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Author's Note: This story depicts grief and social anxiety, and how taking care of others can sometimes help you take care of yourself. The events are fictional, but I hope you enjoy and that it brings you comfort if you need it. Photo by Simone Dalmeri on Unsplash Sarah sighed as she carefully pulled back a curtain just a smidge; just enough to look outside. She saw the shifting grey, just like the one that hummed inside her like an old box TV set with no signal and knew before the first drop fell that it was going to rain. "Of course," she said, quietly, to no one in particular. In fact, to no one at all. Sarah was 22 and lived alone. Some would say she was lucky not to have to exist alongside a gaggle of roommates, or with her parents. But they wouldn’t know, just by looking at her, that her only family was her Gran, and that she died a year ago, leaving her the house. And leaving her all alone.          Sarah supposed some people would still consider her lucky, having the house all to herself in this economy. They were right, in a way, but again, they weren’t to know that the last time she’d left the house - beyond the front or back doorstep - was to attend her Gran’s funeral. That she hadn’t brushed her teeth in about three weeks. That she could barely get out of bed most days. But how would they know, anyway? She never left the house - she just couldn’t - not with all the noise, and heat, and eyes on her, like laser beams. The one time she tried to go in her garden she couldn’t breathe and had to rush inside before she passed out, because if she did there would be no one to find her for weeks, maybe even months. Sarah sighed, imagining the raindrops falling against the windowpanes covered constantly by heavy curtains. She remembered, for a moment, the game she used to play as a child, how she would pick a raindrop and trace its trail down the window and wait to see if it was the first of the cluster of raindrops that reached the bottom. Sarah almost pulled the curtain back, just to see, but as she moved her hand towards the fabric, anxiety shot through her as though she'd been struck by lightning. It was then that she heard it, a strange scratching at her front door. The anxiety jolted, almost as if there was an aftershock. Sarah stepped away as if on impulse, and sat on her sofa, waiting, desperately, for that sound to go away. Unfortunately for Sarah, the sound continued for what felt like hours. And as the sound continued, the anxiety continued to reverberate through her, her hands and feet buzzing with pins and needles. And still, the scratching sound continued. In moments like this, she always tried to distract herself. What was that trick she read online? Five things she can see, four things she can hear… She tried her best, but she couldn't seem to focus on any other sound that wasn't the scratching at the door - even the fierce rain that roared alongside the wind outside. She tried her best... "All you've got to do is try your best, love," Sarah suddenly heard her Gran's voice, as clear as day. It was something that she always said, especially when Sarah was struggling with things, like her exams or the school football team tryouts. It used to be something she would try and remember, after her Gran died, to help her get out of bed or find something to eat. But lately, she hadn't thought of it so much. She supposed she'd used it to get by so much that it had lost its magical effect. Just the idea of that made Sarah’s chest ache like someone had just punched it. She didn't want to stop remembering her Gran. Louisa Fielding had practically raised her. But on top of being her guardian and pretty much her mum, she was so incredibly kind - always baking enough treats to feed the streets, cheering everyone up during bad weather, and keeping plenty of cash on hand in case she passed someone homeless to offer some food and a night at the hotel. Of course, she also had her wild sense of humour - most of Sarah's memories involving her Gran involved the both of them laughing, or at the very least, smiling. Yes, Louisa Fielding was the best person Sarah ever knew. And the person with the biggest, funniest heart. Until it stopped. Sarah caught her breath as reality caught up with her. She was sat alone and anxious in her dead Gran's house. And there was still that damn scratching noise, going on and on by the front door. "All you've got to do is your best, love." Sarah wondered what her best would be, right now. Not being anxious? But it was that scratching that made her feel anxious in the first place… Alright, Sarah thought. I will. Her hands trembled as she reached to open the door, but she still managed to pull it open despite the wind roaring against it. Whatever Sarah thought would be there, she certainly didn't expect a tiny, soaking wet little bundle of fur. A gasp escaped her lips, and in that time, the bundle of fur rushed inside, as if the noise was inviting it in. Sarah shut the door, still shaking, and turned to see the wet ball of fur sat, dripping on the carpet beneath it. Under the wet, matted grey, Sarah could see two black pupils, looking up at her. They stared at each other for a moment, before the bundle of fur shook itself furiously, sending water everywhere as if it had suddenly started raining inside. "No!", Sarah cried, as she reeled from the cold water; she was soaked, and almost started trembling herself, if she wasn't so distracted by the small, furry dog that had just revealed itself. It turned its head slightly as if trying to decipher what she was saying. It had long, matted black fur, and two ears that stuck up on its head, that Sarah thought, at that moment, almost looked like antennas. "Sorry," Sarah said, quickly, and much quieter. The dog tilted its head back up as she spoke, seemingly understanding. It gave a soft bark, which Sarah thought, for a moment, almost sounded like the dog was saying hello. The absurdity of that thought made Sarah smile, and then the dog started gently wagging its tail. The sight of this made Sarah’s anxiety lessen, just a little, and she realised that the dog was still dripping wet - and so was she. Not that it mattered, really, as she hadn't changed out of these pyjamas in a few days. Weeks, even. But if she was going to dry the dog, she may as well change into a fresh set afterwards. "Shall we get us dry?" Sarah asked the animal who simply wagged its tail as though enthusiastically agreeing with her. *  It had been a few days with the dog before Sarah decided to see if he had an owner. Sure, it seemed happy enough - Sarah even let it sleep on the end of her bed - but she couldn't bear letting it stay if it was someone else's family. She couldn't just take it from someone. She wouldn't. But before she took him to the vet, she needed to make him more presentable. She didn't want anyone to think badly of her - she was anxious enough at the mere prospect of leaving the house as it was. Bathing the scruffy little thing was actually kind of fun. Sarah managed to rub soap into the dog's fur until it decided to shake again, covering her in soap, too. Instead of being frustrated or upset, it made her smile. She finished bathing the dog before jumping in the shower herself to wash off the soap and apply human soap and wash herself too - she was already in there, so she might as well, right? It was only when she was brushing the dog's long, matted fur afterwards, that she realised that was the first shower she'd taken in a while. The first time she'd even had the energy to consider going in the shower, let alone having one. And as the thought entered her mind, the small dog wrinkled slightly before licking her hand and bringing her back to the present. "Good dog," Sarah said, and she started to brush again, counting as she did so, and breathing easier with every new number.   *  Despite the positive steps Sarah had taken today, her hands shook as she went to open the front door. At just the thought of stepping out there - of being around other people - Sarah felt her breathing quicken, her chest hitching faster and faster as the reality of what she was about to do hit her like a slap in the face. As she turned away from the door, she felt a soft pressure against her legs. Sarah looked down to see the dog stretched up and resting its front paws on her legs, as if it was trying its hardest to reach her. It did a gentle, soft bark, before attempting the jump again. Eventually, what the dog was trying to do broke through her anxious thoughts and appeared in her mind: He was trying to leap up at her and into her arms. The dog did a soft bark again - "Pick me up," it seemed to be trying to say, "Pick me up!" So, Sarah obliged. But as soon as she picked the dog up, leaving its lead to dangle like a cord towards the floor, the dog stopped moving. Instead, it curled up in her arms and even nuzzled its nose into the crook of her elbow. Sarah stayed still, not wanting to wake him, and realised she could hear its heart beating, so softly, through its fur. Just listening to it for a few minutes, standing stock-still, was enough to steady her own anxious heartbeat until eventually, she felt okay again, and her anxiety was at bay. Not wanting to disturb the sleeping animal in her arms, Sarah impulsively decided to carry the dog to the vet, just as it was. While anxiety crackled through her as soon as she took a step away from the house, Sarah tried her hardest to just focus on the dog's steady heartbeat as it slept soundly in her arms. And somehow, that helped her keep putting one foot in front of the other, to the sound of the little dog's heart beating. Ba-bump, one step, ba-bump, two steps, ba-bump, three steps… Before she knew it, Sarah found herself at the vet, only slightly drenched in sweat, and she’d walked the whole way there without collapsing, and even without having an anxiety attack. The receptionist at the front desk smiled kindly as Sarah approached. "Do you have an appointment, love?" She asked. Sarah tried to ignore the worry bubbling up inside her as she replied. "Yes, in about 5 minutes," Sarah managed to say, before gesturing to the dog in her arms. "Aw bless," the receptionist said, still smiling. "Tired, is he?" Sarah just nodded. "And a bit scared." "Aw, don’t worry," the receptionist said, talking more to the dog now than to her. "Just do your best in there, alright? That's all you've gotta do." Sarah nodded, grateful, and rushed to sit down before the receptionist saw the tears that sprung into her eyes at her very familiar words.   * It wasn't long before they were called in by a vet with colourful tattoos of a cat and a dog on each arm, angled and etched as if they were greeting each other over the vet’s chest. "Hello," the vet said softly, more than the dog than to Sarah, which put her at ease. "Who do we have here, then?" The dog stirred in her arms and jumped deftly onto the steel examination table. "Um," Sarah said, suddenly realising that she'd never given the poor creature a name, "I..." Anxiety crackled in her chest, and she caught her breath in her throat, making her cough. God, maybe this whole thing was a mistake. "It's alright," said the vet, as if they could sense her anxiety. "It took me weeks to name my last kitten. Let's just start the examination and we can go from there, alright?" Sarah nodded and stepped back, grateful the focus would no longer be on her. The dog sat calmly and didn't object to anything the vet did during the examination and various bits of paperwork on the computer. When they were done, the vet even patted the dog on the head, saying "Good boy." "Boy?" Sarah asked. Gender hadn't crossed her mind either. "Yup," said the vet. "And he's not microchipped either, so unless you'd like us to take care of him until he finds a new home—" "No," Sarah cut the vet off with a quickness that surprised even herself. "He's coming home with me." At that, the dog started wagging its tail, and the vet smiled. "Alright then. Before I let you go, have you had any thoughts of a name for this little lad?" Sarah thought for a moment before a name appeared in her mind, as bright and clear as a summer's day. As loud and joyous as her Gran's laugh - the perfect name. "Lou," said Sarah. "His name is Lou." The dog kept on wagging his tail, quicker now, and licked her cheek as she reached out to pick him up. "Well, he seems to like it. And Lou - that’s a lovely name," said the vet, with a smile. It is, Sarah thought, both there and as she carried Lou home. Just the sound of it made her smile. Lou, Lou, Lou… Sarah would later realise that her trip home was the first time she’d left the house since her Nan’s funeral and she hadn’t focused on her anxiety, or let it consume her. Despite the brisk walk there and back, Sarah collapsed heavily on the sofa as soon as she got through the door. Thankfully, Lou happily jumped on her lap, settling as he rested his head on Sarah’s hand. She couldn't move it now, but she realised that when she could, she felt like she could brush her teeth, or even her hair, especially since Lou was so well groomed - she might as well be too, right? Or at the very least, she would try her best, she thought, shutting her eyes, just for a moment, as she listened to Lou softly breathing in and out, in and out… That's all she had to do - and it didn't seem so difficult now. She was no longer alone, after all. And for the first time in a long time, just as she was about to fall into a peaceful sleep, Sarah realised she might just agree with anyone who called her lucky - yes, because now she had Lou to take care of, and him to take care of her.

