It is a collaboration problem. The two must work together from the beginning, not sequentially. AI and NLP have a meaningful and exciting role to play in how we understand and respond to young people's mental health. The considerations above are not reasons to slow down. They are the reasons to build carefully, validate rigorously, and ensure clinical knowledge shapes these tools from the ground up.

Image Source: Bill Pennell on Unsplash It was Saturday, the 25th of April 2026, The Day Before My Marathon. The London marathon, obviously. I thought I was chill about running it, but in reality, I was just in denial. It is easier to pretend that something is not true or is not happening; it gives us the time to adapt to the distressing/upsetting/anxious thoughts or events, either in anticipation (like me) or after they have happened. Denial is one of the defence mechanisms, so-called by psychoanalysts because they help us cope with the weight of unpleasant reality. Ok, you can argue that actively choosing to register for a Marathon should not qualify as “unpleasant reality”. Yet, how many times are unpleasant realities of our own making? Choice does not make difficult things easier; it just makes it easier to feel ashamed when they occur. So, I was saying, it was the Day Before My Marathon, and I was unconsciously trying to limit the impact of this proximate event on my mind. Little did I know that the ripples were coming backwards, from the future to me, underwater, then breaking up closer to the surface and creating turbulence in my mind. The first ripple came when I woke up at 6 AM. It is not unusual for me to wake up at 6 AM; as I am getting older, it happens once or twice a week. What was unusual was my dreamy state of mind after awakening. I wanted to get up – I thought, since I am awake, I might as well do some work (or some writing) – but as soon as I had firmed this resolution in mind, I would fall asleep again and dream (cannot remember them). Then, after a few minutes, I would wake up again, focus my mental energy on the plan for getting up, and then I would fall asleep again, with more dreaming. And this happened repeatedly. Putting it into words may not convey the weirdness of the situation, but it felt unnatural to me, as if I was under the influence of drugs (I swear I wasn’t). Feeling sleepy and falling asleep are also defence mechanisms: an attempt to give us some respite from whatever stresses us. Dreams are small holes in this defence mechanism, pushing through our preoccupations but masked to appear (most of the time) less frightful than reality. This is why dreams are one of the tools that psychoanalysts use to understand people’s thoughts and emotions. So, now I am thinking that I was trying to sleep to avoid the anxiety of the approaching marathon, and my dreams kept reminding me that the marathon was looming around the corner, even if I cannot remember the content of the dreams. The second ripple was the drumming of a woodpecker I heard in the morning. I am lucky that my London flat is high on the top floor of a house on a hill surrounded by big and majestic trees (all in other people’s gardens), and occasionally I can hear a woodpecker drumming. I read once that this sound is very powerful and can be heard from half a mile away, so distance calculation by its sound is very inaccurate. Yet, this time it sounded really close, like, really close. My immediate thought when I heard it? This must be a good omen for the marathon. And so, an apparently unrelated event – what has a woodpecker got to do with running? – immediately allowed the unconscious anticipation of the marathon to bubble up to my conscious mind. This was magical thinking at its best: this is what we do when we give special power to events, people or places. It is another defence mechanism, operating at both individual and societal levels, as it allows us to feel in control and make sense of unpredictable events. Astrology, horoscopes, superstition, evil eye, ghosts: all cultures and all of us have some expression of magical thinking. I am kind of superstitious, being from Naples. For example, I never pass the salt hand-to-hand to another person (if you do not understand this, Google it). Also, I kind of believe in the Zodiac: otherwise, how come my personality fits exactly the description of the Pisces sign? And of course, as a Fujian White Crane Kung Fu martial artist, I am also a spot-on fire horse. Talking about magical thinking, something else surprising happened on the Day Before My Marathon: Rebecca Kuang published a Substack post. Cover of The Poppy War by R.F. Kuang (Harper Voyager). For those of you who don’t know her, then, first, where have you been for the last few years? And second, don’t miss this young Chinese American writer with an exceptional fantasy and a really engaging style. I have read all six novels she has written so far. The surprising thing here was that she has only ever written three Substack posts: