‘Growing Together’ is the theme of this year’s Children’s Mental Health Week, which is taking place between the 7th and 13th of February 2022. It was launched in 2015 by Place2Be, a children’s mental health charity aiming to highlight the importance of young people’s mental health. This year, Place2Be are encouraging both young people and adults to consider how they have grown emotionally and ways that they can help others to grow. As a researcher currently studying young people’s mental health, I see the real-world impact these mental health discussions can have, and so, in this blog, I will explore how encouraging mental health discourse amongst young people can help us grow and collectively improve the mental health landscape. Our social and emotional development as children, being able to recognise, manage and communicate our feelings, helps us build our self-confidence, empathy, and our ability to form meaningful relationships as we enter young adulthood. Considering the last couple of years and how difficult they have been for all of us, the theme of ‘Growing Together’ is incredibly fitting and one that I am very excited about. During our younger years, we go through a tremendous amount of growth. We grow as individuals, begin to carve out our personalities, and figure out who we are. We grapple with how we see ourselves, who we choose to befriend and how we traverse the world as it becomes so much bigger and so much more complicated. We face new challenges and gain new, potentially life-changing, experiences, which shape our perspectives, influence our decisions, and help us overcome unfamiliar obstacles. It is a rollercoaster period of our lives and one where our relationship with and how we manage our mental health is absolutely critical. Young People and Mental Health As of January 2022, we know that at least 1 in 6 children and young people in the UK have a diagnosable mental health condition. We also know that over half of all mental health disorders actually start before the age of 14, and that 75% start by the age of 24. Young people face so many challenges and adversities which can impact their mental health, such as bullying, bereavement, body image, worrying about their future, managing their relationship with social media, and the list goes on. I’m a research assistant on the eBRAIN Study at the Institute of Psychiatry, Psychology and Neuroscience; eBRAIN is a study of brain development and mental health among young people in London. A massive part of my role is speaking to young people (aged 11–17) about their life experiences and their emotional health, hearing their perspectives, getting to know them better and finding out about their personalities and interests — this is by far my favourite aspect of my job. As researchers on the eBRAIN study, we have the awesome opportunity to visit different secondary schools across London and hold workshops and presentations on mental health, stress, and anxiety. The young people we meet have undoubtedly demonstrated the huge strides we have made as a society and how far the discussion around mental health has come. Their mental health literacy and understanding is far more advanced than I remember it being when I was in secondary school in east London, around a decade ago. Mental health literacy can be defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management and prevention’. The approach to mental health now is wildly different and has clearly improved a lot over the years. In my experience, we didn’t have any discussions whatsoever around mental health at school, during my adolescence, and there was so much stigma surrounding it. Our knowledge, awareness and understanding of mental health during that time was very limited, if not non-existent. Hearing how contrastingly positive and open the mental health discourse is amongst children and young people today is reassuring, to say the least. However, there is still a long journey ahead of us in terms of reducing the stigma, improving the understanding and general discourse around mental health, as well as bringing visibility to the support options available and how to seek help in the first place. The more informed we are, the more we are able to speak up and normalise reaching out for help and communicating our emotions and mental health struggles. What Does Talking About Mental Health Look Like? Research has suggested that poor mental health literacy is an obstruction to seeking mental health support during adolescence. Being able to recognise and disclose when we are experiencing difficulties with our mental health can also be hindered by stigma and feelings of shame or embarrassment. This stigma contributes to young people’s view of mental illness or difficulties and reduces the likelihood of them seeking help or treatment. We can improve our mental health literacy and reduce this stigma in a number of ways. One area where we can improve is speaking up about our own mental health, good or bad, if we are comfortable in doing so. Talking about your own experiences with your mental health or with mental health problems can inspire and empower others to seek support or speak up about their own mental health difficulties. This ripple effect is crucial to our emotional growth, as individuals and within our communities. However, it is important to remember to ask whoever you are communicating with if they have the mental capacity to listen, and that you do not assume that they have the mental space available. Something we stress in our eBRAIN mental health workshops is ‘it is impossible to know what someone’s mental health is like without talking to them’ — this is a sentiment I carry with me everywhere I go and try my best to be mindful of, no matter who I am speaking to. We can ask our peers, family, and friends how they really are, and have compassionate, empathetic, and caring conversations. Exhibiting genuine care and truly listening to young people, whether they are struggling or not, can make an enormous difference and reassure them that it is absolutely ok and important to talk about the issues we face with our mental health. Education certainly plays a colossal role in the improvement of our mental health literacy. We can educate ourselves about mental health in several ways, one being seeking out information online. What better place to start than right here on InSPIre the Mind? So many incredible writers have detailed their lived experience right here on the platform and it’s a great way to begin understanding unfamiliar perspectives and what it is like to experience a mental illness or go through a period of worse mental health. Another fantastic resource we can utilise is mental health charities; there is a vast amount of information and guidance online about all things mental health, thanks to the work of these organisations. Here are some of my personal UK-based favourites (and I would highly recommend them!): Mind, YoungMinds, Samaritans, and Maytree (I actually wrote a blog on InSPIre the Mind about Maytree, which you can read here). We can also educate ourselves through attending free workshops, undertaking online courses and speaking to mental health professionals. These opportunities are more abundant than you might expect! Being the Change Young people are our future and I wholeheartedly believe that their generation will lead the positive change and growth that we want to see in mental health, and the future of mental health altogether. I am hoping that we, as a wider society, can provide young people with the warmth, guidance and tools they need to help shape the approach to mental health and how we can make it more accessible to all. I, along with many others, believe we can be the change we want to see. — — — If you are interested in working with young people in this capacity, Place2Be offer a free ‘Mental Health Champions — Foundation’ programme and ‘DfE assured Senior Mental Health Leads Training’ to enhance professionals’ understanding of children’s mental health. They also offer a number of child counselling qualifications for specialising in working with children and young people. If you are struggling and need support, you can get in touch with these services and organisations which offer help and support directly: Talk to the Samaritans — they offer 24-hour emotional support in full confidence. You can call them for free on 116 123 / jo@samaritans.org.uk Shout Crisis Text Line — you can text Shout to 85258 if you are experiencing a personal crisis, are unable to cope and need support Rethink Mental Illness — you can call Rethink Mon-Fri 10am-2pm on 0300 5000 927 (calls are charged at your local rate) for practical advice on therapy and medication, financial issues, police, courts, prison and your rights under the Mental Health Act Mind — you can call the Mind Infoline on 0300 123 3393 / info@mind.org.uk, the Mind Legal Advice service on 0300 466 6463 / legal@mind.org.uk Get support from a mental health charity — Whether you’re concerned about yourself or a loved one, these mental health charities, organisations and support groups can offer expert advice: https://www.nhs.uk/conditions/stress-anxiety-depression/mental-health-helplines/ Speak to somebody you trust Talk to your GP