Now, at the age of 58, I’m arguably in the autumn of my life. As the days draw in and the leaves begin to fall, it feels like the right time of year to consider the new symptoms I’ve been dealing with caused by the onset of menopause, such as palpitations, hot flushes and my old foe insomnia, to name but a delightful few. For me, hormonal change has been a trigger for anxiety over the years – and diet has been one answer to my problems. Research published  recently published by King’s College London and Zoe , the science and nutrition company, has found an association similar to what I have long found to be true for myself: that what we eat can help reduce menopausal symptoms. The study looked at 4,287 menopausal women, and found that those that ate a healthier diet with a higher number of plant-based foods, had fewer experiences of hot flushes and mood swings. However, the research didn’t have a control group, which means a group that did not make the dietary changes, therefore further research is needed to know whether it was diet alone, or other lifestyle changes that contributed. Nevertheless, it is true for me that eating a healthier, high-fibre diet guards against the negative consequences of hormonal changes in midlife. Men, too, can suffer from hormonal strife. Some men experience their own version of ‘male menopause’, also known as the ‘ andropause ’ . The ‘male menopause’ can affect men in their late 40s to 50s, and whilst the most prominent symptoms can be related to libido, many men also experience changes in energy levels, sleep cycles and mood. It can sometimes be related to the steady, small decline in testosterone. However, more commonly, causes are more closely related to lifestyle and psychological factors. But, what are hormones? Hormones are the body’s chemical messengers, which are secreted from various glands throughout the body, and into the bloodstream, which transports them to organs and tissues. We have several different types of hormones, responsible for among other things, reproduction, growth, and, of course, mood. In women, oestrogen and progesterone are both connected to mood. Recent evidence suggests that serotonin might be the mechanism through which oestrogen affects mood and behaviour, as oestrogen has been shown to increase the concentration of serotonin receptors in the brain. So, we need to keep an eye on our oestrogen supplies. Similarly, a sharp drop in progesterone after birth has been linked  to ‘baby blues’. The  baby blues  are symptoms such as low mood, tearfulness, and anxiety, which occur in the first week after birth and then subside. Those who have struggled with anxiety or depression before childbirth are especially vulnerable. How to help our hormonal balance?   I’ve let food be my medicine over the past few years to deal with my mood swings and hot flushes. I’ve written my book The Happy Kitchen: Good Mood Food   with the nutritional therapist Alice Mackintosh. She has helped me stay calm and steady for the past five years and ride the hormonal rollercoaster of menopause. In our book, we include recipes using these ingredients and synthesise the research explaining why they make such a difference to our hormonal balance. I hope eating these foods will help you as much as it has helped me. Here are my top four choices – and a recipe to help too. 1. Brazil Nuts for thyroid health: The thyroid is an important hormonal gland that plays a major role in the metabolism, growth and maturation of the body. It takes iodine from the foods we eat to make two main hormones, triiodothyronine (T3) and thyroxine (T4). In some parts of the world, iodine deficiency   is a common cause of hypothyroidism but iodine deficiency is uncommon in the UK and at the moment I don’t suffer from it. However, to protect against iodine deficiency, eating shellfish and white fish can boost your iodine levels, as well as selenium. Selenium is an essential trace element, which is present in most foods, particularly Brazil nuts, offal and fish. In addition to supporting the thyroid, it plays an important role in the immune and nervous system. Try our "Five-Minute Raw Chocolates" from our cookbook : they contain Brazil nuts. But be careful not to eat more than a couple a day, as too much selenium can be toxic , and one Brazil nuts contains almost twice what our daily need - one or two a day would about right. 2. Edamame Beans for phytoestrogens: Phytoestrogens , also sometimes called ‘dietary oestrogens’, are compounds derived from plants with oestrogen-like properties, and are found in a wide variety of foods, notably soy, edamame beans, flaxseed and wheatgerm. Some research has found phytoestrogens may benefit the health and mood of menopausal women by gently boosting their oestrogen supplies.  The only way to find out if these foods will benefit you is to try eating a moderate amount, around three times a week, and keep a record of how you feel. I would start with edamame beans: they are now easy to buy, are a good source of phytoestrogens, and provide plenty of fibre too.   3. Almonds for calcium: Making sure I have enough calcium has been helpful in my quest to feel steady as a menopausal woman. There is plenty of evidence for its importance in preventing bone loss and reducing fracture risk. Edamame, almonds, green leafy vegetables, organic cheese and natural yoghurt are all useful sources of calcium. However, I’ve found eating almonds the easiest way to boost my supplies. You can eat them as a snack, or toast them for added crunchiness, not to mention adding to salads or chopped up and sprinkled on soups or yoghurt. 4. Kale for folate: To best support the delicate balance of oestrogen and progesterone we need a well-functioning liver. Research has suggested that vitamin B12 and folate are essential to the proper functioning of the liver, and also help maintain our hormones, and therefore our moods. Leafy greens such as kale provide folate. In our cookbook we have a recipe for "Calming Green Broth" , which includes kale. Kale is also rich in fibre, which helps support a well-functioning digestive system, so it’s another top choice for a menopausal woman. Calming Green Broth Recipe You can be flexible with the green vegetables you use. Cauliflower, for example, works as well as broccoli, and you can replace the cavolo nero, which is Italian for black cabbage, with kale or cabbage. If you can’t find a bouquet garni, bundle up any spare bay, rosemary or thyme with string and make your own. – Serves 2 – Ingredients 1 tablespoon olive oil 1 leek, roughly chopped1 courgette, roughly chopped100g broccoli, roughly chopped Handful of fresh parsley, roughly chopped 4 garlic cloves, finely chopped or crushed 500ml vegetable stock 1 bouquet garni 100g cavolo nero, kale or spring greens 100g spinach leaves Pinch of chilli flakes (optional) 1 teaspoon tamari (optional) Recipe 1. Heat the oil in a large saucepan and sauté the leek, courgette and broccoli with the parsley and garlic for 2-3 minutes. 2. Add the stock and bouquet garni. 3. Chop the greens or cavolo nero into strips (the broth won’t be blended, so keep them quite small) and add them to the pan too. Don't stir them in – let them sit on top. 4. Cover the pot with a lid, turn the heat down to low and leave it to simmer for 20-25 minutes. 5. About 4 minutes before the end of cooking time, add the spinach leaves. These will wilt quickly. 6. If you like a little more spice, you can add the tamari and chilli flakes. Remember to take out the bouquet garni before serving.