one in August and November last year, and one the Day Before the Marathon. Was this a third ripple from the future? If so, what did it mean? Was this another good omen for me as a marathon runner? Or as a writer? Rebecca Kuang runs, by the way. So does another of my favourite authors, Haruki Murakami. So, back to the Substack post. Was it telling me that perhaps being a writer is like running a marathon: continuous pain and rare joy? Or was it telling me that I could be a writer? That, as I have the energy, commitment and grit to train for, and to run, two marathons in two years, perhaps I have what it takes at least to train to be a writer? My Marathon went well. A personal best and no unbearable pain, all in all, it was a good result. So, my defence mechanisms did work. They kept me reasonably relaxed while a healthy tension was building in the background, ready for the 4-hour-43-minute sprint. And my magical thinking also worked. I am sure all the good omens did help my running. Let’s hope they also help my writing. Image Source: Provided by Author (Carmine Pariante)

It seems that my social media feed is full of the word ‘whimsy’ at the moment. Move over nonchalance, welcome whimsy. It’s being covered on Instagram and Tiktok. It’s being picked up by podcasters. But what is it really? According to the Cambridge English dictionary, the word whimsy refers to ‘unusual, funny, and pleasant ideas or qualities.’ It ties in well with imaginative, playful ideas that aren’t particularly serious or profound. Content creators, influencers, and digital blogs on social media are sharing tips on how to be more whimsical this season, and explain how it has made them happier. While slightly off topic from being whimsy per se, I have also been inspired by this piece I read in Science magazine in November last year. I loved that the author spoke about how embracing her silly side made her a better scientist, especially as scientists have the stereotype of being very serious and demure, with no capacity for laughter. While being silly and being whimsical are not exactly the same, the key message I’d like to share is that it’s okay to not always be so serious and to take things slow. Image by Toa Heftiba on Unsplash Amid harmful and detrimental social media trends like ‘looksmaxxing’ , I like this little corner of the internet that is all about positivity. I’m so pleased that we’re now shifting our focus onto happiness. Since this discussion has been trending on social media, I’ve found myself reflecting on the fact that whimsy has always been around me. To paraphrase the iconic quote from the film Love Actually, "If you look for it, I’ve got a sneaky feeling you’ll find that WHIMSY is actually all around." I find inspiration in my father’s wardrobe. At the workplace, he wears his whites, his blues, his beiges. But, in his personal life, he’s known by all his friends and family for rocking up to social events in brightly coloured shirts. And he’s not ashamed of it in the slightest bit. It’s what makes him whimsical, it’s what makes him, him. I find inspiration in my childhood best friend’s events. She once planned our Christmas party around the theme of a woodland backdrop. She personalised the decoration to each of us, which was so whimsical, yet so personal. Image by Zyanya Citlalli on Unsplash+ I find inspiration in skipping with my niece in the parking lot of Costco. Under the concrete slabs and cars all around, we make it a game to skip to and from the entrance, not bothering about who’s watching us. Focusing on being whimsical helps my wellbeing, because it allows me to switch off from a constant state of activity. Whether in my career as a Trial Manager, doing my PhD, or during my fitness journey, being whimsical allows me to embrace my inner child when everyday life may feel super serious. I have since come across research that indeed found that adult playfulness can help cope with stress. It doesn't make me immature, it doesn't make me unprofessional, it simply means I'm human. Now that I’ve spoken about the trend, what it means, and why it inspires me, I’ll share some of the ways I’ve integrated it into my life, and how you can do the same. Dopamine Décor: The dopamine décor trend has become increasingly popular, and I’ve designed my little rental flat in Central London this way. According to Elle Décor, this style encourages designing spaces with a focus on personal pleasure rather than specific aesthetics. Think vibrant colours, vivid patterns, things that are personal to you, but wouldn’t necessarily be picked up by someone else. For me, this means hanging up artwork that makes me happy, and that has a personal meaning for me. Colour coding my bookshelf, having colourful plant pots, even something as simple as having a teacup or mug collection that isn’t coordinated but collecting them over the years because they make me smile. For me, this means having my morning cup of coffee from my Disney Cinderella mug, or