When I’m not playing video games, I am a research assistant on the eBRAIN study, researching adolescent brain development and mental health in London. I am a huge advocate for mental health and tackling the stigma around it. In my previous blog, I talked about the reality of feeling suicidal and how services like Maytree play a vital role in suicide prevention. In this blog, I’ll be discussing the rise of livestreaming as a popular form of online media and communication, the parasocial interactions between streamers and viewers, and how this new platform has impacted the conversation around mental health. Parasocial relationships are one-sided psychological bonds between members of an audience and the entertainer or performer, where the audience feels they know the performer, and in some cases, feel they are their friend, but these feelings are not reciprocated. As somebody who spends quite a lot (a LOT) of time playing video games and consuming gaming-related content, I have first-hand experience of being part of online gaming communities and the positive effects it can have on your life. Some of my closest friends are people who were once strangers I met through playing online multiplayer games. The evolution of these communities and the global shift of human communication throughout the years has been monumental and rapid, particularly over the past year where we migrated online for school, work and recreation, in the form of virtual coffee meetings and zoom quizzes. Not being able to see our friends, family and colleagues in person for such long periods of time has inevitably invoked feelings of loneliness and a lack of true human connection. Many of us found solace and safety in our online communities, whether it was within the gaming sphere or elsewhere. In fact, the number of monthly active users on Discord, a voice over internet protocol platform designed with gaming communities in mind, doubled by the end of 2020, reaching 140 million people! For those who find socialising in real life difficult or daunting, being able to hang out with your mates online is a godsend. Discord and similar platforms provide a space to build meaningful relationships, friendships and thriving communities, in spite of physical distance. Another space frequented by gamers is Twitch, one of the most popular online livestreaming platforms today, with a focus on video games, esports tournaments and IRL streams, involving various activities and hobbies. Livestreaming video games really took off in the mid-2010’s and has solidified its place in the online entertainment industry, with 7 million creators streaming monthly on Twitch alone. Although watching content on Twitch is free, creators or streamers can earn money in several ways, whether it’s donations and subscriptions from viewers, rolling advertisements, acquiring brand sponsorships, or selling merchandise. Even conventional celebrities regularly stream on Twitch, notable favourites being Doja Cat, T-Pain and Logic. Parasocial Paradise What’s so enthralling about Twitch is the variety of streams and entertainment available, and the individual reasons why you might watch them. Is it the streamer’s personality, relatability, and charm? Their raw gaming skill or knowledge? Or is it the comfort that their presence on the screen brings? When we react intensely to the latest episode of [insert your favourite TV show or podcast here], the last thing we’d expect is for the characters or hosts to respond to us, no matter how personally connected to them or their experiences we may feel. On Twitch, this isn’t the case. Livestreaming presents a whole new kind of interaction, where the normally very palpable barrier between the content creator and the content consumer (the audience) has been dissolved. Each stream has its own unique chat room where viewers, also referred to collectively as ‘chat’, can interact with each other and the streamer, who can react in real-time. Viewers can support their favourite streamers through monthly subscriptions or monetary donations, where they can add a personalised message for the streamer to read, an attractive proposition for viewers who are drawn to these opportunities to interact. However, by design, Twitch isn’t an ideal platform for one-on-one interactions, especially in busier, more popular streams, where there are often tens of thousands of viewers in the chat. This relationship between creators and viewers is very much one-sided. Viewers can develop interest in the streamer and learn about them, their hobbies and interests, their personal lives. Streamers, on the other hand, will not have the same level of interest in their viewers. These mediated, one-sided relationships can be referred to as parasocial. The concept of parasocial relationships or interactions is far from new, having been coined in the 1950’s to refer to the psychological relationship between an audience member and performers on TV or voices on radio. Unlike TV, Twitch offers a level of social reciprocity and the opportunity to be noticed and acknowledged by streamers, which can potentially lead to the development of an unhealthy attachment with said streamer, seeing them as a friend rather than entertainer. Parasocial interactions aren’t inherently damaging but they can become problematic depending on the specific circumstances. Mental Health Discourse Twitch, and platforms like it, can provide respite, distraction, and escapism, similar to that provided by video games, and can be a huge support when coping with difficult life events. In fact, the mass parasocial interaction between streamers and their viewers has facilitated discussion around mental health, and even allowed individuals to anonymously open up about adversities they are facing and their own mental health problems. Twitch has been highlighted as a ‘popular platform for mental health discussions’, depending on the streamer, the theme of their channel, their content and their communities. This shift of mental health talk online is, in my opinion, a valuable one and not exclusive to gaming communities or services like Twitch. Mental health discussions have also taken place on Twitter and other social media websites. The anonymity or even visibility attainable online can be comforting to those who may struggle to disclose their troubles in person or reach out to relevant services for help. A streamer who I find particularly interesting is Dr. Alok Kanojia, otherwise known as Dr. K or ‘HealthyGamer_GG’ on Twitch, a Harvard-trained psychiatrist who livestreams interviews with well-known gamers and streamers, and creates educational content regarding mental health, tailoring it for gaming culture. The co-founding of Healthy Gamer with his wife stemmed from his own gaming addiction and need to understand it. As a mental health professional and advocate, Dr. K has streamed to thousands of viewers tackling various topics, such as depression, anxiety, and suicidality, as well as things like procrastination (something I am very familiar with) and meditation. “The more overwhelmed I’d feel the more I’d play video games. And the more I’d play video games the more overwhelmed I’d feel. And it turned into a vicious cycle” — Dr. K Through his content, Dr. K has been able to guide many people within the Twitch community and hopefully leave them feeling more comfortable with tackling their mental health problems and accessing appropriate services. He has created room for vulnerability and real conversation about the kinds of struggles that we all face. “You be vulnerable, you share, don’t worry alone, remember that your struggles are a multiplayer game, too. If you want to help someone, start by asking for help.” — Dr. K The benefits of engaging with livestreams are undeniable, especially during a pandemic. Whether you are visiting a stream for relaxing entertainment, expressive information sharing, escapism, trends, companionship, social interaction or as a habitual time pass, the sense of community and the value of the space that comes with it is unique. It is, however, always important to maintain a balance and to implement healthy boundaries with livestreaming, both as a viewer or streamer. My hope is that these platforms and new ways of communicating continue positively contributing to the discussion surrounding mental health in a digital age.

Trigger warning: This blog discusses domestic abuse and intimate partner violence which some readers may find distressing. Celebrity scandals, cancellations, and turmoil are the coals that keep the fire of news outlet clickbait titles, damaging stereotypes, and sweeping generalisations roaring. It is part of our nature, as humans, to be interested in other humans’ lives, especially those we deem incredibly successful, famous, and wealthy. The idea sold is ‘How can rich people have problems?’ so the moment a celebrity’s troubles are publicised for all to see, some can’t help but indulge, and sometimes even revel, in their suffering. The suffering that signifies they aren’t any different from you or me. In the spring of this year, we collectively obsessed over one of the most public, high-profile ordeals of our time. One which divided the internet, spawned hundreds of memes, and had Twitter detectives all charged up and entirely absorbed in its fine details. The Johnny Depp Defamation Trial was a 7-week flaring feud between previously married celebrity actors: Amber Heard and Johnny Depp. The trial wasn’t the first defamation lawsuit fired between the two — only the first broadcast to millions online — yet this particular case garnered a baffling amount of attention, with thousands eager to give their own ‘two cents’ on the situation. As a mental health researcher actively working to tackle and reduce the stigma surrounding mental health difficulties, my focus (and where my genuine interest lies) here is the portrayal of Amber Heard and her diagnoses by the media, and the consequent impact on the way mental health conditions are framed, particularly when celebrities are involved. Female Celebrity Mental Health in the Media When the mental health struggles of a household name are strewn across the tabloids, it is easy for those of us who aren’t rich and famous to fall into the trap of forgoing empathy. Being a celebrity comes with its own ugly challenges and intense pressures, let alone mental health struggles; constant surveillance, every movement documented and scrutinised, every step becomes a spectacle. Distortions in the press and sensationalism have been around as long as ‘celebrity scandals’ have been a thing. Countless female celebrities have had their mental health difficulties put under the microscope in a callous fashion over the years. We all remember how Britney Spears was presented (and received) in the media following her decision to shave off her hair in 2007, branded as having a ‘public meltdown’, ‘erratic’, ‘mental’ and ‘crazy’. Earlier this year, Doja Cat also shaved her head, and tabloids, as well as her fans, were immediately worried for her mental health, speculating whether she needs professional help, despite Doja expressing the choice had nothing to do with her mental wellbeing. Other famous victims of tabloid journalism include Lindsay Lohan, Lady Gaga, and the late and great Amy Winehouse, to name a few. Their mental health, their struggles with addiction, their diagnoses, appearance and behaviour, all hot topics of discussion and juicy gossip material. Amber Heard was also a victim of the tabloids throughout the Johnny Depp Defamation Trial. Everybody had something to say about the pair on social media, whether it was #JusticeForJohnnyDepp or #AmberHeardDeservesAnApology, the majority seeming to favour Depp and attempting to preserve his image. Johnny Depp, being the world’s beloved Captain Jack Sparrow in Disney’s Pirates of the Caribbean series, didn’t receive nearly as much flak from the media or the internet. Moira Donegan, of The Guardian, described the trial as ‘an orgy of misogyny’, delving into the various ways Heard was publicly berated, and the different social angles surrounding the trial. However, as the trial unfolded, it was clear that both Depp and Heard appeared to have exhibited cruel, abusive, manipulative and inexcusable behaviours. In the end, the jury found both Depp and Heard liable for defaming each other and it was the intent of malice (and evidence supporting this) that was the basis of the ruling. The Wrongful Weaponisation of Mental Health Conditions Johnny Depp and Amber Heard have had a tumultuous relationship, to say the least. Six years ago, during the very early stages of their divorce, Heard filed and secured a domestic restraining order against Depp, disclosing experiences of emotional, verbal, and physical abuse, which Depp denied. The trial earlier this year was the second lawsuit between Depp and Heard involving the sensitive topic of intimate partner violence, defined as ‘any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship’ by the World Health Organisation. When investigating such delicate allegations, it is logical to gain a clearer, more whole picture of which factors, what evidence, might influence the verdict. Dr. Shannon Curry, a clinical and forensic psychologist hired by Depp’s legal team, provided a testimony where Heard’s mental health was the central topic of discussion, including the questioning of Dr. Curry’s intentions by Heard’s attorney, Elaine Bredehoft, during a cross-examination. Dr. Curry testified that “the result of Ms. Heard’s evaluation supported two diagnoses: borderline personality disorder and histrionic personality disorder”, following multiple tests where Heard’s scores were consistent with the diagnoses and identification of evidence of those diagnoses in Heard’s records and self-report. Dr. Curry also determined a number of characteristics that Amber Heard showed through test results: ‘tending to have inner hostility & rage, externalization of blame and can often be very judgmental of others while remaining self-righteous.’ Other mental health conditions discussed were post-traumatic stress disorder (PTSD) (as testified by Dr. Dawn Hughes, Heard’s clinical psychologist), anxiety and emotional reactivity. The psychiatric analysis and the subsequent diagnoses were relevant to the trial, as these personality disorders may have skewed Amber Heard’s own perception of events. Dr. Curry’s testimony spurred an avalanche of harrowing headlines, highlighting Amber Heard’s diagnoses. Definitions: “In general, someone with a personality disorder will differ significantly from an average person in terms of how he or she thinks, perceives, feels or relates to others.” — NHS “Borderline personality disorder is a mental illness that severely impacts a person’s ability to regulate their emotions. This loss of emotional control can increase impulsivity, affect how a person feels about themselves, and negatively impact their relationships with others. Effective treatments are available to manage the symptoms of borderline personality disorder.” — National Institute of Mental Health “A histrionic personality disorder, or commonly known as a dramatic personality disorder, is a psychiatric disorder distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors” — StatPearls Publishing Personality disorders are one of the most stigmatised, misunderstood mental health conditions, due to low public knowledge and misperception of symptoms as poor behaviour. There are also potential co-occurring disorders to consider, such as PTSD, which makes the diagnosis and treatment of personality disorders much more difficult. It is also important to mention that the exact cause of personality disorders is unclear, but research suggests a combination of factors, including genetics and environmental influences, such as experiencing abuse during childhood. Being diagnosed with a personality disorder, or any mental health condition for that matter, doesn’t absolve somebody of abuse, and abusiveness is not inherently a symptom of a personality disorder. The media presented a deeply damaging rhetoric, using Amber Heard’s mental health diagnoses as a weapon, a justification, a reason to explain Heard’s unacceptable behaviour which came to light during the trial. This approach only perpetuates the stigma surrounding personality disorders. It furthers the stereotype that those diagnosed with personality disorders or mental health conditions are innately abusive, which is very far from the truth. Clickbait titles and clout-chasing angles have been shown to be highly influential, despite their often sensationalist nature. The impacts of clickbait titles and damaging narratives spun by the media are definite and cannot be ignored. It stings that this comes following the pandemic and the subsequent greater acknowledgement, awareness and understanding of mental illnesses. We desperately need to re-examine the way we present mental health in the media, regardless of social status or fame, to destigmatise personality disorders and increase mental health literacy amonst the public. Resources Refuge: For women and children. Against domestic violence. ManKind Initiative: Male Victims of Domestic Abuse — Please call 01823 334244 to speak to us confidentially National Domestic Abuse Helpline — freephone 24-hour helpline: 0808 2000 247 Talk to the Samaritans — they offer 24-hour emotional support in full confidence. You can call them for free on 116 123 / jo@samaritans.org.uk Shout Crisis Text Line — you can text Shout to 85258 if you are experiencing a personal crisis, are unable to cope and need support Rethink Mental Illness — you can call Rethink Mon-Fri 10am-2pm on 0300 5000 927 (calls are charged at your local rate) for practical advice on therapy and medication, financial issues, police, courts, prison and your rights under the Mental Health Act Mind — you can call the Mind Infoline on 0300 123 3393 / info@mind.org.uk, the Mind Legal Advice service on 0300 466 6463 / legal@mind.org.uk Get support from a mental health charity — Whether you’re concerned about yourself or a loved one, these mental health charities, organisations and support groups can offer expert advice

Am I a Fraud? — Imposter Syndrome and How We Can Overcome It (Part 2 of 2) This is part 2 of a 2-part series, where we will explore the various ways we can overcome imposter syndrome, the research supporting these methods, and what leaders can do to help alleviate feelings of imposterism within their teams. In part 1, we defined and developed a deeper understanding of what imposter syndrome is, and what it looks like. How can we overcome imposter syndrome? If you want to stop feeling like an imposter, you have to stop thinking like an imposter. Our inner narrative, what we tell ourselves and how we see ourselves, can heavily impact our self-esteem and confidence, so it’s very important to be intentional with your inner narrative. When you have thoughts which feed into these feelings of imposterism, ask yourself ‘does that thought help or hinder me?’. Identifying and reframing those thoughts to overcome the doubts you’re having can mean that, over time, you really will begin to believe the new (and true) thoughts that you do belong where you are and that you are capable and competent. This way, we minimise these feelings into an ‘imposter moment rather than an imposter life’, as eloquently summarised by Dr. Valerie Young. People who don’t feel like impostors are no more intelligent or competent or capable than the rest of us. It’s very good news, because it means we just have to learn to think like non-impostors.” — Dr. Valerie Young What else can we do? We need to remember that as humans, we have emotions, and it can be easy to confuse how we feel with the facts; you might be having a rough day at work, but that doesn’t mean you’re bad at your job. Be kind to yourself and exercise compassion on those tougher days. Also, it’s completely ok to say, ‘I don’t know’. Not knowing the answer immediately just means you don’t know the answer yet and this is something you can look into. On that note of learning, look at failure as an opportunity to learn — we all make mistakes and it’s what we learn from that mistake and how we move forward that matters, not the failure itself. List and acknowledge your successes, it’s easy to forget how much we achieve every day, even menial tasks can be highlighted as positive progress. When people ask for your opinion or input, try not to second guess yourself — remember that you were hired for a reason and your input is valued. When you have imposter thoughts, remind yourself: I’m not an imposter, I earned my seat at this table, and if there was no seat for me, I brought my own stool and made space for myself at the table. Finally, feigning confidence, despite sounding a bit ridiculous, naturally increases your confidence over time — ‘fake it till you make it’ holds some truth! What can leaders do? As a leader, you can help reduce feelings of imposterism in your teams by creating an inclusive and open environment where people feel heard and don’t fear judgement. Using regular positive feedback and recognising people’s accomplishments, no matter how small, reassures your team that they are on the right track and helps draw attention to where things are going well. This helps to foster an encouraging environment where team members feel more inclined to be innovative and step out of their comfort zones. You can even ask your team to create ‘brag books’ where they list all of their own wins at work — seeing your achievements listed on paper can make a huge difference. Finally, another simple yet incredibly valuable thing that you as a leader can do is talk about to your own mistakes. This demonstrates to your team that no matter your level of expertise or seniority, you can still fail and learn from it, reminding your team that they’re only human. Imposter syndrome certainly permeates both our personal and professional lives; it’s something which requires our attention and energy to overcome. This journey of eliminating these feelings of fraudulence is a long and potentially arduous one. Hopefully, part 2 of this 2-part blog has helped provide some insight on how we can begin to tackle our imposter syndrome and work towards feeling much more confident in our abilities and positions, both in the workplace and at home. You can give the Clance Impostor Phenomenon Test a go yourself to find out the extent of your own imposter syndrome here. ‘The Impostor Test was developed to help individuals determine whether or not they have IP characteristics and, if so, to what extent they are suffering. After taking the Impostor Test, add together the numbers of the responses to each statement. If the total score is 40 or less, the respondent has few Impostor characteristics; if the score is between 41 and 60, the respondent has moderate IP experiences; a score between 61 and 80 means the respondent frequently has Impostor feelings; and a score higher than 80 means the respondent often has intense IP experiences. The higher the score, the more frequently and seriously the Impostor Phenomenon interferes in a person’s life.’