My name is Rustom, and I’m a fitness instructor and a music therapist based in Mumbai, India. As part of my work, I conduct fitness and bootcamp training sessions for children and adults in Mumbai. Working with individuals with special needs fell into my lap, when my first Down syndrome student, (whose name is Mihaan) came to my fitness class for children. Down’s syndrome occurs when an individual is born with an extra chromosome , and people with this condition often face developmental challenges . When he joined my class, I decided not to read about the condition to allow myself to go with my own instinct. Along the way, I got to know Mihaan more and more and began to notice and admire his purity and innocence, as well as his outstanding sense of humour. As word of mouth spread, I started working more with special populations. Not only did I see a difference in myself and how I was learning to adjust, but I saw a difference in the other ‘neurotypical’ students as well. Gradually, my class became a mixed bag of every shape, size, and capacity, and I was so proud of it.  In 2022, Mihaan told me he was interested in running the   Tata 10 km Marathon  in Mumbai, which takes place in January each year. We decided to dive into this challenge together, and so our training began. This entire process taught me things I never expected, and completely changed my mindset. As a trainer, my first goal is always to understand and accept the individual nature of the person I train. No two people are the same, so how could the path they take and the progress they make be? Each person is different, but each person is human, and humans have their differences and their flaws - my goal is to honour this and treat them with patience, friendship, and respect, no matter what they’re labelled as. The teaching method that I use is secondary to all this. I’ve never wanted to be labelled as a teacher myself. I’d rather be a friend who can support them and maybe guide them just a bit.    So, we started really slow, with maybe jogging a maximum of four to five stretches of 200 metres. Gradually we increased to walking and jogging two kilometres and, after that, everything just seemed to fall into place.    This journey taught me a lot about running with Mihaan. I am an ex-timing runner- which means finishing a run in a pre-identified timeframe, beginning with each training session as well. But, with Mihaan I had to get ready to adjust my experience to fit his needs and train him to the best of my ability. I had to throw the concept of doing the run within a particular time out of the window for the first time. We would not run continuously, which is the usual strategy when training for a marathon. Occasionally, as we first started, we would not run for stretches of 100 metres. The main goal of this process is to make the run a fun run - not only for Mihaan, but for me as well. I had to be ready to stop at regular intervals - whether it was for patting dogs walking at Mumbai’s world-famous Marine Drive , or talking to people as we went along. Unlike my previous experience as a trainer, I could not plan anything.   And it was so freeing.    To say Mihaan loves talking is an understatement. He talks almost every step of his run. Traditionally, if I was training someone, I would tell them to preserve their energy during practice. I could easily have told him to not talk and to preserve his energy while he runs, but that would just spoil his fun. Because we were talking through the run we could not wear earphones, so we would carry a mini speaker so both of us could enjoy music while we ran.   We would run. We would sing. We would chat. When people saw Mihaan and me running, they’d be envious of the fun we seemed to be having and wanted to join in. Soon, we suddenly had an entourage of people running with us. In the process, he also inspired other specially-abled individuals to participate in the 10 km. He also had the chance to meet athletic superstars Yohan Blake and Katie Moon , and his jovial personality and well-thought-out jokes made them laugh. Today, Mihaan is preparing for his third 10 km marathon. He can now run stretches of more than 1 km. Between his marathons in 2023 and 2024, he dropped a whole hour. But that doesn’t matter, because we still enjoy doing it so much.

Part II: The effect of Ozempic on people suffering with eating disorders    Trigger warning: The following article contains discussions about eating disorders with explicit descriptions. Some readers may find this distressing.     Ozempic and its derivatives have been all the buzz in the media over the last year, due to their ability to promote weight loss. In my previous article , I explored exactly what these drugs are, how they work, as well as how they have hindered progress within the body positivity movement. In this article, I will focus on how Ozempic and its media prominence can affect those with eating disorders.   The negative impact of Ozempic on eating disorders  According to the NHS , “an eating disorder is a mental health condition where you use the control of food to cope with feelings and other situations”. They can come in the form of eating too little , eating excessive quantities in discrete time periods, or going to great lengths to get rid of any food consumed  – such as self-inducing vomit, exercising excessively, or misusing laxatives.    In people suffering with, in recovery from, or at risk of an eating disorder, having access to a drug which suppresses appetite has the potential to cause significant harm. Especially for eating disorders characterised by a restricted eating pattern, such as anorexia nervosa , the idea of a drug which will help maintain restrictive ‘goals’ is incredibly dangerous. Indeed, there are even reports of doctors prescribing Ozempic for people who are anxious about their weight , without any screening or background checks.     There is not yet any concrete research available on the impact of these weight loss drugs on people with or recovering from eating disorders. As a scientist, research is usually the place I go to, especially when trying to relay evidence on a topic. However, in this case, I can offer some personal opinions on the matter.     In 2020, I suffered with anorexia – as did roughly 60,000 people  in the UK alone. Luckily, due to the support of my friends and family, I was able to quickly come back to a healthy weight, and I would now class myself as fully recovered.     Writing these articles has caused me to wonder how my story might have been different if I had known about Ozempic during that time. At the height of my eating disorder, my mind was constantly preoccupied with thoughts of food and weight . Hearing about Ozempic now, I can see how the media buzz and ongoing discussions of weight loss could have easily fuelled my obsession with food and thinness. The way these drugs are portrayed as offering easy, cosmetic ‘benefits’ only reinforces the harmful belief that being thin is what matters most. From my own experience, I know how quickly this mindset can take over, and it’s concerning to think about the damage it could do, even for those who aren’t using the drug themselves.    An important thing I also learned is that being recovered is not just about being of a healthy weight. It involves a difficult path of learning to navigate food choices without constant anxiety, and separating self-worth from body size. This is why conversations around weight loss and drugs like Ozempic need to be approached with caution. People in recovery may seem outwardly healthy, but they can still be vulnerable to triggers. During my recovery, when I was uncomfortable in my growing body, I would’ve likely jumped at the opportunity to take a drug which made restricting effortless.    This is why it’s crucial to recognize that what may appear as a harmless ‘quick fix’ can have serious consequences. If someone of a clearly healthy weight requested  bariatric surgery , they would be swiftly turned away. So, why should the situation be different when this drug essentially has the same effects? Research shows  that anorexia is one of the deadliest psychiatric illnesses, emphasizing the need to protect these vulnerable groups when discussing and prescribing these drugs.    Two sides of the coin: Ozempic as a treatment for eating disorders?  However, there are some who would also argue that Ozempic and other similar drugs can help people with certain eating disorders. For example, it has been suggested  that for people suffering with binge eating disorder or bulimia nervosa (both of which are characterised by uncontrollable episodes  of eating large quantities of food in a  discrete  amount of time), Ozempic can help to suppress the urge to binge and help to quieten food noise .  However, it should be considered that having an eating disorder does not mean you always fit into one  specific category  of, for example, binge eating or anorexia. Indeed, many go through natural processes of ‘symptom switching’  throughout their eating disorder (whereby they switch  from a disordered eating pattern fitting one disorder to another). For many with binge eating disorder (BED), resisting the binge is the ultimate goal, and being ‘better’ at this restriction due to taking Ozempic may cause them to actually consume very little throughout the day . This may ultimately cause BED to morph into a restricted eating disorder, such as anorexia.     Furthermore, the effects of Ozempic disappear  once people stop taking it.  Research shows  that for BED, the most important thing is to treat the core psychopathology underlying the urge to binge (for example, by reducing impulsivity and compulsivity ). Using Ozempic as a sole treatment for binge eating disorders is unlikely to target these processes, and thus the urge to binge may return if they stop taking it. However, studies have suggested  that when used in combination with psychological approaches such as cognitive behavioural therapy, drugs like Ozempic may help with the treatment process by improving compliance but should still be prescribed with caution.     Clearly, the story surrounding Ozempic is incredibly complex and highlights the need for careful consideration and awareness. The media’s focus on weight loss and cosmetic benefits can have serious implications for those struggling with eating disorders, potentially exacerbating their challenges. It’s essential to approach these narratives thoughtfully and seek out reliable support.  If you are struggling and need support, below are a few helpful organizations that offer both resources and direct assistance:     https://www.beateatingdisorders.org.uk/    https://www.talk-ed.org.uk/    https://www.eatingdisorderhope.com/treatment-for-eating-disorders/international/united-kingdom/u-k-eating-disorder-organizations-charities

The FREED project In September 2024 we will be celebrating the 10th birthday of FREED (first episode rapid early intervention for eating disorders). FREED is a service that provides treatment and care for young people aged 16-25 who are in the early stages of an eating disorder. It is designed to focus on the needs of the individual, taking into consideration their age, life stage and personal circumstances, then tailoring treatment accordingly. Adolescence into emerging adulthood is the peak period of onset for eating disorders and a time of significant neurodevelopmental, educational and social changes for young people. FREED has evolved from a small local innovation in South London, tested in a single-centre study to a multi-award-winning national programme that has been rolled out successfully in eating disorder services all over England. It has also inspired similar programmes internationally. How did the journey start? We started developing FREED at a time when eating disorder services across the UK were struggling with lengthy waiting lists, and young people potentially being hospitalised hundreds of kilometres away from family and friends .  