having my Jellycat collection of fun foods. Image by Elena Helade on Unsplash+ Whimsical Hobbies: I’ve been a big hobby person of late. I wrote this piece for Inspire the Mind, about new hobbies and their impact on my wellbeing. Recently, a whimsical hobby I’ve picked up is bedazzling my books. It’s a new DIY craft where you stick on your book cover flat backed rhinestones. I personally do this to my fantasy fiction books, making it an all-immersive experience. When I’m reading said books, I put on my TV or galaxy projector to the setting of my book (If you, like me are currently reading the ACOTAR series, you’ll understand), making reading a fully visual, relaxing experience. Whimsical, but still so relaxing. (Re) watching Children’s Movies: I’ve been a big advocate for watching children’s movies because of the comfort they bring. So much so, I wrote about it last year. When I’m particularly stressed, I’ll rewatch my favourite Disney classic, The Little Mermaid II. It reminds me that I do not need to take everything so seriously all the time. This allows me to switch off, unwind from a busy day, and show up to do my best the following day, having truly enjoyed my evening off. Photo by Jacqueline Brandwayn on Unsplash Bringing Whimsy into Food and Drink: I was never allowed to eat candy as a child because it would give me a terrible sore throat. So, as an adult, I treat myself to colourful candy (I love a pick n' mix), fun ice cream flavours, those that an adult wouldn’t typically consume. Being whimsical in this sense, is a way of treating your inner child. Sometimes, I add some edible flowers to my salads and fresh fruit. Just to make it more fun. At one point, I even had a stint of adding edible glitter to my beverages. Not quite sure why I stopped, but I used to add fruits and glitter to my ice cubes, even if I was having sparkling water, just to make it a bit more fun. So, whether it’s my colourful basil pot, or my colour coded bookshelf, or bedazzling my books, it reminds me that it’s okay not to be serious all the time. If you look for it, dear reader, I have a (not so) sneaky feeling that whimsy is all around you. So, I urge you to explore it, embrace it, and make it a part of your life.

There are stories one hears at the gym that are impossible to forget. I am Giovanna, a passionate pharmacist with a deep commitment to pharmaceutical care, mental health, and healthcare communication. As a former athlete and dedicated “gym rat”, I translate the discipline and resilience gained from competitive sports (I was in the Italian kayak Olympic team in 2010-2012) into my professional practice, and I have learnt that the deepest wounds are frequently the invisible ones. These injuries are concealed behind the social media profile of a fit, smiling individual whose running shoes are eternally ready. That is precisely why I wish to discuss REDs, or Relative Energy Deficiency in Sport: a silent, frequently undiagnosed condition that afflicts athletes of all abilities. I choose to address this now because society is finally beginning to speak openly about mental health within the sporting arena. Indeed, ITM has already published pieces on women in sport and on Simone Biles’s struggles with mental health. I now want to add this piece, on the fact that true healing in sport commences in the mind. Sara’s Story Sara is thirty years of age and works in the public sector. When you see her at the gym, your immediate assumption is “This person possesses total control over her life”. Her routine comprises a morning run, the weights room in the evening, swimming on Tuesdays, and cycling or climbing at the weekend. She boasts a lean physique and iron discipline. She smiles at you whilst discussing personal bests and rigorous training sessions. Then, gradually, she reveals the rest. She has not had a menstrual cycle for more than five years. Medical professionals have diagnosed her with osteoporosis - at the mere age of thirty. She suffers from insulin resistance and high cholesterol. And her relationship with food? “Sometimes, it is complicated…” she states, selecting her words with evident caution. However, the ordeal Sara is enduring has a clinical designation: REDs. Image Source: Drazen Zigic on Freepik What is REDs and Why is it So Hard to Detect Relative Energy Deficiency in Sport (REDs) is a syndrome wherein the energy one consumes through nutrition is insufficient to sustain both the energy demands of physical exertion and the body’s vital physiological functions: hormonal balance, bone health, immunity, and metabolic rate. It is akin to attempting to power a metropolis with only half the electricity it requires; inevitably, essential systems will shut down. The central concept is low energy availability, and it does not necessarily manifest as a diagnosed eating disorder. It can simply, and insidiously, be the consequence of an increase in training intensity without a corresponding elevation in caloric intake. This deficit