Am I a Fraud? -  Imposter Syndrome and How We Can Overcome It (Part 1 of 2) Have you ever thought ‘am I truly deserving of my position?’, felt like you don’t quite fit in the large shoes you’re supposed to fill, or that you’re somehow pulling the wool over the eyes of your peers, colleagues, and supervisors? Or maybe that you just ‘got lucky’? This feeling of being a fraud and lingering doubt, that you somehow tricked and are still tricking the people around you, is actually something many of us will experience at one point or another throughout our careers or indeed, lifetimes. In fact, you’d be surprised to know that even those you admire have also felt the fear of being exposed as an imposter. This is part 1 of a 2-part blog, exploring what imposter syndrome is, the history and research behind it, and who it affects. Having both experienced and observed imposter syndrome throughout my academic and professional journeys, I was really keen to delve into this topic and find out why so many people, especially those who would be considered highly accomplished, experience imposter syndrome, how it comes about, and the various ways in which it manifests. Imposter syndrome — finding it difficult to acknowledge or internalise our achievements and doubting our abilities despite compelling evidence — is quite a common psychological experience in academia and across many other professions. ‘How am I here?’ is something I catch myself asking often, especially as an early career researcher surrounded by highly esteemed academics and professors. I am a bit too familiar with the thought that my successes aren’t due to my abilities, qualifications or achievements, that maybe I am fooling everyone around me and one day I’ll be found out. In fact, when asked how I landed my role as a Research Assistant on the eBRAIN Study at the Institute of Psychiatry, Psychology and Neuroscience, one of my instinctive answers is ‘I got super lucky!’. But in answering so, I fail to recognise all of the hard work and effort exerted leading up to securing this role, which I am so grateful to have. The Imposter Phenomenon The imposter phenomenon, first coined and identified by psychologists Dr. Pauline Clance and Dr. Suzanne Imes in 1978, theorised that women alone experienced imposterism. Through clinical observations during therapeutic sessions with high-achieving women, they found that despite objective evidence of their successes, the women they interviewed still believed they were imposters and feared having this intellectual and professional fraudulence discovered. The women experienced anxiety, depression, dissatisfaction with life, a lack of self-confidence, and frustration having not met their own high standards of achievement. The never-ending self-doubt brought on by imposter syndrome can damage both our professional and personal lives, as these constant feelings of inadequacy act as barriers within our relationships, jobs and our personal self-esteem, diminishing our enjoyment of life. Failing to internalise our successes or abilities adversely affects how we see ourselves and can hinder our growth. Why do we experience imposter syndrome? We can experience imposter syndrome for a number of reasons. One, which I recognise personally as one of my strongest catalysts for imposterism, is achievement and intelligence being linked to social contexts, family environments, and perfectionism. Growing up in an environment where there is immense value and pressure placed on grades and achievement can lead to feeling like an imposter later on, particularly when parents or guardians are conflicting in their extreme praise and criticism, wavering between the two. This external pressure to do well isn’t confined to our homes. “People often internalise these ideas: that in order to be loved or be lovable, ‘I need to achieve,’ it becomes a self-perpetuating cycle.” — Dr. Audrey Ervin Today, there is intense societal pressure caving in on us from all angles, whether it’s seeing our peers’ and colleagues’ achievements plastered all over social media or the wave of entrepreneurial hustle culture that has gripped newer generations through stories of seemingly overnight success. Social platforms like LinkedIn, Twitter, and Instagram have made it a lot easier to see how well others are doing in their careers and personal lives. The problem truly arises when we equate our success and achievement with our self-worth, seeking approval and love through our accomplishments. For those of us who suffer from perfectionism (guilty!), we create a distorted and unrealistic definition of competence. We know that perfection is unattainable, yet we strive for an unsustainable level of capability, stretching our capacity to its limits and again, feeling like an imposter when things go awry. Who does it affect? Anybody can view themselves as an imposter if they struggle to internalise their achievements. However, imposter syndrome disproportionately affects high-achieving people, such as those within academia or high-pressure corporate environments, who find it very difficult to accept their accomplishments. Being chosen for an award or to give a presentation can spur those thoughts of ‘Why me? Surely there’s someone more qualified for this?’ and it can be challenging to believe that you are an expert in your field or someone who is worth listening to. I definitely struggled with this belief throughout my academic career, questioning my own knowledge and skills, despite tangible evidence. It has also been found that women, particularly women of colour, women in minority groups, women working in STEM (Science, Technology, Engineering and Mathematics) fields, and international students, are more likely to experience imposter syndrome. I didn’t find this too surprising, considering the overwhelming pressure on women to prove themselves, especially in a professional environment, living up to the standards we perceive of our male counter parts. “A sense of belonging fosters confidence. The more people who look or sound like you, the more confident you feel. And conversely, the fewer people who look or sound like you, it can and does for many people impact their confidence” — Dr. Valerie Young “Women, women of colour, especially black women, as well as the LGBTQ community are most at risk. When you experience systemic oppression or are directly or indirectly told your whole life that you are less-than or underserving of success and you begin to achieve things in a way that goes against a long-standing narrative in the mind, imposter syndrome will occur” — Brian Daniel Norton “We’re more likely to experience imposter syndrome if we don’t see many examples of people who look like us or share our background who are clearly succeeding in our field” — Dr. Emily Hu Patterns in people who experience imposter feelings Dr. Valerie Young, an imposter syndrome expert, has identified a number of patterns in people who experience imposter syndrome: Perfectionists set extremely high expectations for themselves, feel like failures even if they meet majority of their goals, and small mistakes will result in them questioning their ability or competence Soloists feel they have to complete tasks on their own, and struggle to ask for help as this means that they are indeed a failure or a fraud Experts feel they need to have all of the information and knowledge before starting a project, constantly look for new qualifications or training to help them improve, feel they need to meet all criteria in a job specification in order to apply, feel hesitant to ask questions or speak up in meetings in fear of appearing unintelligent Natural Geniuses think they aren’t good enough when struggling with work or having to exert extra effort, are accustomed to skills and capability coming easily so when hard work is required, this is confirmation that they’re a fraud Superhumans push themselves to their limits work-wise, working harder than those around them to confirm they aren’t imposters, feel they need to excel in all aspects of life: work, relationships etc., feel stressed when not accomplishing something You may see some of your own imposter tendencies in these patterns — being able to acknowledge how our imposterism manifests is always a good starting point to tackling it. So, now we know what imposter syndrome is and how to identify it, how exactly can we begin to overcome our imposter syndrome? In part 2 of this 2-part series, we we will explore the various ways we can overcome imposter syndrome, the research supporting these methods, and what leaders can do to help alleviate feelings of imposterism within their teams. You can give the Clance Impostor Phenomenon Test a go yourself to find out the extent of your own imposter syndrome here. ‘The Impostor Test was developed to help individuals determine whether or not they have IP characteristics and, if so, to what extent they are suffering. After taking the Impostor Test, add together the numbers of the responses to each statement. If the total score is 40 or less, the respondent has few Impostor characteristics; if the score is between 41 and 60, the respondent has moderate IP experiences; a score between 61 and 80 means the respondent frequently has Impostor feelings; and a score higher than 80 means the respondent often has intense IP experiences. The higher the score, the more frequently and seriously the Impostor Phenomenon interferes in a person’s life.’