We decided we wanted to do something about this desperate situation by delivering early well-coordinated care for young people presenting to treatment for the first time. In developing FREED, we were inspired by the work of Pat McGorry and colleagues, who had shown that early intervention makes a big difference in the lives of young people with psychosis, with much better outcomes for early intervention than for traditional care up to 10 years later. Pat McGorry is also a pioneer of youth mental health, highlighting the need for making treatments and health services youth-friendly, inclusive, and easily accessible. Finally, we also took on board Jeff Arnett’s concept of emerging adulthood, as a distinct and unique period of development from the late teens through the twenties, characterised by ‘in-betweenness’, (i.e., where the person is no longer an adolescent, but also not yet a fully-fledged adult). The impact and success of FREED "I nearly dropped out of university last year when my illness was at its most aggressive. I can only thank FREED for quite literally saving my life" Research has shown that FREED reduces the duration of untreated illness (time between onset and first evidence-based treatment), improves treatment uptake and dramatically improves clinical outcomes. For example, 60% of young people with anorexia nervosa receiving FREED are fully weight-recovered at 12 months, whereas just under 20% of similar young people (in terms of diagnosis and illness duration) receiving usual treatment were recovered. FREED also reduces the cost to services, by reducing the need for intensive treatments, such as in-patient or day-treatment. Lastly, FREED is highly acceptable to patients and families. The reason why FREED has been so successful seems to be that it hits a double sweet spot.   Firstly, as a model it hits the so-called innovation sweet spot: It is desirable (i.e. it adds value), feasible (i.e. it can be implemented), viable (i.e. it has substantial return on investment, is cost-saving and contributes to long-term growth) and sustainable (i.e. it does not have negative environmental or social impacts). Secondly, at an individual patient level, it also hits a sweet spot, between the person’s emerging motivation for treatment, their strong developmental need for ‘adulting’ and the malleability and less entrenched nature of eating disorder symptoms early in the illness, meaning that key factors for achieving change and recovery are lined up optimally.    The FREED project ‘It is not rocket science’ Some have suggested that FREED is simple "good practice" and that "it is not rocket science". Thank goodness, it is not rocket science: there are no convoluted theories or incomprehensible language needed to understand the principles or practice of FREED. The aim is simply to "get it right the first time", meaning that we intervene speedily, flexibly, and with evidence-based approaches tailored to young people’s personal and developmental needs and their early illness stage. Having said that, whilst FREED is based on a deceptively simple idea, how early intervention is done really matters. There are examples of ambitious early intervention initiatives for eating disorders that have been ineffective and have not been able to show either a shortened duration of illness or improved outcomes. Early intervention creates a win-win situation FREED is designed as a "service within a wider eating disorders service". The reason for this is to avoid the fragmentation, communication issues, potential for duplication of effort, and access hurdles/bureaucratisation that come with multiple separate services. It also means that any cost savings achieved by the introduction of FREED into a team (through reduction of inpatient admissions) can readily be reinvested into the same service, thereby benefitting all service users, including those with long-standing illnesses. “We have no nay-sayers, just operational challenges” On the strength of the evidence supporting it, FREED was adopted in 2020 by the Academic Health Sciences Networks (AHSNs; now the Health Innovation Networks) into their national programme for scaling. With AHSN support and some additional funds from NHS England, we successfully rolled out FREED to all eligible Trusts in England during the pandemic, training hundreds of clinicians. Towards the end of the programme in Autumn 2022/Spring 2023, we interviewed clinicians and AHSN leads from most regions in England about their views on FREED, its implementation and its sustainability. The views of these different stakeholders closely mirrored each other and were uniformly enthusiastic: People fully endorsed the concept of early intervention and FREED, noted the improved patient outcomes and also how empowering FREED is in bringing out the best in clinical teams. Stakeholders also acknowledged that there are operational challenges, for example, in terms of how to deliver early intervention when managing staffing shortages and increased referral numbers. However, stakeholders agreed that these challenges could be and should be overcome. In the words of one AHSN representative: "early intervention is not optional; it is a necessity". Where to next? We are operating in an NHS that has been described by Health Secretary, Wes Streeting, as "broken" . In this context, and given a rise in eating disorders incidence since the pandemic, FREED, whilst embedded into teams across England, remains at risk of being delivered as ‘FREED in name only (FRINO)’. Therefore, appropriate and continued secure funding is needed to support its delivery with fidelity. FREED on its own is an important cornerstone for early intervention in eating disorders, but there is much more that needs doing. The next frontier for early intervention in eating disorders must be brainier and better and to tear down systemic, institutional, and administrative barriers to early intervention. To make intervention even earlier, awareness raising and early detection are important, as there are still far too many people who do not access the help they deserve, especially those from minoritised ethnic groups, those from lower SES backgrounds, those with resource insecurities, and those from minoritised gender and sexual identity groups. There are further inequalities in that the under 18s can self-refer to services whilst young people aged 18+ seen in adult services often have gate-keeping hurdles thrown in their path. These inequalities urgently need to be rectified. But how can we make early intervention 'brainier and better'? This involves developing a much better understanding of the interplay between biological and psychosocial risk factors for eating disorders and how these intersect with risk factors for other mental health disorders. Such knowledge could lead to much more personalised prevention and early intervention of eating disorders that will further improve outcomes. Our large UKRI-funded EDIFY research programme focuses on many of these questions - you can visit our website to learn more EDIFYresearch.co.uk .

Warning: The following article contains spoilers for the movie ‘Inside Out 2’ In 2015, Pixar’s "Inside Out" captured the hearts of both young and old by creatively depicting the inner workings of 11-year-old Riley’s mind. Now, "Inside Out 2," set two years later, continues Riley’s story as she enters puberty, taking steps to add more emotional complexity. This film has been praised for its innovative portrayal of emotions and mental health, and it is the highest-grossing film of 2024 . In this article, I will explore how "Inside Out 2" tackles complex themes in an accessible manner, helping viewers navigate and understand complicated emotions in a fun and digestible way. The sense of Self and the inner emotional conflict In the first film, we got to know Riley’s core emotions—Joy, Sadness, Fear, Disgust, and Anger—who work together from 'Headquarters' to guide her actions. In the sequel, set during a weekend hockey camp just before she starts high school, Riley's emotional world expands as she enters puberty. Alongside her familiar emotions, new ones make their debut: Anxiety, Ennui (boredom), Envy, Nostalgia, and Embarrassment.   Anxiety takes centre stage in Inside Out 2 . From the moment her erratic and hyper character arrives in Headquarters, she disrupts the balance by imagining worst-case "what-if" scenarios and trying to take control of Riley’s actions. When Joy dismisses her pessimistic approach, Anxiety forces Joy, Sadness, Anger, Fear, and Disgust to the "Back of the Mind," insisting that “Riley’s life needs more sophisticated emotions than all of you.” I’m sure many would agree with me when I say that this portrayal of Anxiety as a dominant force really hits home. I can relate to the idea of anxiety taking over and pushing aside all other emotions, especially when I was a teenager and didn’t yet know how to manage it. One of the film’s standout features is the “Sense of Self,” an object built from memories stored in the Belief System. Initially, Joy has a purely positive Sense of Self (one which repeats the phrase “I’m a good person”) by retaining only positive memories, but once Anxiety takes over, she reshapes it into something dominated by anxious emotions (causing it to state also “I’m not good enough”). This shift leads Riley to make questionable choices, such as abandoning her friends and recklessly trying to impress the hockey coach.   As a teenager, I remember putting immense pressure on myself, thinking that any mistake—whether in exams or social situations—would define my future. In the film, Anxiety views the hockey game as a make-or-break moment for Riley’s future, leading to a pivotal panic attack when things don’t go as planned. The panic attack Like many who’ve seen the film, I found the panic attack scene both incredibly emotional and completely relatable. After Riley is sent to the penalty box during the hockey game, Anxiety spirals out of control, creating a whirlwind of panic at the control panel. Joy enters the chaos and finds Anxiety frozen in the middle, flickering and overwhelmed. It’s hard to put the power of this scene into words, so I’d urge anyone to watch the film in order to truly understand its impact. Finally, Joy manages to pull Anxiety away from the controls, and in a heartbreaking moment, Anxiety says:   “I was just trying to protect her.”   Accepting all emotions and seeing all aspects of yourself honestly The emotions realise that the only way to help Riley through her panic attack is to create a new Sense of Self—one that embraces both positive and negative emotions. This message is key: anxiety isn’t something to eliminate, but to manage. It reminds us that anxiety can be helpful in high-pressure situations and that most of the time, our Anxiety is only trying to help us.   In the first Inside Out film , the key message is the important role that sadness plays in our lives. The sequel sticks to this theme and continues to highlight the value of negative emotions. For example, in one of the final scenes, Anxiety begins to panic and spiral, but the emotions ask her to take a seat and calm down. Once calm, Anxiety then does her ‘job’ by reminding them about Riley’s Spanish test. Reflecting on my own teenage years, especially around exam time, I’ve realised that my anxiety often pushed me to succeed, driving me to take my achievements seriously and stay focused. One of my favourite parts of the movie is how Riley’s new Sense of Self reflects her growth. Instead of only believing “I am a good person,” she accepts a broader range of beliefs: “I make mistakes,” “I need help,” “I’m strong.” This shift is a powerful message about adulthood and self-acceptance. We can be good friends and still make mistakes, be confident but still feel nervous. By accepting all parts of ourselves, we can face life’s ups and downs without panicking when things don’t go perfectly. This message is particularly important for someone going through puberty, where teenagers tend to be incredibly hard on themselves and their newly arising emotions and characteristics.   The film consulted psychologist Dacher Keltner from the University of California, Berkeley, who explained that the ending—where all emotions are accepted—is rooted in research showing that happiness isn’t just about joy. Stress, anger, fear, and even envy play important roles in our well-being. While society has made great strides in accepting mental health disorders, there’s still a misconception that we should only embrace positive emotions. This mindset can be counterproductive, as thinking that something is wrong with us the moment we feel sad or anxious gives those feelings more power.   My only critique to the movie is how easily the other emotions manage to calm Anxiety, which feels more like the typical "happy ending" of a children’s movie than a nuanced portrayal of teenage anxiety. Many who deal with anxiety may wish it were that simple, but in reality, it’s more complex. Still, it’s important to remember that Inside Out 2 is a Disney film, where a happy ending is a prerequisite.   Of course, "Inside Out 2" does not capture the full complexity of the human brain and all its emotions. It is believed that we may have upwards of 25 different emotions , but creating a character for each one would have made the film too chaotic and confusing, not to mention a bit of a storytelling nightmare. Despite these omissions, the movie makes significant strides in helping both children and adults understand emotions and mental health, and importantly gives mental health awareness even more mainstream media representation.