can be entirely intentional or wholly inadvertent. The International Olympic Committee has formally recognised REDs as a multifaceted syndrome affecting both sexes, although female athletes have historically been the primary focus of research. The physical ramifications are thoroughly documented: metabolic alterations, loss of bone mineral density, reproductive dysfunction, and immunosuppression. Yet, the psychological dimension - the aspect concerning who you are, how you process thoughts, and how you feel - has long languished in the shadows. The Link Between Mind and REDs: Cause and Effect Mental health in the context of REDs is not a peripheral issue; it rests at the very core of the matter. Furthermore, the relationship is bidirectional. On one hand, particular psychological traits, such as perfectionism, a rigid athletic identity, a pervasive fear of weight gain, and an overwhelming need for control, can prompt an athlete to unconsciously restrict their caloric intake or compulsively escalate their training regimen. Eating disorders, across all their manifestations, remain among the most prevalent causes of low energy availability; however, even in the absence of a formal clinical diagnosis, distorted cognitive patterns regarding body image and nutrition can prove equally destructive. Conversely, the energy deficiency itself profoundly alters brain chemistry. Scientific research published in recent years documents that the early warning signs of REDs include mood fluctuations, chronic fatigue, sleep disturbances, irritability, and general psychological distress. Over time, anxiety, depressive symptoms, a marked decline in subjective well-being, and, in severe instances, psychiatric disorders begin to emerge. “At first, I was happy. I felt light and full of energy. Then, I began waking up tired, becoming annoyed over trivial matters, and thinking about food obsessively. But I assumed it was down to work or stress” Sara recounts. When the Body Heals, But the Mind Does Not This is where the most vastly underestimated aspect of recovery comes into play. If REDs could be cured simply by the directive to “eat more”, a nutritionist alone would suffice. However, clinical research is unequivocal: physical recovery, the stabilisation of hormonal biomarkers, the restoration of bone density, and the return of reproductive function cannot occur unless the psychological dimension is simultaneously addressed. In truth, if rigid dietary habits, negative self-talk, compulsive exercise routines, and anxiety linked to body weight are permitted to persist, the destructive cycle will inevitably repeat itself. The modern treatment pathways proposed by the most recent scientific literature converge upon an integrated, multidisciplinary team model. This includes a sports physician, a nutritionist, a sports dietitian, and a mental health professional equipped to explore the underlying factors that predispose, trigger, and perpetuate the condition. For Sara, this required the profound realisation that controlling her physical activity and nutritional intake was merely a mechanism for managing a more deeply rooted anxiety, one that was linked to something entirely different. Psychological Flexibility as the Key to Healing There is a pivotal concept that scientific research is increasingly bringing to the forefront: psychological flexibility. It is the absolute antithesis of the rigidity in dietary rules, the inflexibility of training programmes, and the damaging identity of the “high-performing athlete at all costs” that fuels REDs from within. It involves learning to adjust your training regime without feeling like a failure. It means accepting a meal that is not part of your original plan without viewing it as a catastrophe. It requires recognising your inherent worth, entirely independent of the distance you have covered on the track. It sounds remarkably simple, but it is not. Nevertheless, this is the precise direction in which the most effective therapeutic journey lies. Sara is still training today. She trains less, but she trains better. She has embarked upon a multidisciplinary treatment programme. She notes that the most difficult hurdle was to stop perceiving treatment as a personal defeat. Image Source: fxquadro on Freepik Health Must Come First Whether you are an athlete, a coach, a parent, or simply an individual who trains and recognises a reflection of yourself in this article, take careful note: REDs does not solely afflict elite competitors. It affects those who train with unwavering dedication, those who constantly strive to improve, and those who have woven sport fundamentally into their identity. And if something feels wrong - if you are so exhausted that sleep does not provide relief, if your menstrual cycle has ceased, if you obsess over what you consume or what you burn - asking for professional help is not a weakness. It is, in fact, the crucial first step towards achieving truly sustainable performance.