Drowning — Swimming through the Crushing Weight of Suicide What is the Problem? — a Mountain to Overcome but a Mountain Nonetheless Breaking a bone is glaringly obvious and visible. Everyone signs your cast and asks, ‘how on Earth did that happen?’. They are sympathetic and attentive, making sure to ask if you need help. Mental illness isn’t always visible. As a consequence, poor mental health can often be overlooked by those around us and even ourselves and can therefore worsen over time and become severe and debilitating. But mental health is equally as important as physical health. In fact, mental illness can manifest itself in many physical ways, such as difficulty sleeping, severe headaches, muscle tension and lethargy. Personally, I have always viewed mental health as physical health. Our brain is one of the most vital organs in our body. The stigma-charged statement of ‘it’s all in your head’ rings true here in a sinister way; our mental health should not be ignored. The state of our emotional, psychological and social wellbeing determines how capable we are of making the most of our potential, coping with life and playing a full part in our family, workplace, community and friendships. Our mental health is crucial to our overall wellbeing and happiness. When we struggle to cope with the many challenges of daily life, our mental health deteriorates and sometimes these struggles can cause us to feel suicidal. After facing the catastrophic, burning train wreck that was 2020, it is clear now more than ever that suicidal thoughts and feelings can affect anyone, no matter your age, gender, occupation or background. Mental health should be a core focus in our communities and wider society, as a worldwide issue which requires attention and care. In 2019 alone, 5316 people died by suicide in England, with around 75% of them being men. Suicide statistics, although staggering and daunting, highlight the need for interventions which can help prevent individuals from reaching a point in their life where they feel nothing can fix their situation. My own experience of suicidal thoughts and feelings is an overwhelming one. I have felt intense hopelessness and worthlessness, which has exacerbated my anxiety and depression. It has consumed me in the past, in a way nothing else has, plunging me into a dark place where I felt I had no control. What helped me? Why am I still here? I am very fortunate and grateful to have a strong support system of friends, colleagues and family members who have listened to my struggles without judgement and provided me with the space I need to address my feelings and negative thoughts. I have also found benefit within the resources available to me, attending counselling appointments at university and reaching out to relevant services when I found the energy and strength to do so. The good news is suicide can be prevented. If you know someone who is suicidal and want to help, there are various approaches, one of the most profound being an empathetic approach. Demonstrating empathy and simply listening can be incredibly powerful. The living proof is the many institutions working towards alleviating the suffering of those experiencing suicidal thoughts and feelings, one of them being Maytree, which I have had the pleasure of volunteering with for the past year or so. Breathing Fresh Air — A Glimpse of Light at Maytree What is Maytree? Maytree is a unique residential respite centre based in North London, for people who are feeling suicidal, offering a free one-off stay of five days and four nights. Offers of a stay are made following a few phone calls with different volunteers, discussing the potential guest’s current situation and their experience with suicidal thoughts and feelings, and an assessment at the house with a co-ordinator, the senior and highly trained members of staff who make Maytree possible and support both guests and volunteers alike. Inspired by the Samaritans’ approach, Maytree provides a non-medical, non-judgemental and safe environment for adults in suicidal crisis to rest, reflect and be sincerely heard in complete confidence. The alleviation of suffering, encouragement of re-engagement with life and the restoration of hope are all cornerstones of Maytree’s mission, one which deeply resonates with me and many others. How did I get involved? I first heard about Maytree at university from an ex-volunteer, whilst attending a talk exploring careers in mental health research. I had never heard of a charity quite like Maytree. The concept of such a service was both remarkable and reassuring; I remember feeling so hopeful and itching to find out more. Having experienced mental illness and suicidal ideation myself, I firmly decided to apply to volunteer at Maytree in July 2019 and was offered a place on the training course to become a volunteer befriender. The training consisted of five 3-hour thorough sessions throughout September 2019. I found myself in a room with a group of people who all wanted to help people who are feeling suicidal, regardless of our diverse reasons for venturing on our Maytree volunteering journeys. The process was honest and whole, providing us with a comprehensive experience of supporting suicidal guests and callers. We delved into recent suicide statistics, how to listen effectively, how to handle challenging situations, recognising flashbacks and dissociations, and communicating with empathy. Despite the severity of suicide and the aspects surrounding it, we were able to bond over soothing cups of tea, delicious international treats and actively testing our newly gained knowledge through some good old roleplay. Maytree throughout Lockdown Unfortunately, the house is currently closed due to the pandemic. However, this hasn’t stopped everyone at Maytree providing support to those who need it over the phone and via email, where possible. In March 2020, I took part in the Maytree Movement Marathon, alongside Alaistair Campbell, Joy Crookes and some fellow volunteers, in an effort to raise money for the suicide prevention work Maytree does. We were able to raise a whopping £5,640! It was a perfect way to stay connected to my colleagues at Maytree, whilst supporting the life-changing work they do. I have had the pleasure of seeing the amazing work that Maytree does first-hand, and the hope and kindness Maytree spreads. What is it normally like? When you walk through Maytree’s celadon green door, a sense of serenity and calm instantly washes over you. The house, despite normally being pretty busy and full of guests, volunteers and co-ordinators, radiates a sweet stillness throughout the so carefully created cosy spaces. My personal favourites are the kitchen and the garden. Whether I’m making a tea and grabbing a custard cream at the start of my shift or sharing a delicious soup cooked by one of the wonderful guests for lunch at the table, the kitchen is the heart of the house, a space for coming together and general warmth. The floor to ceiling glass windows and door leading out to the garden make the kitchen feel open and welcoming, sometimes celestially embellished with raindrops (classic British weather) but always letting in the refreshing daylight, which elegantly spills and fills the room. The garden is full of blossoming vibrant flowers and plants, intertwining trees, with different spots to sit and chat, and occasionally homing a furry friend, the neighbour’s cat. As a volunteer, I befriend guests over the telephone, email and face to face at Maytree. I also help with the running of the house, all of the day to day tasks which keep the house gently humming along. Speaking to guests and hearing their troubles, helping them explore the series of events which have led to them staying at Maytree, can be challenging at times but is also immensely fulfilling. Seeing guests grow and gain hope throughout their stay is an extraordinary experience. And to me, and so many, Maytree is an extraordinary place. If you are struggling and need support, you can get in touch with these services and organisations which offer help and support directly: Maytree is currently offering email and telephone support between 8am and 8pm at the present time. Residential stays will resume at a later date when the house re-opens: 020 7263 7070 / maytree@maytree.org.uk Talk to the Samaritans — they offer 24-hour emotional support in full confidence. You can call them for free on 116 123 / jo@samaritans.org.uk Shout Crisis Text Line — you can text Shout to 85258 if you are experiencing a personal crisis, are unable to cope and need support Rethink Mental Illness — you can call Rethink Mon-Fri 10am-2pm on 0300 5000 927 (calls are charged at your local rate) for practical advice on therapy and medication, financial issues, police, courts, prison and your rights under the Mental Health Act Mind — you can call the Mind Infoline on 0300 123 3393 / info@mind.org.uk, the Mind Legal Advice service on 0300 466 6463 / legal@mind.org.uk Get support from a mental health charity — Whether you’re concerned about yourself or a loved one, these mental health charities, organisations and support groups can offer expert advice: https://www.nhs.uk/conditions/stress-anxiety-depression/mental-health-helplines/ Speak to somebody you trust Talk to your GP

Spirituality and science are considered irreconcilable by many. The former is an intensely subjective, first-person experience; the latter is based on strict objectivity, empiricism, and replicability. I, as a psychiatrist For most of my adult life, I have considered myself a scientist. Having experienced first-hand the horrors of religious violence, I grew up in India as a ‘devout atheist’. Scornful of organised religion, suspicious of Gurus, and mockingly condescending of personal accounts of a mystical nature. My professional training as a psychiatrist further guarded me against taking the validity and veracity of subjective experience at face value. While the abnormal experiences such as hearing voices or seeing things (hallucinations) of schizophrenia are as real to a sufferer as sunrise is to me every morning, we don’t confer the status of ‘reality’ to such symptoms; psychotic disorders are fundamentally impairments of reality testing. Even if not psychotic, our mind plays tricks upon us. We are all prone to misperceiving and misinterpreting data we receive through our mental apparatus. As the popular saying goes, the plural of anecdote is not evidence. For years, therefore, I did not share a personal experience that had occurred in a post-operative state when I was in my early twenties. I decided to share it with my son Arion one morning during the school run. From early childhood, Arion has been deeply interested in such matters, often discussing his Religious Education lessons at school, and asking intriguing questions about religion, life, the nature of reality, and God. Arion insisted that I write about my experience. I did so, with considerable trepidation, and submitted it to the Journal of Nervous and Mental Diseases. I was surprised that it was sent for peer review, relieved by the reviewers’ comments, and delighted by its eventual publication, “Stairway to Heaven” in the Journal of Nervous and Mental Disease. I had expected at best rejection and at worst ridicule. Several members of the public wrote to me, mostly to share their own experiences. Except for one disparaging email, most respondents were positive about the paper, and many said that they felt validated in their own experience. I, as awareness In the paper, I describe an experience of dream-like state while recovering from general anaesthesia for a major operation. I still recall the entire experience vividly. I was lucky to have shared it ‘live’ with my father who substantiated my account when I was fully conscious. I perceived something that in hindsight I can only describe as “the big bang” bringing the universe into existence. I felt a complete understanding of the cosmos as a dance between five entities: matter, energy, time, space, and life. Matter and energy were interchangeable, as were time and space; but each combination, along with total ‘life force’ existed as a constant. The experience ended as abruptly as it had begun. For months afterwards, I had an intense feeling of peace, purpose and meaning, despite being in considerable physical pain and discomfort. Once I started reading about such experiences, I realised the commonality of phenomenology of such experiences across vast tracts of time, geography, and cultures. William James first described four qualities of such experiences: a) ineffability: inadequacy of words to describe the quality of the experience; b) noesis: significant knowledge received and perceived immediately and directly, with a sense of authority; c) transiency: self-limiting nature of the states but which can be recalled from memory and may recur; and d) passivity: individual having no sense of control over the experience. There is now a substantial literature on such phenomena, their genesis, and likely neurophysiological basis. Aldous Huxley had a similar experience under the influence of mescaline, beautifully described in his book The Doors of Perception. While very fond of the writings of Huxley and the music of the Doors, for many years I considered my experience to be no different from a hallucinogenic ‘trip’. A year following the experience, I became consumed with working for children who had experienced religious violence. I forgot about the experience, or more accurately, other matters gained salience in my life, alongside my deepening disdain for all matters religious. Arriving in Britain in 1991, I was enthralled by this culture’s pervasive scientific materialism, which seemed self-evidently superior to the famed spirituality of India. A wiser me As I have got older, the intellectual certainties of my youth have crumbled one by one. The longer I practice psychiatry, the more neuroscience I learn, the more I contemplate the mental phenomenon and the wider I read about the area, the less dogmatic I become about materialism as the sole explanation of reality. I haven’t lost my cynicism about many contemporary Gurus with their glib assertions and DIY homilies. Human gullibility is fed by vulnerability and adversities, and our mind’s endless inventiveness in how it fools us has been widely studied. I have tried to stay true to the principles of science in my clinical and academic work, and have never discussed the experience, or allowed it to influence my judgement or practice as a psychiatrist. But in my own understanding, I am now open to the possibility of non-material dimensions to reality, and the inherent limitations of using the tools of the mind to fully understand the mind. The commonality of such experiences cannot by itself be proof of their veracity. Distressing hallucinations and paranoid delusions don’t become ‘real’ just because so many people have them. After all, a distressed mind has only a few ways to signal its distress. It cannot blow out blue smoke from the ears; it can only reveal itself in errors of mental function. But unlike psychopathology of mental illness, mystical or spiritual experiences are not associated with dysfunction or functional impairment. Most people who report such experiences describe their impact as intensely positive and sometimes life changing. The resurgent interest in the use of psychedelics in treating serious mental disorders offers a perfect opportunity to stop seeing the subjective as oppositional to science. Psychiatry is fundamentally the study of the subjective, and as doctors, we focus necessarily on disease and dysfunction. Perhaps exploring positive aspects of wellbeing, including those related to phenomena such as mindfulness, contemplation and, dare one say, spirituality, may help resolved ‘hard problems’ such as the mind-body relationship, consciousness, and the nature of reality itself.