Anorexia nervosa  (AN) is a serious eating disorder  affecting the body and brain, with significant implications for physical and mental health. The defining characteristics of AN are excessive weight loss and malnutrition. This condition is caused by extreme dietary restriction, a distorted body image and, in many cases, excessive exercise. In addition to the visible effects, this disorder significantly impacts brain structure and function. While I have not been diagnosed with an eating disorder, I have observed its detrimental effects  on my immediate family members. Given my background in medicine and neuroscience, I am aware of the mounting evidence indicating that numerous psychiatric disorders have substantial biological foundations. This knowledge can transform how we approach treatment, allowing us to develop more targeted and effective interventions. I believe that improved treatments for AN are forthcoming and that research in this field will ultimately facilitate patients' recovery and enhance their quality of life. Recently, I was involved in a study entitled "Dynamic Structural Brain Changes in Anorexia Nervosa: A Replication Study, Mega-analysis, and Virtual Histology Approach" . We used structural magnetic resonance imaging to explore how AN affects the brain and how proper treatment can reverse these changes. The Study: Who Was Involved and What Did They Do? One of the key factors in understanding how AN affects the brain and vice-versa is examining brain volume changes in individuals with AN. Previous research had shown mixed results , as some studies indicated reductions in some brain structures in acutely underweight patients, while others showed increases or no differences. Additionally, the biological mechanisms driving these changes were even more unclear. Our new study aimed to clarify these changes by examining the brains of a large group of people with AN. By comparing brain scans of individuals with AN, those who had recovered, and healthy controls, we hoped to improve our understanding of the brain's response to this disorder. Significant Findings: Reductions and Recoveries Our research revealed that those suffering from this disorder experience a strong reduction in both grey and white matter volumes throughout the whole brain. Grey matter is crucial for processing information in the brain, while white matter connects different brain regions, facilitating communication. Interestingly, even though the reductions were widespread, some brain regions were less affected than others, or even not affected at all. And, importantly, these reductions were not permanent. Upon partial weight restoration, rapid increases in these brain structures were observed. This suggests that the brain can partially recover with appropriate weight gain. For those who had fully recovered from AN, their brains looked similar to healthy controls, indicating that full recovery of grey and white matter volumes is possible with sustained weight restoration. This finding offers hope, highlighting the brain's remarkable resilience and capacity for recovery. The Brain's Battle: Who gets the resources? To understand why some regions seem immune to the drastic brain volume reduction in the acute state of anorexia, we employed a “virtual histology” approach. This method links differences in brain volume to the typical location of specific brain cells, and their corresponding function and role. This showed that regions with big and well-integrated neurons are the most affected. Furthermore, this implies that AN primarily impacts brain areas that are energetically demanding and highly interconnected. Conversely, regions of the brain less affected by AN were associated with other cell types, such as astrocytes and microglia. This suggests that these cells might be more resilient to the effects of AN, possibly due to different energy requirements or protective mechanisms. This finding is significant because it highlights the impact of AN on the brain's most energetically demanding and interconnected regions. These areas play crucial roles in cognitive functions, emotional regulation, and overall brain health. Understanding how AN disrupts these connections can help inform treatment strategies aimed at restoring normal brain function. What Does This Mean for Patients? For those suffering from anorexia nervosa, these findings help explain some of the cognitive and emotional difficulties they face. Reduced brain volume can affect everything from decision-making to emotional regulation, making daily life even more challenging. Understanding these brain changes is crucial because it highlights the importance of treating anorexia as a serious mental health disorder, not just an issue of weight and body image. And on the other hand, this emphasises the seriousness of the disorder. Early intervention is crucial because it can help the brain start healing sooner, improving the chances of full recovery. What Does This Mean for Health Care Professionals? Refeeding and nutritional support are already key components of anorexia treatment. This study suggests that restoring proper nutrition might also help reverse some brain volume loss. Healthcare providers must ensure patients receive early and sustained intervention. Secondly, Cognitive Behavioural Therapy (CBT) has been effective in treating anorexia by addressing distorted thoughts and behaviours. Understanding the specific brain areas affected could lead to more tailored CBT approaches that focus on improving cognitive functions related to these regions. While anorexia nervosa remains a challenging disorder to treat, this research offers hope. By shedding light on the brain changes involved, we reveal possibilities for more effective treatments . For patients, understanding that their struggles have a biological basis can be validating, and help encourage them to stick with their treatment plans. A Message to Those Struggling If you or someone you know is dealing with anorexia nervosa, know that you are not alone. Advances in research are continually improving our understanding of this disorder, leading to better treatments and support. It's important to seek help and adhere to treatment plans designed by healthcare professionals. Your brain, like your body, can heal with the right support and care . Support for eating disorders: UK’s Eating Disorder Charity (BEAT) FREED: First Episode Rapid Early Intervention for Eating Disorders

Trigger warning: This article discusses suicide. Some readers may find this distressing. Massive increases in referrals to Child and Adolescent Mental Health Services (CAMHS) over the last few years have led health professionals, including myself as a doctor, to question why. Child mental health is important to me as I have personally seen peers experience mental health problems at school, and I believe this is such a crucial time to offer support and interventions. Looking at statistics from the NHS Child and Adolescent Mental Health Services (CAMHS), the number of children currently under CAMHS care has risen from 493,434 in October 2023 to 496,897 in November 2023. Shockingly, the number of children under 18 requiring emergency mental health support has also increased by 53% since 2019 . It is important to think about the contributing factors to these numbers, so professionals can better support young people and implement change that will help. As CAMHS services see a massive surge of referrals at the beginning of the school year , and a large part of life as a child and adolescent is school life, I wanted to explore factors that can occur in a school environment. Specifically, I will explore factors that may be contributing to the increased mental health referrals, and the initiatives schools can implement. So, let's break down some contributing factors. 1) Academic Pressure and Stress Over the last several years, there has been a global decrease in school satisfaction for teenage students. This decrease in satisfaction has been linked with perceived school pressure , which is more pronounced in girls compared to boys. Additionally, this academic pressure can contribute to both physical health symptoms such as fatigue , and mental health problems such as depression, anxiety , and sadly in severe cases, death by suicide. One study looked at the causes of 595 adolescent suicide cases and found academic pressures were a recurring contributing factor. Additionally, another study found a positive association between academic pressure and timing within the school year (around the exam period), and at least one mental health outcome of anxiety, depression, self-harm, or suicidality. 2) Social Dynamics and Peer Relationships Recently, social dynamics and peer relationships have gained a lot of media attention due to the COVID-19 pandemic. The pandemic helped to understand the importance of peer relations, as it revealed a lot about the effects of restricted social interactions on school-aged children. For example, 2,160 parents of children participated in an online survey investigating the effects on mental health with school closure . In 16-17% of the children, there was an increased exposure to mental health and peer problems. In this group, mental health and peer problems were directly associated with a lack of friendship, which highlights the importance of a friendship group for mental well-being. Importantly, it has also been found that peer support is as protective in preventing low mental well-being as both school, adult support, and family support combined. 