A tense body means a tense mind. Equally, if you are physically relaxed, it is impossible to be anything other than mentally relaxed. Relaxing our muscles calms the central nervous system, reduces the production of adrenaline and directs oxygen away from an overly active brain. On those days when I can’t control my racing thoughts and struggle to relax my mind, it is a relief to approach the problem a different way by relaxing my body instead. Less a case of mind over body, more body over mind. Yet much of our lives alienates us from our physical selves — we live in our heads and store tension and fear in our muscles. We can see this in the way mammals shake themselves all over to rid themselves of tension and stress after they escape from a predator. Luckily, we can become re-connected with our bodies, and more appreciative of all they do for us. You might like to imagine that your body has emotions and needs to be cared for, almost as if it were a separate entity. A good way to do so is to embrace your physicality with specific poses for relaxation. One good exercise is to deliberately become rigid and stiff, with tense shoulders and clenched fists for a few seconds, and then relax. To take this further, try the yoga wind-down positions, Child’s Pose and Rock n’ Roll: details of how to do these are further down. One study found that people who practised yoga for an hour experienced an increase in levels of GABA, a brain chemical linked to calm, compared with a zero increase within a control group, who read for an hour instead. Another relaxing exercise is to slacken all of the body’s muscle groups, one by one. I like to get comfortable somewhere and then mentally run through each muscle group in turn. By telling myself the muscle is relaxed, it then softens. Thinking about my body and movement in this way has been a departure for me. Until recently, whenever I thought about physical activity, I imagined the cardio-vascular, heart-pumping, sweat-dripping kind — although this is important for our moods too. My new enthusiasm is for physical activity more closely linked to my emotional self. The focus required for my relaxation exercises means I can’t worry about anything else whilst I am doing them. I have included some of my favourite poses here. Joining a yoga class is next on my list, but meanwhile, I bow to you. Or, as they say in Sanskrit, namaste. YOUR TURN TO USE YOUR BODY TO RELAX YOUR MIND WITH SOME POSES AND A BODY SCAN: Before you begin… Tense your shoulders, scrunch up your face and make your hands into fists for ten seconds. Notice how stressed this pose makes you feel. Now release, and try these poses for contrast. 1. Child’s pose Kneel on a mat or rug. Bring your knees together, lower your buttocks onto your feet and lean forward to rest your torso on your knees, so your forehead touches the mat. A variation of this, which many prefer, is to open out your knees which means your chest is lowered in the space between them. Place your arms alongside and behind you or outstretched in front of you for an extra back stretch. Be aware of your breathing. 2. Rock n’ roll Lie down with your back straight and your arms resting slightly away from your body. Support your back with a small cushion or rolled-up towel if necessary. Bring your knees to your chest and put your arms around your shins, or thighs if easier. Keeping your spine in contact with the floor, roll your knees over to the right and then to the left, and then move your knees around in a gentle circular movement. Be aware of your breathing throughout. Relax your body into the floor as you rock and roll. Be aware of yourself alone, in this moment. Stay aware of your breathing. Release your legs and gently lower one and then the other to the ground. Rest. 3. The body scan Visualise the image of a body in your mind’s eye. Keeping this image in your head, focus on the feet, and notice how your own feet are feeling. Repeat to yourself silently inside, ‘my toes are relaxing, my toes are now relaxed’ — this is a method called ‘auto-suggestion’ this is developed by the psychologist Émile Coué. Begin moving your mind’s eye up through your heels, ankles, and on up your calves towards your knees. Again, notice each of your muscle groups in turn, and tell yourself each time that the particular muscle group is relaxing, the muscles are now relaxed. Now move up both thighs to the pelvic area and then slowly up to the waist. Keep releasing each muscle group, and keep silently telling yourself that you are relaxing, the muscles are now relaxed. Then slowly shift your focus to your hands and up your arms to your elbows, armpits and shoulders. Keep silently talking to yourself, telling yourself that you are relaxing, the muscles are now relaxed. After your shoulders, focus on your torso, traveling upwards from the waist, to the rib cage, chest and back. Keep talking quietly about how you are feeling relaxed, the muscles are now relaxed. Now move up to your neck, then face, through to the top of your head. Keep talking quietly about how these muscles are relaxing, they are now relaxed. Then reverse the flow of attention and go all the way back through the muscle groups from your head to your toes. Enjoy the feeling of your body sitting comfortably and the warm relaxation as you release all your muscle groups in turn and talk to yourself as you do so. Notice how focusing on your body also relaxes your mind. Use this relaxation whilst lying in bed to get to sleep, or any other time you would like to relax. NOTE FROM THE EDITORS: We are thrilled to have British Author and Mental Health Advocate, Rachel Kelly, writing for InSPIre the Mind. Rachel has written as a journalist for The Times and has written books including Black Rainbow: How Words Healed Me — My Journey Through Depression, Walking on Sunshine: 52 Small Steps to Happiness, The Happy Kitchen — Good Mood Food and her latest, Singing in the Rain: 52 Practical Steps to Happiness — An Inspirational Workbook. This is the first blog of a three part series: part two coming next week.