One in seven young people experiences an issue with their mental health, and many adults who experience problems with their mental health experience their first symptoms during adolescence. Researching the biological basis of mental health in young people can provide insights into the mechanisms underlying mental illnesses, which can inform the development of more effective treatments. It can help identify potential risk factors and early warning signs, enabling early intervention and prevention of mental health disorders. One study currently focusing on this is the eBRAIN study, which is being run at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London (KCL). The eBRAIN study investigates the impact of early life adversity on young people's brain development and mental health. The study involves participants aged 11-14 from London who have a brain scan, give biological samples, and answer lots of questions about their life experiences, thoughts, and feelings. My name is Stanley, I am a 15-year-old student in London and I am a participant in the eBRAIN study. I first heard of the eBRAIN study when two researchers from KCL presented an assembly at my school explaining the study and inviting us to take part. They also spoke to us about mental health. This is where, for the first time, I and many of my peers were educated on the stigma surrounding mental health issues, particularly, how many people with mental health problems are treated differently and their struggles ignored just because it is not a visible illness and is sometimes viewed to be a sign of weakness or vulnerability. Having known people struggling with mental health issues at the time due to lockdown and stress, my instant response was, "that’s wrong" and then, "what can I do about it?" Having the opportunity to take part in the eBRAIN study gave me a way to channel my frustrations and hopefully, to create a positive impact on the world. What was it like to take part? The idea of someone studying the growth of my brain was amazing in itself, but the idea that that data might then be used to help the 1-in-7 young people struggling with mental health issues truly resonated with me. I felt that for once I would be able to bring about change to an issue that I was passionate about. Before taking part in eBRAIN, mental health studies were a mystery to me — an enigma that eleven-year-old me could not quite wrap his little head around. I understood the basic concept of studying human behaviour and biological changes, but not how that could be translated into some sort of remedy for healing mental health issues. The first study visit began with questionnaires on my mental health and emotional experiences over both a short time period of two weeks and then also a long-term period of six months. There was also a quiz on non-verbal reasoning that tests pattern recognition and a vocab quiz which tested my ability to explain different words. I also had an interview conducted by one of the researchers including questions on my thoughts and feelings, and any stressful life experiences that I might have had during my childhood. The next part of the study visit included saliva, urine, and blood samples being taken. I was quite nervous initially because it was the first time that I’d met the researchers and my first time giving biological samples, but after I realised how easy it was, I calmed down and settled into the visit. The questionnaires were a particular point of interest for me as they made me consider elements of my life and their implications which I may have taken for granted before, such as a loving two-parent household. The vocab and non-verbal reasoning tests I particularly enjoyed because of their ability to challenge me and force me to work, to conjure definitions of words, or connect the dots to find a pattern through a series of images. Eventually, it was time for the Magnetic Resonance Imaging (MRI) scan where detailed images of my brain and surrounding tissues were taken using strong magnetic fields. Inside the MRI I had to lie still for the most part, however, there was one task where I had to complete a simple ‘Yes or No’ quiz done by the use of a handheld controller. Two face images were shown and I had to decide if they were the same face showing the same emotion. The MRI took roughly three-quarters of an hour. It made me feel ill and a little bit motion sick just from the vibrations, but I knew that if I was in trouble during the scan, the staff had equipped me with an emergency buzzer so my mind was at rest. It was also very loud; however, I found that with the earplugs I was able to quickly adjust and after a while, you can kind of just zone it out. Finally, I filled out a feedback sheet and final paperwork before receiving my vouchers and going home! After my first study visit, I then completed two further study visits, a year apart. What did I think of the overall experience? Throughout the process of eBRAIN my outlook on mental health and research has changed, through the development of both myself as a person and having a deeper understanding of the study itself, the pieces began to click together in my head. Since both a healthy diet and regular exercise are crucial to the maintenance of good mental health as well as brain development, it makes logical sense to study the effects of these factors on adolescents and see if there is a direct correlation to mental resilience in these people. The study also considers different adverse life events that may increase the likelihood of experiencing symptoms of poor mental health such as experiences of bullying, family separation, or being a victim of crime. It really helps to bring to light the challenges that many people face, not just in London or the rest of the UK but all over the world in general, that might cause them to feel this way or struggle with mental health issues. Oftentimes it can be the continual presence of a smaller issue, like hurtful comments or altercations with friends that if not addressed can grow over time and morph into something severely detrimental to the wellbeing of the person. I had a really good experience with eBRAIN and I feel that it has helped me to learn a lot about myself and caused me to consider many things that normally would have gone unnoticed such as the aforementioned factors like diet and exercise. Also, in a way, it has helped me to open up about thoughts and feelings that may have remained hidden if not for my participation in this study. I suppose throughout the whole process my one key belief has remained which is that the stigma around mental health is utterly and entirely wrong and unfounded. That principle kept me going throughout some of the less enjoyable parts of the study, like the MRI scan! Overall, it was an amazing experience, and I was and still am grateful for the opportunity I received to be part of something much bigger that could have a widespread impact on the wellbeing of my peers and agemates. Final Thoughts In my opinion, the best way to encourage other young people like me to take part in studies of this nature is to make sure that they have a very personal experience of it — like you do with eBRAIN through the one-to-one interviews and questionnaires — and to help them understand what they are a part of as well as nurturing their growth as they become mature young adults in the world today. To get the most accurate and honest responses, the participants must feel that they are in a safe space with requirements of confidentiality and privacy so that they feel free and comfortable to share their true thoughts and feelings on the subject matter, whatever it may be. I look forward to taking part in any further studies in which I can make a difference or bring about change.