3) Bullying and Harassment   Bullying and harassment can take place in many forms for children of school age. This includes physical, verbal, emotional, relational, and more recently cyber bullying. We know that children who experience more than one form of bullying are more predisposed to longer-term social-emotional effects. These effects can include feeling anxious or depressed, acting out or being aggressive, and having a desire to get back at others. These physical and psychological symptoms can also predispose young people to later mental health issues, with bullying consistently being associated with poor mental health . So what can schools do? The UK government recommend that a whole school multifaceted approach is needed to achieve   " a safe, calm and supportive learning environment” . This approach can include promoting inclusivity and respect, enabling student voice, and providing curriculum teaching to support emotional learnin g . In addition, schools can offer targeted support to those that need it , and work together with parents and carers to support their children. The Department of Education also emphasises the importance of peer relationships, and recommends school peer mentoring schemes designed to increase self-esteem, emotional health, and wellbeing across the student population. What about other schemes? In 2017, the Government outlined plans in the "Green Paper for Transforming children and young people’s mental health" , with a goal to enhance mental health access, including establishing community-based mental health support teams (MHSTs), training senior mental health leads and reducing CAMHS waiting times. The program introduced significant changes, such as establishing MHSTs in educational settings to link with local CAMHS services, with direct NHS supervision. Additionally, the program aimed to train senior mental health leads in all eligible state-funded schools and colleges by 2025. In addition, individual NHS trusts also have strategies to combat the increasing demand for CAMHS services. An example of this is the CUES program (South London and Maudsley NHS Foundation Trust), designed to equip primary-aged school children with therapy techniques to prevent later mental health problems, with promising outcomes. Are these schemes adequate? Despite government initiatives, schools are still struggling to deal with the increasing mental health problems at school. In a survey of nearly 18,000 members of the National Education Union, educators were questioned about student mental health. Results revealed insufficient access to specialised support services, such as CAMHS, learning support assistants, councillors, nurses, trained mental health first aiders, senior mental health leads. Many teachers cited excessive workload, lack of staff and inadequate government priorities as key barriers to student support. Teachers also expressed concerns over lengthy CAMHS waiting lists, with some children not qualifying for services despite evident need.   Whilst more work is needed, the schemes discussed are a step in the right direction. The government has made a commitment to young people's mental health, with educational settings being a focus of service provision. Additionally, there is evidence that school-based mental health services overcome some of the barriers that prevent access to mental health services for children and youths, such as shortage of medical or psychological mental health professionals, mental health stigma, or the lack of transportation opportunities. Therefore, I look forward to seeing future progress and the outcomes of the government initiatives!

At some point in life, we all feel some unnecessary jitters. It might manifest in stuttered words during a presentation or a hammering heart in an unfamiliar crowd. Often, we confuse these nerves with an actual disorder. However, the difference between introverts and the socially anxious lies in the persistent dread of socialization: being a homebody who thrives in ‘me-time’, versus having a panic attack at the thought of attending a party, distinguishes the two. Whether it’s a full-blown disorder, or a random disturbance that pops up every once in a while, there’s a way to tackle these difficulties. Cognitive Behaviour Therapy (CBT), a type of talking therapy, is widely used to deal with debilitating social anxiety. The core philosophy behind CBT lies in relearning & rewiring our thoughts. It usually involves identifying maladaptive beliefs, and then restructuring or eliminating them. Some of these ingrained thought processes, targeted by CBT,  are called Cognitive Biases. Cognitive Biases are subjective, irrational & far from reality. They are skewed due to our faulty perceptions and can cloud sensible decision-making. Indeed, certain unconscious biases make us more susceptible to social anxiety.  Psychoeducation is a transformative tool that CBT employs to substitute distorted beliefs with informed rationale. It demystifies the how’s & whys of our inner workings and provides invaluable insights that guide us to reevaluate & regulate our emotions and actions. As a writer & mental health counsellor, the mere knowledge of cognitive biases helped me minimize my own anxiety around social situations. This allowed me to recognize, analyse and offset my triggers.  Here are a few biases that may be exacerbating your social anxiety. Biases of Attention Remember when you tried to go on a diet or cut your carbs intake? And suddenly all you could see was people devouring pizzas and pasta. This is called Attention Bias . Our moods, affiliations and needs determine what we focus on. As a result, we can become so engrossed in our current train of thought that all irrelevant stimuli are blatantly ignored. For instance, a low mood might make you notice more depressing news than positive developments. For the socially anxious this bias augments their fears. Since our attention span is limited & highly skewed, situational anxiety makes us attend more threatening stimuli. It becomes hard to detach from social threats or divert towards positivity. Since we become selective in picking cues of positive interactions; our attention is solely oriented towards disapproval from others. For instance, while giving a speech, a socially anxious person might hyperfocus more on the frowns in a crowd rather than their pleased expressions, awaiting criticism and ignoring praise. Biases of Memory How we remember an event is based on its intensity, importance, prevalence and emotions attached to it. As much as we like to pride ourselves on our recall prowess, people rarely remember the exact replicas of reality. Each snippet is tinged with our personal preferences. There are multiple biases based on the selective nature of our memory recall. Confirmation Bias - This bias refers to our tendency to seek & believe information that confirms our pre-existing beliefs. This takes us farther from facts and leans towards vague or false assertions. For instance, believing a dog breed is more violent than others because it barked at you once, and then looking for evidence that perpetuates your theory while ignoring other breeds that statistically attack more people. Or a person with a fear of rejection might enter every situation certain of getting rejected.  Recency Bias - A fresh memory is far more prominent in our mind and affects us more deeply than the older ones. We are quick to build long-lasting beliefs based on a single recent incident & let it overshadow all our past experiences. For instance, if a person is recently mocked over their outfit, they’d ignore all the times when they were praised for their fashion sense in the past. For the socially anxious these memory distortions play highly against their favour. They tend to remember more negative events than positive ones. They barely recall pleasing social interactions & events and if they do, these memories are blurry at best. This further makes them apprehensive of future social interactions. Biases of Interpretation How one perceives the world depends on the intricate balance of their beliefs. In turn, their perception dictates their feelings & emotions around any situation. More often than not, there is no big bad threat around us. Yet, with an anxious mind, we feel perturbed in ambiguous social situations. We find it much easier & more believable to infer such moments as negative. To an anxious person, two colleagues whispering and giggling over a meme might seem like they are laughing at their expense. A partner’s frown over a soggy breadstick might feel directed to them as contempt. With social anxiety, we tend to misinterpret social cues and others’ actions. This further fuels the anxiety. Biases of Imagery All of us have a solid mental picture of ourselves. The adjectives we use to describe our persona sum up our self-image & self-concept. A positive perspective can amp up our self-esteem while a negative view diminishes our self-worth. The socially anxious often find it hard to imagine themselves in a favourable light. An impaired vision of one's traits, capabilities, and goals intensifies their social anxiety. They fail to see themselves as relevant, fun or worthy individuals and thus expect rejection & abandonment. Tackling Cognitive Biases While we can’t completely escape these biases, their effect on our social anxiety can be mitigated . Take some time to see what ticks you off, and analyse when and why it happens. Diving into the root cause can help you gain a clear sense of self. Learning why certain situations make you uneasy can let you know how to counteract them with reason. Understanding these cognitive biases makes it easier to rationalise & neutralise them.  Recognizing these biases and reorganizing your thought process is the first step. Usually, psychoeducation is paired with professional help and gradual exposure to anxiety-inducing situations. Rewiring your beliefs to align with a more positive outlook can allow you to self-soothe in the throes of social anxiety. Take a look at life & others with an impartial lens and you’ll be able to see beyond these cognitive biases. To read more about cognitive biases in anxiety you can read Inspire The Mind’s previous blog .