A coldish evening and I am back from a class on how to give a presentation, cradling a mug of celebratory hot chocolate. Even the thought of the lesson had given me the heebie-jeebies. I had fretted that I would make a fool of myself by freezing and forgetting my words. Humiliation is one of the most powerful emotions, and humiliating moments are often those we find hardest to forget. I did not want to be embarrassed. But I went because avoiding what I am frightened of usually only makes it worse. The best way to overcome my fears is to find the courage to face them, hard as that can be. As Eleanor Roosevelt supposedly said, do one thing every day that scares you. So that’s why I found myself in a group of ten students and longing to be back home, cuddling Sammy in front of the telly. But my mood began to change thanks to a sympathetic tutor dressed in an inviting apricot kaftan. She told us how we would overcome our fears and move out of our comfort zones by practising in baby steps. We would adopt the Pre, During, and After method — or the PDA approach (no, not as in a Public Display of Affection!). First, the Pre. This meant we would prepare for the presentation. We would remind ourselves of our purpose in being at the workshop, and how we would talk to a friend who was feeling nervous. We would practise in front of a mirror and in pairs. We were advised to use some relaxing standing exercises to steady ourselves. Then the During stage, when we would present to all the strangers in the class. During these first two stages, we were supposed to stick with any anxious feelings, accepting the discomfort until it gradually dissipated and using breathing exercises if need be. The more we did this, she said, the more we would build up what psychologists call our ‘distress tolerance’ — our ability to withstand negative emotions or distressing states. We could even reframe anxious feelings as energising and arousing instead. Then, in the After stage, we would discuss how we felt our about presentations and any other techniques we might include to improve them. Her method worked. I was able to face the group without a pounding heart when I did my own presentation, and learnt much in the chat afterwards. Going forward, our coach suggested that we could continue our journey out of our comfort zones by listing those situations that fill us with fear, or those we avoid. So in my case, that might be giving a presentation to 20 people rather than the ten I had faced that night. We should list these scenarios from least scary to most frightening. Then we should build our confidence by tackling the easier ones first. If you begin with something too challenging, you might just give up all together. In addition, in the absence of a coach like her, was there anyone else who could support us as we embraced new challenges? Understanding why we prefer to stay in our comfort zone can also, counter-intuitively, make us more adventurous. We humans are loss averse. We dislike loss far more than we like an equivalent gain. Such a cognitive bias probably kept us safe amid the dangers of the African savannah, where the downsides of taking risks were as big as the lions on the prowl. But there are dangers in not being a risk-taker: our ancestors also benefited from variety, whether of habitats, food or mating partners (though this is not an excuse for infidelity!). In fact, the American educational psychologist, Carol Dweck, argues that we need to adopt a ‘growth’ rather than a ‘fixed’ mind-set: if something is hard, then that’s a good sign as it shows our brains are growing and adjusting. We need to question our self-imposed limits on what we can achieve and expand our horizons. We imagine that when we are thrown out of our usual comfort zone, all is lost. But it is only then that what is new and good often begins. And that includes a mug of hot chocolate afterwards. YOUR TURN TO FACE YOUR FEARS AND CHALLENGE YOURSELF WHEN YOU WOULD RATHER WATCH TELLY OR TALK TO YOUR PET: 1. Write on the dartboard the activities you will try that are out of your comfort zone. The more frightening the situation you face, the more points you receive. Think of it like a dartboard, only this time you aren’t aiming for the bull’s eye. You may find it daunting to think of as many as three different challenging situations, so just start with a 10-point activity if that feels more comfortable and perhaps come back to this exercise in a few weeks’ time. 2. Now choose a 10-point activity from your dartboard to ease yourself into this process. Here is a reminder of the PDA method. Have a think about the questions below and then plot your own PDA on the steps in the image on the next page. The Pre stage– How you will prepare before the activity Why are you doing this? Is there a way of practising ahead? How would you reassure a nervous friend who was contemplating something outside their comfort zone? The During stage– How you will prepare for doing the actual activity Using breathing to stay steady Accepting difficult feelings and letting them dissipate