Have you ever thought about how you experience stimuli in the environment around you? Do you tend to seek out new people and places, eager to soak up every type you can, or does constant sensory input exhaust you? I’m Livia, a regular contributor here at Inspire the Mind, and I relate to the latter. Crowds overwhelm me, I can never tolerate a packed schedule for long, and I get extremely hangry, in other words, being hungry makes me irritable – not great when you are caught out and about and do not have a snack ready to hand. As a homebody who adores stillness, my senses exhaust me when I am exposed to a lot of busyness. If you can relate to what I say, you may experience Sensory Processing Sensitivity (SPS). Sensory Processing Sensitivity, Explained Sensory Processing Sensitivity was popularised as a theory by psychologist Elaine Aaron, who suspected that she had found a new personality trait that stems from an extra sensitive nervous system. According to Aaron, SPS means that you are more aware of what goes on around you, even subtle changes, and process that sensory data more slowly and thoroughly. In turn, you feel more than most, and are overwhelmed faster than others. She created a test, where takers ponder for themselves whether they are, for example, greatly put off by violent movies, loud environments, and changes in life, and have an overall greater need for rest. Those who score at the very top, Aaron meant, have Sensory Processing Sensitivity, and may be called Highly Sensitive Persons (HSPs). Top Notch Nervous Systems Over the last decade, more research has been undertaken to understand Sensory Processing Sensitivity better scientifically. Researchers looking at the brain scans of people who report top HSP test scores, for example, have found that we do seem to be objectively differently sensitive. A recent study showed that brain regions that are relevant for awareness and empathy, such as the amygdala, showed more activity when HSPs saw photos of strangers whose faces expressed various moods — for example, happy and sad — compared to those who scored much lower. Fascinatingly, research has also suggested that HSPs even seem to be more aware of their own bodies, and feel physical sensations, such as a hungry stomach or strong pulse, more vividly. What causes that extra load of SPS that makes somebody extra sensitive to external and internal stimuli has not been established, but may result from several factors, such as genes and childhood experiences. A Challenge... High sensitivity is a healthy trait that is not exactly uncommon, as an estimated third of everybody on the planet has SPS. But as HSPs often say, sensitivity plays a real part in shaping a life and should not be trivialised. For better and for worse, a sensitive brain stays sensitive wherever it goes, and can become extra challenging when you face some unpleasantness on the way. On an everyday note, to constantly respond more saps energy, and a bombardment of sensory data makes HSPs prone to suffer extra from stress when exposed for long. Burnout, for example, appears to be more common for nurses who have SPS. It might also not help that our society tends to respect toughness and see sensitivity as weakness: many HSPs appear to feel lonely and odd around others. ... and a Blessing But that extra bit of SPS can be an advantage, too — so much that more and more say that high sensitivity should be promoted as a superpower instead. Researchers have found that HSPs are on average more creative and have stronger bonds to nature and more powerful responses to ASMR. Love, too, seem to take on a somewhat more colourful form — in the study where HSPs showed higher brain activity when exposed to the moods of strangers, their brain scans also showed that they responded more strongly when they got to see photos of loved ones. Those are some lovely perks, and even though HSPs are more devastated by heartbreak and trauma, an enhanced response to whatever happens around them seems to grant HSPs better chances to make faster progress in therapy, both as children and as adults. The same sensory depth that makes them more prone to struggle when they have to handle stress, then, may mean they are extra empowered when they stay balanced. Makes sense, then, that sensitivity researchers use the metaphor of an orchid — a delicate flower that blooms gorgeously under the very right conditions — to refer to Highly Sensitive Persons. Nurturing the Orchid Nevertheless, HSPs cannot command the climate, and getting support and consciously following a wellbeing strategy can help them stay healthy. In a day and age where we are encouraged to stay busy and stay tough, HSPs need to be better than most at saying no to unnecessary stressors — such as that loud party — that exhaust them from sensory overload. Instead, to better the chances at that extra gladness that HSPs are capable of, they are recommended to put themselves first and arrange the everyday to suit their sensitivity. To accept your sensitivity and care for yourself, says Elaine Aaron herself, becomes extra necessary when undue stress comes along. Sensitivity as Strength When you are exhausted after a regular day, ready to go under the covers as soon as you get home, sensitivity does not really seem like a strength. But when humans evolved, tens of thousands of years ago, we had to overcome a very dangerous world together. A person who sensed the savannah around them better was probably more fearful, but could also detect a sneaky, nearby danger, such as a predator, faster. The group was stronger with people of different capabilities. Sensory Processing Sensitivity can be seen as a superpower, then, that has helped humans survive. When it seems to amplify negative human experiences, however, it can make life overwhelming. Even so, I welcome my SPS. When not pressed by a busy room, I’d dare say that I seem to talentedly see beauty everywhere. A tendency to respond extra to whatever happens around you makes the lovely even more lovely. I would not have it any other way.

Our new research shows that more people with depression than previously estimated could have increased activation of their immune system What are we looking at? If you are familiar with Inspire the Mind, you will probably know that depression is a complex mental health condition that in a significant proportion of people is associated with increased levels of inflammation. As a psychiatrist and a researcher at King’s College London, I am particularly interested in understanding the biological mechanisms involved in this intricate relationship, as they might help identify a subgroup of individuals with depression who could benefit from specific interventions targeting inflammation, for both treatment and prevention. In our recently published research, we tried to broaden our understanding of the relationship between depression and inflammation. We analysed specific markers (mRNAs) in the blood of people with and without depression and we showed that more depressed patients than previously thought have an increased activation of their immune system. Notably, this immune activation is present not only in people classically considered as having inflammation, such patients who do not respond to routinely-available antidepressants, but also in other groups of depressed patients, opening novel paths to understanding the biology of depression. Let’s take a step back. What do we mean by inflammation and why is it so important? Inflammation is the activation of the immune system and the natural response of our body to anything that is perceived as damage, such as an injury or an infection. It is therefore clearly a useful mechanism (especially in the short term) that helps us in maintaining our well-being. However, just like many things in medicine (and life), what is good in some circumstances and/or in an adequate amount may become harmful when in excess. Under certain conditions, indeed, inflammation can become chronic (sustained over time), or it can be triggered without an external threat. In these cases, inflammation is associated with – and can contribute to – a wide range of health problems, including mental health disorders such as depression. What do we know about the relationship between depression and inflammation? There is strong and consistent evidence of clinically-significant, "low grade" inflammation in around 20-30% of people with depression. However, the exact mechanisms behind the relationship between depression and inflammation remain a topic of ongoing research, and disentangling this evidence is indeed the keystone of my studies. Notably, people with depression and inflammation are also less likely to respond to conventional antidepressant treatments, further highlighting the need for tailored research in this field. What are we measuring when measuring inflammation? The importance of gene expression. Most of the published research on inflammation in mental health uses the levels of a protein in the blood, called C-reactive protein (or CRP). CRP is a protein produced by the liver in response to immune signals secreted by blood immune cells (the “white cells”) during inflammation. It is therefore widely used as a marker of inflammation (by measuring CRP levels in the blood) in clinical and research settings. However, when we are measuring CRP (or any other protein) we are looking at the final product of a complex process called “translation” - translation of gene expression (mRNAs) into proteins. In a nutshell, genes are segments of the DNA (deoxyribonucleic acid – the molecule that carries all the essential information to our lives). Genes are present in all our cells, but they can be “switched on or off” based on different circumstances, such as during inflammation. Once a gene is “switched on” (or activated), it sets a series of actions within a cell before we see its end product – protein. As such, first it is transcribed into a molecule called mRNA (messenger ribonucleic acid) and then translated into a protein. With gene expression, the information encoded in our genes (what we broadly call the genotype) is translated into functional products, such as proteins, ultimately producing the entirety of our observable traits (what we call the phenotype), such as the colour of our eyes or our height. Therefore, while the genotype can be considered like a file with all our information in it, the phenotype is how this information is interpreted and adapted to external circumstances. By applying this to our research, the measurement of mRNA levels can tell us about this process in reverse, that is, if protein levels provide a reliable snapshot of what happened “behind the scenes”, at a gene level. Usually, mRNA levels are the markers used to measure gene expression. We all recently became familiar with the concept of mRNAs and their therapeutic potential. For example, mRNA vaccines have been developed for COVID-19 and other clinical conditions. In all these cases, a specific mRNA is used to produce the correspondent protein, that will help the body in exerting a clinical response. Our new study Here comes our new study, which we recently published in Translational Psychiatry. We investigated whether some mRNA profiles, specifically those related to the immune system, can provide a broader understanding of the connection between depression and inflammation. Interestingly, we found a higher mRNA expression of genes which encode for immune-related proteins in individuals with depression, independently of CRP levels. In fact, even depressed people with CRP levels that are normal, showing no evidence of inflammation, have increased levels of immune-related mRNAs. This evidence suggests that the immune dysregulation in depression is not limited to the inflammation seen in elevated CRP levels alone, highlighting the complexity of immune processes and suggesting the involvement of additional biological mechanisms at play in the gene expression process. The evidence we provide is an important piece of the puzzle, but we need to do more research to understand the exact mechanisms through which these immune-related gene expression patterns translate into inflammation at the protein level, like CRP. By understanding this process, we can be more accurate in our diagnoses and effective treatments for depression, ultimately improving the lives of individuals living with this challenging mental health condition. Professor Carmine M. Pariante, senior author of the study and Editor in Chief of Inspire the Mind, commented: “These important findings will allow us to identify the molecular pathways involved in depression and also help to more accurately identify those who have different types of immune responses which could pave the way for more personalised approaches to treatment.” On the path to precision psychiatry Summing up, inflammation is relevant to a large subgroup of people with depression, probably larger than we thought, but it is also complex, and we can see that in the many ways it can be measured. To add to the complexity, it is important to highlight that not everyone with depression is inflamed. Just like not every person with depression will have the same clinical response to a specific treatment. Therefore, as researchers and clinicians, we should always remember this when treating people and when doing research. Embracing the diversity and recognising shared biological alterations producing a disease, is not an easy task but one that could finally improve the way we manage the condition and truly advance the field towards a precision psychiatry. “Lives can be meaningfully transformed. Real progress can be made, but only when we identify and test specific biological mechanisms known to affect symptoms — and then develop drugs that treat those symptoms” Professor Andrew H. Miller and Doctor Charles L. Raison on Inspire the Mind.