In my second year of medical school, I had the opportunity to choose my student-selected component of the course. There were several interesting options, ranging from short language courses to exploring case studies in medical law. However, one option stood out: ‘Cultural psychiatry.’   As a woman of colour, I'd always been fascinated with how culture shapes our understanding of mental health. In my Nigerian community, for instance, mental illness is often shrouded in stigma, with many attributing it to evil spirits' possession or drug use .   The course promised to explore the role of cultural and transcultural factors in the world of psychiatry. This meant exploring how a patient's background could influence everything from how they experience symptoms to their ultimate prognosis. We'd also be looking at fascinating concepts like   ‘culturally bound psychiatric syndromes .’ Culturally bound psychiatric syndromes are experiences which are recognisable as illnesses and thought to only exist within a specific culture. An example of a culturally bound psychiatric syndrome is susto , a term used in Latino cultures. 'Susto' can occur when someone experiences a frightening event and feels their soul has left their body, causing symptoms like listlessness and poor appetite. Another example is brain fag syndrome found in West Africa, which is associated with mental strain, and manifests as confusion and tiredness.   The interaction between different cultures poses unique challenges in the field of psychiatry, which has led to the development of cultural psychiatry . The General Medical Council acknowledges the importance of doctors endeavouring to understand the impact of culture and personal experiences on the care that they provide to patients. Indeed, it is not enough for clinicians to just be accepting of other cultures; everyone should endeavour to learn about other cultures beyond the stereotypes.   I am British. I am Black British. I am Nigerian. When thinking about culture, the first thought is often about a person’s ethnicity, nationality, or race. For example, I am black. That is a cultural identity for me, but even within that seemingly defined group, there are several different cultural groups that I belong to.   There is, for example, a different cultural experience for Black British people and African Americans. Even within the Black British label, there are different cultural experiences. Whilst a small example, there is an ongoing discussion between people of African and Caribbean descent about pronouncing the food plantain - those of African descent commonly pronounce it plantAYNE, whilst those of Caribbean descent commonly pronounce it planTIN .   Even within the seemingly specific label of Black-British-African, there are several ethnic divisions. We can look to the frequent discussion amongst West African nations regarding ownership and execution of the best jollof ri ce. What is culture? “Culture” was adapted from "cultura animi" (cultivation of the soul), a term coined by the Roman speaker Cicero . At this time, it referred to how humans moved towards developing an understanding of philosophy. Edward Taylor proposed an anthropological definition of culture which “includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society”, this showed culture to be a collaboration.   The current Cambridge dictionary definition of culture is “the way of life, especially the general customs and beliefs, of a particular group of people at a particular time.”   Looking at these three definitions, we can see that culture is more than race or ethnicity. Culture is created, learned and shared. Culture is dynamic and open to interpretation. It is important to stress that culture can change, especially with evolving technology and cross-cultural interaction.   Beyond race, nationality, and ethnicity, cultural identity is a vast spectrum. It is important to understand that different cultural identities can intersect. For example, I am Black British, but I am also a woman and a medical student. All of which are important aspects of how I experience and navigate the world. Cultural concepts of distress The concept of culturally bound syndromes has now been replaced with ‘ cultural concepts of distress ’ in the DSM -5 , a book used to classify mental health disorders. This has been a positive change, as the term now acknowledges that all mental disorders can be culturally shaped. Understanding cultural concepts of distress  is crucial for dismantling barriers to mental health care. An individual's cultural background shapes their perception of mental illness, coping mechanisms, and even help-seeking behaviour.   Cultural concepts of distress encompass three key areas: cultural syndromes, cultural idioms of distress, and cultural explanations.   Cultural syndromes  are unique clusters of symptoms specific to certain cultures. They include many of the same conditions as the former ‘culturally-bound psychiatric syndromes’ in the DSM-5. However, whilst these cultural syndromes may be more common in certain cultures, they may not be solely unique to that culture.   For example, hikikomori is a cultural syndrome characterized by extreme social withdrawal and originated in Japan . However, recent international studies have found the phenomena of hikikomori has been observed outside of Japan .   Secondly, we have cultural idioms of distress. Cultural idioms are ways of expressing emotional suffering, often through culturally specific terms that may not directly translate to Western diagnoses. For example, the Punjabi term , “ sinking heart ” , might be used instead of "depression" or "anxiety."  Mental health professionals should be aware of these idioms to assess a patient's condition accurately.   When a patient expresses distress through an unfamiliar phrase, like "feeling a sinking heart", asking "What does that mean to you?" can encourage the patient to share context, ultimately facilitating a better understanding of culturally specific idioms of distress, and informing a more accurate assessment.   Lastly, cultural explanations view mental distress through the values, beliefs, and norms of a person's culture. The cause of distress for that person may be explained as the result of spiritual imbalances or social disharmony within that person's culture.   Therefore, by recognizing these cultural concepts, one can acknowledge the vast variation in how people experience and express mental health concerns. Where to go from here? Intrigued by the world of culture in psychiatry? Here are some places to learn more:   The Royal College of Psychiatrists offers a dedicated course on cultural psychiatry. Check out their website.  The Royal College of Psychiatrists also has a Transcultural Psychiatry Special Interest Group. Consider joining to network with and learn more from like-minded individuals.   The most important thing is to keep cultivating genuine curiosity about other cultures. Remember that culture is dynamic, and cultural nuances are constantly evolving. Try to continuously engage with other cultures through books, documentaries, or even conversations with people from diverse backgrounds.   Try to avoid making assumptions regarding a person’s cultural identity based on appearance. Instead, ask open-ended questions to understand their unique experience within their cultural context. Everyone, but clinicians in particular, should strive to pay attention not just to the words, but also to the emotions and body language of the others.

We at Inspire the Mind would like to extend our deepest sympathies to the families affected by the tragedy at Southport. Trigger warning: This article mentions violence and terrorism, which might be distressing to some readers. Taylor Swift has been a household name for quite some time now. But ever since she embarked on her world-famous, record-breaking Eras Tour in March last year, not a day goes by without mention of her. I wrote part one of this series in June when she performed at Wembley for 3 nights, which you can read here . After having the incredible opportunity of getting tickets to see the show live on the 16th of August, I am back with a new addition to my ‘Swiftie series’ as I playfully call it, this time focussing on the concert experience. Before I proceed to talk about the concert, I’m mindful of the events that have transpired over the past month, relating to the Eras Tour in general, and Taylor Swift herself. On the 29th of July, a knifeman attacked a Taylor Swift-themed yoga and dance event in Southport, England. Very sadly, three young girls, aged 6,7, and 9 lost their lives , with many others being injured. As a Taylor Swift fan, it makes me extremely upset to think that an event designed to bring joy, fun, and excitement had such a horrifying ending, especially since music is something meant to unite people of all ages. My heart goes out to all the families and loved ones affected, and I extend my deepest condolences. Further, on the 7th of August, the day before Taylor Swift was set to perform in Vienna for three nights, her shows were cancelled, due to confirmation from the Austrian government of a planned terror attack . The details that emerged about this thwarted attack were rather grim, with the suspect planning to “kill as many people as possible.” This news brought to mind the horrific bombing at the Ariana Grande concert in Manchester in 2017, which led to the deaths of 22 people, including children . In fact, the news from Vienna and Southport instilled such a sense of fear in me, that I stopped looking for tickets for the second leg of performances in London, which I had made my mission for the past year. I was incredibly lucky to find tickets the morning of the show on the 16th of August, which I decided to purchase after learning about Wembley Stadium’s safety precautions. Even then, every loud sound and every commotion in my peripheral vision made me anxious. As the show drew to a close and we began to exit the stadium, I was quite anxious as I could not shake the thoughts of the horrific Ariana Grande concert bombing. It made me quite upset to think that an event which I had been waiting for, for such a long time had a sense of anxiety and fear surrounding it. When I finally reached home that night, I thanked my stars that I made it safe and sound. I wouldn’t have imagined that those would be the thoughts in my head after the concert, instead of the positive memories I’d made that day.   Amid the negativity and fear surrounding large concerts, I constantly remind myself that these places bring people together, for a common, shared hobby: a love for music. That being said, I’d like to shift focus to something more positive. Numerous media outlets have spoken about the Eras including a BBC article  I recently came across   talking about fans experiencing “post-concert amnesia”. The power of social media introduced me to Laura and Anum, both avid Swifties who went to concerts in different cities. I sat down to chat with them about their experiences of watching the Eras Tour live. (For context, these conversations were before the events at Southport and Vienna took place, and before I secured tickets myself). A little bit of background:   First, I spoke with Laura, a researcher who has been working in the field of neuroimaging for 5 years, with a special interest in psychosis and cognition. Outside of work, she enjoys live music and going to concerts. She’s been a fan ever since the beginning of Swift’s 18-year-long career when her Debut Album was first released.   My next chat was with Anum, a Senior Research Manager at Wellcome in the Mental Health Field Building Team, with a background in psychiatric research. Anum has supported Taylor Swift since her famous song “Love Story”, from the Fearless Era. Whenever a new song or album was released, she’d listen to it, but she became a “really big Swiftie” around age 17 or 18.   What they both spoke about, which is a common sentiment shared by all three of us, is that there is a “Taylor Swift song for every mood”. Both talked about how they’ve grown up with her music, and as young girls, her lyrics spoke to them. I for one relate to this, with memories of singing “Our Song” as an 8-year-old in my hometown to dancing to the song “22” on my 22nd birthday in London.   Experiencing the Eras Tour live- does post-concert amnesia exist?:   I was intrigued by the BBC article that spoke about post-concert amnesia because, to be honest, I didn’t experience it. I remember every little detail, both, from embedding them in my head, and recording key moments on my phone. But what about Laura and Anum?   Laura had the opportunity to attend the Eras tour more than once, and each day was a different experience, all very emotional. As she attended the concert in different cities, she spoke of how it was quite intense leading to her not remembering parts of the show. She referred to it as a “blackout type of excitement.” From a neuroscience perspective, she spoke about how the intensity of emotions experienced could lead to an amnesia-like feeling. Anum’s experience was similar to mine. She tried to embed “every bit of it” in her brain so she wouldn’t forget the experience. She remembers all the details of the show she attended in June, and she too, attended more than one.   The common themes that emerged from these conversations relate largely to the pure joy of experiencing the show live. Since the concert film was released on Disney+, I have rewatched it countless times. Yet, when I saw her come out on stage for the first time in front of me, it was an entirely different experience. In fact, to remember the moment forever, I had my video camera on, to record my raw, immediate reaction. And that is something that brings a smile to my face every time I watch it. At that moment, I’d forgotten about the anxiety and fear leading up to the show that was at the back of my mind.   With the European leg of the Eras tour now wrapped up, I now reflect on everything I’ve spoken about in this article. Concerts and music-themed events are meant to spread joy, to bring people together, and be a place of positivity. They’re not meant to be a place of violence, of terror, of sadness and death. Especially for all of Swift’s youngest fans. A vast amount of literature talks about how experiences of childhood trauma have a negative impact on mental health and overall development across a person’s lifetime. It is my hope that concerts remain a safe place for fans, a place of joy, and a true appreciation of music.