The After stage– How will you make the most of having found your courage? What you have learnt What you might do differently next time Adopting a growth mind-set going forward NOTE FROM THE EDITORS: We are thrilled to have British Author and Mental Health Advocate, Rachel Kelly, writing for InSPIre the Mind. Rachel has written as a journalist for The Times and has written books including Black Rainbow: How Words Healed Me — My Journey Through Depression, Walking on Sunshine: 52 Small Steps to Happiness, The Happy Kitchen — Good Mood Food and her latest, Singing in the Rain: 52 Practical Steps to Happiness — An Inspirational Workbook. This is the first blog of a three part series: part three coming soon. Rachel Kelly Website: www.rachel-kelly.net Twitter: www.twitter.com/rachelkellynet

I have spent much of the morning trying to find the right sentence with which to start an article. I am playing with the phrase ‘it is a truth universally acknowledged’, but I don’t like borrowing from Jane Austen. I am aware it’s a clichéd approach, yet I can’t find an alternative. The harder I try to perfect my sentence, the worse it reads. I know I must stop soon or I will trip over a hidden rabbit hole I know only too well — that of being a perfectionist. Feeling we must be perfect is a growing problem in our digital age: comparing our humdrum existence with the shiny lives of celebrities makes us feel that anything less than perfect is not good enough. Yet often it is those who shine most brightly and seem to have supposedly perfect lives who actually find life the hardest. The brighter the light, the darker the shadow. One study even links some types of perfectionism to increased rates of suicide. In some cases, setting exacting standards can be appropriate — if you are a surgeon or a pilot, for example. But in my own less exacting life it is easy to apply perfectionist standards when they are not needed, or are inappropriate or even damaging. In the past, I have set myself overly high ideals and imagined there is no middle way between succeeding and failing: a frightening prospect. And because my standards were too demanding, I have often felt a failure, as naturally I have not always met those standards. I have concentrated on what has gone wrong, with little compassion for myself, rather than remembering what has gone right. What could be less motivating than focusing on our blunders? How then to change? Start by thinking of someone you admire. Now consider. Did they ever fluff anything? Of course they did! Then, recognise perfectionism is often linked to a black-and-white thinking approach. I am either a brilliantwriter or a dreadful clichéd hack. Of course, neither are true. Replace this approach with a gentler, more realistic narrative. Note what you have achieved rather than what you have failed to do. And remind yourself that by cracking on, over time your writing will improve (you hope). I like the story of a ceramics teacher who divided his pupils into two groups. One group was asked to make as many pots as they could, and the other group to make one perfect pot. In the end, the group who focused on quantity rather than quality made the best pots. Their pots were smoother, with less bumps and a more pleasing shape, even though the students produced more, and worked more quickly. Why? Because those who made more pots were trying, failing and learning. Those who were trying for the perfect pot didn’t take any risks for fear of failure, which is why their skills didn’t improve. Fail more, but master more too. As few of us have access to a kiln, I have adapted this idea into a flower drawing exercise. It is not about being brilliant and including every last floral detail. It is about giving something a go. Imperfect action is better than perfect inaction. You could develop this idea by deliberately trying to do something less well, just to see what happens. Try giving yourself a time frame, as procrastination and perfectionism are linked. It’s harder to stay a perfectionist when you have a set time period in which to complete a task, which is not the same as an invitation to rush. When you have finished your drawings, ask someone else about the images. Sometimes our anxiety about perfectionism is because we worry about what others will think, which holds us back. Yet in reality, others tend not to expect the level of detail or skill we feel we need to provide. Imagining their criticism demotivates us. That is a truth that’s universally acknowledged. co-editors attempt NOTE FROM THE EDITORS: We are thrilled to have British Author and Mental Health Advocate, Rachel Kelly, writing for InSPIre the Mind. Rachel has written as a journalist for The Times and has written books including Black Rainbow: How Words Healed Me — My Journey Through Depression, Walking on Sunshine: 52 Small Steps to Happiness, The Happy Kitchen — Good Mood Food and her latest, Singing in the Rain: 52 Practical Steps to Happiness — An Inspirational Workbook. Rachel Kelly Website: www.rachel-kelly.net Twitter: www.twitter.com/rachelkellynet