Predicting the Unpredictable Last week, I took part in a Challenge Workshop on Immunopsychiatry, a branch of psychiatry that explores the connection between mental health and the immune system (the system that defends us against potentially dangerous microorganisms, such as viruses, keeping us healthy), in a wonderful location in Switzerland. The workshop brought together the most experienced researchers worldwide to present their recent discoveries and to brainstorm all together on how to foster the state of the art of the field. I am a psychotherapist and a researcher working at the Unit of Psychiatry and Clinical Psychobiology, Division of Neuroscience, IRCCS San Raffaele Hospital in Milano, Italy. I was invited as a junior faculty member to present my and my brilliant colleagues' research in an on-fire 15-minute talk in front of this unique audience. You can only imagine the pressure. What psychologically helped me? The fact that my presentation was on one of the current hottest topics: the use of machine learning to personalise treatments in psychiatry. Talking about Artificial Intelligence (AI) is now commonplace. The whole world is engaged in creating the "perfect" AI; just note the clamour around the chatbot ChatGPT that has boosted the giants of Silicon Valley and beyond. This is also happening in mental health. But for very specific reasons associated with the limits of research in the last 20 years. Unsolved clinical issues in psychiatry Mental health is a severe concern in terms of public health; we have also seen it with the COVID-19 pandemic. Depression, for example, is a leading cause of disability worldwide, affecting one in twenty people, a number that is steadily increasing. Nowadays, the diagnosis and treatment processes are mainly based on the collection of signs and symptoms and on what the clinician can observe and investigate during an interview, often when the patient is already ill. Furthermore, in most cases, patients show a mixed clinical picture, and, in many other cases, treatments are not effective in ameliorating the individual well-being, forcing several attempts before finding an effective treatment. For instance, in depression, approximately 30% of depressed patients do not respond to popular antidepressant treatments such as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). Why is this happening? Because the diagnosis is based on symptoms and not on biological and psychological causes. So, it can prevent the identification of the best treatment option. For this reason, over the last 20 years, the research has moved to identify the biological and behavioural factors involved in the etiopathogenesis (that is the cause and subsequent development of a condition) of mental disorders. This includes brain structure and function, genetics, and the inflammatory profile. However, things somehow were not working. What if it is all about heterogeneity? Even within the same diagnosis, different people may experience different profiles of symptoms and severity. For example, two individuals with depression may exhibit completely different symptom patterns, such as insomnia versus hypersomnia (i.e., feeling excessively tired during the day or sleeping longer than usual), or loss versus increase of appetite. Furthermore, the causes of mental health disorders are also multifactorial and can vary significantly between individuals. While genetics play a role, also environmental factors, life experiences, trauma, and social determinants of health can contribute and interact in a very personal way to the development and course of psychiatric disorders. So, things are not working because we are probably too unique and different among ourselves. And this is where AI comes into play, or rather a specific branch of it: machine learning. Machine learning exploits algorithms to learn from data how to make accurate predictions and can help in harnessing the power of big data, identifying recurring or hidden patterns among billions of variables and participants. In this way, algorithms can stratify, or aggregate, patients according to their specific biological, behavioural, and psychological characteristics, building more homogeneous subgroups of patients. With this, we can define new "diagnoses" based on these signatures, nearest to the biology and other individual features. This can help clinicians make more accurate predictions about patient outcomes and improve the early detection of mental health disorders and the development of more effective intervention strategies, tailored to individual needs: thus, a precision psychiatry. In the near future, clinicians may be able to include further diagnostic elements, provided by supportive AI tools, to guide their therapeutic choice. Not too different from what already happens in other branches of medicine, where a physician can propose the most effective intervention based on a blood test or radiological imaging. But when we talk about the mind, diagnosis, and related solutions can be more complicated. Ethical aspects that cannot be neglected It is mandatory to consider the ethical issues involved when we talk about AI and machine learning, but the questions to be raised are different: from data ownership and protection to privacy, from the management of potential bias or errors in the algorithms’ training to the implications in terms of indications on treatment and diagnosis. There is still a long way to go before being able to use these algorithms in clinical practice, but a categorical refusal of these new methodologies would be counterproductive, considering their potential benefits. New guidelines are also being defined at the European and International levels to regulate the application of this technology and its use in care processes. Well, I was curious to see how ChatGPT would suggest concluding an article about the potential impact of machine learning in psychiatry. It replied, "In conclusion, the incorporation of machine learning in psychiatry has the potential to reshape the field, empowering clinicians with advanced tools for early detection, precise diagnosis, and tailored treatment strategies, ultimately enhancing mental healthcare outcomes." Maybe it’s a bit scholastic but I cannot disagree with it.

Hello, I’m Heidi, and I do research to make clinical trials more inclusive. In this article, I’m going to share some of my knowledge, explain why improving trials is so important in our mission to improve health, and hopefully encourage you to share some of my passion and excitement for the subject too. First things first, what is a clinical trial? Clinical trials offer a way to rigorously test health interventions to ensure that they are safe and effective. Health interventions include medications, types of surgery, medical devices, talking therapies, lifestyle behaviours, and more. In trials, participants are usually split into two groups: those that will receive the intervention and those that will receive the control. A control group may make you think about placebos or sugar pills, but that isn’t always the case. In phase three trials, if there is already a way to manage or treat a condition, we commonly use "usual care" or "treatment as usual" as our control group as our aim is to find a new intervention that improves on the current standard of care. The feature that makes trials unique is the way that participants are split into those groups; typically, we use a technique called randomisation. Participants do not choose which group they would like to be in, instead, they are randomly allocated, which prevents selection bias from creeping in. If there are specific characteristics of people that might impact the outcome of the intervention, then these characteristics are distributed across the groups and controlled for, meaning that any difference that we see in the outcome of the research can be explained only by the intervention. My experience is in phase three trials, where the safety of the intervention for people has already been tested over a period of weeks or months. Phase three trials aim to evaluate an intervention’s effectiveness in a bigger group of participants and to gather safety data over a longer timescale. What about the research to improve clinical trials? Just as interventions can be improved, the way we evaluate them can be improved too. I do research that explores how to design trials to ensure that their results apply to more people. Methodological changes might require more time or money, but in the long term, I believe it will save money and improve health. If individual trials provide results that apply to more people, specifically people that are currently under-served by health research, we can avoid the need to do more trials in the future. Mental ill health is experienced by people with various characteristics. A trial that is testing an intervention that could alleviate the symptoms of mental ill health should therefore include a diverse range of people with those characteristics. For example, if a trial only includes white women under the age of 35, we will struggle to apply the trial’s results to anyone that is not a white woman under the age of 35. We cannot confidently apply the trial’s results to groups of people that have not been represented in the trial population. If you are not represented, you are under-served. Being underserved by health research can be the result of a few different things: Lower inclusion in research than would be expected from population estimates. High healthcare burden that is not matched by the volume of research designed for the group. Significant differences in how a group responds to or engages with healthcare interventions compared with other groups, with research neglecting to address these factors. It is important to note here that most differences between people are not biological. The characteristics that influence how people approach a trial are largely due to cultural or social differences. Understanding why people do or do not engage with trials means that they can be designed to reduce barriers and increase facilitating factors. Participant populations of most trials are not as diverse as the wider population, leaving much of our society under-served by the research that we do. Who is under-served by health research? According to the UK’s National Institute for Health and Care Research INCLUDE project, if you identify with any of the following factors, you are currently under-served by health research: Demographic factors: Age extremes, women of childbearing age, minoritised ethnicity, LGBTQIA+, and educational disadvantage. Disease-specific factors: Rare disease, genetic disease sub-types, and brain cancer metastases. Health status: Mental ill health, people without the capacity to consent for themselves (e.g., psychosis), pregnancy, learning or physical disabilities, smoking, multiple health conditions, and addiction. Social and economic factors: Full-time employment or unemployment, military veterans, living in remote areas, carers, language barriers, digital exclusion, socioeconomic disadvantage, and alternative residential circumstances (e.g., migrants, asylum seekers, care homes, prison populations, traveller communities, and homeless people). The fact that clinical trials probably do not include people that look like you is part of the reason for the avoidable health inequalities based on ethnicity, gender, and socioeconomic status that we see in society today. That is why it matters that clinical trials probably do not include people like you.