A few months ago, while walking home, I heard a child screaming about not wanting to leave the playground. The parents were also shouting, “Stop crying… we won’t go the playground anymore… if you don’t stop crying we will leave you here.” The child, around 3 years old, was exhausted. When he heard his parents threatening him, he started screaming even more until, eventually, he stopped crying and went back on his bike to go home. What happened? A child, most likely exhausted by the day and the emotions he was experiencing, was having what is commonly referred to as a "tantrum". I don’t particularly like this term, I prefer to refer to these episodes as episodes of emotional dysregulation . Emotional Dysregulation: A child acting their age When a little child is experiencing intense emotions such as anger, frustration, boredom, or feels overwhelmed, they won’t be able to put those emotions and needs into words, as their brain is still very immature. They are still learning about emotions: what they are, how to name them, and how to regulate them. Therefore, infants and toddlers communicate with their behaviours, and these behaviours are often misinterpreted as misbehaviours  that must be corrected. Clear examples of these "misbehaviours" include crying, hitting, biting, screaming, whining, throwing things on the floor, disorganized behaviours, and "general tantrums". Tiredness, overstimulation, hunger and stress increase the probability of these behaviours. A child who is expressing these behaviours is not misbehaving. They are just saying: "I am tired, I am experiencing intense emotions which I don’t know anything about and cannot handle. I need your help to get through these emotions, without ignoring them. I need your help to feel better". Being a little child is hard work. The inability to communicate properly creates frustration. Also, they haven’t developed compassion yet, so they don’t understand the consequences of their behaviours, lack impulse control, and struggle to accept a “no”. They need understanding, attention, and love, although their behaviour may communicate the opposite and may be difficult to tolerate. These episodes are developmentally normal for infants and toddlers, who are not mini adults but just children with brains at the early stages of development. Indeed, these episodes typically begin between 12 and 18 months, peak at around 2 years of age, and then gradually disappear between 4 and 5 years. Indeed, as the children’s vocabulary increases, they are better able to put their emotions into words, reducing the occurrence of emotional dysregulation episodes and "misbehaviours". The work of the caregiver: The constant process of co-regulation The work of the sensitive caregiver is not to suppress the behaviour but to try and understand what the child is saying, and help them regulate the intense emotions they are experiencing and put them into words.   We have talked about emotional regulation in a previous blog.   Emotional regulation is the ability to regulate internal emotions, i.e., the ability to calm down, reduce the intensity of our feelings and control our behaviour, so we can respond most optimally to the stimuli. It does not mean repressing emotions, but modulating internal states and reactions. This is a crucial competence for our well-being as it helps us understand our emotions and those of others, successfully managing stressful situations and remaining resilient.   If we think that emotional regulation can sometimes be difficult even for adults, this can be almost impossible for young children.   Young children rely on their caregivers to help them with their emotional regulation, as their brain is still very immature. The prefrontal cortex, which is a key area involved in emotion regulation,  is one of the last parts of the brain to develop . For this reason, they need someone else to help them regulate their internal states and emotions, so they feel calm again, in a process called hetero-regulation  or co-regulation .   Co-regulation is difficult and tiring work for the caregivers, as they need to regulate their own emotions first, to be able to regulate the child’s emotions. This means: first controlling negative emotions that may arise from the episode (e.g., anger, frustration) and impulsive behaviours that may come out (e.g., wanting to tell the child off to correct the unwanted behaviour, or sometimes wanting to shout or punish the child); then focusing on calming the child. However, this work is extremely important as little children learn self-regulation with time, through the repeated experience of co-regulation with the caregivers in the first years of life. In this way, with time and brain maturity, children learn to eventually control their emotions and behaviour  independently (i.e., self-regulation). Children learn from us; they absorb our emotions and how we cope with difficult situations and then imitate our behaviours. This is why it is fundamental to work on our self-regulation first and model positive reactions to stressful situations to the children. What to do and not do during episodes of emotional dysregulation For babies, physical contact is the strongest way to regulate emotions. Later on, words can also be introduced to help regulate children’s internal states.   As parents, we need to learn about staying in the emotion, without judging it as good or bad or wanting to stop it. This is not an innate competence but something that needs practice.   This is even more difficult if we are tired, going through stressful situations, lack a support network, or have grown up with the idea that these episodes need to be corrected.   When an episode of emotional dysregulation occurs, it is important to:   Stay calm (regulate your emotions first), ignore other people around you, and share your calm. As stated by Knost, "When little people are overwhelmed by big emotions, it is our job to share our calm, not join their chaos". Be present Maintain eye-contact Start with non-verbal communication : stay close to the child, go down at their level and, if possible, offer some contact, for example, a touch or a hug. This will start calming them down. Then, talk to them to  understand , validate  and regulate the emotion . Communicating to your child that you understand and accept their frustration, will help them understand that their emotions are important. Consider this as an example: "I can see you are angry (recognition of the emotion), as you wanted to jump from that stone (recognition of the origin of the emotion). I understand it and it is ok to feel angry about it (validating the emotion). I know it is exciting to do new things (recognition that what the child feels is legitimate), but you could fall if you jumped on your own, we can do it together (there is a solution)". Validating the emotion and how the child feels is crucial. This does not mean that we need to accept "unwanted" behaviours and not set boundaries. Assertive communication is important: "I know you are sad (recognition of the emotion) as you wanted an ice cream for breakfast (recognition of the origin of the emotion). It is ok to feel sad (validation) but you cannot hit mommy (set boundaries)". It is essential to show love towards the child, but not accept the behaviour. It is also crucial to try and put emotions in words, as this helps the child to build skills for later.   On the contrary, these things should be avoided: Angry comments, shouting and punishment (e.g., because you are behaving badly, you are not going to the park anymore/ you won’t have this thing that you like for dinner) Invalidating the emotion  (e.g., stop crying, crying is useless; what you are doing does not make sense; you have got nothing to cry about, you are fine) Judging the child for the behaviour (e.g., you are a spoilt/naughty child, you are acting like a baby) Lectures/logical explanations  (e.g., you are old enough to behave properly, there is no reason to cry for such a stupid thing). Time out  (e.g., now you are going to your room to reflect on what you have done) Return the behaviour (e.g., hit back). This will create confusion on whether that behaviour is acceptable   All these strategies can prolong a tantrum without resolving it while also communicating to the child that their emotions are not right, in turn impeding their healthy emotional development. These episodes   of emotional dysregulation are not indicators that the child is misbehaving or is "spoilt", but just how little children communicate their intense emotions. The role of the caregiver is to help the child calm down and put their emotions into words. Next time someone scolds you for not telling off your child during a tantrum, rest assured that you are doing the right thing.